Acromio-clavicular joint reconstruction

This leaflet will advise you on having an acromioclavicular joint reconstruction and outline the recovery of your shoulder following surgery 

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Why do I need this operation? 

The acromioclavicular joint (ACJ) is the joint between the collar bone and part of the shoulder blade called the acromion. This joint can be disrupted (partially or fully dislocated) during a heavy fall onto the shoulder or a direct blow. The ligaments between the collar bone and clavicle are ruptured during this making the collarbone unstable and painful. 

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The operation 

The aim of the operation is to stabilise the end of the collarbone in relationship to the shoulder balde which should make the ACJ pain free and restore function to the shoulder and arm. If the operation is done with a few weeks of the injury the operation it may be that the ACJ can be stabilised with strong sutures and small metal buttons in a special configuration. This will allow the native ligaments to heal. If the instability has been present for a long period the native ligament will need to be replaced by either an artificial ligament or another native ligament which can be transferred from a different part of the shoulder (a modified Weaver-Dunn procedure). The end of the clavicle is removed to prevent further pain from the connection between the collarbone and the shoulderblade which is often arthritic at this point. The operation may be keyhole or through a small incision over the top of the shoulder and may be combined with another procedure if there is a co-existing problem (e.g. tendon or ligament injury in the shoulder joint). 

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Potential complications 

Even when an operation goes well and achieves what it meant to do, there are a small proportion of patients (about 5%) who do not improve following surgery. Unfortunately any operation has a chance of having a complication. Fortunately the chance of having a complication is small (<5%) and having a significant complication that will have a negative effect on the outcome of surgery is even smaller (<1%). The following are specific complications associated with an ACJ reconstruction: 

Ligament stretch or failure this is probably the most common complication with this procedure. Even with an excellent surgical repair the ligament may not keep the collarbone perfectly re-aligned with the acromion. However if the ligament does fail, patients typically retain the benefits of improved function and pain and rarely need further surgery. 

Palpable knots/metalwork as the top of the clavicle sits just underneath the skin it may be that the implants used to perform the repair become palpable once the swelling from the injury/surgery has dissipated. These may cause irritation - especially when carrying a strap over the shoulder. If this becomes a persistent problem then a small procedure may be done to remove part of the implant usually under local anaesthetic. 

Infection superficial wound infections are more common and can often be treated with a short course of antibiotics. Deep infections within the joint are rare but would require you to come into hospital to have the shoulder washed out and go on intravenous antibiotics 

Nerve injury this is unlikely to occur as the operative field is well away from the known position of nerves. Sometimes nerves can get compressed or squashed during surgery which will present will numbness and weakness but this is likely to resolve within a few days. A complete nerve injury is likely to lead to a permanent disability. 

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The shoulder after ACJ reconstruction 

Hospital stay: Normally done as a day case 

Arm immobilisation: Sling for 4 weeks 

Total recovery period: up to 6 months 

Return to driving: 4 to 6 weeks 

Return to work: Desk based job - 1 to 3 weeks Manual job - 3 months 

Return to sports: Non-contact from 3 months Contact/overhead from 6 months

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Reverse Shoulder Replacement

This leaflet will advise you on undergoing a reverse shoulder replacement and outline the recovery of your shoulder following the surgery. 

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The shoulder 

Your shoulder is a ball-and-socket joint made up from the head of your upper arm bone (humerus) and shoulder socket (glenoid) which is part of the shoulder blade (scapula). Your shoulder has developed a special form of arthritis because the tendons (rotator cuff) that normally controlled the ball have worn out this is causing pain and loss of movement. Most commonly cause for this is genetic (i.e. some people are prone to developing this form of arthritis than others and it may be their parents suffered from the same condition), but it may be you have had a previous injury or surgery to the shoulder (such as a normal shoulder replacement). A reverse shoulder replacement will give you the best chance of having a pain-free functional shoulder. Once fully recovered you should expect to a better range of movement than before surgery. 

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The concept of the reverse shoulder replacement 

It may be that your shoulder no longer has enough rotator cuff tendons working to put in a conventional "anatomical" shoulder replacement. The problem of the tendon deficiency is bypassed by inserting a reverse shoulder replacement. There are other reasons for performing a reverse shoulder replacement including distorted anatomy possibly from a previous fracture. 

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The operation 

The aim of the operation is to replace the diseased joint surfaces with artificial prostheses. The top of the humerus (the ball part of the joint) is replaced with a socket made from plastic and metal. The side of the scapula (the socket part of the joint) is replaced with a metal half sphere. The operation will be typically done through a vertical incision over the front of the shoulder. 

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Potential complications 

Unfortunately any operation has a chance of having a complication. Fortunately the chance of having a complication is small (<5%) and having a significant complication that will have a negative effect on the outcome of surgery is even smaller (<1%). The following are specific complications associated undergoing a shoulder replacement: 

    Infection superficial wound infections can often be treated with a short course of antibiotics but ideally we would like you to contact the surgical team prior to your GP starting any medication. Deep infections within the joint are rare but would require you to come into hospital to have the shoulder washed out and go on intravenous antibiotics. The worst case scenario is that the replacement has to be removed and a new one put in which is sometimes done in two stages about 3 months apart 

Dislocation during the operation the surgeon will assess the tension of the soft tissue to make sure the replacement is positioned to give it maximal stability. This will not stop it dislocating especially if you fall onto the shoulder. Often the shoulder can be relocated with a manipulation under sedation or a short anaesthetic. If the shoulder continues to dislocate you may need a revision operation. 

Fracture occasionally, when the prosthetic components are being inserted the bone can fracture. Usually this is not a major problem and the surgeon can fix the fracture during the operation. It may be that your rehabilitation is slowed down. 

Stiffness some of your rehabilitation involves resolving the stiffness created by surgery and getting back a good range of movement - after 3 months you should have a good functional range of movement and optimal movement will take between 9 months and 1 year. 

Nerve injury the surgeon has to work close to the main nerves going to the arm during the surgery. Sometimes nerves can get compressed or squashed during surgery which will present will numbness and weakness but this is likely to resolve within a few days. Permanent nerve injury is exceptionally rare but would lead to significant disability. 

Loosening the prosthesis will be embedded solidly in the bone following surgery but after many years of use the components can become worn and loose. At this point the shoulder may start to become painful and loose range of movement. Normally this does not happen until after ten years, if it happens earlier there many another problem with the replacement. 

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The shoulder joint after surgery 

 Length of hospital stay: Normally 1 to 2 days 

Arm immobilisation: 4 weeks in sling or brace (see image) 

Total recovery period: 9 to 12 months 

Return to driving: 6 to 8 weeks 

Return to work: Desk based job - 4 to 6 weeks Manual job - 4 months 

Return to sports: Non-contact from 6 months Contact/overhead from 9 months 

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