© 2019 Journal of Shoulder and Elbow Surgery Board of Trustees Background: The literature is unclear as to the optimal surgical management of a symptomatic os acromiale that has failed nonoperative treatment. Surgical options include excision, acromioplasty, and open reduction and internal fixation. The purpose of this study is to summarize the described methods and compare their reported outcomes with the goal to provide direction on how to surgically manage os acromiale. Methods: We performed a systematic review of the current medical literature. Fifteen studies met all the inclusion criteria. Two hundred eleven total subjects (220 shoulders) underwent surgical treatment for a symptomatic os acromiale. There were 140 men and 71 women with a mean age of 49.6 ± 9.1 years. The mean follow-up duration was 40 ± 11.6 months. Surgical techniques used in the included studies were excision, acromioplasty, and open reduction with internal fixation. Concurrent surgical procedures performed were also included. Results: Meso-os acromiale was the most common type (167 cases, 94.4%). The most common surgical technique was internal fixation (135 cases, 60.8%), with screw fixation being the majority (76 cases, 56.3%). Excision (65 cases, 29.3%) was the second most used technique. The most common concurrent surgical procedure performed was rotator cuff repair (125 cases, 56.3%), followed by distal clavicle excision (31 cases, 14%). Conclusions: All surgical techniques employed resulted in improvement in postsurgical clinical outcomes without any technique demonstrating superior results. Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes.