Four randomized controlled trials (RCTs) comprising 244 patients with Rockwood type III acromioclavicular (AC) joint dislocation were included in this systematic review and meta-analysis comparing operative versus conservative treatment. The pooled outcomes of interest included Constant score (CS), coracoclavicular distance (CCD), pain levels, and complication rates. Results indicated no significant difference in long-term functional outcomes between the two treatment approaches. Operative treatment provided superior early pain relief at all follow-up points; however, it did not translate into better long-term functional outcomes and was associated with a higher incidence of posttraumatic osteoarthritis and hardware-related complications. Conservative treatment resulted in fewer complications and similar long-term results. These findings suggest that conservative management is a viable option, and treatment decisions should be individualized.