文献出处：Bayram S, Akgül T, Özmen E, Kendirci AŞ, Demirel M, Kılıçoğlu Öİ. Critical Limit of Lower-Extremity Lengthening in Total Hip Arthroplasty: An Intraoperative Neuromonitorization Study. J Bone Joint Surg Am. 2020;102(8):664–673. doi:10.2106/JBJS.19.00988
Critical Limit of Lower-Extremity Lengthening in Total Hip Arthroplasty: An Intraoperative Neuromonitorization Study
全髋关节置换术中下肢延长的极限值：
一项术中神经监测研究
译者：张蔷
Background: The effect of limb lengthening on neural structures was assessed with use of intraoperative neuromonitoring (IONM) during primary total hip arthroplasty (THA). The relationship between the critical limit of lengthening and anthropometric measurements was evaluated.
背景：我们在初次全髋关节置换术中利用术中神经监测设备（IONM）测试了下肢延长对神经的影响。然后我们将肢体延长的危机值与人体测量学指标进行了对照。
Methods: Motor evoked potentials (MEPs) from the deep peroneal nerve (tibialis anterior muscle), tibial nerve (gastrocnemius muscle), and femoral nerve (quadriceps muscle), as well as somatosensory evoked potentials (SEPs) from the posterior tibial nerve, were recorded in 16 patients undergoing THA. Height, weight, the distance between the anterior superior iliac spine and the medial malleolus (ASIS-MM distance), and the total femoral length were measured preoperatively. Lower-extremity traction was performed after resection of the femoral head, and the amount of extremity lengthening was measured with use of an image intensifier. A maximum of 50% reduction in any one of the SEP or MEP amplitudes or a 10% increase in the SEP latency were considered to be indicative of the critical limit of lengthening.
方法：我们选择了16例全髋关节置换手术病例，神经监测指标包括源自腓深神经（胫前肌）、胫神经（腓肠肌）和股神经（股四头肌）的运动诱发电位值，以及来自胫后神经的躯体感觉诱发电位。术前测量指标包括身高、体重、髂前上棘到内踝的距离（ASIS-MM）和股骨全长。术中切断股骨头后开始进行下肢牵引，用图像增强器测量肢体延长值。我们将运动诱发电位或躯体感觉诱发电位值下降超过50%或躯体诱发电位延迟期增加超过10%定义为躯体延长的危机状态。
植入电极
术中牵引
Results: Initial IONM changes (indicating the safe limit of lengthening) and maximum allowed IONM changes (indicating the critical limit of lengthening) were reached in the deep peroneal nerve in all cases. The mean safe limit of lengthening (and standard deviation) was 14.9 ± 6.2 mm (3% relative to femoral length and 1.7% relative to ASIS-MM distance), whereas the critical limit of lengthening was exceeded at a mean of 22.4 ± 5.6 mm (5% relative to femoral length and 2.6% relative to ASIS-MM distance). When the critical limit was reached in the deep peroneal nerve, the mean decrease in MEP amplitudes was 27% (95% confidence interval [CI], 22.1% to 32.7%) for the tibial nerve and 12% (95% CI, 6.9% to 18.1%) for the femoral nerve. There was a positive correlation between critical lengthening and femoral length (r = 0.782; p < 0.001), ASIS-MM distance (r = 0.811; p < 0.001), and height (r = 0.835; p = 0.001). No correlation existed between the critical lengthening amount and the decrease in amplitude in the tibial and femoral nerves.
结果：我们在腓深神经测量中达到初始神经监测值（提示肢体延长的安全值）以及允许的最大神经监测值（提示肢体延长的危机值）。肢体延长的平均安全值（和标准差）为14.9±6.2mm（大概为股骨长度的3%，ASIS-MM距离的1.7%），平均危机值为22.4±5.6mm（大概为股骨长度的5%，ASIS-MM距离的2.6%）。当腓深神经到达危机值时，胫神经的运动诱发电位值平均下降27%（95%置信区间[CI], 22.1%-32.7%），股神经的运动诱发电位值平均下降12%（95%CI, 6.9%-18.1%）。肢体延长值与股骨长度（r=0.782; p<0.001），ASIS-MM距离（r=0.811; p<0.001）和身高（r=0.835; p=0.001）呈正相关，而与胫神经和股神经电位下降值无相关性。
肢体延长安全范围
Conclusions: The critical limit of nerve lengthening was directly correlated with anthropometric measurements. Nerve lengthening of 5% relative to femoral length and of 2.6% relative to ASIS-MM distance was found to be critical; however, these limits depended on the predetermined threshold values for IONM.
结论：神经延长的危机值与人体测量值相关，肢体延长超过股骨长度的5%、ASIS-MM距离的2.6%会使神经陷入危机状态；当然，我们测量出的安全范围也取决于事先设定好的神经监测阈值。
2022年付费文章汇总（截止5月31日）
一、肩部
二、肱骨
三、肘关节
四、前臂
五、髋部
六、股骨
七、膝关节
八、胫骨
九、踝关节
十、关节
十一、其他
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