Reconstruction of ACJ

What is Reconstruction of ACJ?

Reconstruction of ACJ (Acromio-clavicular joint) is a surgical procedure preferred for the treatment of high grade acromioclavicular joint injuries.  Its main purpose is to restore the connection between collar bone(clavicle) and upperlimb through scapula (shoulder blade). In acute injuries, damaged ligaments are let to heal by reducing the ACJ separation by strong sutures, endobuttons, tape or plate. For chronic injuries, tendon grafts, artificial polyester ligament is looped around the clavicle (collarbone) and the coracoid bone (a bony prominence present at the front of your shoulder) which replaces the torn ligaments. Reconstruction of ACJ is helpful for stabilization of the acromioclavicular joint and prevention of pain, weakness and instability in selected cases.

 

What are the indications for the procedure?

  • Acute type IV, V or VI injuries of acromioclavicular joint
  • Chronic type III injuries where conservative treatment fails to provide relief.
  • Open injuries
  • Superior shoulder suspensory complex injuries
  • Injuries to the neighbouring structures such as blood vessels, ligaments, nerves or collarbone
  • Persistent pain after 3 months of injury
  • Acute injuries in athletes, labourers, and patient with disability and cosmetic concerns

 

What are the benefits?

ACJ reconstruction is beneficial for-

  • Pain relief
  • Stable shoulder
  • Improvement in function of the joint
  • Increased strength of shoulder
  • Stable joint

 

What are the risks?

ACJ reconstruction is usually a safe surgery. The possible risks of this surgery can be-

  1. Infection (1 %)
  2. Nerve injury (< 1 %)
  3. Bleeding from the neighbouring blood vessels
  4. Blood clots (< 1 %)
  5. Frozen shoulder or stiffness in the shoulder (1- 2 %)
  6. Failure of the operation (2%)
  7. Irritation from the hardware used
  8. The clavicle may appear slightly higher than its normal position.

 

How should I prepare for the procedure?

If you have selected reconstruction surgery of ACJ, you should be prepared for the following-

  1. Before surgery, your surgeon will investigate your general condition through certain tests such as blood tests, electrocardiogram or chest X-ray to rule out any health risks. This helps to rule out any possible risks of surgery such as bleeding, heart diseases etc.
  2. It is advisable to inform your surgeon about any medications or supplements (esp. Blood thinners) you are taking. He may ask you to stop them before the surgery as they may complicate the operation.
  3. If you are a smoker, you should stop smoking at least 48 hours before the operation. Smoking increases the risk of chest and wound infection. It also affects your recovery process after the surgery by slowing it down. Some patients require help for household activities as many activities that require upper movement of the shoulder and other household activities such as bathing, dressing, laundry and cooking for few weeks nearly six weeks.
  4. Any infection in the body including common cold or a cough should be cleared up before the operation.
  5. You should also stop eating or drinking 8 hours before the operation.
  6. Positive attitude towards the operation and your condition are necessary for the success of the surgery. This will help you for better health benefits and faster recovery.

 

How is it performed?

  • The operation is performed under general anaesthesia or local anaesthesia. In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation but he cannot feel whatever is happening in the surgical area. Your surgeon can select the combination of both local and general anaesthetic.
  • Positioning– The position of the patient during the operation is semi beach chair position
  • Procedure- a 3-4cm incision is made at the top of the shoulder and the joint identified.
  1. Acute injuries – The joint is reduced and stabilised with strong sutures, endobuttons, tape or plates and screws
  2. Chronic injuries – In majority of cases a cm of collar bone is excised from the outer end to reduce the joint. This is then stabilised with more stronger materials like tendon grafts, artificial polyester ligament etc.

In both the procedures, holes are made on shoulder blade (coracoid) and  collar bone to stabiles the sutures, ligaments etc. The capsule is then closed with an absorbable suture followed by the closing of fat and skin and the arm is placed in a sling. The operation takes 1 to 2 hours for the complete procedure.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery; patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • The initial aim is to provide comfort and rest to the arm with the use of a sling.
  • Before discharge, your physiotherapist will teach you gentle exercises of fingers, wrist, elbow and pendulum exercises for the shoulder. This is necessary to prevent stiffness and pain and to maintain the strength of the muscles near your shoulder after healing.
  • After two weeks of the surgery, the patient is reviewed for the wound check and physical therapy is advised to facilitate rehabilitation.
  • The shoulder sling is removed after 6 weeks and patients are allowed a full range of movements.
  • The patient can progress to more strenuous activities (swimming, driving, lightweights in gym etc) from six weeks to three months. This will be guided by your surgeon and is based on the radiographic and clinical assessment.
  • The wound should be massaged (typically after 2 weeks) using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness, helps scar to mature).
  • It is advisable to avoid contact sports, injury or lifting anything heavy on the affected side for 3 months. The duration may increase or decrease based on the personality of injury and method of reconstruction.
  • Physiotherapy is important to return back to normal functioning and for complete recovery, it can take from 6 months to 2 years.

 

ACJ reconstruction_1

The ligament that stabilises the collar bone to shoulder blade acromioclaviclular ligament (yellow star) and Coraco-clavicular ligament (red star).

Acute ACJ injury:

ACJ reconstruction_2

  1. 30 year old gentleman had a fall from bicycle and had an acute ACJ dislocation or separation (arrow); B. The dislocation was reduced (black dotted line) and held with a strong suture attached to the metal buttons (arrows) on the collarbone (clavicle) and coracoid (shoulder blade).

Chronic ACJ injury:

ACJ reconstruction_3

  1. 40 year old gentleman had a fall from ladder and had an ACJ dislocation or separation (arrow)and was treated conservatively for 2 years; B. As he continued to struggle with pain and discomfort, he had lateral end clavicle excision, ACJ reconstruction with LARS ligament connecting the collarbone (clavicle) and coracoid (shoulder blade).

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