Coracoclavicular ligament reconstruction

ACJ stabilisation
Summary

This operation is performed for symptoms following an acromioclavicular joint (ACJ) dislocation.  The coracoclavicular ligaments hold the clavicle onto the coracoid process of the shoulder blade.  Trauma can cause the ligaments to rupture leading to ACJ dislocation.  Most patients will develop a noticeable lump at the end of the clavicle.  However, symptoms of pain and weakness vary significantly.  If the dislocation is substantial or symptoms persist despite a period of rest then a coracoclavicular ligament reconstruction is considered.  This involves wrapping a synthetic ligament around the coracoid and attaching it to the clavicle.

Factors to Consider

You have been diagnosed with an acromioclavicular joint (ACJ) injury/dislocation.  The majority of patients will experience pain for the first few months following this injury before it settles to an acceptable level.  The clavicle will be more prominent to look at but surgery should only be considered for ongoing symptoms of pain or weakness.  The coracoclavicular ligaments that have ruptured will not repair on their own and so, if symptoms persist, a reconstruction using a synthetic ligament is required.  The operation is the same straight after the injury or many months later and so it is usually a good idea to wait and see if symptoms settle before considering surgery.

What are the risks?

All operations involve an element of risk.  The risks for this particular operation are small but it is important that you are aware of them.

The risk of infection is very small and is thought to be about 0.5%.  Most infections will settle simply with antibiotics.

Damage to nerves and blood vessels around the shoulder can occur but this is rare.

The reconstruction can loosen causing the clavicle to become more prominent.  Symptoms may not worsen despite this though.  The bone around the clavicle or coracoid where the synthetic ligament is secured can fracture but this is rare.

Symptoms of pain and weakness can persist sometime despite the appearances of a successful operation.  This may be due to a different condition in the shoulder or relate to the original injury.

Description of Surgery

The operation can usually be performed as a daycase procedure but you will need to ensure that there is someone to drop you off and pick you up from the hospital.  You will also need to have a responsible adult at home with you on the night of the operation.

A 10cm incision is made over the top of your shoulder, known as a “bra-strap” incision.  A small amount of the end of the clavicle is cut off and the ACJ is reduced.  A synthetic ligament is passed around the coracoid and then secured to the clavicle.  The operation usually takes about 60 minutes.

Anaesthetic

The operation is performed under a general anaesthetic and so you will be given instructions as to when you need to stop eating and drinking (normally the night before) before you come into hospital.  

It is common for you to be offered a nerve block to help with the pain.  The nerve block allows excellent pain relief immediately after the operation.  It is considered a safe method of providing pain relief with few complications (less than 1%).  You will wake up with a numb arm, similar to when you sleep on your arm awkwardly.  The block wears off within 12-24 hours and so it is important to take pain killers the night after the surgery even if you don’t have pain when you go to sleep.The anaesthetist will talk more about the nerve block when they see you.  If you do not want a nerve block your pain can be well controlled with local anaesthetic given during the operation.

After Surgery

After surgery

Pain

Local anaesthetic or a nerve block will be used during the operation and so you will feel comfortable when you first wake up.  The nerve block can make your whole arm feel numb.  This can last up to 12 hours but the shoulder may be sore after it wears off.  You will be given a combination of pain killers to go home with.  It is important that you take regular pain relief so that you can start moving your arm early.  

You may also be given an icepack.  The nurses will show you how to place the icepack on your shoulder.  The icepack should be taken off after 15 minutes  and can be used every 2 hours.

Sling

You will wake up with your arm in a sling.  The arm should be comfortable but it is important to let the nurses know if you have pain so that further pain killers can be given.  The sling is for comfort only and so you can take it on and off as you wish.  Most patients stop using the sling after a few weeks.  You don’t need to wear the sling to sleep.

Dressings

The wound is closed using dissolvable stitches.  There will be dressings applied to the wound following your operation.  These can occasionally come off and will need to be replaced during the first 2 weeks after surgery to protect the wound.  

The dressings are splash proof but not waterproof and so you should avoid getting them wet.

The stitches do not need to be removed but there may be loops at each end of the wound that can be trimmed.  The nurses will arrange this to be done at your local GP practice before you are discharged.

Physiotherapy

Physiotherapy is important to ensure that your shoulder fully recovers.  It is important to avoid heavy lifting for 3 months following surgery to allow the synthetic ligament to heal fully.

The physiotherapist should see you before the operation to explain some simple exercises you can do after the operation.  They will also ensure a physiotherapy appointment is made for you within 3 weeks of the operation.  Physiotherapy can be arranged local to you.  

Driving

You can drive when you feel you are safe to drive.  This means that you feel confident that you have full control of your car and are able to swerve out of the way of something in the road.  This will vary between patients but normally takes 3-6 weeks.  

Return to work

This depends on what your job is.  You should be able to return to a “desk job” within a few weeks of your surgery.  If you have a more manual job it can take up to 12 weeks before you feel ready to return to work.  Please discuss this further with your surgeon or physiotherapist if you feel unsure.  A sick note can be given to you at the time of your surgery if required.  Please ask the nurses on the ward if you need one.

What to expect

Recovery following surgery can be quite variable.  Most people will feel the first 4 weeks are quite uncomfortable.  Movement below shoulder height should become more comfortable during these 4 weeks.  Your symptoms should be improved/improving by 3 months with the majority fully recovered by 6 months.  It can, however, take up to a year for some patients to fully improve.