肩峰撞擊征二型肩峰行關(guān)節(jié)鏡下肩峰成形術(shù)與關(guān)節(jié)鏡下單純肩峰下清理術(shù)療效比較

蘇雨亮 楊梁

·論著·

肩峰撞擊征二型肩峰行關(guān)節(jié)鏡下肩峰成形術(shù)與關(guān)節(jié)鏡下單純肩峰下清理術(shù)療效比較

蘇雨亮 楊梁

目的分析評價關(guān)節(jié)鏡下肩峰成形術(shù)與關(guān)節(jié)鏡下單純肩峰下清理術(shù)在治療肩峰撞擊征二型肩峰患者的療效比較。方法選取2013年6月至2014年12月大連醫(yī)科大學(xué)附屬第二醫(yī)院收治的57例肩峰撞擊征二型肩峰患者，隨機分成2組，其中行關(guān)節(jié)鏡下肩峰成形術(shù)組32例，男20例，女12例，平均年齡（51．53±8．87）歲（39～68歲）；行關(guān)節(jié)鏡下單純肩峰下清理術(shù)組25例，男13例，女12例，平均年齡（53．52±8．53）歲（42～70歲）。術(shù)前、術(shù)后定期使用美國加州大學(xué)洛杉磯分校（University of California at Los Angeles，UCLA）肩關(guān)節(jié)評分對肩關(guān)節(jié)功能隨訪評測。結(jié)果所有患者均獲得隨訪，隨訪平均時間（7．95±3．65）個月（3～18個月）。關(guān)節(jié)鏡下肩峰成形術(shù)組術(shù)前UCLA評分（9．43±1．34）分，末次隨訪評分（33．15±3．78）分，優(yōu)良率88%；關(guān)節(jié)鏡下單純肩峰下清理術(shù)組術(shù)前 UCLA評分（6．40±1．15）分，末次隨訪評分（32．68±3．95）分，優(yōu)良率84%。兩組末次測評的UCLA評分較術(shù)前均明顯提高，兩組術(shù)后UCLA評分及優(yōu)良率比較差異無統(tǒng)計學(xué)意義（χ2＝0．009，P＞0．05）。結(jié)論關(guān)節(jié)鏡下肩峰成形術(shù)與關(guān)節(jié)鏡下單純肩峰下清理術(shù)都能明顯改善肩峰撞擊征二型肩峰患者的癥狀。肩峰撞擊征二型肩峰患者更推薦行關(guān)節(jié)鏡下單純肩峰下清理術(shù)。

肩峰撞擊征；二型肩峰；肩峰成形術(shù)；肩峰下清理術(shù)

肩峰撞擊征是引起肩部疼痛的主要原因之一。在經(jīng)歷至少3個月的保守治療，如烤電、熱敷、肩峰下間隙麻醉性藥物注射，仍達不到滿意效果時，手術(shù)干預(yù)成為其解決癥狀的可靠手段。目前肩峰撞擊征的主要手術(shù)治療方式有肩峰成形術(shù)與肩峰下清理術(shù)兩種方式。本文定位于肩峰形態(tài)分型中的二型肩峰，探討現(xiàn)有主流術(shù)式肩峰成形術(shù)與肩峰下清理術(shù)的療效比較及哪一種術(shù)式對于肩峰撞擊征二型肩峰患者更具應(yīng)用價值。

資料與方法

一、一般資料

2013年6月至2014年12月大連醫(yī)科大學(xué)附屬第二醫(yī)院關(guān)節(jié)外科診治的肩峰撞擊征二型肩峰患者57例，隨機分成2組，其中關(guān)節(jié)鏡下肩峰成形術(shù)組患者32例（A組），男20例，女12例，平均年齡（51．53±8．87）歲（39～68歲）；關(guān)節(jié)鏡下單純肩峰下清理術(shù)組患者25例（B組），其中男13例，女12例，平均年齡（53．52±8．53）歲（42～70歲）。兩組患者一般情況比較見表1。所有患者均存在患肩疼痛，主動活動范圍受限。肩峰撞擊征專科檢查：Neer sign（＋），Hawkins sign（＋），Job試驗（－），疼痛弧為60～120°。岡上肌出口位X線片提示為二型肩峰。經(jīng)過平均（7．95±3．65）個月（3～18個月）的保守治療未達到患者滿意要求。MRI提示肩袖斷裂需縫合肩袖的患者及肩部存在其他結(jié)構(gòu)區(qū)紊亂，如盂肱關(guān)節(jié)不穩(wěn)、凍結(jié)肩、Bankart損傷、肩鎖關(guān)節(jié)炎等排除在本次實驗之外。

二、手術(shù)方法

采用側(cè)臥位，患者軀干向后傾斜30°，患肩外展4 5°，前傾15°，牽引重量約3kg。采用標(biāo)準(zhǔn)后側(cè)入路進入盂肱關(guān)節(jié)內(nèi)，探查盂肱關(guān)節(jié)內(nèi)盂唇、肩胛下肌、關(guān)節(jié)囊韌帶及肱二頭肌長頭肌腱止點復(fù)合體情況。探查上方肩袖下表面是否存在肩袖撕裂，肱二頭肌長頭肌腱鞘膜是否存在炎癥磨損表現(xiàn)。

表1 兩組患者一般情況比較

1．肩峰下清理術(shù)：盂肱關(guān)節(jié)探查完畢后，經(jīng)同一后側(cè)入路進入肩峰下間隙，于肩峰外側(cè)緣中線靠前選取前外側(cè)入路，通過前外側(cè)入路徹底切除滑囊組織暴露下方肩袖肌腱，正常肩袖肌腱呈白色，發(fā)亮，肌腱纖維整齊平行排列。而病變的肩袖組織呈灰色，發(fā)暗，纖維排列紊亂，個別患者肩袖肌腱存在小撕裂，但肌腱厚度仍足以維持肩袖正常功能，不需要通過縫合加強。此種情況下需要通過刨刀沿肩袖纖維走行方向擺動清除變性的肩袖肌腱組織，這種變性組織是引起癥狀的主要因素之一（圖1～3）。

2．肩峰成形術(shù)：在單純清理基礎(chǔ)上，鏡頭以后側(cè)入路為觀察入路，外側(cè)入路進入射頻部分解離前外側(cè)肩峰端喙肩韌帶止點，暴露肩峰下表面骨質(zhì)，可探查到肩峰前外側(cè)緣稍彎曲，與二型肩峰描述相同，個別患者在彎曲肩峰末端可探查到增生骨刺。進入3．5mm打磨頭自肩峰前外側(cè)緣開始逐層打磨肩峰至肩峰彎曲部分變平為止。為保證肩峰下表面的平坦，鏡頭與打磨頭交換入路，以前外側(cè)入路為觀察入路，打磨頭自后側(cè)入路進入補充打磨肩峰下表面直至視野下平坦（圖4～6）。

圖1 清理前肩峰下間隙

圖2 射頻止血清理滑膜

圖3 清理后肩峰下間隙

三、術(shù)后處理

術(shù)后第2天開始康復(fù)功能鍛煉。1～6周以被動活動范圍為主，避免關(guān)節(jié)囊粘連；7～12周開始主動鍛煉恢復(fù)肩袖肌群及三角肌肌力；4～6個月可適當(dāng)參加低對抗性或低頻率抬臂過肩運動；6～12個月可嘗試性進行高強度對抗性運動或高頻率抬臂過肩運動。

四、隨訪及療效評價

患者分別于術(shù)后1周、6周、12周定期隨訪。隨訪內(nèi)容包括：功能鍛煉情況，患肢主動及被動活動度，患肢肌力。兩組患者于術(shù)前、術(shù)后定期采用美國加州大學(xué)洛杉磯分校（university of California at Los Angeles，UCLA）肩關(guān)節(jié)評分對患者肩關(guān)節(jié)功能進行評價。UCLA評分滿分35分，其中疼痛及功能評價分別為10分，活動度、肌力及滿意度評價分別有5分，34～35分為優(yōu)秀；28～33分為良好；21～27分為可；0～20分為差。

圖4 肩峰下間隙喙肩韌帶情況

圖5 喙肩韌帶肩峰附著端射頻分離，顯露肩峰骨質(zhì)形態(tài)

五、統(tǒng)計學(xué)分析

使用SPSS 19．0統(tǒng)計軟件進行數(shù)據(jù)分析。對于計數(shù)資料使用卡方檢驗；計量資料用±s表示，并進行正態(tài)檢驗。兩組之間比較采用t檢驗。P＜0．05為差異有統(tǒng)計學(xué)意義。

圖6 打磨后二型肩峰變成一型肩峰

結(jié) 果

兩組患者全部完成隨訪，未出現(xiàn)因癥狀惡化需要二次手術(shù)情況，未出現(xiàn)因其他影響肩部癥狀的疾病。其中大部分患者術(shù)后癥狀及功能改善明顯，UCLA評分均較術(shù)前改善明顯。

術(shù)前 A 組 UCLA 評分（9．43±1．34）分，B 組UCLA評分（9．64±1．41）分，兩組間患者肩關(guān)節(jié)功能差異無統(tǒng)計學(xué)意義（t＝0．574，P＞0．05）。術(shù)后1周 A組 UCLA評分（14．19±1．73）分，B組 UCLA評分（14．60±1．44）分，術(shù)后1周兩組肩關(guān)節(jié)功能恢復(fù)較術(shù)前明顯改善，兩組間差異無統(tǒng)計學(xué)意義（t＝0．954，P＞0．05）。術(shù)后6周 A 組 UCLA 評分（20．56±2．69）分，B 組 UCLA 評分（22．16±2．46）分，兩組間肩關(guān)節(jié)功能恢復(fù)差異無統(tǒng)計學(xué)意義（t＝1．312，P＞0．05）。術(shù)后12周 A 組 UCLA 評分（26．47±3．26）分，B 組 UCLA 評分（27．00±3．41）分，兩組間肩關(guān)節(jié)功能恢復(fù)差異無統(tǒng)計學(xué)意義（t＝0．597，P＞0．05）。末次隨訪 A 組 UCLA 評分（33．15±3．78）分，B 組 UCLA 評分（32．68±3．95）分，兩組間肩關(guān)節(jié)功能恢復(fù)差異無統(tǒng)計學(xué)意義（t＝0．457，P＞0．05，圖7）。

A組平均隨訪時間為（11．34±2．03）個月（8～15個月），UCLA評分自術(shù)前（9．43±1．34）分改善到術(shù)后末次隨訪（33．15±3．78）分，其中 UCLA評分分級優(yōu)有21人（66%），良有7人（22%），一般有3人（9%），差有1 人（3%），優(yōu)良率為 88%；B 組平均 隨訪時間為（11．20±1．89）個月（8～15個月），UCLA評分自術(shù)前（9．64±1．41）分改善到術(shù)后末次隨訪（32．68±3．95）分，其中按照 UCLA評分分級優(yōu)13人（52%），良8人（32%），一般3人（12%），差1人（4%），優(yōu)良率為84%（圖8）。

圖7 兩組患者不同時間段UCLA評分變化趨勢圖

圖8 兩組患者末次隨訪中UCLA評分分級情況比較

討 論

Bigliani于1986年介紹了一種肩峰分類的方法，其中Ⅰ型為平坦型，Ⅱ型為彎曲型，Ⅲ型為鉤型。這種肩峰的分類方法簡便、易用，通過一張岡上肌出口位X線片即可實現(xiàn)，盡管后續(xù)改良肩峰分型［1］及四型肩峰［2］相繼提出，臨床中肩峰的三度分型接受度最高、應(yīng)用最廣泛。

作者于臨床中發(fā)現(xiàn)Ⅰ型肩峰前外側(cè)緣較平坦，對肩峰下間隙的影響較小，即使肩袖退變導(dǎo)致其限制肱骨頭的作用減弱，在抬臂過肩時肱骨頭的上移也很難造成肩峰下間隙的過度狹窄而導(dǎo)致肩袖與肩峰產(chǎn)生撞擊。Ⅰ型肩峰的肩峰撞擊征患者其癥狀產(chǎn)生多與肩袖退變引起的撕裂或者肩峰下滑囊炎存在直接關(guān)系；而Ⅲ型肩峰由于其末端向下彎曲，肩峰下間隙極度縮窄，并且Ⅲ型肩峰牽拉性骨刺發(fā)生率明顯高于Ⅰ型與Ⅱ型肩峰［3］，牽拉性骨刺產(chǎn)生進一步縮窄了肩峰下間隙，加劇了肩袖與肩峰前外側(cè)撞擊的幾率［4］。并且術(shù)中發(fā)現(xiàn)隨著年齡的增加Ⅲ型肩峰的出現(xiàn)幾率也隨之增加，文獻中存在報道喙肩韌帶的牽拉是導(dǎo)致Ⅲ型肩峰形成的一個重要誘因［5］。

肩峰成形作為Neer［6］的重要成就之一在臨床應(yīng)用十分廣泛，其對肩峰前1/3的切除有效的解除了抬臂過肩過程中肩峰與肩袖間產(chǎn)生的高壓力。Ellman［7］在肩峰撞擊征的治療中將關(guān)節(jié)鏡的引入改變了傳統(tǒng)的切開治療方式，其較小的侵入性、相對短的住院周期及短時間內(nèi)即可恢復(fù)工作等優(yōu)勢讓其逐漸取代了傳統(tǒng)的切開手術(shù)［8－9］。

肩峰成形是在外因主導(dǎo)的前提下提出的，即肩峰撞擊征的病因主要以出口的狹窄為主，人為的增加出口的高度理論上可避免撞擊的再次發(fā)生。但越來越多的學(xué)者［10－11］發(fā)現(xiàn)退行性病變因素在肩峰撞擊征的發(fā)生中占有更重要的地位。退變因素的發(fā)生主要與頻繁抬臂過肩運動有關(guān)，如擲類運動員、游泳運動員、重體力勞動者。頻繁負荷造成肩袖肌腱的疲勞性力弱，一方面導(dǎo)致其對抗肱骨頭的作用降低，在抬臂過肩時引起繼發(fā)性撞擊發(fā)生；另一方面肩袖肌腱過度負荷導(dǎo)致肱骨大結(jié)節(jié)止點處出現(xiàn)撕裂引起癥狀（這種撕裂多發(fā)生于肩袖關(guān)節(jié)面［12］）。

基于此病因作者認為肩峰成形的實施雖可有效緩解癥狀，但并不能解決退變問題的發(fā)生、發(fā)展，并且肩峰前外側(cè)的切除及喙肩韌帶的離斷是以犧牲肩關(guān)節(jié)的穩(wěn)定性為代價。喙肩韌帶，肩關(guān)節(jié)運動的重要靜態(tài)穩(wěn)定結(jié)構(gòu)，切除后將進一步加劇肩袖肌腱的負荷承受［13］，理論上將加劇肩袖退變的發(fā)生［14］。在強調(diào)喙肩韌帶重要作用的驅(qū)動下部分學(xué)者開始探索肩峰成形中喙肩韌帶的保留可能［15－16］。

2005年Budoff等［17］介紹了通過單純清理術(shù)的方式治療肩峰撞擊征，平均隨訪了114個月取得了79%的優(yōu)良率。隨后相關(guān)關(guān)節(jié)鏡下清理術(shù)的報道［18］都取得了不差于肩峰成形術(shù)的效果。病變肩袖肌腱及滑囊的徹底清理緩解了患者的癥狀，而喙肩韌帶完整性及肩峰前外部位保留，避免了對肩關(guān)節(jié)穩(wěn)定結(jié)構(gòu)的破壞。

在目前體育運動日漸流行的前提下，術(shù)后能繼續(xù)參與高強度體育運動是患者希望通過手術(shù)達到的主要目的。作者接觸的患者群體中普遍對肩部穩(wěn)定性的要求較高，而肩部的退行性改變，如牽拉性骨刺或者Ⅲ型肩峰并不常見，因此盡量保留其穩(wěn)定結(jié)構(gòu)如喙肩韌帶等對這一患者群體具有積極意義。

目前的共識是對于大部分Ⅰ型肩峰患者可單純行關(guān)節(jié)鏡下肩峰下清理術(shù)，而對于Ⅲ型肩峰患者，考慮到大多數(shù)患者存在肩峰下間隙的過于狹窄，作者認為外因仍占主導(dǎo)地位，行關(guān)節(jié)鏡下肩峰成形術(shù)成為了最適合的治療手段。2004年Gartsman等［19］學(xué)者發(fā)表了一篇前瞻性隨機研究將Ⅱ型肩峰作為樣本納入條件，而對于Ⅱ型肩峰并沒有過多討論。而本研究則是以Ⅱ型肩峰為強調(diào)內(nèi)容進行的手術(shù)對比分析。

本研究樣本量較小及時間較短，需要臨床更大樣本量及長期隨訪的數(shù)據(jù)支持。本文的目的在于探索個體化治療在臨床中的應(yīng)用。Ⅱ型肩峰術(shù)式研究只是邁出重要的一小步，在這一成熟領(lǐng)域仍然有很多問題亟待各位關(guān)節(jié)外科或者運動醫(yī)學(xué)方面的學(xué)者去解決。謹以此希望為肩峰撞擊征的治療提供微薄之力。

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Clinical outcomes of arthroscopic acromioplasty versus arthroscopic subacromial debridement for curved acromion in subacromial impingement syndrome

Su Yuliang，Yang Liang．Department of Jiont Surgery，the Second Hospital of Dalian Medical University，Dalian 116023，China
C
orresponding author：Yang Liang，Email：yangliangyang＠126．com

BackgroundSubacromial impingement syndrome is one of the main cause of shoulder pain．When the satisfactory effect is not achieved with at least 3months of conservative treatments including diathermy，hot compress and subacromial injection of the narcotic drugs，surgery becomes a reliable option for relieving the symptoms．Nowadays，arthroscopic acromioplasty and arthroscopic subacromial debridement are the two most commonly used surgical approaches in treating the subacromial impingement syndrome．The purpose of this study is to discuss the efficiency comparison between arthroscopic acromioplasty and arthroscopic subacromial debridement and their applicational values in better treating the type II acromion with subacromial impingement syndrome．Methods（1）General data．From June 2013to December 2014，57patients have been diagnosed with the type II acromion with subacromial impingement syndrome using the radiography in the second hospital of Dalian medical university．Through prospective randomized controlled method，patients were randomly assigned into 2groups：32patients（20male and 12female）in the arthroscopic acromioplasty group with a mean age of（51．53±8．87）years（39to 68years）；25patients（13male and 12female）in the arthroscopic subacromial debridement group with a mean age of（53．52±8．53）years（42to 70years）．Before the surgery was considered，all patients were suffered from shoulder pain and limited scope of active activities．The following specialized examinations were done：Neer sign（＋），Hawkins sign（＋），Job test（－），painful arc：60－120°．The X－ray of the exit position of supraspinatus muscle suggested the type II acromion．All patients who followed the protocol of conservative treatment with a mean time of（7．95±3．65）months（3to 18months）did not meet their satisfaction．The patients with rotator cuff fractures suggested by MRI and other structural disorders of the shoulder including glenohumeral instability，frozen shoulder，Bankart damage and acromioclavicular arthritis were excluded from this study．（2）Operation method．The patient was kept with lateral position，and the trunk leaned back to 30degrees with the shoulder abduction of 45 degrees．The forerake was 15degrees，and the traction weight was about 3kg．The glenohumeral joint was accessed from the standard posterior approach to explore glenohumeral labrum，subscapularis muscle，joint capsule ligament and long head of biceps tendon complex．Presences of the fracture on the bottom surface of the upper rotator cuff and the inflammation and wearing at the tendon sheath of the long head of biceps brachii muscle were further examined．①The arthroscopic subacromial debridement．After the glenohumeral joint examination，the subacromial space was accessed from the same posterior approach．The slippery bursa tissue was removed through the anterolateral approach in order to exposed the rotator cuff tendon．The healthy rotator cuff tendon is white，shiny，and the tendon fibers neatly arrange in parallel．However，the rotator cuff that undergoes pathological changes is gray，dark and disordered．While small torn existed in the rotator cuff tendon of individual patients，strengthen by suture was not required as the thickness of the tendon was enough to maintain the normal function of the rotator cuff．It is necessary to use the plane cutter to clean up the denatured shoulder sleeve tendon tissue along the shoulder sleeve fiber because the degenerate tissue is one of the main factors that cause the symptoms．②The arthroscopic acromioplasty．On the basis of simple cleaning，the arthroscopy lens accessed in to observe from the posterior approach．Then，the end of coracoacromial ligament of the anterolateral acromial was dissociated from the lateral approach to exposed the subacromial surface．Similar to the description of the type II acromion，it was found that the anterolateral margin of the acromion was slightly curved．The hyperplasia bone spur was even probed at the end of the curved acromion for some patients．The 3．5mm grinding head was applied to flatten the curved anterolateral margin of the acromion．In order to ensure that the surface of the acromion is flat，the lens and the grinding head exchange approaches by having the anterolateral approach for observation and the posterior approach for supplemental polishing by the；grinding head．（3）Postoperative management．Rehabilitation exercise was performed starting from the second day after operation．From 1week to 6weeks，the passive activity was executed to avoid the joint adhesion．During the same period，the passive range of motion of the shoulder was also under recovery through practices．From 7weeks to 12weeks，the strengths of the rotator cuff muscle and the deltoid muscle were recovered via active exercise．From 4months to 6months，the low antagonistic movement or the low frequency movement of arm lifting over the shoulder was encouraged to participate appropriately．From 6months to 12months，the high－intensity combat sports or the high frequency movement of arm lifting over the shoulder was recommended to be tried．（4）Follow－up and curative effect evaluation．After the operation，the patients were followed up at the time point of 1week，6weeks，12 weeks．The contents of the follow－up included：functional exercises，active and passive activities of the affected limb，and the muscle strength of the affected limb．The University of California at Los Angeles（UCLA）shoulder score was regularly used to evaluate the shoulder joint function of the two groups of patients preoperatively and postoperatively．The pain and the functional evaluation include a score range of 10points：0point for the worst and 10points for the best；The activity，the muscle strength and the satisfactory evaluation include a score range of 5points：0points for the worst and 5 points for the best；The UCLA evaluation has a full score of 35points：34－35for excellence；28－33for good；21－27for acceptable；0－20for poor．ResultsTwo groups of patients with a total number of 57 cases were all followed－up，and the second operation caused by the worsening of the symptoms was never required．Furthermore，other disease that affects the shoulder symptoms did not occur．The symptom，the function and the UCLA evaluation of the majority of patients have obviousimprovements after the surgery．The arthroscopic acromioplasty group gets the preoperative UCLA score of （9．43 ± 1．34）points，and the arthroscopic subacromial debridement group get the preoperative UCLA score of（9．64±1．41）points．There is no significant statistical difference between the joint function of the two groups of patients （P ＞0．05）．After 1week，the arthroscopic acromioplasty group gets the UCLA score of（14．19±1．73）points．During the same period，the arthroscopic subacromial debridement group get the UCLA score of（14．60±1．44）points．There is no significant improvement of the shoulder joint function for both groups 1week after the operation（P＞0．05），and there is no significant statistical difference between the two groups（P ＞0．05）．After 6 weeks，the arthroscopic acromioplasty group gets the UCLA score of（20．56±2．69）points．At the same time，the arthroscopic subacromial debridement group get the UCLA score of（22．16±2．46）points．There is significant improvement of the shoulder joint function for both groups 6weeks after the surgery（P ＞0．05），and there is no significant statistical difference between the two groups（P＞0．05）．After 12weeks，the arthroscopic acromioplasty group gets the UCLA score of（26．47±3．26）points．At the same time，the arthroscopic subacromial debridement group get the UCLA score of（27．00±3．41）points．There is significant improvement of the shoulder joint function for both groups 12 weeks after the operation（P ＞0．05），and there is no significant statistical difference between the two groups（P ＞0．05）．During the last follow－up，the arthroscopic acromioplasty group gets the UCLA score of（33．15±3．78）points．Meanwhile，the arthroscopic subacromial debridement group get the UCLA score of（32．68±3．95）points．There is no significant statistical difference between the recovery of the shoulder joint function of the two groups （P ＞0．05）．After （11．34±2．03）months （8－15 months）of follow－up，the UCLA score of the arthroscopic acromioplasty group increases from （9．43±1．34）points to（33．15±3．78）points．After（11．20±1．89）months of follow－up，the UCLA score of the arthroscopic subacromial debridement group increases from （9．64±1．41）points to （32．68±3．95）points．The percentages of good and excellent are found to be 88%for the arthroscopic acromioplasty group and 84%for the arthroscopic subacromial debridement group．Conclusions While both surgical methods can significantly relieve the symptoms of patients with type II acromion，the arthroscopic subacromial debridement has advantages in treating the curved acromion．

Impingement syndrome；Curved acromion；Acromioplasty；Debridement

2016－04－22）

（本文編輯：胡桂英；英文編輯：陳建海、張曉萌、張立佳）

10．3877/cma．j．issn．2095－5790．2017．01．008

116023 大連醫(yī)科大學(xué)附屬第二醫(yī)院關(guān)節(jié)外科

楊梁，Email：yangliangyang＠126．com

蘇雨亮，楊梁．肩峰撞擊征二型肩峰行關(guān)節(jié)鏡下肩峰成形術(shù)與關(guān)節(jié)鏡下單純肩峰下清理術(shù)療效比較 ［J/CD］．中華肩肘外科電子雜志，2017，5（1）：47－53．