AC Joint Repair and Reconstruction

Introduction

The acromio-claviclar (AC) joint is at the outer (lateral) end of the clavicle (collar bone). It is stabilised by ligaments: acromio-clavicular, conoid and trapezoid ligaments. The joint has cartilage at the end of the articulating bones as well as a disc of cartilage which aids smooth shoulder movement.

Like all joints, the AC joint can “wear out” with the development of osteoarthritis. This is more likely in those with repeated stresses of the joint (manual labour, weight training) or following injury that has damaged joint surface and stability of joint (falls).

The patient primarily complains of pain (made worse by positions that require placing the arm higher than the shoulder), and weakness secondary to pain. The diagnosis of osteoarthritis of the ACJ is usually made following clinical assessment of the patient. Investigations with X-rays of the ACJ will support the diagnosis and usually shows the typical features of osteoarthritis – narrowing of the joint and/or cyst formation. Occasionally further investigations such as MRI or bone scan can be helpful. In some circumstances, an injection of local anaesthetic with or without corticosteroid) into the ACJ can help to confirm the diagnosis and predict the success of surgery.

Excision of acromio-clavicular joint is very effective in relieving pain.

Indications for surgery

Pain not relieved by activity modification or with analgesia and non-steroidal anti-inflammatory medication.

Peri-operative Patient education

At the time of consultation, Dr Lane will give a full explanation of the proposed surgery, expected recovery and outcome. Information leaflets supplied by the Australian Orthopaedic Association are also supplied for your information. If there are any concerns the staff at Lake Kawana Specialist Centre are happy to take calls and if needed, further consultation with Dr Lane is encouraged.

Pre-operative Instructions

Anti-inflammatory drugs such as Feldene, Naprosyn, Indocid, Voltaren, Mobic and Celebrex should be stopped 5 days before surgery. These drugs increase the risk of bleeding. Aspirin or other blood thinning drug use prior surgery should be discussed with Dr Lane as this would depend on the patients underlying medical condition. The shoulder to be operated on should be free of cuts, sores or abrasions as this would increase the risk of infection following surgery. If you have damaged skin, your surgery will be postponed until healed.

This procedure is usually done as a day procedure. Our reception staff will give clear instructions when to attend the Hospital for admission. You are advised to bring any relevant X-rays or MRI scans. Please bring your Medicare cards, DVA or any private health care cards to the admissions area. Do not eat or drink for 6 hours prior to your procedure.

  • You will be admitted by the duty nurse and baseline observations taken.
  • A theatre gown is given to wear.
  • The shoulder will be inspected by the nursing staff and anti-septic lotion applied to the area which is then covered by a sterile drape.
  • The legs will have TED stockings applied to reduce the risk of thrombosis following surgery.

You will be taken from The Day Hospital to the theatre complex by the nursing staff and then to the anaesthetic bay which is situated next to the operating room. There you will meet your anaesthetist. ACJ excision is performed under a General Anaesthetic when you are asleep. Pre-operative intravenous antibiotics are given before surgery to reduce the risk of post-operative infection and intravenous fluids given throughout the procedure.

Procedure

When you are asleep in the operating room, the shoulder area is prepped with an anti-septic solution and patient covered with sterile drapes with a window for the operative site. The surgery time is usually 30 minutes. Dr Lane makes a small incision (3 to 4 cm long) over the AC joint. The procedure involves removing the end of the collar bone and the reconstruction of the AC joint. This does not affect function or strength in any significant way. Once the source of the pain has been removed, function and strength usually improve. The space that is left following excision of the AC joint is filled with a fibrous tissue which acts as a pseudo-joint.

The skin is closed with sutures or staples, local anaesthetic infiltrated around the operative site to further aid post-operative pain relief, primapore and sterile dressing applied.

You will have a sling applied for comfort. At the end of surgery, you will be taken into the Recovery Room and once adequately awake, observations stable and you have had something to eat and drink you will be discharged home.

Dr Lane will usually see you in the recovery room and explain the operative procedure. The anaesthetist will prescribe medication for pain relief. It is important that you have someone to take you home following the operation.

Post-operative Instructions

It is important to keep the dressings dry until follow up 10- 14 days after surgery. The bulky outer dressing can be removed in 3 days keeping primapore in place. The sling should be worn for comfort.  Dr Lane will have instructed you to perform a series of simple movements prior to review, to prevent the stiffness of the joint. The arm should be removed from the sling and passive pendulous exercises performed when leaning forward using the non-operative arm for support. The operative arm should let the hand hang down and then let the arm swing forward and back, side to side and in circles (clockwise and then anti-clockwise). Then you should swing the arm in each direction for 30 seconds and repeat three times, exercising 4 times daily.

At the post-operative appointment, your sutures will be removed and Dr Lane will discuss the operative findings. You will be guided on a continued exercise programme. Strengthening work can be gently introduces at 3-4 weeks following surgery – which can be supervised by a physiotherapist.

You can usually drive 2 weeks following surgery and return to work at around the same time if work is sedentary or desk job. A more physically demanding job may take up to 6 weeks.

Return to conventional weight lifting and contact sport is usually possible at 6 weeks following surgery.

Risks

General risks associated with Anaesthetic (rare)

  • Death.
  • Myocardial infarction.
  • Short term confusion.
  • Stroke.
  • Deep venous thrombosis.
  • Pneumonia.

Local complications (uncommon)

  • Infection. This usually involves the skin and responds to antibiotics (sometimes intravenous requiring hospital admission). If the infection is deeper and involves the ligament this may have to be removed surgically. The risk of infection is less than 1%.
  • Wound healing may be delayed or thickened. The latter more likely if there is a history of keloid scarring following skin lesions or surgery.
  • Bleeding due to vascular injury.
  • Post-operative stiffness.
  • Post-operative pain (rare). The majority of patients have improved pain.
  • Regional pain syndrome. This can be associated with swelling, colour changes and stiffness. This is a rare complication which manifests as disproportionate pain following surgery.
  • Pneumothorax – given the proximity of surgery to the lung there is always the potential of penetration of chest wall and collapse of lung (pneumothorax). Every effort is made by the surgeon to prevent this complication during surgery.

Smokers, diabetics and patients with multiple medical co-morbid conditions are at a higher risk of complications.