The Procedure
An acromioclavicular joint excision, often abbreviated to ACJ excision (or ACJEx) is a surgery where a small segment of the clavicle (collarbone) is removed. The resected area of the joint is replaced by fibrous scar tissue. The surgery is performed to effectively relieve pain from arthritic changes in the ACJ or other injuries, where bone is rubbing against bone, causing pain and inflammation.
Think of it this way: Your AC joint is worn out and the cartilage that separates the two sides of the joint has worn away and is no longer there. Without the cartilage separating the ends of the bone on either side of the joint, the bones on either side of the joint come together and start rubbing against each other. Bone rubbing against bone in a joint isn’t a good thing. When a joint that has lost its cartilage and has bone rubbing against bone, it causes pain. The more you do with that joint, the more inflamed it becomes and the more painful it is. Normally, resting that joint by decreasing the amount you do with it will settle the inflammation down and the pain will lessen and even go away. Sometimes, the joint has become so inflamed and so disordered that resting the joint isn’t enough to get the pain to go away. This is when surgery becomes a consideration. With the worn-out AC joint, the surgical option is to excise a little bone from either side of the joint (mostly from the clavicle (collar bone) side of the joint) so that the two bone ends are not rubbing into each other. We know from biomechanical studies that 5mm of bone resection is required to prevent the two ends of the AC joint rubbing into each other. Over time, fibrous tissue usually fills in the gap between the two bone ends. That fibrous tissue is not as good as the cartilage you were born with, however it’s better than bone rubbing into bone.
The ACJEx can be performed as an open procedure or as an arthroscopic procedure. The advantage of performing the ACJEx arthroscopically is that the superior capsule of the AC joint can be maintained intact, which decreases the risk of the AC joint becoming unstable following the procedure. Instability of the AC interspace is the big issue complicating surgical excision of the AC joint. Twenty years ago, when the surgery was performed as an open procedure, excising 1.5 to 2cm of the distal clavicle resulted in instability affecting around 10% of patients following the surgery. The risk of instability symptoms is increased by excising too much bone and by cutting the superior capsule of the AC joint. The strongest parts of the AC joint capsule are posterior and superior and these parts of the AC joint capsule can be preserved when performing the procedure arthroscopically.
I perform AC joint excisions arthroscopically (keyhole) and typically I will book about 1.5 hours of theatre time for the procedure.
Pre Op
Whilst you wait for your surgery date, there are a few things to do:
- Speak to your health fund to confirm if the hospital fee for your surgery is covered on your policy
- Speak to your anaesthetist to confirm their fees
- Register your details with the hospital
- Read through, complete and return your paperwork to my office
- Plan your transport to and from the hospital. You won’t be able to drive yourself home after the surgery, so make sure you have a travel plan in place
- If required, arrange any recommended pre op physio appointments
- If required, get any pre op pathology tests (e.g., blood tests)
- Use benzoyl peroxide 5% wash on your shoulder for 5 applications: twice a day for two days, and then again on the morning of the surgery. This will help reduce your risk of infection from Cutibacterium acnes.
- Pack a bag for your hospital stay including regular medications in the original packaging, a loose button-up shirt to wear after surgery, nightwear, personal items including toiletries. If you have sleep apnoea, you must bring your CPAP machine.
- If you are on any blood thinners ring my office and confirm when to stop taking them before the operation.
- If you are on any diabetic tablet medications ring your anaesthetist and confirm whether you need to stop taking them before the operation
- Confirm your admission details with my office one to two business days prior to surgery
Though this can seem overwhelming, you will be provided with detailed instructions on what needs to be done so your surgery journey can be as smooth as possible.
Complications
General risks of surgery include:
- Bruising & haematoma: this will vary for each patient. Bruising is a normal side effect of surgery and usually resolves in a short time.
- Infection: infection is a rare but possible risk and is usually treated with antibiotics.
- DVT and PE: deep vein thrombosis and pulmonary embolism are blood clots that form in either the lower limbs or lungs. If left untreated, DVT and PE can have serious effects, however if treated promptly, the risks are significantly lowered. More information can be found here (hyperlink to UC Blood Clot pamphlet)
- Anaesthetic risks: general anaesthetic (GA) carries a number of risks, which will be discussed in detail with your anaesthetist prior to surgery. Fortunately, Australia is one of the safest places to undergo a GA. In Australia, the risk of mortality from GA is around 1 in 100,000. For context, the risk of death in a car accident inQueensland is around 1 in 10,000 per year.
- Wound issues: some superficial issues can develop in surgical wounds postoperatively; however most will require a small intervention to resolve the problem.
The ACJEx is typically a low-risk surgery. Specific risks and complications include:
- Technical issues: in some instances, not enough bone is removed during the procedure, which results in poor results. Sometimes, the superior capsule may not be preserved during surgery which can increase the risk of AC instability after the surgery
- Frozen shoulder is more common with procedures of the shoulder joint proper (the glenohumeral joint but can be precipitated by any surgery around the shoulder region
- Nerve or blood vessel damage is exceedingly rare
- Shoulder instability of the Acromioclavicular(AC) interspace
- Persistent pain
- Incomplete relief of the preoperative symptoms:remember excising the AC joint doesn’t give you a normal AC joint like the one you were born with, however it is better than one that is worn out and really painful
Day of Surgery
Your admission details will be confirmed one to two business days prior to surgery. You will need to make note of your admission time and your fasting time. Your admission time may be as early as 6am. If you aren’t local to Brisbane, it is usually recommended that you stay the night before in case your admission is early.
When you arrive at the hospital, you will go through the admissions process and then be taken through to the surgical waiting area. Your anaesthetist will have a short consultation with you before you go into theatre and under general anaesthetic. I will say hi to you before the surgery in the anaesthetic bay of the operating theatre and mark your operation site with you.
Your hospital stay will usually be one night. You will be discharged usually after 10am. I will see you before your discharge. I will provide you with a folder containing a detailed postoperative pack including a letter telling you what I found at surgery and exactly what I did in your operation, along with information about your rehabilitation and postoperative care. Remember to have someone available to take you home from the hospital.
Post Op Recovery & Healing
Recovery after the ACJEx is simple, as no surgical repair is performed, thus there is no risk of “tearing” anything and you don’t need a sling after the surgery. I prefer you not to wear a sling, however you can wear a sling in the first week for comfort if you need to, or if your shoulder is really sore. You can resume driving once you can confidently and safely control your vehicle. Usually this is a few days to a week after the operation.
jMovement and exercises are commenced immediately after the surgery to promote gentle function and restore passive and active shoulder movements. Depending on the nature of duties, returning to work after surgery may be possible after a week, however this will be dependent on individual needs and progress.
Rehabilitation
Rehabilitation after ACJEx focuses on restoring range of motion. It can take up to six months after surgery to see the full range of movement, however the range of motion is improved immediately after surgery.
Physiotherapy Guidelines
Day One Physiotherapy Guidelines
The hospital physio will demonstrate how to fit your sling and how to eat, shower & dress whilst in your sling. Please make sure you go through these things with the physio so that you get them really clear in your mind before you leave hospital.
Goal:
- Promotion of gentle function and restoration of passive and active shoulder range of motion
Day One:
- Education and Reassurance: no surgical repair, ok to start moving, will not “pull anything apart”
- Sling: for comfort only, aim to cease wearing within a week, check fit, demonstrate activities of daily living (showering, dressing etc)
- ADL’s (activities of daily living): good to use the arm for light activities eg dressing/eating, function within pain limits.No repetitive or loaded work above chest height.
- Pain relief: ice, positioning, posture, pain medications as prescribed
- AAROM (active-assisted range of motion)exercises: no limitation in range, move into all directions as able, focus initially on flexion and external rotation, possible exercises include:
- Circular pendulum
- AA (active-assisted) external rotation at neutral
- Supine flexion
- Forward lean on bench
- Horizontal flexion
- Supine Hand to head
- Internal rotation - hand to hip with neutral scapula
- Patient may refer to Extend Rehab or Dr Cutbush's website for exercise videos
Considerations: Excision of ACJ (Acromioclavicular Joint) - possible higher levels of pain, reduce Forward shoulder flexion (HF) and Hand Behind Back (HBB) exercises initially if required
Follow up:
- With local physiotherapist week 2 to check AROM (active range of motion) and PROM (passive range of motion) improving. Week 6 postop consult with Dr Cutbush and Shoulder Physiotherapist. Your postop consultations can be either in person or by a telehealth video consultation (Facetime or WhatsApp), just let my office know which works for you.
Results After Surgery
ACJEx is typically a very effective procedure for improving pain and shoulder function. The majority of patients can return to normal levels of activity after surgery. Keep in mind, all shoulder rehab is much slower than most people would like it to be. Rehab often takes at least 4 months following an AC joint excision. It’s not uncommon for the shoulder to ache for some time after the surgery.