Acromio-clavicular Joint (ACJ) Injury

What sort of problems?

The acromio-clavicular (AC) joint is where the collarbone (clavicle) meets the acromion (roof of the shoulder) towards the tip of the shoulder. It is not a very mobile joint; it has a cartilage disc within it, a capsule around it and is surrounded by ligaments to stabilise it.

There are two main problems that occur with the acromio-clavicular joint:

Arthritis – also known as degeneration, it is caused by use or by old trauma (i.e. disruption). People who do a lot of overhead activities, weightlifting or athletes participating in contact sports are vulnerable. Treatment is intially with physiotherapy, anti-inflammatory medication and cortisone injections.

Disruptions – These are traumatic injuries usually caused by a fall onto the tip of shoulder. Swelling and prominence of the joint is easily seen after injury. There are 6 grades of disruption (see figure), with increasing severity. Grades 1, 2 and 3 do not require emergent surgery and can be treated with physiotherapy and anti-inflammatories. Grades 4, 5 and 6 do require early surgery (reducing the disruption and fixing it in place).

Who should have surgery?

Arthritis – Failed non-operative treatment i.e. ongoing pain. Surgery is AC joint excision. This involves removal of the AC joint.

Disruption – as aforementioned, grade 4, 5 and 6 injuries require early surgery to stabilise the joint. Grade 1, 2 and 3 injuries usually do not require surgery; most patients recover without further problems except permanent prominence of the joint. However, manual workers or overhead athletes may have persistent pain or functional restrictions (>6 months). In this circumstance, grade 1 and 2 injuries require AC joint excision. Grade 3 injuries require matching the bone ends up again and stabilising the joint in that position.

Types of acromioclavicular joint disruption

Will I need any tests/scans?

It is likely that X-rays diagnose AC joint disruptions. Arthritis can also be seen on X-ray but occasionally early degeneration is seen on MRI or Ultrasound scan. Please see the section Surgery FAQs to see if you will need any other tests e.g. blood tests before your surgery.

How is it done?

AC joint excision – this procedure is carried out under general and/or regional anaesthesia. It can be performed using shoulder arthroscopy. Two or three portals (incision <1cm) are made around the shoulder and the joint is excised using a shaver and a burr. A sub-acromial decompression is usually performed simultaneously.

AC joint stabilisation - this procedure is carried out under general and/or regional anaesthesia also. It is an open procedure. An incision is made at the front of the shoulder. In the chronic cases, the end of the collarbone often needs to be excised (approx 1cm) so that the joint can be reduced to its normal position. To hold the collarbone down, a biological ligament reconstruction device is used – AC Graftrope. It is anchored to the coracoid process below and fixed to the clavicle with a single bio-absorbable screw.

The arm is always placed into a polysling for comfort and to immobilise the shoulder to allow tissues to heal for both procedures. Can I go home the same day?

More often than not, as with most arthroscopic surgery, this is a day case procedure. Occasionally an overnight stay is advised depending on post-operative comfort levels, medical co-morbidity and time of day of the surgery.

What about after the operation?

You will see a physiotherapist before discharge to be instructed on simple exercises to carry out in the short term. This usually involves simple pendulum exercises out of the polysling and light stretches, often with assistance (e.g. your other arm or your physiotherapist) and you will be instructed on axillary hygeine. You should aim to exercise the shoulder 3-4 times a day; although the shoulder will be sore to start, there should be no lasting pain or pain that is not alleviated by the analgesia prescribed to take home. Sleeping with a pillow under the shoulder is recommended. It will be painful to sleep on the side of the operated arm for weeks.

Restrictions of movement: no heavy lifting (>5kg) for 3 months.

You will be prescribed analgesia to take home and Mr Patel strongly advocates its use to keep pain to a minimum; it should be noted that pain is more difficult to control if allowed to establish itself. Mr Patel recommends the regular application of ice as an adjunct to relieve pain and swelling in the acute post-operative period.

You will see Mr Patel two weeks after surgery for a wound check (and stitch removal) and a physiotherapy program will ensue thereafter which is paramount to the success of the operation. You are likely to have been seeing a physiotherapist before the operation and Mr Patel will liaise with him/her in detail to advise on the post-operative exercise program. For these procedures, Mr Patel recommends return to work (sedentary) when you feel able; for manual work this may be 3-6 months. Driving and swimming breastroke can resume after 2-3 weeks for AC joint excision and after 6-8 weeks for AC joint stabilisation. Return to freestyle swimming, overhead athletic activity and contact sport is recommended at 3-4 months for both procedures, but is often guided by the strength of the individual.

What are the potential complications?

All surgery carries a risk. Specific risks to arthroscopic AC joint excision are:

Infection – this can be either superficial (portals) or within the joint. You will be given antibiotics to reduce this risk.

Stiffness – It is very important that some mobility of the shoulder is maintained after surgery. The physiotherapist will advise on simple exercises that can be carried out at home. Mr Patel also recommends that you take regular analgesia and use ice (see Surgery FAQs) to help minimise post-operative discomfort and facilitate early movements.

Bleeding – this may require a return to the operating room for removal of blood clots and to stop the bleeding

Neurological – patients often describe a patch of numbness or a heavy feeling around the shoulder in the early post-operative phase. This is commonly swelling related and resolves as swelling reduces and full shoulder mobility is recovered.

Residual symptoms – unfortunately, no guarantees can be offered regarding curing your symptoms, despite the surgeon’s best efforts. In this case, further management and treatment options will be discussed with you.

For open AC joint stabilisation, additional risks are:

Device failure – rarely, the AC Graftrope used for reconstruction can fail (break) or the screw can migrate or cut out of the bone. In this circumstance, further surgery is required