Name: 一种新型关节镜内侧结结缝合桥修复术，采用防撕防技术治疗肩袖撕裂 (视频) | JoVE Journal
Uploaded: 2026-01-13T14:00:00.000+00:00
Duration: 6 min 41 s
Description: 了解关节镜内侧结结缝合桥修复术结合防撕防技术治疗肩袖撕裂的方法。该技术通过优化生物力学性能促进肌腱愈合并降低再撕裂风险，为骨科手术提供新选择。

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特别感谢 Hui Yu 提供的示意图。

已获得患者同意发表的知情同意书，且本手术方案已获本院机构审查委员会批准（批准号：K2022-077-00）。
注意：纳入与排除标准如下： 
纳入标准包括：(i) 有症状的全层肩袖撕裂。(ii) 保守治疗失败。(iii) 双排缝合修复。(iv) 完全修复。 
排除标准包括：(i) 无法修复的肩袖撕裂。(ii) 部分厚度的肩袖撕裂。(iii) Goutallier分级 &#62; 3。(iv) 肩盂肱关节的关节炎性改变。(v) 神经受累。
1. 手术操作
<ol>
	<li>患者体位与入路定位
	<ol>
		<li>在实施全身麻醉和臂丛神经阻滞后，将患者置于侧卧位。确定并标记关节镜手术所需的入路位置（图1A）。</li>
		<li>以无菌方式铺巾。对患侧肩关节施加6 kg的牵引重量（图1B）。</li>
	</ol>
	</li>
	<li>诊断性关节镜检查
	<ol>
		<li>通过后方入路将关节镜置入盂肱关节。</li>
		<li>经肩袖间隙建立前方入路，并全面检查所有关节内结构。如有必要，此时可行肱二头肌长头腱切断术或腱固定术，并修复肩胛下肌。</li>
		<li>将关节镜转入肩峰下间隙，建立前外侧和后外侧入路。</li>
		<li>行肩峰下囊切除术和肩峰成形术。清理撕裂边缘，以明确撕裂形态（图2A）。</li>
		<li>使用缝线抓取器暂时复位撕裂的肩袖肌腱。评估是否需要松解肌腱，并选择最合适的固定方法（图2B）。</li>
	</ol>
	</li>
	<li>内侧缝合锚钉置入
	<ol>
		<li>准备骨面，在大结节关节缘处通过前方入路置入2枚双线缝合锚钉（4.5 mm BR Anchor）。</li>
		<li>将第一枚锚钉置于大结节前内侧、靠近肱二头肌沟的位置，经前方入路置入。</li>
		<li>通过后外侧入路，在第一枚锚钉后方1.5 cm处置入第二枚锚钉（图3）。</li>
	</ol>
	</li>
	<li>缝线穿引
	<ol>
		<li>使用左/右弯缝线钩（缝线钩，45°弯角），同时将来自第一枚锚钉的一条紫色缝线和一条条纹缝线经冈上肌肌腱止点近端约2–3 mm处的前部穿入，位置位于肌腱连接处外侧。</li>
		<li>依次将来自第一枚锚钉的紫色和条纹缝线的另一端从前向后穿过撕裂的冈上肌肌腱，穿刺点位于前一穿刺点后方。确保缝线在撕裂肌腱的前半部分均匀分布。</li>
		<li>以类似方式将来自第二枚锚钉的缝线穿过冈上肌肌腱，确保缝线在撕裂肌腱的后半部分均匀分布（图4）。</li>
	</ol>
	</li>
	<li>缝线管理
	<ol>
		<li>从前外侧入路拉出第一枚锚钉的两条条纹缝线末端，并用滑动结固定，将结置于第一枚锚钉后方条纹缝线穿出点处。</li>
		<li>拉出第二枚锚钉的两条紫色缝线末端，用滑动结打结，并将结置于第二枚锚钉前方紫色缝线穿出点处。</li>
	</ol>
	</li>
	<li>外侧无结缝合锚钉置入
	<ol>
		<li>在大结节外侧皮质上钻一个导向孔，使其与第一枚内侧锚钉对齐。</li>
		<li>将来自第一枚内侧锚钉的2条紫色缝线和1条条纹缝线，以及来自第二枚内侧锚钉的1条紫色缝线，共同穿入无结锚钉（4.75 mm Knotless BR Anchor）的孔眼中。</li>
		<li>确保缝线张力适当，将无结锚钉旋入预备好的骨孔中。</li>
		<li>重复上述步骤，置入第二枚无结锚钉（图5）。</li>
	</ol>
	</li>
</ol>
2. 术后方案
<ol>
	<li>康复
	<ol>
		<li>术后将肩部用吊带固定6周。</li>
		<li>术后3周开始进行被动活动度训练，并在术后6周逐步过渡到主动活动度训练。</li>
		<li>术后12周开始进行力量训练。</li>
	</ol>
	</li>
	<li>随访
	<ol>
		<li>常规随访就诊可使医疗团队跟踪患者的恢复情况，并提供康复指导。</li>
		<li>在术后3个月、6个月和12个月时评估肩关节功能，并在术后12个月随访时进行MRI检查以评估肌腱愈合情况。 
		注：术后1年MRI检查中，Sugaya 1、2和3型定义为肌腱愈合，而Sugaya 4型和5型视为再撕裂24。MRI由两名肌肉骨骼放射科医师独立评估，分歧通过共识解决。</li>
	</ol>
	</li>
</ol>

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<li>Bills, C. C., Field, E. D., Field, L. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((%26%2334%3BDouble-row+rip-stop%26%2334%3B+technique+for+arthroscopic+rotator+cuff+repair%5BTitle%5D)+AND+%22Arthrosc+Tech%22%5BJournal%5D)">&#34;Double-row rip-stop&#34; technique for arthroscopic rotator cuff repair.</a> Arthrosc Tech. 6 (5), e2053-e2059 (2017).</li>
<li>Ma, C. B., Comerford, L., Wilson, J., Puttlitz, C. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Biomechanical+evaluation+of+arthroscopic+rotator+cuff+repairs%3A+Double-row+compared+with+single-row+fixation%5BTitle%5D)+AND+%22J+Bone+Joint+Surg+Am%22%5BJournal%5D)">Biomechanical evaluation of arthroscopic rotator cuff repairs: Double-row compared with single-row fixation.</a> J Bone Joint Surg Am. 88 (2), 403-410 (2006).</li>
<li>Castagna, A., Garofalo, R., Conti, M., Borroni, M., Snyder, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Arthroscopic+rotator+cuff+repair+using+a+triple-loaded+suture+anchor+and+a+modified+Mason-Allen+technique+%28Alex+stitch%29%5BTitle%5D)+AND+%22Arthroscopy%22%5BJournal%5D)">Arthroscopic rotator cuff repair using a triple-loaded suture anchor and a modified Mason-Allen technique (Alex stitch).</a> Arthroscopy. 23 (4), 440.e1-440.e4 (2007).</li>
<li>Rhee, Y. G., Cho, N. S., Parke, C. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Arthroscopic+rotator+cuff+repair+using+modified+Mason-Allen+medial+row+stitch%3AKnotless+versus+knot-tying+suture+bridge+technique%5BTitle%5D)+AND+%22Am+J+Sports+Med%22%5BJournal%5D)">Arthroscopic rotator cuff repair using modified Mason-Allen medial row stitch:Knotless versus knot-tying suture bridge technique.</a> Am J Sports Med. 40 (11), 2440-2447 (2012).</li>
<li>Fang, C. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Modified+double-pulley+and+rip-stop+suture+bridge+technique+in+arthroscopic+rotator+cuff+repair%5BTitle%5D)+AND+%22Arthrosc+Tech%22%5BJournal%5D)">Modified double-pulley and rip-stop suture bridge technique in arthroscopic rotator cuff repair.</a> Arthrosc Tech. 12 (2), e301-e305 (2023).</li>
</ol>

作者声明，他们不存在任何已知的相互竞争的财务利益或个人关系，这些利益或关系可能被认为影响了本文所报告的工作。

近年来，各种缝线桥接修复技术的发展显著推动了肩袖撕裂的治疗5,6,7,11,12。尽管这些技术在临床上取得了成功，但在增强肌腱-骨愈合和降低再撕裂率方面仍存在挑战。实现成功愈合的一个关键因素是在关节处建立严密的封闭，以防止滑膜液和滑囊中的基质金属蛋白酶和炎性细胞因子（已知对愈合有害的物质）渗入肌腱-骨界面26,27。其他研究表明，与无结技术相比，内侧打结构型能够提供更有效的密闭封闭，这是通过增加压迫面积和压力实现的，有助于最小化愈合部位的间隙形成13。此外，初始固定强度是决定肌腱-骨持久愈合的关键因素。生物力学研究显示，内侧打结式缝线桥接修复具有更优的...

肩袖撕裂仍是肩关节外科医生最常见的病理问题，其发病率随年龄增长而升高1,2,3,4。关节镜下缝线桥技术已成为将撕裂的肩袖肌腱重新附着于肱骨近端大结节解剖止点的广泛应用方法5,6,7。该技术不仅具有更优的生物力学特性，而且与传统的单排和双排修复技术相比，愈合率更高7,8,9,10,11,12。
根据内排缝线是否打结，缝线桥接修复术可进一步分类。既往研究表明，与无结构型相比，包含内排打结的修复方式可显著增加足印区接触面积和界面压力，提高失效负载强度，并提供更佳的稳定性和刚度13,14,15。尽管具有上述优势，再撕裂仍是常见的并发症，其中大多数发生在内排打结的缝线桥接修复术中的内侧部位（2型再撕裂）5,7,16。
由于肌腱-缝线界面似乎是修复结构中最薄弱的环节，缝线切割脱出被认为是导致2型再撕裂的重要因素17,18,19。鉴于2型再撕裂常伴随较差的功能预后以及复杂的翻修手术，迫切需要优化现有的内侧打结缝线桥接修复技术5,20。止裂式缝合构型已显示出减少缝线切割脱出的潜力，从而增强缝线-肌腱界面的完整性21,22,23。基于此，我们提出一种新的手术技术，将止裂式构型整合到内侧打结缝线桥接修复中。该技术旨在改善肌腱愈合，降低中小型至巨大、可复位的肩袖撕裂且肌腱质量较差患者的再撕裂风险。

<table><tbody><tr><td>4.5 mm HEALIX ADVANCE BR 锚钉</td><td>Depuy Mitek</td><td>222296</td><td>内侧锚钉&amp;nbsp;</td></tr><tr><td>4.75 mm HEALIX ADVANCE BR 锚钉</td><td>Depuy Mitek</td><td>222330</td><td>外侧锚钉</td></tr><tr><td>Spectrum I 缝线钩，45&amp;deg;左弯</td><td>Conmed</td><td>97.14115</td><td></td></tr><tr><td>Spectrum I 缝线钩，45&amp;deg;右弯</td><td>Conmed</td><td>97.14215</td><td></td></tr><tr><td>缝线抓取器</td><td>Arthrex</td><td>AR-13971W</td><td></td></tr></tbody></table>

一种新型关节镜下内侧打结缝合桥修复联合防撕脱技术治疗肩袖撕裂

A Novel Arthroscopic Medial Knot-Tying Suture-Bridge Repair with Rip-Stop Technique for Rotator Cuff Tears

肩袖撕裂仍是肩关节外科医生面临的最常见损伤之一。尽管关节镜下缝线桥修复术已展现出更优的生物力学特性并取得了令人满意的临床效果，但肌腱再撕裂仍是持续存在的难题。为解决这一问题，我们对现有修复技术进行了多项改进。其中一项改进是在缝线桥修复中加入内侧打结，这可以减少间隙形成，实现密闭性修复，从而促进肌腱-骨愈合。另一项关键改进是在内排缝线中采用防撕裂（rip-stop）构型，该构型可降低缝线切割肌腱的风险，增强缝线-肌腱界面的抗拉强度，并减少II型再撕裂的发生风险。因此，我们提出一种新型混合修复技术，将内侧打结的缝线桥修复与防撕裂构型整合为单一结构。此外，该新修复技术还可减少所需的缝线穿引次数和缝线锚钉数量，从而简化手术操作流程。综上所述，该方法为肩袖撕裂的治疗提供了一种可行且有效的替代方案，可能有助于降低术后再撕裂的发生率。

一名65岁女性患者因右侧肩关节中等大小的肩袖撕裂，由一位具有20年以上临床经验的资深肩关节外科医生采用所述技术进行了关节镜下肩袖修复术。术后1年随访时，其视觉模拟评分（VAS）疼痛评分由术前的6分显著改善至0分。美国肩肘外科医师评分（ASES）从53.33分显著提高至91.67分。患者肩关节活动范围完全恢复，前屈达165º，外旋达60º，内旋可达T10水平，与健侧相当（图7）。术后1年MRI检查证实肩袖肌腱已完全愈合（图8）。未观察到任何术后并发症。
<img alt="肩关节镜手术的术中标记与设置，骨科手术，患者体位。" class="xfigimg" src="/files/ftp_upload/68388/68388fig1.jpg" data-altupdatedat="1773720005000" data-alt="图1"> 
<strong class="xf...

本方案介绍了一种优化的肩袖修复技术，该技术结合了内侧打结缝线桥接修复与防撕裂配置，旨在促进肩袖愈合并最大限度降低再撕裂风险。

肩袖撕裂仍是肩关节外科医生最常见的损伤之一。尽管关节镜下缝线桥修复术已证明……

肩袖撕裂较为常见，由于关节镜下缝线桥技术在内侧打结具有更优的生物力学特性和更高的愈合率，因此被广泛应用。然而，因缝线在内侧切割导致的II型再撕裂仍是一个挑战，而在修复中引入防撕脱（rip-stop）结构可能改善肌腱愈合并降低再撕裂风险。本视频中，我们将介绍用于肩袖撕裂的关节镜下内侧打结缝线桥联合防撕脱技术的修复方法。已获得患者知情同意，同意发表本病例资料，且本研究已通过我院机构审查委员会批准。我们的手术方案包含以下步骤：在实施全身麻醉和臂丛神经阻滞后，将患者置于侧卧位。确定并标记关节镜手术所需的入路位置。以无菌方式处理患者，并在患侧肩部施加6公斤重物进行牵引。全面检查所有关节内结构。必要时在此阶段行肱二头肌长头腱切断术或固定术，并修复肩胛下肌。进行肩峰下囊切除术和肩峰成形术。清理撕裂边缘以确定撕裂模式。使用缝线抓取器暂时复位撕裂的肩袖肌腱。准备骨床。在肱骨大结节的关节边缘插入两个双排缝合锚钉。通过前侧入路，将第一个锚钉置于靠近肱二头肌沟的肱骨大结节内中区域。通过后外侧入路，在第一个锚钉后方1.5厘米处放置第二个锚钉。使用缝合钩，将第一个锚钉的一条紫色缝线和一条条纹缝线同时穿过冈上肌前部，位置位于肌腱-肌肉连接处外侧约2至3毫米处。随后，将第一个锚钉的紫色缝线和条纹缝线的另一端依次从前方到后方穿过撕裂的冈上肌腱，穿刺点位于前次穿刺位置的后侧。确保缝线肢均匀分布在撕裂的肩袖肌腱前半部分。将第二个锚钉的缝线肢以类似于第一个锚钉缝线肢的方式穿过冈上肌。确保缝线肢均匀分布在撕裂肌腱的后半部分。从第一个锚钉拉出条纹缝线的两端，经前外侧入路，用滑动结固定，并将结置于第一条纹缝线后侧支穿出的位置。从第二个锚钉拉出紫色缝线的两端，用滑动结打结，并将结置于第二紫色缝线前侧支穿出的位置。然后将来自第一个内侧锚钉的两根紫色缝线支、一根条纹缝线支，以及来自第二个内侧锚钉的一根紫色缝线支，一同穿过无结锚钉的附加孔道。确保未来缝线的张力适当，并将无结锚钉置入预备好的骨孔中。重复上一步骤以置入第二枚无结锚钉。关节镜下评估肩袖修复的完整性。术后一年，患者疼痛显著缓解，肩关节功能完全恢复，活动范围正常。术后一年的MRI检查证实肩袖肌腱已完全愈合。综上所述，我们认为采用内侧打结缝线桥技术结合防撕裂配置的修复方法，既能改善愈合环境，又能降低再撕裂风险，为肩袖撕裂提供了一种更优的治疗选择。

a-novel-arthroscopic-medial-knot-tying-suture-bridge-repair-with-rip

Research

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JoVE Journal

Medicine

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一种新型关节镜内侧结结缝合桥修复术，采用防撕防技术治疗肩袖撕裂

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