ACJ Stabilisation Protocol

Waking up
Most patients feel dizzy and tired for a few hours after the surgery. You can simply sleep it off. Some patients may feel nausea and even experience some vomiting as well, but with modern anaesthesia, this is very much less common, and should not last more than 2-3 hours.

Pain
Pain from ACJ stabilisation is generally tolerable. Many patients, in fact, feel that pain is improved from pre-surgery because they do not feel like the arm is being dragged down by gravity anymore.

If pain is bothersome, it can be controlled with a combination of medications and/or a nerve block administered while the patient is still under anaesthesia (see section on Anaesthesia and Sedation to learn more). Nurses and the anaesthetist is always on hand to help ensure you are not in too much discomfort.
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Wounds and dressings
There will be a bulky dressing over the shoulder which can be removed either on the same day (at night) or the next morning. You will find small waterproof dressings (the size of 2 band-aids placed side by side) underneath the bulky dressing. You can take a shower, but please do not take baths or soak in water until the wounds are well healed.

Stitches
Stitches used may or may not need removal after 12-14 days. This is on a case-by-case basis. But if required, this can be quickly and easily done at ours or any doctor’s office.

Going home and medications
Most patients go home from hospital either later on the same day of the surgery, or the next morning. You will be discharged with pain medications, which many patients may not even take! But if you have pain, do not be worried about taking pain medications.

The pain medications prescribed are simple, non-addictive ones which will not cause problems in the future. Antibiotics are not usually required, unless there are some concerns with regards to increased infection risks like a eczema over the skin, pimples around the area, previous tendency to get infections etc.

Arm sling
Most patients will wear a simple sling for 3 – 6 weeks. You may remove the sling and rest the arm at your side, as long as your arm is supported. While you are either standing or sitting, I advise that patients wear the arm slings all the time. It is also prudent to to sleep with while wearing the arm sling for the first couple of weeks.

Movements
In the immediate few weeks after the surgery, simply allow the shoulder to rest. Avoid trying to raise your arm as much as possible. If it is comfortable, you can do simple pendular movements of the shoulder (bending over slightly while keeping the arm completely relaxed and limp then making small circular movements with the arm), but after doing the pendular movements, place put the arm back in the arm sling.
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Initial follow up schedule
For a typical patient, the timeline is usually:

• Return home either on same day of surgery or the next morning
• Review in clinic on post-operative day (POD) 5 for first dressing change (this is advised because the hot and humid weather in Singapore often makes the skin under the dressing irritated)
• Review in clinic on POD 12 – 14 for removal of stitches and dressing. A water-resistant spray will be applied so you can shower over the healed wound without needing anymore dressings.
• Physiotherapy can commence at any time. If patients have more discomfort in the surrounding muscles, they can often get some relief with physiotherapy. But if they would rather allow wounds to heal and give the shoulder some time to settle down before commencing physiotherapy, it is also reasonable. I usually start patients on physiotherapy about 2 weeks after the surgery.

All patients will have stiffness in their shoulder after surgery. This is temporary, although it may take 3 – 6 months to regain full movements in the shoulder.

The post-operative protocol below is meant as a guide and is deliberately concise so that patients will not be swamped with excessive details.Please also note that I may vary the timings of the protocol on a case by case basis.
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Week 0 – 1: (Goal: Pain control, healing of wounds)

• Arm sling is advised. If you would like to remove the sling for a while, you can do so, but please support the arm on either an arm rest or a pillow.
• Ensure that you frequently flex and extend your elbow, wrist and fingers to avoid swelling of the extremity.
• Periodic icing of the shoulder will also help to reduce swelling and soreness.
• You can do gentle pendular movements of the shoulder if you like, but please support the arm in a sling or using a pillow once you have finished with the pendular exercise.

Week 1 – 6: (Goal: Regain passive and active range of movement [ROM])

• Commence passive and gentle active assisted ROM. Passive ROM refers to movement of the shoulder with help of your other arm or a physiotherapist, while using little to no strength from the operated shoulder. Active assisted ROM refers to moving the shoulder with assistance, but also using some strength from the operated shoulder.
• Work on strength of the muscles around the shoulder eg the deltoid muscles and muscles around the scapular.
• Progressive increase in passive ROM but do not stretch or stress the shoulder.
• Wean off the arm sling around week 4 – 6.

Week 6 – 12: (Goal: Work on active and ROM)

• Work on regaining full ROM in the shoulder.
• Start gentle strength training.
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Month 3 – 6: (Goal: Achieve full active ROM and start work on strength)

• Continue to work on attaining full ROM in both passive and active ROM.
• Continue strength training of the shoulder.

Month 6 onwards: (Goal: Return to sport)

• Return to contact sports.
• Work with physiotherapist and sports trainer to address any gaps in the recovery.