Distal Clavicle Excision (Mumford Procedure)

Distal Clavicle Excision (DCE), commonly known as the Mumford procedure, is a surgical treatment used to address pain and dysfunction caused by acromioclavicular (AC) joint osteoarthritis. Initially described by Mumford and Gurd in 1941 as an open surgical technique, DCE has since evolved with the advancement of arthroscopic techniques, which are now commonly preferred for their reduced invasiveness and quicker recovery.

What Is AC Joint Osteoarthritis?

The acromioclavicular (AC) joint is the small joint where the clavicle (collarbone) meets the acromion (part of the scapula). Over time or due to repetitive stress—particularly in weightlifters, athletes, and elderly individuals—the cartilage in this joint can wear down, resulting in osteoarthritis. Symptoms include pain during overhead activities, tenderness over the joint, and limited shoulder motion.

Initial Management

Conservative treatment is typically the first approach and includes:

• Anti-inflammatory medications
• Physical therapy
• Activity modification
• Corticosteroid injections

If these fail to provide relief, DCE becomes a surgical option.

Surgical Approaches

Open DCE

The traditional Mumford procedure involves an open surgical approach, where a segment (1.5 to 2.0 cm) of the distal clavicle is removed. While this offers excellent visualization, it may result in:

• Cosmetic concerns (larger scars)
• Postoperative pain or stiffness
• Deltoid or ligament injury risks

Despite these risks, many surgeons still opt for open techniques, especially in complex cases.

Arthroscopic DCE

Arthroscopic techniques have grown in popularity due to:

• Smaller incisions
• Faster recovery
• Lower complication rates

However, these procedures can be technically challenging. One main issue is the lack of depth perception and spatial reference, which can result in under- or over-resection of the bone. These complications can lead to persistent pain or joint instability.

The Fluoroscopic K-Wire Technique

This modern variation of the arthroscopic Mumford procedure utilizes a fluoroscopic Kirschner wire (K-wire) as a visual and mechanical guide to ensure accurate resection of the distal clavicle. Here’s how it works:

Preoperative Preparation

• The patient is placed in a beach chair position, with careful padding and spinal alignment.
• MRI is used preoperatively to assess soft tissue and ligament integrity

Subacromial Decompression

• Through standard arthroscopic portals, surgeons access the subacromial space.
• A combination of a shaver and electrocautery is used to remove bursal tissue and resect ~4 mm of acromion bone to improve visualization.

K-Wire Placement

• A spinal needle is inserted vertically into the AC joint to act as a landmark.
• A 1.5-mm K-wire is then placed 7 mm medially from the needle using a wire guide
• Radiographs confirm the correct trajectory and placement

Clavicle Resection

• A 5-mm burr is used to resect the distal clavicle until the tip of the K-wire is reached, acting as a visual stop to prevent over-resection
• Resection continues vertically along the K-wire for even removal .
• Once the resection is complete, the wire is removed, and the clavicle is smoothed using arthroscopic tools

Postoperative Imaging and Recovery

• Final fluoroscopy confirms a smooth, vertical resection plane and intact ligaments
• The patient is placed in an abduction sling for 1 week.
• Physical therapy begins after the first week.

Advantages of the K-Wire Technique

Advantages	Disadvantages
Ensures accurate bone removal	Requires subacromial decompression
Reduces risk of over-resection	Radiation exposure from fluoroscopy
Preserves AC ligaments	Potential risk of iatrogenic injury from wire placement

The main benefit is improved accuracy, especially for less experienced surgeons. This method helps bridge the gap between open and arthroscopic methods while preserving the advantages of both.

Pearls and Pitfalls

Pearls	Pitfalls
Use early needle localization for accurate portal placement	K-wire may dislodge if not placed through both cortices
Confirm K-wire with multiple imaging angles	Inaccurate portal placement increases trauma risk
Use the K-wire as a clear visual end-point	Avoid placing K-wire beyond inferior clavicle border

 

Conclusion

The Distal Clavicle Excision, or Mumford procedure, remains a time-tested solution for persistent AC joint osteoarthritis. Whether performed through an open or arthroscopic approach, outcomes largely depend on precise surgical technique. The fluoroscopic K-wire–guided arthroscopic method provides a safe, reliable, and repeatable solution that minimizes resection errors and preserves essential ligament structures.

For patients with persistent AC joint pain unresponsive to conservative treatment, the Mumford procedure—particularly when done arthroscopically using modern guidance techniques—offers high success rates and rapid recovery, restoring function and quality of life.

 

Do you have more questions?

Q. What is a distal clavicle excision (Mumford procedure)?
A. It is a surgical procedure that involves removing the end portion of the clavicle (collarbone) to relieve pain and improve shoulder function, typically due to arthritis or impingement at the acromioclavicular (AC) joint.

Q. Why is the Mumford procedure performed?
A. It is performed to treat persistent shoulder pain caused by arthritis or injury at the AC joint when non-surgical treatments have failed.

Q. What causes the pain treated by distal clavicle excision?
A. The pain is usually caused by arthritis, osteolysis, or trauma leading to degeneration or instability of the AC joint.

Q. What are the symptoms of AC joint arthritis?
A. Symptoms include pain at the top of the shoulder, especially during overhead activity, weightlifting, or sleeping on the affected side.

Q. How is the diagnosis of AC joint arthritis made?
A. Diagnosis is based on physical examination, patient history, and imaging such as X-rays or MRI scans.

Q. What are the treatment options before surgery?
A. Non-surgical treatments include rest, ice, anti-inflammatory medications, corticosteroid injections, and physical therapy.

Q. When is surgery recommended for AC joint issues?
A. Surgery is recommended when conservative treatments fail to relieve symptoms and pain significantly affects daily life.

Q. What happens during a distal clavicle excision?
A. The surgeon removes 5 to 10 mm of the distal end of the clavicle to eliminate contact between the bones at the AC joint.

Q. Can the procedure be done arthroscopically?
A. Yes, the surgery can be performed arthroscopically using small incisions and a camera for guidance.

Q. What are the advantages of arthroscopic Mumford procedure?
A. Advantages include less postoperative pain, smaller incisions, faster recovery, and less tissue damage.

Q. How long does the surgery take?
A. The procedure typically takes less than an hour to perform.

Q. What type of anesthesia is used?
A. The procedure is usually performed under general anesthesia or regional nerve block.

Q. What is the expected recovery time?
A. Recovery generally takes a few weeks to a few months depending on individual factors and rehabilitation progress.

Q. What is the rehabilitation process like?
A. Rehabilitation includes a brief period of rest followed by physical therapy focusing on restoring range of motion and strength.

Q. When can patients return to work or sports?
A. Most patients return to desk jobs within a few days and sports or heavy labor within a few months, depending on their healing progress.

Q. Are there any risks associated with the procedure?
A. Risks include infection, stiffness, continued pain, and damage to surrounding tissues, although complications are rare.

Q. What is the success rate of the Mumford procedure?
A. The procedure has a high success rate with most patients experiencing significant pain relief and return to function.