Acromio-clavicular Joint excision

Excision of the lateral end of the clavicle is a procedure performed for persistent pain in the AC Joint usually related to arthritis in the joint. it is often related to heavy lifting activity. Each year the Upper Limb Centre sees several patients who are keen weight trainers or body builders in their 30s or 40s who have developed AC Joint arthritis. As such it is a "young man's Arthritis". Treatment is usually conservative initially with simple measures such as activity modification, physiotherapy, rest etc. Steroid injects can be very effective and are usually performed using a special xray machine to carefully guide the injection into the joint. 

Often the above measures provide only temporary relief and in these patients suergery can be recommended. At the Upper Limb Centre the treatment of choice is usually an arthroscopic excision of the AC joint through 2 or 3 very small incisions using a special camera to view the procedure. Frequently the procedure is carried out at the same time as a sub-acromial decompression in patients with impingement and AC joint wear and tear.

Key-hole Excision of lateral end of clavicle takes about 30mins to perform. Normally the patient is given a general anaesthetic. An injection of local anaesthetic can be given into the lower neck to anaesthetise the arm, which lasts for about 12-14 hours following the operation. This keeps the patient very comfortable through their early recovery.

The patient wakes up in a sling in the theatre recovery unit. They are then transferred back to the ward. Most surgery is performed as a day case but some older or frailer patients stay in over night. Physiotherapy is started early with the first sessions given before the patient goes home. Full range of movement exercises as started as soon as the patient can tolerate it. Your physiotherapist will advise you on what you can do and give you a personalised routine of exercises. Normally the sling can be removed after 48 hours. You will normally be off work for about 6 weeks though some patients take longer and some shorter.

Here are some common questions that patients ask with their answers.

What does the operation involve?

The operation is performed using keyhole surgery. The objective of the operation is to remove just under 1 cm of bone from the end of the clavicle. These patients have considerable pain related to the cartilage damage within the joint. After excising the lateral clavicle the pain is usually improves.

What are the risks of surgery?

All operations involve an element of risk. You should be aware of them before and after your surgery.

The risks include:

Complcations relating to the anaesthetic such as sickness, nausea or rarely cardiac, respiratory or nerve problems (less than 1% each, i.e. less than one person out of one hundred).

Infection. These are usually superficial wound problems. Occasionally deep infection may occur many months after the operation. (less than 1%)

Persistent pain and/or stiffness in/around the shoulder. Up to 20% of patients will have symptoms continuing after the operation.

Damage to the nerves and blood vessels around the shoulder. (less than 1%)

The need to re-do surgery is rare. In less than 5% of cases, further surgery is needed within 10 years.

Please discuss these issues with a doctor if you would like further information.

Will the surgery be painful?

Although you will only have small scars, this procedure can be painful due to the surgery performed inside your shoulder.During the operation it is likely you will be given a nerve block were an injection of local anaesthetic is given around the nerves in your shoulder. This usually means that you will not have any feeling or movement in your arm whan you wake from the anaesthetic, and this can last several hours. When you begin to feel the sensation returning (often a ‘pins and needles’ feeling) you should start taking the pain medication that you have been givn. It is recommended that you take pain medication before full sensation returns. Use medication regularly to begin with, to keep the pain under control. If you require further medication, please visit your General Practitioner (GP). You should take great care of your arm whilst it is numb. You could injure it without being able to feel it. Keep your arm away from sources of heat and cold and keep it in the sling to help keep it safe and close to your side.

Do I need to wear a sling?

The sling is for comfort only. You can take it on and off as you wish. When the nerve block has worn off, you do not need to have your arm strapped to your body. Normally the sling is discarded after a few days. You may find it helpful to wear the sling at night (with or without the body strap) for the first few nights, particularly if you tend to lie on your side. Alternatively you can rest your arm on pillows placed in front of you. If you are lying on your back to sleep you may find placing a thin pillow or small rolled towel under your upper arm will be comfortable.

Do I need to do exercises?

Yes! You will be shown exercises by your physiotherapist and you will need to continue with the exercises once you go home. They aim to stop your shoulder getting stiff and to strengthen the muscles around your shoulder. The early exercises are shown inthe physiotherapy section.

What do I do about the wounds?

You may have two or three very small wounds around the shoulder which are approximately 5mm in length. Thes small incisions allowed the surgeon to use a special camera and other small instruments during the operation. Normally, a single stitch is used to help the would heal. You should keep the wounds clean and dry until they are healed. Typically the stitches are removed at 10 days by the nurse at your G.P. surgery. You will need to make an appointment at the surgery to have this done. You can wash or shower but avoid letting the shower head spray directly onto the wound.  Avoid using spray deodorant, talcum powder or perfumes near or on the wounds until they are healed.

When do I return to hospital?

A follow up appointment will be made with your physiotherapist within 2 weeks of your surgery to check on progress. Please discuss any queries or worries you may have when you are at the clinic. Arrangements can be made by the physiotherapist for you to be reviewed in Mr Hughes’ clinic if you have any significant problems.

Are there things that I should avoid?

There are no restrictions (other than the pain) to movement in any direction. Do not be frightened to start moving your arm. Gradually the movements will become less painful.

Avoid heavy lifting for 1 week. In general, avoid lifting anything heavier than a kettle half full of water.

Be aware that activities at or above shoulder height stress the area that has been operated on. Do not do these activities unnecessarily. Try and keep your arm out of positions which increase the pain. Its important that you give your shoulder 2 weeks of appropriate rest.

 How am I likely to progress?

The discomfort from the operation will gradually lessen over the first few should be able to move your arm comfortably below shoulder height by 2-4 weeks and above shoulder height by 6 weeks. Frequently when AC Joint excision is added to a sub-acromial decompression the recovery is slower. Patients frequently are still quite symptomatic 6 weeks post operation though most symptoms regularly settle by 3 months. Normally the operation is done to relieve pain from your shoulder and this usually happens within 6 months (for 80%-90% of people according to the research). However, there may be improvements for up to 1 year.

© Peter James Hughes 2015