What are the indications and considerations for the Mumford procedure in treating orthopedic conditions such as shoulder instability?

Mumford Procedure (Distal Clavicle Resection)

Primary Indication

The Mumford procedure (distal clavicle resection) is indicated for persistent acromioclavicular (AC) joint pain that has failed conservative treatment, particularly in patients with AC joint arthritis or osteolysis. 1, 2, 3

Key Clinical Considerations Before Surgery

Rule Out Alternative Pathology First

• In younger patients (under 40 years) with traumatic history, perform glenohumeral arthroscopy to exclude SLAP lesions before proceeding with distal clavicle resection. 4
• SLAP lesions were found in 75% of patients who underwent glenohumeral arthroscopy after previous Mumford procedures, suggesting missed diagnoses. 4
• Patients with SLAP pathology typically have deep pain at the bicipital groove with cross-chest adduction when the forearm is pronated (thumb down), which improves with supination (thumb up). 4

Conservative Management Requirements

• Conservative treatment must be attempted and failed before surgical intervention is considered. 1, 2
• The specific duration or components of conservative management are not well-defined in the available evidence, but this represents standard practice before elective orthopedic procedures. 5

Surgical Technique Considerations

Arthroscopic vs. Open Approach

• Arthroscopic distal clavicle resection is the preferred approach as it reproduces excellent results while avoiding risks of open surgery including joint instability and muscle weakness. 3
• The procedure can be performed through either a direct (superior) approach or indirect (subacromial) approach. 3
• Both approaches are effective when resection is performed systematically with postoperative measurement of resection amount. 3

Amount of Resection

• Neither the amount nor completeness of distal clavicle resection significantly affects clinical outcomes. 1, 2
• However, significant retained lateral clavicular spikes may require additional surgery for excision. 1
• The procedure should be performed using standard three-portal shoulder arthroscopy technique. 6

Expected Outcomes

Efficacy

• All patients in reported series had significant improvement of distal clavicular pain following arthroscopic Mumford procedure. 1, 2
• The procedure is safe and effective for alleviating AC joint pain. 1, 2

Concomitant Procedures

• The Mumford procedure can be safely combined with rotator cuff repair when both pathologies are present. 1, 2
• In one series, 39 of 57 patients (68%) had concomitant rotator cuff repairs without compromising outcomes. 1, 2

Critical Pitfalls to Avoid

Misdiagnosis in Young Patients

• The most important pitfall is performing distal clavicle resection for presumed AC arthritis in younger patients without ruling out SLAP lesions. 4
• 86% of patients with SLAP lesions discovered after failed Mumford procedures had their initial surgery for "AC arthritis." 4
• Most of these patients (14 of 15) had pain attributable to specific traumatic events, which should raise suspicion for intra-articular pathology. 4

Patient Selection

• Ensure the primary pain generator is truly the AC joint and not referred pain from other shoulder pathology. 4
• Document failed conservative management before proceeding. 1, 2