Abstract
Background:
Acromioclavicular (AC) joint arthritis is a common cause of shoulder pain in young patients. Management has been focused on relieving pain mainly with conservative nonsurgical procedures such as corticoid injections, physical therapy and even, recently, orthobiological interventions with platelet-rich plasma and hyaluronic acid injections. However, failed conservative management opens the door to surgical interventions such as the arthroscopic distal third of the clavicle resection.
Indications:
Patients submitted to this surgery must have a confirmed diagnosis of an arthritic, painful AC joint that has not been properly responding to nonoperative management.
Technique Description:
The surgical procedure is done in the beach chair position with standard arthroscopic portals. After a proper intraarticular evaluation of the structures and ruling out any other causes of pain, the surgeon passes to the subacromial space. Identification of the AC joint is made by following the coracoacromial ligament medial and with manipulation of the clavicle from the patient's skin. Debridement should start by releasing the anterior and posterior ligaments to allow for proper visualization of the articulation. A bur or a 5.5-mm shaver is used to start resection of the distal third of the clavicle under visualization and with care to not create a vault. The procedure is considered done when a smooth articular surface is visualized and with at least 5 mm of space between the clavicle and the acromion.
Results:
The proposed technique, which is a variant of the classic distal clavicle excision, has shown improved functional outcomes with reproducible postoperative scores and low complications rates in the setting of patients with isolated AC joint arthritis.
Conclusion:
Surgical management of the painful, arthritic AC joint has been evolving alongside with the history of shoulder arthroscopy; the proposed arthroscopic approach is an easy and effective way of freeing the patient of pain and discomfort with quick return to activities and sports.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
Hello everyone, my name is Gustavo Gil. I'm an orthopedic surgeon and knee and shoulder surgeon at Clínica Fundación Valle de Lili at Cali, Colombia. Today, along with our surgical group, I am going to show you our step-by-step resection of the distal third of the clavicle or Mumford procedure in a young patient with an acromioclavicular (AC) joint arthritis.
None of the authors have any conflicts of interest.
Background
As an overview, we are going to talk about distal clavicle resection or Mumford procedure. We will discuss a little bit of background and then we will show our case presentation and decision-making. We will also show our step-by-step surgical procedure, and to conclude I will talk about our postoperative management, rehabilitation protocol, and expected outcome of the procedure.
To begin, we have to know how to approach a painful AC joint. We know it is a pretty common cause of consultation in our day to day life. The main cause of the painful AC joint is clearly arthritis. 2 Although for this we may have 2 different patients, young versus elderly, we will focus on the young patient who commonly performs overhead activities or lifts weights.
The management has to be gradual. We do know that many patients get better just with physical therapies. In those patients where no proper response can be made, there are non-steroidal anti-inflammatory drugs and corticoid injections. 5 But when everything has failed, we offer the patient surgical management, and we perform arthroscopic resection due to minimally invasive approach.
Indications
I am going to begin by showing our patient in discussion. He is a 29-year-old male, right arm dominant, with a 2-year history of right shoulder pain. This patient has been treated by his physician with conservative, nonoperative management, including physiotherapy and a couple of more treatments that have shown to be ineffective. When he approached our office, we performed a local anesthetic and corticoid injection in his AC joint due to his clinical symptoms. He says his pain completely disappeared for 1 month, which confirms our diagnostic impression. He also has an American Shoulder and Elbow Surgeons (ASES) score of 65 points.
On physical examination, he has a full and normal range of motion of his right shoulder with normal strength when compared with his contralateral arm. He also has a positive O’Brien sign and clear pain and tenderness at palpation of his AC joint.
His diagnostic examination shows a normal radiograph, with little to no evidence of AC joint pathology; however, when we look at his magnetic resonance imaging, we can clearly see the bone edema and inflammatory changes of the AC joint, especially in the clavicular side of the joint, and subchondral cysts on the acromial side.
This may finally confirm our diagnosis of an arthritic AC joint in the context of a young patient, with subchondral edema and has not been responding properly to conservative management. All reasons why this patient, for us, is a perfect candidate to undergo surgical management for distal third of the clavicle resection or Mumford procedure.
Technique Description
The procedure is done in the beach chair position. We begin our case by performing the landmark marking over the skin to allow identification of the structures. As always, we perform a diagnostic arthroscopy, taking a good look at the subscapular tendon, the cartilage, and the biceps labrum to rule out any other causes of pain that may be present in this patient. We also take a good look at the articular side of the rotator cuff.
We then pass to the subacromial space. Once in this space, we identify the acromion and the coracoacromial ligament. We use this as a reference to follow the acromion medially using the radiofrequency to control bleeding. We then finally have a good look at what clearly is the articular side of the clavicle, and by moving it from the superior part we confirm our location. As we continue the dissection, the structures begin to appear clear. In cases like this, a dissection of the anterior capsule is needed to approach the most anterior border of the AC joint for a regular resection. We then perform an anterior portal considering that we must be able to freely move and reach the acromion and clavicle. Then, we must insert the shaver or the bur to work first on the clavicular side, resecting part of articular cartilage. The upper capsule should also be debrided and approached from this anterior portal. We continue with the resection of the cartilage until the exposure of the subchondral bone is visible. For better visualization, we suggest an instrument should be positioned from the lateral portal to lower the bursa. This will allow better visualization of what we are working on.
Care must be taken to remove every osteophyte or irregularity of the articular side of the clavicle. We must also be very careful in extending the resection to the most posterior and anterior border of the clavicle and not creating a vault by staying in the same site. Bleeding, regular subchondral bone should be visible from this view to be able to pass the next stage, where the scope should be angled and the lens directed upward to visualize the most superior part of the AC joint; this will allow us to work in parts not visible through the other camera angle. Also managing the acromial side of the joint is better visualized with this angled view. After you identify a regular space with no osteophytes, bleeding bone, and proper space between the clavicle and the acromion, the procedure can be considered completed.
Results
This is the patient in his 10th day postoperative control showing partial regain of his shoulder movement, as soon as he exits surgery he gets included in our physical therapy program where he is allowed full passive range of motion without any weight training. This is the patient in his 8th week postoperative control showing regain of his full range of motion with almost no pain with movement or palpation of his AC joint. We expect this patient to go back to his sporting activities at 3 months postoperative.
Discussion
As for the expected outcomes, it is important to note that the whole body of literature for the setting of AC joint arthritis is really heterogeneous, with no randomized controlled trials and no level 1 evidence studies proving that the surgical procedure is superior to any other measures. This means that the focus of investigation needs to be done in this field to achieve better evidence. What we have available in the literature, in 2023, is the work by Welch et al, 9 published in Shoulder and Elbow journal, a systematic review of the literature of the treatment of primary AC joint arthritis. This study showed that with distal clavicle resection functional scores improved from an average of 52.1% before the operation to 87.8% afterward. It also showed that participants having between 0.5 and 2 cm of clavicle excision had good outcomes. Also in 2023, Leon 7 published her prospective case series in the International Journal of Shoulder and Elbow. She states how her patients reported statistically significant improvement in range of motion and visual analogue scales scores when intervened with distal clavicle resection for the management of isolated AC joint arthritis with a return to sports and work of 3 and 1 month, respectively. Finally, in a systematic review and meta-analysis made by Hohmann et al 4 in 2019, published in Archives of Orthopedic and Trauma Surgery, they showed that the patients submitted to distal clavicle resection improved their functional results. But when comparing open versus arthroscopic techniques, they showed similar functional results and clinical outcomes.
In the references, we included the publications with higher level of evidence that were found by the authors to further sustain this as a standard procedure for isolated AC arthritis.1,3,6,8,10
Thank you so much for the attention.
Footnotes
Submitted October 8, 2023; accepted March 24, 2024.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
