Shoulder Surgery

Arthroscopic AC Joint Resection

Arthroscopic AC Joint Excision

Arthroscopic AC Joint excision is a minimally invasive keyhole procedure to treat AC Joint arthritis. It is often done as a part of other keyhole procedures in the shoulder, such as a subacromial decompression and acromioplasty, biceps tenodesis and a rotator cuff repair.

After an isolated arthroscopic ACJ excision a sling is worn for 1-2 weeks; and JPL therapy commenced two weeks after surgery. Strengthening is allowed at 6 weeks; and full unrestricted activity is possible at 6-12 weeks after surgery. This pathway may vary if other procedures are carried out at the same time.

Arthroscopy is a procedure where keyhole incisions are used to insert surgical instruments into a joint. In this case the shoulder joint, subacromial space, and finally the acromioclavicular joint are all accessed and visualised. 

A metallic burr is then used to “excise” (or remove) the arthritic end of the collarbone (distal clavicle excision).

Xray image showing AC Joint Arthritis in preparation for Arthroscopic AC Joint Resection

Xray image showing Athroscopic AC Joint resection

The main goal of an Arthroscopic ACJ excision is to treat the ACJ arthritis by removing bone from the distal clavicle (outside part of the collarbone) and medial (inside part) acromion. To access the AC Joint, however, it is necessary to first do a subacromial decompression and acromioplasty. 

So in all cases of Arthroscopic  ACJ excision, this is combined with a subacromial decompression and acromioplasty. It is important to also pre-surgery to identify if biceps tendonitis or a rotator cuff tear is present as they are frequently associated and can be treated arthroscopically at the same time.

  • The procedure is performed under a General Anaesthetic where you will be positioned on your side and the affected arm secured in a special arm holder. 
  • Small key-hole incisions (about 0.5-1cm) are made and the camera and surgical instruments are placed inside the shoulder. Usually, 3 small incisions are enough to carefully take out the bone spurs, bursa and AC Joint
  • A thorough 15-point examination of the shoulder joint is made via the arthroscopic camera and pictures are taken to document findings. 

Bone spur and bursa

The area above the tendon and any bursitis is shaved away carefully and the bone spur is identified. A special 5.5mm metallic burr is then used to shave away the spur and create more room to allow the tendon to move freely. 

AC Joint excision

  • Having cleared out the subacromial space and bone spur, the AC Joint is identified; then about 6mm of bone from the end of the collarbone and 2mm of bone from the end of the acromion (roof of the shoulder) is removed with a metallic burr (all keyhole). 
  • All of the wounds are then closed and dressings applied. Your arm will be placed in a sling.
  • Dr Pant will then organise close follow up at regular intervals and liaise with your Physiotherapist to maximise your recovery. 
  • Generally, a sling is worn for a few weeks and JPL rehabilitation is commenced immediately. 

Medical diagram showing the Arthroscopic burr used to remove the end of the collar bone during AC Joint resection

 

There are three essential components to a good outcome from your surgery:

  • Your surgeon
  • You as a patient
  • Your physiotherapist

Post-operative physiotherapy

Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery; it will be modified to suit your individual circumstance.

The JPL pathway allows for self-directed, early passive shoulder range of movement: 

  • Passive = assisted with your other arm
  • Active = you move the affected arm independently

Therapy overview 

After the surgery you will be in a sling and protect your shoulder to allow the shoulder to heal. At two weeks after the surgery Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery.

The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the shoulder begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Shoulder strengthening is commenced at 6 weeks post isolated AC Joint Excision surgery. 

Sling

  • A sling is required for the first 2-6 weeks after your surgery
  • In some instances you may only need a sling for 1-2 weeks – Dr Pant will discuss if this applies to you.

The type of sling is selected specific to you and your shoulder surgery. 

Subacromial Decompression +/- Biceps tenotomy/tenodesis +/- AC Joint Resection

  • Normal sling

Driving after shoulder surgery

  • After shoulder surgery you will be in a sling and you may be unable to drive
  • This does vary depending on the complexity of your surgery and the patient. Some patients may be able to drive at 1-2 weeks; and some may not be able to drive for the full 6-12 weeks. This will be discussed at your follow up appointments.

Showering and getting dressed

  • You may take the sling off to shower
  • Lean forward and allow your arm to “dangle” to wash under your arms
  • The dressings applied are waterproof and you may shower with them on
  • Usually before you are discharged from Hospital, your dressings are changed after your morning shower.
  • These “new” dressings are then kept intact until your review at 10-14 days
  • If the dressings start to peel at the edges – you may reinforce them
  • If the dressings discolour with discharge (yellow or green) you may have a wound infection; do not be alarmed just yet – please notify SSU (02 9215 6100 or admin@drpant.com.au) and we will give you a plan.
  • When getting dressed, you may use your good arm to move your affected (operated arm) to place your arms through the sleeves carefully

Sleeping after Shoulder Surgery

  • Most patients find it difficult to lie flat after shoulder surgery (especially after rotator cuff repair)
  • Consider using a few pillows to prop yourself up and sleep at a slight incline; this may be necessary for 4-6 weeks after surgery. If you have had an isolated ACJ excision and subacromial decompression, you may take your sling off to sleep. 

Elbow and hand movement

  • Keep your elbow and hands joints moving and supple for the duration of time you are in the sling
  • The best time to move your elbow (into full extension and flexion) is when you are in the shower, just out of the shower and about to get dressed.

Surgery is a carefully choreographed process and you are being treated by a sub-specialist shoulder surgeon and a highly experienced team; however, all surgeries inherently carry some risk of complications. 

The risk of complications after clavicle fracture surgery is less than 1% in the Sydney Shoulder Unit experience. General risks include:

  • Infection
  • Bleeding
  • Wound healing problems
  • Damage to blood vessels or nerves
  • Sensory changes around the surgical scar

Specific risks relating to Arthroscopic ACJ excision surgery: 

  • Recurrence of AC Joint arthritis over time
  • Neurovascular injury during surgery
  • Frozen shoulder (5% risk)

Patients who smoke, use tobacco products, have diabetes, or are elderly are at higher risk of complications both during and after surgery. They are also more likely to have problems with wound and bone healing. Most healthy patients, however, cope well with keyhole shoulder surgery and are unlikely to have complications. 

Patient results

AC Joint Arthritis

This 48 year old gentleman presented with pain over the top of his shoulder over many months. A diagnosis of AC Joint arthritis was made and he responded well to an ultrasound guided cortisone injection initially. However, that wore off over a few months and he was unable to sleep on the affected shoulder and very keen to get back to his active lifestyle, so he elected to proceed with surgery.

He underwent an Arthroscopic Acromioclavicular Joint (ACJ) excision via 3 small keyhole incisions. His procedure was routine, he stayed overnight in hospital, and was discharged home the following morning with oral painkillers.

He commenced immediate range of motion and discarded his sling between 1 -2 weeks after surgery. At three months, he is back to the gym and kayaking and is happy with his outcome; his keyhole incisions were only barely visible at the 3 month follow up.

Arthroscopic AC Joint excision is a very successful operation when non-surgical measures have been exhausted.

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