肱二头肌长头

ClassificationandAnalysisofPathologyoftheLongHeadof

theBicepsTendoninCompleteRotatorCuffTears

Chien-HaoChen,MD;Chih-HwaChen,MD;Chih-HsiangChang,MD;Chun-ISu,MD;

Kun-ChungWang,MD;I-ChunWang,MD;Hsien-TaoLiu,MD;Chung-MingYu,MD;

Kuo-YaoHsu1,MD

Background:Pathologyofthelongheadofthebicepstendon(LHB)iscommonlyassoci-

atedwithrotatorcufftears(RCTs).Superiorlabralanterior-posterior(SLAP)

poofthisstudywastoinclude

SLAPlesionsaspartofLHBpathologyinsurgicalcasofRCTanddefine

theroleofSLAPlesionsinRCTs.

Methods:Weretrospectivelyevaluatedclinicaldatafrom176casofcompleteRCT

surgery,theLHBwasarthroscopicallyexam-

ied6-typeclassificationwasudtodescribetheLHBpatholo-

gyinthecas:tendinitis,subluxation,dislocation,partialtear,complete

ationshipofLHBpathologytodifferent

characteristicsofRCTswasstatisticallyanalyzed.

Results:OfRCTcas,33%hadType1(tendinitis),11%hadType2(subluxation),

9%hadType3(dislocation),16%hadType4(partialtear),7%hadType5

(completerupture)and6%hadType6(SLAP)aining18%

hologywereassociated

withRCTsofalongduration(>3months),largearea(>5cm2),andmulti-

yfourpercentofpatients

withaffectedshouldersunderwentsimultaneoussurgeryforbothLHB

pathologyandRCTs.

Conclusion:MostpatientwithRCTswithchronic,massive,andmultipleorsubscapularis

sions,whichweclassified

asasubgroupofLHBpathology,shouldbeidentifiedduringrotatorcuff

surgeryandtreatedappropriately.

(ChangGungMedJ2012;35:263-70)

Keywords:longheadofbicepstendon,rotatorcufftears,SLAPlesions

FromtheDepartmentofOrthopaedicSurgery,ChangGungMemorialHospitalatKeelung;1DepartmentofOrthopaedicSurgery,

ChangGungMemorialHospitalatLinkou,ChangGungUniversityCollegeofMedicine,Taoyuan,Taiwan.

Received:July11,2011;Accepted:Dec.7,2011

Correspondenceto:-HwaChen,DepartmentofOrthopaedicSurgery,ChangGungMemorialHospitalatKeelung.222,

MaijinRd.,AnleDistrict,KeelungCity204,Taiwan(R.O.C.)Tel:886-2-24313131ext.2613;Fax:886-2-24332655;

E-mail:afachen@

Fullthicknessrotatorcufftears(RCTs)isoneof

themostcommonlesionsaffectingtheshoulder

ionsassociatedwithRCTsinclude

acromioclacivulararthritis,pathologyofthelong

headofthebicepstendon(LHB),andlabrallesions.

TheanatomicnatureoftherotatorcuffandLHB

meansthatthetwostructuresareusuallyinjuredat

thesametime,orasaconquenceofinjurytoeither

263OriginalArticle

ChangGungMedJVol.35No.3

May-June2012

Chien-HaoChen,etal

RotatorcufftearsandSLAPlesions

264

almodels,themechanicalpropertiesof

theLHBarealteredintheprenceofRCTs.(1)

ImpingementoftheLHBandthesupraspinatusten-

donorbicepsinstabilitycaudbytearsofthesub-

scapularistendoncouldresultinbicepstendon

ionswerefoundin76%of

patientsreceivingarthroscopicrepairofRCTs.(2)Gill

etalreportedaprevalenceof5%ofpartialtearsof

theLHBin847shoulderarthroscopicexaminations,

andoftho,85%wereassociatedwithRCTs.(3)The

overlappingsymptomsofthistwolesions,suchas

shoulderpainandnightpain,mayoftenbewrongly

hetwodifferent

lesionscanoccurtogether,anyLHBpathology

shouldbeidentifiedandtreatedatthesametimeas

RCTsrepairtopreventcompromioftheclinical

tulatedasimplifiedclas-

sificationofLHBlesionstoemphasizeitsassocia-

tionwithRCTs.(2)Thisclassificationincludesfive

typesofLHBpathology,tendinitis,subluxation,dis-

location,partialtearandcompleterupture.

Reviewingtherearch,MillerandSavoie

foundthat74%ofindividualswithfull-thickness

RCTshadassociatedintraarticularlesions,with

labraltearsbeingthemostcommonlyassociateddis-

order.(4)medarthroscopic

examinationoftheglenohumeraljointin200shoul-

dersin195concutivepatientsbeforearthroscopic

rotatorcuffrepair,notingsuperiorlabralanterior-

posterior(SLAP)lesionsinfivepatients.(5)Toour

knowledge,noclassificationsystemhasyetbeen

developedthatincludesSLAPlesionsasatypeof

tudy,

weclassifiedSLAPlesionsasasubgroupofLHB

pathologyinordertocomprehensivelydemonstrate

theirrelationshipwithRCTsandestablishtheroleof

SLAPlesionsinRCTs.

METHODS

Between1993and2005,176shoulderswith

complete,full-thicknessRCTsreceivingarthroscopic

examinationandrotatorcuffrepairatourinstitution

ere

rageageatthetime

ofsurgerywas56.2years(range,23-78years).The

mechanismofrotatorcuffinjury(traumaticor

degenerative)andthetimeintervalfromtheaccident

orontofsymptomstosurgicaltreatmentwere

ticmechanismsincludedmotor

vehicleaccidents,sportsinjuries,andfallsontothe

esinolderpatients

(>60years)withachronicandinsidiousontof

symptomswhichcouldnotbeattributedtoanytrau-

patientsprentedwithvaryingdegreesoffunctional

limitation,includingshoulderpain,weaknessanda

dywasapproved

bythehospitalInstitutionalReviewBoard.

Allpatientsreceivedroutineradiographicexam-

inations(anteroposteri叉烧包 orandaxillaryview)andmag-

neticresonancearthrogramsoftheshoulderpriorto

sticarthroscopywasperformedini-

tially,followedbyopen,mini-open,orarthroscopic

rcuffpatholo-

gyandassociatedinjuriestotheLHBandlabrum

erevalu-

ateLHBpathology,weapplieda6-typeclassifica-

tion,includingcommentsonthebicepsanchor,loca-

tionandintegrity,todescribethelesions,modified

2005.(2)Lesions

wereclassifiedasfollows:Type1(bicepstendinitis),

Type2(subluxationofthebicepstendon),Type3

(dislocationofthebicepstendon),Types4and5

(partialandcompletebicepstendontears,respective-

ly)andType6(SLAPlesions)(Figure).Thesurgical

proceduresforallRCTcasandeachtypeofLHB

pathology,ifprent,ation

FigureWedefinedthesixtypesofpathologyofthelong

headofthebicepsassociatedwithrotatorcufftearsasbiceps

tendinitis(Type1),subluxationofthebicepstendon(Type2),

dislocationofthebicepstendon(Type3),partialbicepsten-

dontears(Type4),completebicepstendontears(Type5)and

superiorlabralanterior-posterior(SLAP)lesions(Type6).

Type1Type2Type3

Type4Type5Type6

ChangGungMedJVol.35No.3

May-June2012

Chien-HaoChen,etal

RotatorcufftearsandSLAPlesions

265

(moreorlessthan3months),size(largerorsmaller

than5cm2),andtheinvolvedtendon(s)ofRCTsin

differenttypesofLHBpathology(orintactbiceps)

>3monthswere

definedaschronicandtho>5cm2weredefinedas

massivetears.

PrinciplesandindicationsfortreatingLHB

pathologyinRCTs

Inourpatients,surgicaltreatmentofconcomi-

tantLHBpathologyinrotatorcuffrepairincluded

debridement,tenotomy,tenodesisandrepairof

ral,weperformeddebride-

reparabletransverhumeralligamentwasidentified

inType2LHBpathology,

Type3LHBpathology,weperformedatenotomyor

tenodesis,dependingonthepatient’sageandactivity

atenotomyforpatients>50years

orthowhohadlowerfunctionaldemands;other-

wi,tialtearLHB

(Type4),ifthetornareawasgrossly>50%,the

principleoftreatmentwasthesameasforbicepsdis-

ornareawas<50%,weperformed

5

LHBpathology,atenodesiswasperformedonlyfor

e6,we

performeddebridementforSLAPtypeI,III,andIV

(iftheareainvolvedwas<30%oftheLHBthick-

ness)anchorrepairwasindicatedfor

allSLAPtypeIIlesions.

Statisticalanalysis

TheincidenceofLHBpathologyfordifferent

typesofRCTswascalculatedandstatisticallyana-

lyzedusingSPSSsoftwareversion12.(SPSSInc.,

Chicago,IL,U.S.A.).ThePearsonchi-squaretest

wasudtoexaminethedifferencesintheincidence

valueof<0.05wasconsideredsignificant.

RESULTS

Inthe176cas,rotatorcuffrepairswereper-

formedin146shoulders,debridementin16shoul-

ders,tendontransferineightshoulders,andashiftto

shoulderreplacementwithaprosthesisinsixshoul-

pleteRCTsresultedfromtraumain93

shoulders(52%)anddegenerationintheremaining

83(48%).Ninety-five(54%)cashadchronic

-one(35%)RCTsweremassivetears

(>5cm2).

IncidenceofLHBpathologyinRCTs

InourstudiedgroupofcompleteRCTs,82%of

caswereassociatedwithLHB(144/176shoul-

ders).Furthermore,72%(67shoulders)oftraumatic

casand92%(77shoulders)ofdegenerativecas

he144

caswithcombinedLHBpathology,40%(58

shoulders)wereclassifiedasType1,13%(19shoul-

ders)asType2,11%(16shoulders)asType3,20%

(29shoulders)asType4,9%(12shoulders)asType

5and7%(10shoulders)nyder

classification,thetencaswithSLAPlesionswere

furtherdiagnodasthreecasoftypeI,twoeach

oftypesIIandIII,rage

ageofpatientswithbothSLAPlesionsandRCTs

rallincidenceofSLAP

lesionsamongthe176casinourstudywas6%

(10/176)(Table1).

WeobrvedthatthecharacteristicsoftheRCTs

significantlyinfluencedtheincidenceofLHB

mple,patientswhohadRCTsfora

,>3months)weremorelikelyto

haveconcomitantLHBpathologycomparedwith

thowhoprentedwithRCTs<3months(97%vs.

64%,p<0.001).Furthermore,patientswithlarge

,>5cm2)weremorelikelytohavecom-

binedLHBpathologythanthowithsmall(<5

cm2)ones(93%vs.76%,p=0.004)(Table1).Of

the176casofcompleteRCTs,52%(92shoulders)

aswerelesslikely

tohaveLHBpathologythanthowithmultiple

tears(71%vs.94%,p<0.001)(Table2).

Bicepsinstabilityandsubscapularistendon

tears

WeobrvedahigherrateofLHBpathologyin

thegroupwithtornsubscapularistendonsthanin

thowithintactones(97%vs.75%,p<0.001).The

incidenceofbicepsinstability(subluxationordislo-

cation)forthowithcompleteRCTswas20%

(35/176shoulders).Weobrvedthatifthesub-

scapularistendonwastorn,bicepsinstabilitywas

obrvedin48%(27/56shoulders)ofcaswith

rast,ifthesubscapularisten-

donwasintact(throughRCTs),only9%(8/88shoul-

ChangGungMedJVol.35No.3

May-June2012

Chien-HaoChen,etal

RotatorcufftearsandSLAPlesions

266

ders)ofLHBpathologywasdefinedasbicepsinsta-

y-ninepercentofcas(15/19shoul-

ders)withType2bicepslesionshadtornsubscapu-

laristendons,versus75%(12/16shoulders)ofType

3bicepslesions(Table2).

TreatmentforLHBpathology

Nineteenof58shoulderswithType1lesions

19shoulders

withType2lesions,debridementwasperformedin

14;theremainingfiveshouldersreceivedrelocation

the16shoulderswithbicepsdislocation(Type3),11

receivedtenotomy,

Type4lesions,debridementorpartialrectionwas

performedin15of29shoulders,tenodesisinnine

shoulders,sis

wasperformedinamajorityofcasofacompletely

tornLHB(8/12shoulders).ForType6lesions,

debridementwasperformedinvenshoulders(two

SLAPtypeI,threeSLAPtypeIIIandtwoSLAP

typeIV);theremainingthreeshoulderswithSLAP

casofSLAPtypeIVlesionsprentedwithtears

of<30%ofthesuperiorlabrum,soonlyexcisionof

l,onehundredand

venshoulders(74%)underwentsurgerytoaddress

simultaneouslesionsoftheLHBandrotatorcufften-

dons.

DISCUSSION

InjurytotheLHBisoftenresponsibleforshoul-

sful

Table edRotatorCuffTendonsinSixTypesofLHBPathologyinPatientswithCompleteRotatorCuffTears

StatusofLHBType1Type2Type3Type4Type5Type6

LHBNormal

totalpvalue

pathologybiceps

Singlerotatorcufftendontear65(71%)27(29%)92<0.001

Supraspinatus3821902

Subscapularis103612

Multiplerotatorcufftendonstears79(94%)5(6%)84

Supra.+Infra.1323963

Supra.+Subs.585432

Supra.+Infra.+Subs.174121

w/71512116556(97%)2(3%)58<0.001

w/5144186588(75%)30(25%)118

Abbreviations: Infra:infraspinatus;Subs:subscapularis;Supra:supraspinatus;LHB:longheadofthebiceps.

Table hologyand别逼我 DurationandSizeofTearsinPatientswithCompleteRotatorCuffTears

StatusofLHBType1Type2Type3Type4Type5Type6

LHBNormal

totalpvalue

pathologybiceps

CasNo.58(40%)19(13%)16(11%)29(20%)12(9%)10(7%)144(82%)32(18%)176

Rotatorcufftearstime

>3months4(97%)3(3%)95

<0.001

<3months1876125452(64%)29(36%)81

Sizeofrotatorcufftear

>5cm28119157757(93%)4(7%)61

0.004

<5cm25087145387(76%)28(24%)115

Abbreviations:LHB:longheadofthebiceps;RCT:rotatorcufftear.

ChangGungMedJVol.35No.3

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Chien-HaoChen,etal

RotatorcufftearsandSLAPlesions

267

rotatorcuffsurgerythereforedependsuponthe

detectionandpropertreatmentofconcomitantbiceps

ferentclassificationsystemsto

describeLHBlesionswereprentedin3different

studies,(2,6,7)buttheyarecomplexanddifficultto

edtheclassi-

ficationofLHBpathologyassociatedwithRCTsinto

fivetypesofbicepslesions:tendinitis(Type1),sub-

luxation(Type2),dislocation(Type3),partialtear

(Type4),andcompleterupture(Type5).(2)

Unfortunately,thefivetypesoflesionwerecon-

finedtothebicepsgrooveanddidnotincludethe

r,inour

practice,weobrvedthatasmallportionofRCTs

occurwithconcomitantSLAPlesions.

ASLAPlesionwasviewedasadistinctclinical

1990.(8)

TheliteraturesuggeststhattheincidenceofSLAP

lesionsinpatientsundergoingshoulderarthroscopy

rangesfrom6-12%.(9)Theinjuriesareclassically

describedasisolatedlesionsinyoungthrowingath-

r,astudyof139patientswithSLAP

lesionssuggestedthatmost(123/139)wereassociat-

edwithotherintraarticularlesions.(10)Snyderetal.

reportedthat29%ofSLAPlesionswereassociated

withpartial-thicknesstearsoftherotatorcuff,and

11%wereassociatedwithfull-thicknesstears.(8)In

Kimetal’smultivariateanalysis,typeISLAP

lesionsweretypicallyassociatedwithRCTs;typeII

SLAPlesionswerespecificallyassociatedwith

supraspinatustearsinpatients>40years.(10)

AlthoughavarietyofmechanismscreateSLAP

lesions,tedthatthemostcom-

monetiologywastractiononthebicepstendon.(11)A

studyof104cadaversfoundthatdegenerative

changesinthebicepstendonoccurredmainlyinthe

distalbicipitalgrooveandneartheoriginoftheten-

donfromthesuperiorpartoftheglenoidlabrum.(12)

Thisstudyidentifiedthesitesmostsubjecttotendon

quentstudyusingabiomechanical

modelelucidatedtherelationshipofinferiorsubluxa-

tionoftheglenohumeraljointandtypeIISLAP

lesions.(13)Analterationintheloadingdirectionof

theLHBrelativetothefibersatthesuperiorglenoid

maypredispothebiceps/labrumcomplextofail-

chanismmayalsoexplainthedevelop-

mentofSLAPlesionsinbicepssubluxation/disloca-

tionasaconquenceofatornsubscapularistendon.

Further,tedamechanismto

explainthequenceofSLAPlesionsandRCTs.(14)

Intheirtheory,thelogicalmechanism,bothtraumat-

icandchronic,causaspecificlesioninvolvingthe

anteriorsuperiorcorneroftheglenohumeralarticula-

tiontoproduceananteriorsuperiorslideofthe

nstabilitycontinues,therotatorcuff

becomesirritated,causingsymptomsthatmaymimic

onceptofanteri-

orsuperiorlabraltearandanteriorsupraspinatous

(cuff)tearcouldalsoexplainthecauofconcomi-

foundlesion-specificRCTsinSLAPlesionswith

shoulderinstabilityandcondarypudolaxity.(15)

Theypositedthatmicroinstabilityinthettingof

SLAPlesionsmayprecipitateacondarystrain

ghthishadnotbeen

definitelyproven,itissupportedbyveralcadave红豆粥的做法 r-

,inbrief,

whetheraSLAPlesionistheconquenceorcau

ofanRCT,itisdefinitelyoneofthemostimportant

findings,ifprent,duringrotator短直发 cuffrepairs.

AlthoughtheincidenceofSLAPlesionsin

patientsreceivingsurgicaltreatmentforRCTswas

relativelylower(6%)inourstudythanthatofother

typesofLHBpathology(Types1-5,76%),SLAP

lesionsreprentauniqueassociatedpathological

odi-

fied6-typeclassificationwedevidforLHBpathol-

ogy,themostcommonlesionwasType1(40%).We

notedaslightlyhigherincidenceofLHBpathology

inourpatientgroupcomparedwiththatofChenet

al.(82%vs.76%,respectively).(2)Thisdifference

mayresultfromourenrollmentofSLAPlesions,

whichwerenotincludedinthefive-typeclassifica-

tionandmayhavebeenregardedasa“normalbiceps

tendon”inChen’gtheSLAPlesionas

asubgroupofLHBpathology,wefoundthatpatients

withchronic(>3months),massive(>5cm2),and

multipleorsubscapularistendoninvolvementin

RCTshadasignificantlyhigherpossibilityofcon-

comitantLHBpathology(Tables1and2).That

meansthatwhenperformingopenorarthroscopic

rotatorcuffrepair,surgeonsshouldcarefullyevaluate

thebicepstendonbothinthebicepsgrooveandatits

inrtionatthelabrum,particularlyinRCTcas

withchronic,massive,andmultipleorsubscapularis

tendoninvolvement.

SurgicaltreatmentforconcomitantLHBpathol-

ogyduringrotatorcuffrepairincludesdebridement,

ChangGungMedJVol.35No.3

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Chien-HaoChen,etal

RotatorcufftearsandSLAPlesions

268

isiondependsonthe

typeornatureofthebicepslesion,thepatient’sage

andactivitylevel,cosmeticconcerns,andtolerance

gicalmanagementofcon-

comitantrotatorcuffandSLAPlesionsremainscon-

troversial,especiallyinmiddle-agedpatients.

Severalrecentstudieshavereportedclinicalout-

comesaftersimultaneoussurgicaltreatmentforthe

twodisorders,

edgoodclinicaloutcomes,restorationof

motionandahighdegreeofpatientsatisfactionafter

combinedarthroscopicrotatorcuffandlabral

repairs.(16)Franceschiandcolleaguesreportedaran-

domizedcontroltrialthatfoundnoadvantagein

repairingatypeIISLAPlesionwhenassociatedwith

anRCTinpatients>50yearsold.(17)Inthispatient

group,theysuggestedthatperformingatenotomyfor

SLAPtypeIIlesioninRCTsrepaircouldprovidea

ed

improvedsatisfactionandfunctionaloutcomesfor

patients>45yearsoldwithconcomitantarthroscop-

icrotatorcuffrepairanddebridementoftypeII

SLAPlesions,comparedwiththowhounderwent

simultaneousrotatorcuffandtypeIISLAPlesion

repair.(18)However,currentlythereisnodefiniterec-

ommendationfortreatingconcomitantSLAPlesions

heless,stabilizingthelabraltear

shouldtheoreticallydecreathetensileloadonthe

dcolleaguesstudiedtheeffect

ofRCTsonsurgicaloutcomesaftertypeIISLAP

lesionrepairinpatients<50years.(19)Theyfound

thatoncetheSLAPlesionisrepairedandthegleno-

humeralstabilityrestored,theprenceofarotator

threepatientswithSLAPtypeIIlesionsinourstudy

allprentedwithmassiverotatorcufftears.

Althoughtheywereolderthan45years(48,53and

58years),westillrepairedtheSLAPlesionswith

sutureanchorsinsteadofdebridementalone,to

restoreglenohumeraljointstabilityandimprovethe

r

reportcomparedconcomitantarthroscopicrepairsof

SLAPlesionsandRCTswithisolatedarthroscopic

rotatorcuffrepair.(20)Thestudyconcludedthatin

middle-白岩松的书 agedpatients,theresultsofcombinedSLAP

lesionandrotatorcuffrepairwerecomparableto

rwords,ifSLAP

lesionsareidentifiedandtreatedproperlyduringthe

surgicaltreatmentofRCTs,theoutcomecanequal

ore,proper

managementofSLAPlesions,iftheyexist,isthe

keytosuccessfultreatmentofcomplicatedRCTs.

Asaretrospectiveandobrvationaldesign,our

,becauofthecom-

plexstructureofshoulder,combineddisordersoften

study,manypatientsprentedwithshoulderdisor-

dersotherthanRCTsandLHBpathology;wedidnot

nswhoperform

shoulderarthroscopicrotatorcuffrepairshouldalso

payattentiontostructuresotherthanLHBpathology.

Failuretoidentifyandaddressothershoulderlesions

mayleadtounsatisfactorysurgicaloutcomes.

Second,thesurgicaloutcomesofpatientswithLHB

pathologyandRCTswerenotprentedinourstudy

follow-uprateandincomplete

recordsforshoulderfunctionandsymptomsinour

patientsaftersurgicaltreatmentmadecollectingsur-

studiesshould

includethedata,aswellaslongerfollow-ups.

Conclusion

Thisstudyisthefirstobrvationalreportto

includeSLAPlesionsintheclassificationofLHB

vid6-type

classificationisamorecomprehensivearthroscopic

hopethattheconceptof6-typeLHBpathologyin

RCTswillremindarthroscopicsurgeonsofthe

importantlabrum-bicepscomplexwhendoingrota-

torcuffrepair,soastoensurepropersurgicalman-

agement.

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࣎୊ᖼఞ৔ෘତఙᒚᓜঽྤफ़ఙ

ீᙯ༼ᙡᑭෛᐝᐝཔ੃ᐂࣇ೩࣎າᙷೡࢗ

ᐝᐝཔঽត჌པ௲௲ొᕝෘ

ᕝෘ

SLAP

ঽ௚ࢍጯᐝᐝཔঽត൴ᄃপ

୊ᖼఞ৔ෘᙯ

ඕ୊ᖼఞ৔ෘఙࣇ൴ன

33%

ঽଈௐཔᐝᐝ

པঽត

11%

ঽଈௐ௲ঽត

9%

ঽଈௐ௲

ঽត

16%

ঽଈௐొᕝෘঽត

7%

ঽଈௐᕝෘ

ঽត

6%

ঽଈௐ

SLAP

ঽঽត౺

18%

ঽଈᐝᐝ

པពঽតॡࣇ൴னᐝᐝཔঽត൴ྵ૱ᄃೀ࣎

ኳ୊ᖼఞཔ৔ෘ࠹ᐌၙ࣎୧୊ᖼఞ৔ෘ৔ෘࢬ᎕

5

ࡨཔ৔ෘ఺ঽଈ

74%

ঽଈॡତᐝ

ᐝཔঽតᖼఞ৔ෘఙᒚ

ඕኢၙቑಛ୧ᇆᜩࡨཔ୊ᖼఞ৔ෘ඗ᇴঽົ

ᐝᐝཔঽត

SLAP

ঽࣇ೩ᙷᛳᐝᐝཔঽត

ᒖࡶྖநᑕ୊ᖼఞ৔ෘ࣒ྃఙॡ໰ঽଈᓜගዋ༊

ᒚ

(

ᗁᄫ

2012;35:263-70)

ᙯᔣෟᐝᐝཔ୊ᖼఞ৔ෘ

SLAP

ঽ

ᗁᒚੑဥૄษࡔᗁੰ੻ࡊ1ᗁᒚੑဥࡔᗁੰ੻ࡊొጯᗁጯੰ

ഇ઼100711ତྶ઼100127

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