AC Joint Surgery: Post-Operative Problems, Rehabilitation, and Long-Term Considerations

What are the problems after AC joint surgery?

While AC joint surgery can effectively restore stability and alleviate pain, patients may encounter various post-operative challenges, ranging from common complications like pain and stiffness to more severe issues such as infection, hardware failure, or persistent instability, necessitating diligent rehabilitation and close medical follow-up.

Understanding AC Joint Surgery

The acromioclavicular (AC) joint, located at the top of the shoulder where the collarbone (clavicle) meets the shoulder blade (scapula's acromion), is crucial for shoulder mobility and stability. Injuries to this joint, often due to falls or direct impact, range from mild sprains (Type I-II) to severe dislocations (Type III-VI). While conservative management is often effective for lower-grade injuries, higher-grade separations or persistent symptoms may necessitate surgical intervention to reconstruct or stabilize the joint. Despite its benefits, surgery is not without potential problems, which can impact recovery and long-term outcomes.

Common Post-Surgical Complications

Patients undergoing AC joint surgery should be aware of a range of potential issues that can arise during the recovery period.

• Persistent or Worsening Pain: While surgery aims to reduce pain, some individuals may experience ongoing discomfort, either from the surgical site, nerve irritation, or compensatory issues in surrounding musculature. New onset of severe pain could indicate infection or other complications.
• Stiffness and Loss of Range of Motion (ROM): Post-operative immobilization and scar tissue formation can lead to significant shoulder stiffness. Adherence to a structured rehabilitation program is critical to restore full ROM, but some individuals may experience lingering limitations.
• Infection: As with any surgical procedure, there is a risk of infection at the incision site or deeper within the joint. Symptoms include redness, swelling, warmth, pus drainage, and fever, requiring prompt medical attention and often antibiotic treatment.
• Hardware-Related Issues: Many AC joint repair techniques involve the use of internal fixation devices (e.g., screws, plates, wires, synthetic ligaments). These can sometimes cause problems:
  • Hardware prominence: The hardware may become palpable or irritate surrounding soft tissues, causing pain or discomfort.
  • Hardware migration or loosening: The devices can shift from their intended position, leading to loss of fixation or damage to adjacent structures.
  • Hardware breakage: Particularly with long-term stress, fixation devices can fracture.
  • Need for hardware removal: Due to the above issues, a second surgery may be required to remove the hardware.
• Non-Union or Mal-Union: In cases where the surgery involves bone healing (e.g., coracoclavicular ligament reconstruction or distal clavicle resection), the bones may fail to heal properly (non-union) or heal in an incorrect position (mal-union), leading to ongoing pain and instability.
• Osteolysis of the Distal Clavicle: Especially after distal clavicle excision (Mumford procedure), a rare complication known as osteolysis can occur, where the bone at the end of the clavicle begins to resorb, leading to pain and weakness.
• Nerve Damage: Although rare, nerves surrounding the shoulder, such as the supraclavicular or axillary nerves, can be irritated or damaged during surgery, leading to numbness, tingling, or weakness in specific areas.
• Deltoid and Trapezius Weakness or Atrophy: These muscles are critical for shoulder function and are often affected by AC joint injuries and surgery. Post-operative pain, disuse, and potential surgical trauma can lead to weakness or atrophy, requiring targeted rehabilitation.
• Re-injury or Recurrence of Instability: Despite surgical repair, there is a risk of re-injury, especially with a return to high-impact activities. The reconstructed ligaments or repaired joint may fail, leading to recurrent instability or dislocation.
• Cosmetic Concerns: Surgical incisions can result in visible scarring, which may be a concern for some patients.

Rehabilitation Challenges

The post-surgical rehabilitation phase is critical but can present its own set of problems.

• Adherence to Protocol: Strict adherence to the prescribed physical therapy protocol is essential. Deviating from the plan, either by doing too much too soon or not enough, can hinder recovery or lead to complications.
• Pacing of Progress: Recovery is not always linear. Patients may experience plateaus or setbacks, which can be frustrating. Understanding the gradual nature of tissue healing and strength restoration is important.
• Psychological Impact: The prolonged recovery period, persistent pain, and limitations in daily activities can lead to frustration, anxiety, or even depression. Maintaining a positive outlook and seeking support are vital.

Long-Term Considerations

Even after initial recovery, some long-term issues may arise.

• Post-Traumatic Arthritis: The AC joint, like any joint, can develop arthritis over time, particularly if there was significant cartilage damage or if the joint alignment is not perfectly restored. This can lead to chronic pain and stiffness.
• Chronic Pain: Some individuals may experience chronic pain even without clear evidence of pathology, which can significantly impact quality of life.
• Return to Sport/Activity: Achieving a full return to pre-injury levels of sport or activity, especially those involving overhead movements or contact, can be challenging and may not always be fully realized.

When to Seek Medical Attention

It is crucial for patients to be vigilant for signs of complications and to communicate promptly with their healthcare team if they experience any of the following:

• Increased or uncontrolled pain not relieved by medication.
• Signs of infection: fever, chills, redness, warmth, swelling, or pus drainage from the incision site.
• Numbness, tingling, or weakness in the arm or hand.
• Significant swelling or bruising that worsens.
• Sudden loss of the ability to move the arm or shoulder.
• Audible "pop" or "snap" followed by severe pain or instability.

Conclusion

AC joint surgery can be a highly effective treatment for severe AC joint injuries, offering significant improvements in stability and pain reduction. However, a comprehensive understanding of potential post-operative problems is paramount for both patients and healthcare providers. Proactive engagement in a structured rehabilitation program, diligent monitoring for complications, and open communication with the surgical and physical therapy teams are key to optimizing recovery and achieving the best possible long-term outcomes. While challenges may arise, careful management can help navigate these issues and facilitate a successful return to function.