關(guān)節(jié)鏡下經(jīng)肌腱修補(bǔ)治療關(guān)節(jié)側(cè)肩袖部分損傷

汪滋民 李全 王一 沈鋒 許國星 宋爽

·論著·

關(guān)節(jié)鏡下經(jīng)肌腱修補(bǔ)治療關(guān)節(jié)側(cè)肩袖部分損傷

汪滋民 李全 王一 沈鋒 許國星 宋爽

目的探討關(guān)節(jié)鏡下經(jīng)肌腱修補(bǔ)治療關(guān)節(jié)側(cè)肩袖部分撕裂（PASTA）損傷的方法和療效。方法應(yīng)用關(guān)節(jié)鏡下經(jīng)肌腱原位修補(bǔ)技術(shù)，探查清理關(guān)節(jié)側(cè)肩袖部分撕裂后，穿刺損傷部位并用PDS線標(biāo)記，關(guān)節(jié)鏡轉(zhuǎn)換至肩峰下，清理肩峰下滑囊并行肩峰成形術(shù)，評(píng)估滑囊側(cè)肩袖完整性，關(guān)節(jié)鏡轉(zhuǎn)換至盂肱關(guān)節(jié)，保留滑囊側(cè)的岡上肌腱足印，穿岡上肌腱置入鉚釘，過線縫合關(guān)節(jié)側(cè)部分撕裂，肩峰下間隙打結(jié)固定，解剖重建肩袖足印。2008年3月至2010年7月共治療12例PASTA患者，年齡29～72歲，平均（52．9±13．3）歲。結(jié)果手術(shù)治療后隨訪時(shí)間12～36個(gè)月，平均（22±7．3）個(gè)月。依據(jù)美國肩肘外科（ASES）評(píng)分：隨訪總分（89．7±5．6）分，與術(shù)前（49．8±9．8）分相比顯著提高，差異有統(tǒng)計(jì)學(xué)意義（t＝12．25，P ＜0．000 1）；依據(jù)加利福尼亞大學(xué)洛杉磯分校（UCLA）評(píng)分：隨訪總分（30．4±3．2）分，與術(shù)前（17．3±3．3）分相比顯著提高，差異有統(tǒng)計(jì)學(xué)意義（t＝9．87，P ＜0．000 1），優(yōu)良率為91．7%。結(jié)論應(yīng)用經(jīng)肌腱原位修補(bǔ)技術(shù)具有最大限度保留正常的肩袖組織，解剖重建肩袖足印，穩(wěn)定的腱骨界面固定的優(yōu)點(diǎn)，對(duì)于PASTA損傷是一種理想的修補(bǔ)技術(shù)。

關(guān)節(jié)鏡； 肩袖部分損傷； 經(jīng)肌腱修補(bǔ)

肩袖部分損傷可導(dǎo)致患者疼痛和功能受限。Ruotolo等［1］測(cè)量了17具尸體岡上肌腱的足印得到其平均厚度為12mm。Ellman［2］根據(jù)損傷部位將肩袖部分損傷分為關(guān)節(jié)側(cè)撕裂、滑囊側(cè)撕裂和肌腱內(nèi)撕裂，并根據(jù)術(shù)中測(cè)得損傷所累積肩袖的厚度分為1度（≤3mm）、2度（3～6mm）和3度（≥6mm），其中3度損傷超過肩袖厚度的50%。Waibl等［3］提出了關(guān)節(jié)側(cè)肩袖部分撕裂（partial articular surface tendon avulsions，PASTA）損傷一詞，同時(shí)也提出了經(jīng)肌腱修補(bǔ)該損傷的方法。關(guān)節(jié)側(cè)部分肩袖損傷發(fā)病率高，Modi等［4］回顧性分析了100例35歲以上因肩袖病變行關(guān)節(jié)鏡手術(shù)的患者，發(fā)現(xiàn)其中62例有關(guān)節(jié)側(cè)的部分肩袖損傷。Yamanaka等［5］采用關(guān)節(jié)造影追蹤了40例PASTA損傷的患者，平均隨訪412d，發(fā)現(xiàn)關(guān)節(jié)側(cè)的部分肩袖損傷具有撕裂擴(kuò)大（53%）以及進(jìn)展為全層撕裂（28%）的傾向。鑒于此，多數(shù)學(xué)者傾向于對(duì)Ellman 3度以上損傷進(jìn)行修補(bǔ)。修補(bǔ)技術(shù)包括轉(zhuǎn)換成全層撕裂后常規(guī)修補(bǔ)的技術(shù)（切開外側(cè)足印）和經(jīng)肌腱修補(bǔ)技術(shù)（保留未損傷的外側(cè)足印）。與前者相比，經(jīng)肌腱修補(bǔ)技術(shù)保留了外側(cè)殘留的正常肩袖組織，修補(bǔ)后的肩袖長度－張力平衡更趨于正常解剖。目前國內(nèi)尚缺少此類損傷治療結(jié)果的報(bào)道。2008年3月至2010年7月，我們對(duì)12例肩袖PASTA損傷患者采用改良的Lo等［6］的經(jīng)肌腱修補(bǔ)技術(shù)進(jìn)行了關(guān)節(jié)鏡下修補(bǔ)，所有病例隨訪12個(gè)月以上。

資料和方法

一、一般資料

本組12例患者，其中男性5例，女性7例；年齡29～72歲，平均（52．9±13．3）歲。右肩9例，左肩3例，涉及優(yōu)勢(shì)肩9例。6例有肩部外傷史，其中肩著地傷3例，手撐地傷3例。所有患者均有患側(cè)肩部疼痛、夜間痛和肩關(guān)節(jié)活動(dòng)受限，術(shù)前經(jīng)功能鍛煉、物理療法、服用非甾體類抗炎藥和封閉等保守治療1～17個(gè)月（平均6個(gè)月）。體格檢查：肩峰前外側(cè)壓痛11例，Neer撞擊征陽性9例，Hawkins撞擊征陽性9例，60°～120°疼痛弧征陽性7例，Jobe試驗(yàn)陽性9例。所有患者術(shù)前行MRI檢查均顯示肩袖撕裂。

二、手術(shù)方法

患者全身麻醉后，側(cè)臥位患肢輕度外展前屈位牽引，消毒鋪巾，在皮膚表面標(biāo)記肩部諸骨性標(biāo)志和工作入口的位置。首先建立后側(cè)通道，對(duì)盂肱關(guān)節(jié)進(jìn)行鏡檢，采用從外向內(nèi)的技術(shù)建立前方通道并探查盂肱關(guān)節(jié)，用刨刀和射頻對(duì)岡上肌止點(diǎn)損傷清理后，評(píng)估關(guān)節(jié)側(cè)肩袖損傷程度，對(duì)損傷≥6mm寬度的肩袖足印，即Ellman 3度的PASTA損傷進(jìn)行修補(bǔ)（圖1A）。修補(bǔ)前首先要進(jìn)行肩峰下間隙減壓術(shù)，將關(guān)節(jié)鏡經(jīng)后側(cè)同一切口插入肩峰下滑囊，通過前方通道和外側(cè)通道將滑囊組織清除干凈，直至清晰完整的顯露滑囊側(cè)肩袖足印，并對(duì)患者行肩峰成形術(shù)。然后探查是否伴有滑囊側(cè)肩袖損傷，如清創(chuàng)后的外側(cè)殘留肩袖止點(diǎn)菲薄、明顯退變或合并滑囊側(cè)損傷，清理變成全層撕裂后修補(bǔ)；如外側(cè)肩袖止點(diǎn)仍健康完整，同時(shí)又無滑囊側(cè)損傷即可采用經(jīng)肌腱修補(bǔ)術(shù)。關(guān)節(jié)鏡再次經(jīng)后方入口進(jìn)入盂肱關(guān)節(jié)，調(diào)整視野并鎖定PASTA損傷處，用磨鉆對(duì)裸露的大結(jié)節(jié)肩袖內(nèi)側(cè)足印打磨新鮮化，用18號(hào)脊髓穿刺針緊貼肩峰外側(cè)緣穿岡上肌腱刺入盂肱關(guān)節(jié)內(nèi)定位鉚釘置入點(diǎn)和方向。用小尖刀片平行定位針方向穿刺皮膚和肌腱，確定好方向和進(jìn)針點(diǎn)，移除穿刺針，置入鉚釘，根據(jù)肩袖損傷前后徑大小置入1枚5．0mm或2枚3．5mm鉚釘（圖1B）。鉚釘置入點(diǎn)緊貼肱骨頭軟骨與大結(jié)節(jié)骨面成45°角，置入兩枚鉚釘時(shí)，兩枚鉚釘呈前后方向，位于損傷的前緣和后緣。

采用鳥嘴樣過線器穿過損傷的岡上肌腱內(nèi)緣的健康組織逆行引出縫線，縫線間距離≥10mm以形成足夠的組織橋固定肩袖足印；也可采用脊髓穿刺針，先經(jīng)前側(cè)入口將鉚釘上兩股不同顏色縫線中靠后的一股引出，穿刺針從岡上肌腱損傷殘端內(nèi)緣的健康組織中偏后穿刺，觀察位置良好后引入PDS縫線，經(jīng)前方入口引出，作為牽引線逆行引線將鉚釘縫線后股穿過岡上肌腱，再由后向前穿刺岡上肌內(nèi)緣引出其他幾股縫線，如損傷的前后徑不足2cm，也可一次過兩股不同色的縫線（圖1C）。如發(fā)現(xiàn)關(guān)節(jié)側(cè)損傷肌腱殘端回縮，需用抓線鉗從外側(cè)入口穿肌腱置入盂肱關(guān)節(jié)內(nèi)抓持肌腱殘端并協(xié)助復(fù)位，由一名助手持續(xù)握住抓線鉗維持復(fù)位，再由術(shù)者進(jìn)行上述縫合操作。如為兩個(gè)鉚釘可再重復(fù)上述操作后，準(zhǔn)備打結(jié)固定（圖1D）。關(guān)節(jié)鏡再次置入肩峰下間隙，分別將同色的兩股縫線用SMC結(jié)固定。關(guān)節(jié)鏡置入盂肱關(guān)節(jié)內(nèi)評(píng)估肩袖足印重建情況，此時(shí)重建后的肩袖足印緊貼肱骨頭軟骨（圖1E），術(shù)后X線片示鉚釘位置良好（圖1F）。

圖1 Ellman 3度PASTA損傷的關(guān)節(jié)鏡下修復(fù)手術(shù)方式 圖A為鏡下評(píng)估大于6mm寬度的關(guān)節(jié)側(cè)肩袖足印損傷；圖B為鏡下置入1枚5．0mm鉚釘（Smith＆Nephew Twinfix screw）；圖C為肩袖組織間隔1cm引出縫線；圖D為肩峰下間隙鏡下用SMC結(jié)固定；圖E為盂肱關(guān)節(jié)鏡下見重建后的肩袖足印緊貼肱骨頭軟骨；圖F為術(shù)后X線片示鉚釘位置良好

三、術(shù)后康復(fù)

術(shù)后肩關(guān)節(jié)帶枕吊帶固定于輕度外展位4周，術(shù)后早期行鐘擺運(yùn)動(dòng)、Godman運(yùn)動(dòng)，被動(dòng)外旋練習(xí)、肘關(guān)節(jié)屈伸練習(xí)等，4周內(nèi)避免肩過頂運(yùn)動(dòng)。4周后去除吊帶，進(jìn)行過頂拉伸練習(xí)和肩關(guān)節(jié)內(nèi)旋拉伸練習(xí)。10周后開始等張肌力練習(xí)。

四、療效評(píng)價(jià)

采用美國肩肘外科（american shoulder and elbow surgeons，ASES）評(píng)分標(biāo)準(zhǔn)和加利福尼亞大學(xué)洛杉磯分校（university of california at losAngeles，UCLA）評(píng)分標(biāo)準(zhǔn)。ASES評(píng)分的計(jì)算：從患者的調(diào)查表中得到視覺模擬評(píng)分（visual analogous scale，VAS）疼痛評(píng)分和累計(jì)日常生活能力評(píng)分（activity of daily living，ADL），用公式計(jì)算后使之各占50%的權(quán)重。即疼痛評(píng)分＝（10－VAS評(píng)分）×5，功能評(píng)分＝ADL評(píng)分÷3×5，得出疼痛和功能評(píng)分各占50分，兩者相加即總分為100分［7］。UCLA評(píng)分總分為35分，包括疼痛評(píng)分10分、功能評(píng)分10分、關(guān)節(jié)前屈角度評(píng)分5分、前屈肌力評(píng)分5分、患者滿意度5分。34～35分為優(yōu)，28～33分為良，21～27分為可，0～20分為差［8］。

結(jié) 果

12例PASTA損傷患者，接受了經(jīng)肌腱肩袖修補(bǔ)術(shù)。其中男性5例，女性7例；均為Ellman 3度撕裂。手術(shù)后隨訪時(shí)間12～36個(gè)月，平均（22±7．3）個(gè)月。ASES評(píng)分：隨訪總分（89．7±5．6）分，與術(shù)前（49．8±9．8）分 相 比 顯 著 提 高 （t ＝12．25，P ＜0．0001）；UCLA評(píng)分：隨訪總分（30．4±3．2）分，與術(shù)前（17．3±3．3）分相比顯著提高（t＝9．87，P ＜0．0001），優(yōu)良率為91．7%。

討 論

一、關(guān)節(jié)側(cè)肩袖損傷的處理原則

關(guān)節(jié)鏡術(shù)中對(duì)關(guān)節(jié)側(cè)肩袖損傷的處理主要包括：（1）清理肩袖加或不加肩峰下減壓；（2）步驟1加經(jīng)肌腱修補(bǔ)；（3）步驟1加轉(zhuǎn)變?yōu)槿珜铀毫押笮扪a(bǔ)。盡管較早的報(bào)道顯示僅清理肩袖和肩峰下減壓也能夠改善患者的疼痛和功能，但近年來的研究提示清理和減壓并不能夠阻止肩袖部分損傷進(jìn)展為全層撕裂和癥狀的惡化。Kartus等［9］術(shù)后隨訪，B超檢查發(fā)現(xiàn)清創(chuàng)和肩峰成形術(shù)后34．6%的患者部分撕裂進(jìn)展為全層撕裂，而進(jìn)展為全層撕裂的患者其疼痛和功能評(píng)分明顯差于未進(jìn)展者。相反，肩袖修補(bǔ)則能夠取得更可靠的療效，而且能夠阻止肩袖撕裂的進(jìn)展［1011］。詢證醫(yī)學(xué)的證據(jù)表明當(dāng)撕裂≤50%時(shí)，單純清創(chuàng)和肩峰下減壓能夠取得較滿意的結(jié)果；但當(dāng)撕裂≥50%時(shí)，修補(bǔ)才能夠取得滿意的結(jié)果［6，10－13］。傳統(tǒng)的轉(zhuǎn)變?yōu)槿珜铀毫研扪a(bǔ)的技術(shù)具有直接、方便的優(yōu)勢(shì)，并取得了良好的臨床效果［6，12］，但由于修補(bǔ)后的肩袖其骨－肌腱結(jié)合部僅形成瘢痕愈合，難以重塑纖維軟骨性的連接，再撕裂率高［12］。因此，近年來很多學(xué)者開始探索穿肌腱修補(bǔ)技術(shù)以保留滑囊側(cè)尚完整 的 足 印［6，11－12］。研 究 顯 示，穿 肌 腱 修 補(bǔ) 技 術(shù)提高了肩袖修補(bǔ)后的愈合率［12］。

二、對(duì)Lo經(jīng)肌腱修補(bǔ)技術(shù)的改良和體會(huì)

Lo等［6］所報(bào)道的技術(shù)中，采用1～2個(gè)5．0mm鉚釘固定岡上肌內(nèi)側(cè)足印，采用兩個(gè)鉚釘時(shí)，采用雙滑輪技術(shù)在岡上肌腱足印內(nèi)側(cè)表面形成一個(gè)水平的雙股縫線橋有力的固定住內(nèi)排足印。該技術(shù)的優(yōu)點(diǎn)：（1）縫線橋?qū)缧渥阌〉墓潭ň哂猩锪W(xué)上的優(yōu)勢(shì)；（2）雙滑輪技術(shù)減少了穿線的次數(shù)，方便了手術(shù)操作，縮短了手術(shù)時(shí)間。該技術(shù)的缺點(diǎn)：（1）PASTA損傷大多數(shù)情況裸露出的肩袖足印只夠打1個(gè)鉚釘，如勉強(qiáng)打2個(gè)鉚釘有超負(fù)荷的風(fēng)險(xiǎn)；（2）雙滑輪技術(shù)推薦第六指推結(jié)器（國內(nèi)并未引進(jìn)），采用普通推結(jié)器有松結(jié)的風(fēng)險(xiǎn)；（3）對(duì)于一部分殘端回縮較嚴(yán)重的PASTA損傷，Lo技術(shù)穿刺針的位置需要偏內(nèi)置入，導(dǎo)致修補(bǔ)后肩袖張力過大，滑囊側(cè)肩袖組織隆起，肌腱張力失平衡，術(shù)后疼痛加重［13］。我們的改良：（1）推薦置入1個(gè)帶雙線的5．0鉚釘；（2）兩股線可根據(jù)損傷寬度一次或分次過線，2股線用滑結(jié)固定。我們認(rèn)為這樣減少了大結(jié)節(jié)過負(fù)荷和松結(jié)的風(fēng)險(xiǎn)，也減輕了患者費(fèi)用；（3）置入鉚釘后，修補(bǔ)肩袖前，先用抓線鉗穿肌腱抓持回縮的關(guān)節(jié)側(cè)損傷肩袖殘端并協(xié)助復(fù)位于大結(jié)節(jié)足印，維持復(fù)位同時(shí)，脊髓穿刺針穿肌腱過線修補(bǔ)，從而避免縫合后滑囊側(cè)肩袖隆起和肌腱張力失平衡。

綜上所述，對(duì)于≥50%的PASTA損傷治療，經(jīng)肌腱原位修補(bǔ)技術(shù)具有最大限度保留正常的肩袖組織，解剖重建肩袖足印，穩(wěn)定的腱骨界面固定的優(yōu)點(diǎn)。對(duì)Lo經(jīng)肌腱原位修補(bǔ)操作技術(shù)進(jìn)行適當(dāng)改良，能夠達(dá)到較為理想的治療效果。

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Arthroscopic treatment of articular side partial tear of supraspinatus tendon by the trans－tendon approach

Wang Zimin，Li Quan，Wang Yi，Shen Feng，Xu Guoxing，Song Shuang．Department of Orthopedics，Changhai Hospital，Second Military Medical University，Shanghai 200433，China

BackgroundPartial rotator cuff tears result in pain and disfunction in patients．An previous study，the researchers measured the supraspinatus tendon of 17corpses and came to a conclusion that the average thickness of the supraspinatus tendon was 12mm．Divides the rotator cuff tears into partial articular tears，partial bursa tears and intra－tendon tears according to the injury sites．Based on the thickness of injured rotator cuff measured during the operation，the tears are divided into 3degrees：Degree I（≤3mm），DegreeⅡ （3－6mm）and DegreeⅢ （≥ 6mm），and the injured thickness of the DegreeⅢis more than 50%．Waibl et al put forward the concept of partial articular surface tendon avulsions（PASTA）and the trans－tendon approach to repair the injury．The PASTA has a high morbidity．Modi et al reviewed 100cases who were all over 35years old．They recieved an arthroscopic surgery for rotator cuff lesions．Waibl then found 62cases had PASTA．Yamanaka et al followed 40PASTA patients using arthrography，the average follow－up was 412days．They found that the PASTA had a tendency to expand（53%）and to progress to full－thickness tears（28%）．Take this into account，most scholars tend to endorse the decision that tears over degreeⅢ must be repaired．The methods include the conventional repair after the conversion of the full－thickness tear and the direct repair of the tears using the tendon approach．Compared with the former，the tendon repair can save the residual normal rotator cuff tissue，and the length－tension balance after rotator cuff repair is simmilar to normal anatomy．Up to now，China is still lack of treatment reports for such reported injuries．From March 2008to July 2010，we had 12cases of patients with PASTA who recieved the arthroscopictrans－tendon repair using the method improved by Lo．All patients were followed up for 12months or more，and the results are as follows．MethodsI．General Information：There are 12cases in the group，including 5males，7females，whose ages are from 29to 72years old with the average age of 52．9±13．3years old．9lesions were on the right shoulder，3on the left shoulder，and nine on the dominant shoulder．6patients had a history of trauma on their shoulders，of which 3patients hit their shoulders on the ground and 3hit their hands on the ground．All patients have a pain of the injured shoulder，night pain and most had a problem of shoulder mobility．The patients

the preoperative functional exercise，physical therapy，non－steroidal anti－inflammatory drug therapy and local steroid injection for 1to 17months （average 6months）．Physical examination was as follows：11cases had front shoulder lateral tenderness，9cases had positive Neer impingement signs，9cases had positive Hawkins impingement signs，7cases had positive signs of painful arc from 60to 120°，and the Jobe tests of 9cases were positive．The preoperative MRIs of all the patients showed a rotator cuff tear．Surgical methods：After general anesthesia，the patient was placed in the lateral position with little abduction and anteflexion traction．After sterilization and drape，we marked the bony landmarks and the position of the surgery approach in the skin．Build a rear channel at the first step of surgery．Then we made a arthroscopic examination of the glenohumeral joint．Then build a front channel from outside to the front and examine the glenohumeral joint．Use the planer and radio frequency to repair and clear the damage at the end point of the supraspinatus muscle．Assess the extent of the damage of the joint side rotator cuff，and if the damage was up to 6mm in width which means Ellman degree Ⅲ PASTA lesion，the damage needed to be repaired（Figure 1A）．Before the repair，we must take a subacromial decompression．Insert the arthroscope into the subacromial bursa using the same rear incision．Remove and clean the bursa tissue through the front and the lateral channel until the rotator cuff footprints besides the bursa could be exposed clearly and completely．Then the shoulder acromialplasty could be done．The next step was to examine if there is rotator cuff injuries by synovial side．If the residual end point of rotator cuff becomes thin or obvious degeneration or bursa side damage exists，clean up and make it become full－thickness tear，and then repair the damage．If the lateral rotator cuff end point was still healthy and there is no damage of the bursa side，we would do the trans－tendon repair．Insert the Arthroscope into the glenohumeral joint again through the rear entrance，adjust and lock the position of PASTA lesion，polish the greater tuberosity of the rotator cuff using the burr to make the inner side rotator cuff footprints fresh，and use a NO．18spinal needle to get close to the outer edge of the acromion to insert into the supraspinatus tendon till the glenohumeral joint．Then ensure the position and direction of the rivet．Puncture the skin and tendons with a small sharp knife parallel to the direction of the needle，make sure the direction and the needle insert position，remove the needle，and insert a 5．0mm rivet or 23．5mm rivets according to the anteroposterior dimension of rotator cuff injury（Figure 1B）．The rivet should be close to the humeral head cartilage tightly and made a 45°angle with the major tubercle surface．The rivets should be placed in the anteroposterior direction and located in the front and posterior edges．Insert the healthy tissue in the inner rim of the injured supraspinatus tendon by a beak－like thread，and then haul the thread out retrograde．The distance of the threads must be at least 10mm to ensure that there was a bridge enough to fix the rotator cuff footprint．Spinal needle could also be used．First we should haul the latter thread of the two threads in the rivets with different colors through the front approach．Then puncture the healthy tissue of the inner rim of the injured supraspinatus tendon and haul the puncture needle out in the latter direction．If the position was good，the PDS thread was inserted out through the front approach．Using as the direct thread，the latter of the threads was inserted into the supraspinatus tendon retrograde．Then the thread punctured the inner rim of supraspinatus from the behind to the front with other threads．If the anteroposterior dimension of the injured tissue was less than 2cm，two threads with different colors could go through the channel at the same time（Figure 1C）．If the residue injured tendon in the joint side was found retraction，grip pliers should be inserted into the glenohumeral joint through the latter approach to grip the residue tendon for the reduction during the surgery．The assistant hold the grippliers continuously to maintain the reduction，and then the surgeon accomplished the sutures．If there were two rivets used and when the sutures were accomplished，we should make a fixed knot（Figure 1D）．Insert the arthroscope into the subacromial gap again and fix the threads with the same color using the SMC knot separately．Insert the arthroscope into the glenohumeral joint to assess the rebuilding of the rotator cuff footprint，and at this time the rotator cuff footprints was close to the humeral head cartilage（Figure 1E）．Postoperative rehabilitation：The shoulder joint should be fixed in the little abduction position with a strap postoperatively for 4weeks．The pendulum motion，Godman movement，passive external rotation exercises，elbow flexion and extension exercises should proceed early after the surgery．Avoid the shoulder up over the head for 4weeks．After 4weeks，the strap could be removed and patients should do the stretching exercises over the head and stretching exercises in the shoulder rotation．Take isometric exercises 10weeks after the surgery．Efficacy evaluation：Here we use the american shoulder and elbow surgeons（ASES）scoring criteria and the university of california at los angeles（UCLA）scoring criteria．ASES score was calculated as follows：we got a visual analog scale（VAS）from a survey of patients in pain scores and cumulative activity of daily living score（ADL），after the calculation make each accounted for 50%of the weight．The pain score＝（10－VAS score）×5，function score＝ ADL score÷3×5，which means that the pain and function scores account 50points each，and add the total score of 100points．UCLA score criteria total score is 35points，including the pain score of 10points，the function score of 10points，the joint flexion angle score of 5points，the flexion strength score of 5points and the patient satisfaction of 5points．34to 35points are considered as excellent，28to 33as good，21to 27as basically qualified，and 0to 20as poor．Results 12cases of patients had the PASTA receive rotator cuff trans－tendon repair．Among them，there are 5males and 7 females，and all of them had an Ellman degreeⅢ tear．The patients were followed up from 12to 36 months and the average follow－up period was （22±7．3）months．ASES score：follow－up score （89．7±5．6）points，significantly improved compared with the preoperative points（49．8±9．8）（t ＝12．25，P＜0．0001）．The follow－up UCLA score of （30．4±3．2）points improved significantly from the preoperative points of （17．3±3．3）．The excellent rate was 91．7% ．Discussion The principles of the joint side rotator cuff injury：The procedure for the joint lateral rotator cuff injury during the arthroscopic surgery includes：（1）clean up the rotator cuff with or without the subacromial decompression；（2）step 1with the intra－tendon repair；（3）step 1with the repair when the damage becomes into a complete tear．Despite earlier reports concluded that the simple clean of the rotator cuff with the subacromial decompression could relieve the pain and improve the function in patients，recent studies suggest cleaning and decompression cannot prevent the partial rotator cuff tear and damage to become a complete tear and symptoms to be worsen．Kartus et al found that 34．6%of the partial tear patients became a complete tear after a cleaning up of the rotator cuff with the subacromial decompression．And their pain and function scores were significantly less than the patients without a complete tear．By contrast，the rotator cuff repair obtains a more reliable effect，and prevents the progress of the rotator cuff tear．Evidence－based medicine shows that when tear is not more than 50%，the simply debridement of the rotator cuff with the subacromial decompression can achieve satisfactory results．But when the tear is not less than 50%，only the repair will be able to obtain satisfactory results．The traditional way which turns the damage into a complete tear has a direct and convenient advantage，and achieved good clinical results，but it is difficult to remodel the connection of fibrocartilage and has a high re－tear rate，for there is only scar healing in its bone－tendon junction．Thus，recently，many scholars have started to explore the trans－tendon approach to keep the bursa side with intact footprints．Studies have shown that the trans－tendon approach is able to improve the healing rates of the rotator cuff repair．Improvement and experience of the Lo intra－tendon repair technique：According to the technique reported by Lo et al，we can use one or two 5．0mm medial rivets to fix the medial supraspinatus footprint．When using two rivets，make the double pulley to form a horizontal double suture bridge on the surface of the medial supraspinatus footprint to fix the footprint strongly．The advantages of this technique are as follows：（1）the fixation of the suture bridge to the rotator cufffootprint has biomechanical advantages；（2）the double pulley technique reduces the frequency of threading，facilitating the surgical procedure and shortening the operation time．The disadvantages of this technique are as follows：（1）the bare footprints of PASTA only allow one rivet．If we use two rivets，there is a risk of overload；（2）the double pulley technique needs the sixth finger knot pusher which is not introduced to china，and there is a risk of loose knot using the ordinary knot pusher；（3）for some PASTA cases with serious retracting of the residual tissue，the puncture needle should be inserted bias the medial side using the Lo technology．It results in the high tension of the posterior repaired rotator cuff，the synovial tissue bulge and the tendon balance loss，which increase the postoperative pain．Our improvement is as follows：（1）a 5．0rivet with two strands is recommended；（2）two strands can be inserted at once or several times according to the injured width，and two strands are fixed with a slip knot．We think that it reduces the risk of overload of the major tubercle and loose knot，and reduces the cost of patients；（3）after implantation of rivets and before the rotator cuff repair，we can use a grasping grip pliers to grip the retraction residual rotator cuff on the joint side and help to reset the major tubercle footprint．At the same time，the spinal needle is inserted intra－tendon and repair with the strand，thus the synovial tissue bulge and tendon balance loss after the suture would be avoided．Conclusions In summary，for more than 50%PASTA patients，the trans－tendon repair in situ technique can maximumly preserve the normal tissue of the rotator cuff，reconstruct rotator cuff footprint anatomically and have a stable fixed tendon－bone interface．The Lo trans－tendon fixation in situ technology can also receive an ideal therapeutic effect when improved appropriately．

Arthroscopy； Partial rotator cuff tear； Trans－tendon repair

Wang Zimin，Email：ziminw＠foxmail．com

2013－11－30）

（本文編輯：薛芳）

10．3877／cma．j．issn．2095－5790．2014．01．004

200433 上海，第二軍醫(yī)大學(xué)長海醫(yī)院骨科

汪滋民，Email：ziminw＠foxmail．com

汪滋民，李全，王一，等．關(guān)節(jié)鏡下經(jīng)肌腱修補(bǔ)治療肩袖關(guān)節(jié)側(cè)部分損傷［J／CD］．中華肩肘外科電子雜志，2014，2（1）：16－22．