डिस्टल क्लैविकल एक्सिसिशन (मम्फोर्ड प्रक्रिया)

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• In appropriately selected patients, open or arthroscopic distal clavicle resection is necessary to relieve symptoms [9].
• A well-performed distal clavicle excision will likely perform better than a poorly performed one, regardless of whether an open or arthroscopic approach is chosen [1].
• Arthroscopic and open distal clavicle excisions both provide significant pain reduction at 1 year with no significant difference in outcome measures between groups, except for VAS pain score improvement [10].
• Arthroscopic distal clavicle resection has provided more 'good or excellent' results than has the open procedure, but is comprised of low-level evidence [2].
• Among patients undergoing distal clavicle excision for acromioclavicular joint pathology, those having an arthroscopic procedure, specifically through the direct approach, can expect a faster return to activities while obtaining similar long-term outcomes compared with the open procedure [3].
• Simple excision of the outer end of the clavicle has yielded satisfactory results in patients with complete dislocation and subluxation of the acromioclavicular joint, with no residual upward displacement disturbing the patients [4].
• Excision of the outer end of the clavicle is preferred for old dislocations, while open reduction and internal fixation are not recommended due to complications and poor functional results [16].
• Incomplete excision and regrowth of the distal clavicle are the most common causes of revision [6].
• Although distal clavicle excision with 2.5 mm of bone was successful in many specimens, a 5 mm resection guaranteed no bone-to-bone abutment [11].
• The use of intraoperative ultrasound and cannulated dilators allows surgeons to perform distal clavicle excisions in a more efficient, reproducible and safer manner [7].
• Regardless of the technique chosen for distal clavicle resection, portal placement remains paramount in both facilitating surgery and avoiding injury to adjacent extra-articular structures [8].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The clavicle is the first bone to ossify, occurring in the fifth week of gestation [35].
• The clavicle is the only long bone to ossify by intramembranous ossification [35].
• The medial (sternal) epiphysis of the clavicle is the last ossification center to fuse, occurring at age 20 to 25 years [35].
• The primary blood supply to the clavicle is periosteal, and no nutrient artery is present [35].
• The scapula has only one true diarthrodial articulation, the acromioclavicular (AC) joint [35].
• The scapula is attached to the axial skeleton by the acromioclavicular (AC) and sternoclavicular (SC) joints [34].
• The scapula is separated from the chest wall by thin gliding fibro-fatty tissue, allowing smooth excursion over the chest wall [34].
• The scapular spine is an osseous ridge that separates the supraspinatus and infraspinatus fossae [35].
• The acromion has three ossification centers: the metacromion (base), the mesoacromion (middle), and the preacromion (tip) [35].
• Failure of fusion of the acromial ossification centers results in os acromiale [35].
• The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [35].
• The glenoid averages 5° of retroversion in relation to the axis of the scapular body [35].
• The coracoid process serves as the origin for the coracobrachialis muscle and the short head of the biceps tendon [35].
• The pectoralis minor muscle inserts onto the medial coracoid process [35].

Ligaments and Joint Stability¶

• The AC joint is a small diarthrodial joint with an interposed fibrocartilaginous disk [35].
• The superior and posterior AC ligaments are the primary stabilizers to anterior and posterior (horizontal) translation of the clavicle [35].
• The coracoclavicular ligaments (conoid: medial; trapezoid: lateral) are the primary stabilizers to superior (vertical) translation of the distal clavicle [35].
• The superior shoulder suspensory complex (SSSC) provides a stable connection between the scapula and the axial skeleton [35].
• The SSSC is composed of the glenoid, the coracoid process, the coracoclavicular ligaments, the distal clavicle, the AC joint, and the acromion [35].
• The superior strut of the SSSC comprises the middle clavicle [35].
• The inferior strut of the SSSC comprises the lateral scapular border and spine of the scapula [35].
• The trapezoid and conoid ligaments have unique functions in normal shoulder kinematics due to their anatomic attachments [47].
• Kinematic changes associated with AC joint dislocation can be a potential source of pain and dysfunction in the shoulder [48].
• Scapular and clavicular kinematics are affected in AC separation models [50].

Pathophysiology and Injury Patterns¶

• A type I AC injury is an isolated sprain of the AC ligaments with no clinical deformity and normal radiographs [87].
• A type II AC injury consists of a complete tear of the AC ligaments and a sprain of the CC ligaments [87].
• In a type II AC injury, the radiograph shows a more vertical translation of the CC interval (<25%) compared with that of the uninjured shoulder [87].
• The normal coracoclavicular distance measures approximately 1.1 to 1.3 cm [87].
• Injury to the AC ligaments in type II injuries causes AP instability of the AC joint, resulting in an increase of 3.6 mm in anterior and 6.4 mm in posterior translation [87].
• In most patients, the horizontal instability present in type II injuries remains asymptomatic, but long-term problems with AC joint pain are not uncommon [87].
• A type III AC injury involves dislocation secondary to complete disruption of the AC and CC ligaments [87].
• A type III AC injury creates increased vertical translation of the CC distance (25% to 100%) compared with that of the uninjured shoulder [87].
• Type I and II acromioclavicular joint disruptions impair long-term shoulder function in about half of patients 10 years after injury [63].
• Fractures of the clavicle distal to the coracoclavicular ligament have a reputation for failing to unite when treated with methods similar to other clavicle fractures, such as a figure-of-eight bandage or a Billington yoke [28].
• Distal clavicle excision (Mumford procedure) must be reserved for patients in whom the CC ligaments are intact and there is no concomitant instability [12].
• When horizontal or vertical instability exists, results of distal clavicle excision are compromised because the technique does not address instability and may accentuate it [12].

Classification¶

• Fractures of the clavicle are divided into three groups: Group I (middle third), Group II (distal to the coracoclavicular ligament), and Group III (proximal end) [28].
• Fractures of the clavicle distal to the coracoclavicular ligament are classified by Neer into two types [28].
• Multiple classifications for lateral end of clavicle fractures exist, including those of Allman, Craig, and Neer [73].
• Robinson classified clavicular injuries and defined the lateral one-fifth of the clavicle as Type 3 [73].
• The Rockwood classification defines Type I as 0% to <10% superior displacement of the distal clavicle [83].
• The Rockwood classification defines Type II as 10% to ≤25% superior displacement of the distal clavicle [83].
• The Rockwood classification defines Type III as >25% to ≤100% superior displacement of the distal clavicle [83].
• The Rockwood classification defines Type V as >100% superior displacement of the distal clavicle compared with the contralateral side [83].
• A new classification of AC joint instability defines Group 1 as a coracoclavicular distance difference (CCD) ≤30% compared with the contralateral side [83].
• A new classification of AC joint instability defines Group 2 as a coracoclavicular distance difference (CCD) >30% compared with the contralateral side [83].
• Group 1 in the new AC joint instability classification includes all Rockwood type I, type II, and borderline low-grade type III patients [83].
• Group 2 in the new AC joint instability classification represents high-grade AC joint dislocations, including all Rockwood type V patients and the majority of Rockwood type III patients [83].
• The Rockwood Type IV AC injury includes disruption of AC ligaments, disruption of coracoclavicular ligaments, and posterior translation of the clavicle [31].

Clinical Presentation¶

• Patients with displacement greater than 100% of the thickness of the distal clavicle had poorer postoperative clinical outcomes [5].
• Horizontal instability of the clavicle is evident with distal clavicle resection of greater than 10 mm [14].
• Methods to diagnose both superior and posterior translation of the clavicle need further debate [22].
• Clinical examination and surgical treatment should address anatomic restoration of individual structures to optimize the mechanical capability of the claviscapular segment [23].

Investigations¶

Imaging and Diagnostic Assessment¶

• Standardized plain films are almost always sufficient to garner the information needed for shoulder care, and the temptation to "overimage" should be resisted [19].
• The purpose of imaging the shoulder is to help establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition of the shoulder to the patient [19].
• At least two X-ray views should be obtained for shoulder imaging: an anteroposterior in the plane of the glenoid and an axillary projection with the arm in abduction [42].
• Weighted stress radiographs significantly increased the measured elevation of the clavicle and the coracoclavicular distance compared with non-weighted views [89].

Intraoperative Imaging and Technique¶

• Intraoperative use of ultrasound and cannulated dilators allows surgeons to perform distal clavicle excisions in a more efficient, reproducible, and safer manner [7].

Resection Parameters and Biomechanics¶

• A 5-mm distal clavicle resection guaranteed no abutment but decreased joint stiffness [29].

Treatment¶

Indications and Contraindications¶

• Distal clavicle excision must be reserved for patients in whom the coracoclavicular ligaments are intact and there is no concomitant instability [12].
• Clavicular resection reliably produced significant improvement in patients with persistent pain or posttraumatic arthritis [15].

Comparative Outcomes: Open vs. Arthroscopic¶

• Both the direct superior approach and the indirect subacromial approach to the arthroscopic distal clavicle resection result in successful clinical outcome with clinically insignificant difference at final follow-up [57].

Surgical Technique and Biomechanics¶

• The slight increase in the in situ graft force only in the posterosuperior and posterior direction after distal clavicle excision suggests only a marginal protective role of the acromioclavicular articulation [81].

Historical and Alternative Procedures¶

• Simple excision of the outer end of the clavicle has yielded satisfactory results in patients with complete dislocation and subluxation, with no residual upward displacement disturbing the patients [4].
• The new operative procedure described in 1972 combines resection arthroplasty with fixation of the clavicle in an anatomical position [13].

Complications¶

Resection-Related Complications¶

• Persistent pain is the most common complication of distal clavicle resection, potentially resulting from over- or under-resection [78].
• Incomplete resection can occur due to poor visualization [78].
• To prevent under-resection, the acromioclavicular joint should be viewed via an anterior and lateral portal [78].
• Overexuberant resection of the clavicle or disruption of the acromioclavicular and coracoclavicular ligamentous system can result in iatrogenic instability of the acromioclavicular joint [78].
• Posterior translation of the acromioclavicular joint is increased by 32% after a distal clavicle resection with an acromioclavicular capsular incision [78].
• Acromioclavicular joint resection alone should be cautioned in patients with prior acromioclavicular joint instability injuries, as prior capsular or ligamentous disruption may lead to greater instability after resection [78].
• In cases of prior instability, acromioclavicular resection combined with acromioclavicular ligament reconstruction may be needed [78].
• Posterior translation can be reduced to 13% if the distal clavicle resection is completed with a coracoacromial ligament augmentation procedure [78].
• Postoperative iatrogenic instability may require revision surgery or coracoclavicular ligament reconstruction [78].
• Other complications of distal clavicle resection include infection, stiffness, fracture, spontaneous fusion, and complex regional pain syndrome [78].
• A 5 mm resection guaranteed no bone-to-bone abutment in a cadaver model, whereas 2.5 mm resection was successful in many specimens [11].
• Portal placement remains paramount in facilitating surgery and avoiding injury to adjacent extra-articular structures regardless of the technique chosen for distal clavicle resection [8].

Contraindications and Selection Factors¶

• When horizontal or vertical instability exists, results are compromised because the technique does not address instability and may accentuate it [12].

Outcomes and Efficacy¶

• Arthroscopic distal clavicle resection has provided more 'good or excellent' results than the open procedure, but is comprised of low-level evidence [2].
• Patients undergoing arthroscopic distal clavicle excision through the direct approach can expect a faster return to activities while obtaining similar long-term outcomes compared with the open procedure [3].
• In carefully selected patients with isolated acromioclavicular joint pathology, arthroscopic distal clavicle excision results in statistically and clinically significant improvements in range of motion and patient-reported outcome measures [17].
• Simple excision of the outer end of the clavicle has yielded satisfactory results with no residual upward displacement disturbing the patients [4].

Incidence and Demographics¶

• 10 of 894 (1.1%) rotator cuff repairs underwent subsequent distal clavicle resection [30].
• Older patients and females were more likely to experience postoperative complications requiring reoperations, including revision acromioclavicular joint reconstruction, distal clavicle excision, and irrigation and debridement [96].

Recovery¶

• Arthroscopic distal clavicle excision through the direct approach allows for a faster return to activities compared with the open procedure [3].
• More than 90% of patients manage to return to driving within 4 weeks following arthroscopic subacromial decompression and acromioclavicular joint excision [59].
• More than 90% of patients manage to return to work within 6 weeks following arthroscopic subacromial decompression and acromioclavicular joint excision [59].
• Partial claviculectomy offers rapid return to function for chronic symptomatic injuries [24].

Key Evidence¶

• [L5] A well-performed distal clavicle excision will likely perform better than a poorly performed one, regardless of whether an open or arthroscopic approach is chosen. [1] (10.1016/j.arthro.2018.03.004)
• [L3] Arthroscopic distal clavicle resection has provided more 'good or excellent' results than has the open procedure, but is comprised of low-level evidence. [2] (10.1097/blo.0b013e31802f5450)
• [L3] Among patients undergoing distal clavicle excision for acromioclavicular joint pathology, those having an arthroscopic procedure, specifically through the direct approach, can expect a faster return to activities while obtaining similar long-term outcomes compared with the open procedure. [3] (10.1016/j.arthro.2009.12.007)
• [L3] Patients with displacement greater than 100% of the thickness of the distal clavicle had poorer postoperative clinical outcomes. [5] (10.1186/s12891-025-09190-x)
• [L4] Incomplete excision and regrowth of the distal clavicle are the most common causes of revision. [6] (10.1016/j.arthro.2009.06.010)
• [L5] The technique will allow surgeons to perform distal clavicle excisions in a more efficient, reproducible and safer manner. [7] (10.1016/j.eats.2024.103331)
• [Case_report] Regardless of the technique chosen for distal clavicle resection, portal placement remains paramount in both facilitating surgery and avoiding injury to adjacent extra-articular structures. [8] (10.1016/j.jse.2010.08.032)
• [L5] In appropriately selected patients, open or arthroscopic distal clavicle resection is necessary to relieve symptoms. [9] (10.5435/00124635-199905000-00004)
• [L1] Arthroscopic and open distal clavicle excisions both provide significant pain reduction at 1 year with no significant difference in outcome measures between groups, except for VAS pain score improvement. [10] (10.1016/j.jse.2006.10.006)
• [Abstract] Although distal clavicle excision with 2.5 mm of bone was successful in many specimens, a 5 mm resection guaranteed no bone-to-bone abutment. [11] (10.1016/j.jse.2007.02.105)
• [L5] [12] (10.5435/00124635-200904000-00002)
• [L4] The new operative procedure combines resection arthroplasty with fixation of the clavicle in an anatomical position. [13] (10.2106/00004623-197254060-00005)
• [L4] Horizontal instability of the clavicle is evident with distal clavicle resection of greater than 10 mm. [14] (10.1016/j.xrrt.2021.05.003)
• [L3] Late loss of reduction was common, and clavicular resection reliably produced significant improvement in patients with persistent pain or posttraumatic arthritis. [15] (10.2106/00004623-198769070-00013)
• [L4] Excision of the outer end of the clavicle is preferred for old dislocations, while open reduction and internal fixation are not recommended due to complications and poor functional results. [16] (10.2106/00004623-196345080-00024)
• [L4] In carefully selected patients with isolated ACJ pathology, arthroscopic distal clavicle excision results in statistically and clinically significant improvements in range of motion and patient-reported outcome measures. [17] (10.1016/j.jseint.2023.07.014)
• [L4] Methods to diagnose both superior and posterior translation of the clavicle need further debate. [22] (10.1016/j.jseint.2019.11.006)
• [L5] Clinical examination and surgical treatment should address anatomic restoration of individual structures to optimize the mechanical capability of the claviscapular segment. [23] (10.5435/jaaos-d-24-00360)
• [L4] [28] (10.2106/00004623-196749040-00024)
• [L5] A 5-mm distal clavicle resection guaranteed no abutment but decreased joint stiffness. [29] (10.1016/j.arthro.2007.07.004)
• [L3] This records review found that 10 of 894 (1.1%) rotator cuff repairs underwent subsequent distal clavicle resection. [30] (10.1177/2325967119844295)
• [L4] [31] (10.1016/j.arthro.2016.06.013)
• [L5] The trapezoid and conoid ligaments have unique functions in normal shoulder kinematics because of their anatomic attachments. [47] (10.1016/j.arthro.2009.12.031)
• [L5] The kinematic changes could be a potential source of pain and dysfunction in the shoulder with AC joint dislocation. [48] (10.1177/0363546512458571)
• [L5] Scapular and clavicular kinematics were affected in AC separation models. [50] (10.1016/j.jse.2013.01.004)
• [L2] Both the direct superior approach and the indirect subacromial approach to the arthroscopic distal clavicle resection result in successful clinical outcome with clinically insignificant difference at final follow-up. [57] (10.1177/0363546506294855)
• [L3] The results obtained in the present study suggest that more than 90% of the patients manage to return to driving within 4 weeks and to work within 6 weeks following arthroscopic subacromial decompression and acromio-clavicular joint excision. [59] (10.1111/j.1758-5740.2010.00048.x)
• [L4] Type I and II acromioclavicular joint disruptions impair long-term shoulder function in about half of patients 10 years after injury. [63] (10.1177/0363546508319047)
• [L4] [73] (10.1177/1758573214536535)
• [L5] [78] (10.1177/0363546513485359)
• [L5] The slight increase in the in situ graft force only in the posterosuperior and posterior direction after distal clavicle excision suggests only a marginal protective role of the acromioclavicular articulation. [81] (10.1177/0363546510374447)
• [L1] [83] (10.1016/j.jse.2020.10.026)
• [L5] [87] (10.1016/j.jse.2010.10.030)
• [L4] Weighted stress radiographs significantly increased the measured elevation of the clavicle and the coracoclavicular distance compared to non-weighted views. [89] (10.1016/j.jseint.2023.06.011)
• [L4] Older patients and females were more likely to experience postoperative complications requiring reoperations, including revision ACJR, distal clavicle excision, and irrigation and debridement. [96] (10.1007/s00167-016-4206-y)

References¶

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