Acromioclavicular Joint (ACJ) Reconstruction
The acromioclavicular joint is a small joint between the end of your clavicle and the shoulder blade. It does not move like a regular knee or hip joint, but it does connect the arm to your body. There is a small disk of cartilage that is in the joint and there is also some minor rotation at the joint with shoulder movement.
With certain injuries, you can separate the AC joint. There are multiple grades of separation, with most people being a grade I or II. For these grades of separation, we treat the shoulder with conservative treatment, such as physical therapy and sometimes, steroid injections. As the ligaments around the joint progressively tear, the AC joint becomes more unstable. When the joint becomes unstable, a certain set of ligaments called the coracoclavicular (CC) ligaments are torn. There are two of those CC ligaments: the conoid and the trapezoid. As the grade of AC joint separation becomes higher (i.e. some grade III separations and all of grade V separations), it is necessary to surgically repair those ligaments.
Often times after a large AC joint separation, the clavicle bone can be much higher than the end of the shoulder blade. This is what we restore with surgery. In addition to the AC joint injury, there is also a high incidence of other cartilage injury to the shoulder, so often times we obtain an MRI of the shoulder to see if there is any other collateral damage. Your surgeon will talk to you about the specific injuries that you have and what types of procedures need to be done at the same time to fix your shoulder.
The surgery for an AC joint reconstruction is typically an outpatient procedure. You will receive a general anesthetic, in addition to a nerve block to your operative side. The nerve block is placed by the anesthesia service and allows you to wake up relatively pain-free. The block lasts for approximately 12-18 hours, after which you can start easing into your pain medication.
You are positioned into a “beach chair” position, with all of your extremities carefully padded. Your head is also supported in a padded head holder. After performing a “time out”, where we verify the operative site, your arm is cleaned and sterilely draped. If there is anything to be done inside the shoulder joint or to the rotator cuff, we use a small camera and poke hole incisions (i.e. arthroscopically) around the shoulder to perform the repair. Once that is done, we focus on the AC joint reconstruction. Typically we make an incision from the top part of the AC joint down to the coracoid (the bony bump on the front part of the shoulder).
We isolate the AC joint and also isolate your coracoid bone by taking down some of the deltoid muscle. At this point there are two options. If your separation was relatively new, we use a high strength suture that we pass between the coracoid and the clavicle. This new suture stabilizes your AC joint and allows the other CC ligaments (the conoid and trapezoid) to heal. There are two small metal buttons that we use to fix the suture.
If your AC joint separation was more chronic or if you have had a previous surgery to the shoulder area, we use an allograft (a donated) tendon for the reconstruction. We pass the donated tendon around the coracoid and then drill two holes in the clavicle bone. Each end of the tendon is brought through the drill holes and the tendon is fixed to the clavicle with screws. Typically the screws are not metal. Your surgeon will talk to you about the risks and benefits of using donated tendons, but any risk of infection from the donated tendon is extremely small.
The tissues around the AC joint are sutured together and the incisions are closed with staples or sutures.
Occasionally we use a drain in the shoulder to help remove some of the swelling, but this is very rare. Your arm is placed in a sling and pillow device for immobilization. It is very important that you stay in the sling and pillow and adhere to the rehabilitation protocol.
Sometimes we move the shoulder very quickly after the procedure, but other times we keep you in the sling for a couple of weeks prior to even moving the shoulder. This will be explained to you after the procedure and very specific instructions will be given to you and your therapist.
Once your pain is under control, you are eating and keeping food down, and you are medically stable, you can be discharged home. You will get a full set of instructions of Do’s and Don’ts. Basically make sure to keep your incision clean and dry. No showering until your postoperative visit. If you have any questions on what you should be doing or not doing to your shoulder, make sure to ask your surgeon or the nurses/residents. You will be seen in the office for a check up and to remove any staples or sutures in 7 – 10 days after surgery. You will also be given a pain medication prescription. Please take the new addition of pain medication as directed. Eat a healthy diet and get plenty of rest. Also remember that ICE is a form of pain relief and you should ice the shoulder regularly.
Typically you are in the sling for 6 weeks after surgery but are coming out of the sling for very prescribed movements that you will be taught. Physical therapy is an important part of the rehabilitation but depending on how bad your AC joint separation was, your therapy may be delayed so your reconstruction can heal.
We hope this provides a bit more insight into your surgical procedure for AC joint reconstructions. As always, if you have any questions, please contact our office at 248-988-8085.
