Acute Acromio-Clavicular Joint (ACJ) Stabilisation


Indication for surgery:

The indication for AC joint stabilisation is current or anticipated future symptomatic impairment of shoulder function or pain as a consequence of an AC Joint dislocation. If the AC Joint is markedly displaced upwards or backwards then surgery may well improve the long-term outcome. When the deformity is less marked the benefit of surgical stabilisation is less clear. If there is concern regarding the appropriateness of surgery it is best to seek early advice.

Acute stabilisation is generally considered to be within 2-3 weeks of the injury and may involve reduction and stabilisation of the AC Joint allowing the Coraco-Clavicular ligaments to heal or scar at the appropriate length.

Stabilisation of a chronic injury (beyond a few weeks) typically involves a reconstructive procedure, where ligaments or tendons are transferred from elsewhere to reconstruct the Coraco-Clavicular ligaments. This is sometimes termed a Weaver-Dunn procedure after one of the early techniques described.


Anaesthetic:

Surgery is typically undertaken as a day-case procedure, that is you come into hospital and are discharged the same day. If the surgery is undertaken in the afternoon or evening then you may wish to stay in over night and go home first thing the next morning.

The operation is undertaken with a general anaesthetic often with an interscalene nerve block, that is you are fully asleep with further pain relief from a local anaesthetic injection above the Clavicle (collarbone) block. The block typically results in arm numbness and pain relief for 12 to 48 hours following the operation.


Acute Stabilisation:

Acute stabilisation may be obtained using a Tightrope
TM technique. This can be undertaken as a keyhole (arthroscopic) or mini-open technique.


Incisions:

The arthroscopic technique typically involves three or four, half to one-centimetre incisions. One at the back of the shoulder, one or two at the front of the shoulder and one over the top of the shoulder near the AC joint itself.

The mini-open technique uses a single three to four centimetre scar at the top of the shoulder near the AC Joint. The scar typically lies under clothing straps and is usually cosmetically acceptable.

There is little cosmetic difference between the arthroscopic and mini-open techniques


Procedure:


Arthroscopic Technique:

The arthroscopic (keyhole) technique allows assessment of the Gleno-Humeral Joint with a camera. The Coracoid is cleared and the undersurface exposed through a small incision or portal at the front of the shoulder. A special jig is used to guide a wire and then a drill through the Clavicle and then through the Coracoid. The Tightrope
TM system allows a strong pulley mechanism to be pulled though both bones before being ‘flipped’, securing a hold on both the top of the Clavicle and bottom of the Coracoid. The TightropeTM pulley can then be tightened to the appropriate length and by so doing the AC Joint can be reduced and held in the correct position. A second TightropeTM may be passed to offer improved strength and stiffness of the reduction and stabilisation.


Please select the following link to view the .wmv file version if you do not wish to install QuickTime:
ACJ Tightrope animation


Mini-Open Technique:

A small incision is made over the end of the Clavicle (Collarbone). The top of the clavicle is exposed. To allow one or two drill holes to be placed in the optimal positions. The top of the coracoid can be readily identified and exposed without extensive tissue clearance. One or two drill holes can then be drilled through the coracoid with appropriate care. One or two Tightropes
TM can then be pulled through the Clavicle. The Coracoid button may then be pushed through Coracoid drill holes at which point the button will ‘flip’ spontaneously securing the TightropeTM to both the Clavicle and Coracoid. The pulley mechanism then allows reduction and stabilisation of the AC Joint in the correct position. This technique allows the placement of two Tightropes under direct vision with minimal soft tissue disturbance. The soft tissue attachments to the distal clavicle, which may stripped at the time of the dislocation may also be repaired using this technique.


Wound Closure:

Arthroscopic wounds are typically closed using SteriStrips
TM, small butterfly paper stitches, but a single absorbable stitch may be used which does not require removal. These wounds are then typically covered by a number of OpsiteTM dressings.

A mini-open incision is typically closed with an absorbable stitch that does not require removal. Occasionally the ends of this suture need to be trimmed when the dressing is removed at 10 to 14 days. The wound is then usually covered with a number of SteriStrips
TM to protect the wound and minimise scarring. The wound is then covered by an OpsiteTM dressing


Following surgery:

The arm is typically placed in a sling, which is worn for three to four weeks. It is important to follow the rehabilitation protocols for AC Joint stabilistion supervised by a physiotherapist.

Link to AC Joint stabilisation rehabilitation protocol.


Risks associated with the operation:

All operations are associated with a degree of risk but complications associated with an Acute stabilisation are uncommon

Infection (<1%)

Anaesthetic Risks (Anaestheic complications are rare but include Heart Attack (Myocardial Infarction, MI), Stroke (Cerbero-Vascular Accident, CVA) and a clot in the leg (Deep Vein Thrombosis, DVT) or lungs (Pulmonary Embolus, PE).

Damage to nerve or blood vessels (Neuro-Vascular Damage). There may be a small patch of numbness beyond the shoulder scar. These patches when they do occur do not normally cause an issue. More significant injury is very rare.

Stiffness. There is a small risk of developing a stiff or frozen shoulder after the surgery. This should get better on its own but does occasionally require treatment.

Deformity. There is a small risk that the reduction of the joint will be lost resulting in recurrence of the deformity.

Fracture. Further injury to the shoulder may result in a fracture (break) of either the Coracoid or Clavicle. The likelihood of this may be increased by the presence of the small drill holes.

While the probability of symptom improvement is high it remains possible that symptoms may remain unchanged or deteriorate.

Further surgery (Re-operation)

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