Comparing outcomes of medial parapatellar and subvastus approaches in total knee arthroplasty: a randomized controlled trial

The medial parapatellar (MP) approach in total knee arthroplasty is more common, but the subvastus (SV) approach is less insulting to the quadriceps. Whether the SV approach affords better outcomes was investigated using 90 participants with knee osteoarthritis, randomized to receive either SV or MP approaches and followed for 18 months. The primary outcome was the American Knee Society Score (AKSS); secondary outcomes included pain, knee range, quadriceps lag, Oxford Knee Score, 3-m timed "Up and Go" test, days to straight leg raise, surgeon perceived difficulty, operation duration, and length of stay. Analysis (n = 76) revealed no significant difference in AKSS (P = .076) or other outcomes, except the following: AKSS Functional scores at 12 and 18 months, favoring the MP (P = .032 and P = .028 respectively); surgeon's perceived difficulty, favoring the MP (P = .001); and days to straight leg raise, favoring the SV (P = .044). This study found that the SV approach offers no clinical benefit over the MP approach.     

Mini-subvastus approach for total knee arthroplasty

The mini-subvastus surgical technique avoids both quadriceps arthrotomy and patella eversion. Since March 2003, this quad-sparing minimally invasive surgical (MIS) technique has been applied to more than 98% of our primary total knee arthroplasty (TKA) patients. This study compares our first 150 MIS TKA patients to our previous 150 traditional TKA patients. Quadriceps recovery was rapid in the MIS group with 83% able to do a straight leg raise the day after surgery. Hospital length of stay was decreased in the MIS group, 3.4 days, vs the traditional group, 4.1 days (P = .00013). Fewer MIS patients required skilled nursing or rehabilitation center admission. Increased knee flexion was seen for the MIS patients throughout the first 2 years of follow-up. Mean knee flexion at 1 year was 127 degrees for the MIS patients vs 114 degrees in the traditional TKA patients (P < .0001). Comparison between the MIS and traditional techniques demonstrated no increase in the number or severity of complications and no difference in operating room time.     

Postoperative clinical outcome between lateral retraction and eversion of patella following simultaneous bilateral total knee arthroplasty

Aims and objectiveAmong the various exposure technique used in total knee arthroplasty (TKA); the midline medial parapatellar knee approach is most commonly performed; which require mobilisation of patella for adequate surgical exposure. In this study, we compare the effect of patellar eversion with lateral retraction in simultaneous bilateral TKA to find out difference in postoperative clinical outcome between the two patellar mobilisation techniques.MethodsWe enrolled 41 patients who underwent bilateral simultaneous TKR (82 knees) from Nov 2016 to Dec 2018. During surgery patellar eversion was done in one knee and lateral retraction was done in other knee selecting them randomly to reduce the bias. During the follow up period achieving unassisted active straight leg raise (SLR), 90 flexion and complications were recorded. Measurement of Oxford knee society score (OKSS), American knee society score (AKSS), Visual Analogue Scale (VAS) score, and quadriceps strength (measured by handheld dynamometer) was done daily up to one week, 1 month, 3 months, 6 months, and 1 year postoperatively.ResultsThe time of achieving active SLR and 901 flexion postoperatively was quicker in the lateral retraction group with a statistically significant difference. VAS pain score at 1 week and 1 month along with quadriceps strength in 1-month had statistically significant favourable outcomes in the lateral retraction group. Throughout the follow up lateral retraction group had better Oxford and American knee score but the difference being statistically insignificant. No significant difference was found on the complication rate.ConclusionIn comparison to lateral retraction, patellar eversion has an adverse effect in early knee functional recovery after TKA; it delays achieving active SLR, 901 flexion and has unfavourable outcome in functional scores, quadriceps strength, and postoperative pain relief. However it has minimal effects on long term functional outcomes.     

Patellar Eversion Does Not Adversely Affect Quadriceps Recovery Following Total Knee Arthroplasty

Although avoiding patellar eversion during a total knee arthroplasty (TKA) has theoretical benefit in quadriceps recovery, there has been paucity of supportive objective clinical results. We prospectively designed the study whether TKA without patellar eversion has better quadriceps recovery in an objective, dynamometer study. Seventy-two knees undergoing TKA with midvastus approach were randomized into two groups according to patellar eversion or not. Clinical data and objective quadriceps recovery using a dynamometer were investigated preoperatively and postoperative at 6 weeks, 3 months, 6 months and 1 year. There were no statistical differences between two groups throughout the follow-up periods in recovery of quadriceps force or power and clinical data. Choosing to evert patella during TKA using midvastus approach would not adversely affect postoperative quadriceps recovery.     

Comparing Outcomes of Medial Parapatellar and Subvastus Approaches in Total Knee Arthroplasty : A Randomized Controlled Trial

The medial parapatellar (MP) approach in total knee arthroplasty is more common, but the subvastus (SV) approach is less insulting to the quadriceps. Whether the SV approach affords better outcomes was investigated using 90 participants with knee osteoarthritis, randomized to receive either SV or MP approaches and followed for 18 months. The primary outcome was the American Knee Society Score (AKSS); secondary outcomes included pain, knee range, quadriceps lag, Oxford Knee Score, 3-m timed “Up and Go” test, days to straight leg raise, surgeon perceived difficulty, operation duration, and length of stay. Analysis (n = 76) revealed no significant difference in AKSS (P = .076) or other outcomes, except the following: AKSS Functional scores at 12 and 18 months, favoring the MP (P = .032 and P = .028 respectively); surgeon's perceived difficulty, favoring the MP (P = .001); and days to straight leg raise, favoring the SV (P = .044). This study found that the SV approach offers no clinical benefit over the MP approach.     

高强度聚酯纤维缝线减张治疗陈旧性髌腱断裂

目的 探讨陈旧性髌腱断裂的临床特点,介绍采用高强度聚酯纤维缝线减张治疗陈旧性髌腱断裂的手术方法 和术后康复方法 .方法 2002年1月至2007年2月,收治陈旧性髌腱断裂6例,手术切断超长的瘢痕愈合髌腱组织.恢复长度后重新吻合,并在胫骨结节和髌骨两端钻骨孔,采用4根高强度聚酯纤维缝线经骨孔减张保护.术后对患者采用积极的康复锻炼方案:术后第1天即町下地直立行走及被动屈膝90°,休息和睡眠时不须支具石膏固定保护;术后3周起开始练习主动抬腿;术后6周后开始练习快走,负重2 kg直腿抬高;术后12周后开始练习上下楼梯和下蹲;术后6个月后开始正常运动以及蹬跳运动.结果 术后随访1～5年,平均3.2年.患者早期即可以活动并可以下床直立行走,所有患者均未出现再断裂.手术6个月以后,患者均恢复正常的平地行走、跑步能力等,屈膝基本达到对侧的水平,股四头肌力量良好.Lysholm评分均能达到100分.结论 高强度聚酯纤维缝线减张治疗陈旧性髌腱断裂,创伤小,方法 简单,不须外加牵引,不须石膏固定,不须二次手术取内固定.积极的康复训练允许患者早期行走,效果可靠.     

Predicting the loss of knee flexion during limb lengthening using inherent muscle length

Limb lengthening procedures can be associated with loss of range of knee movement, although the amount of knee flexion lost varies markedly between patients. The exact aetiology of this problem is not fully understood. This study investigates whether the amount of joint range that is lost during limb lengthening might be affected by the inherent passive compliance and length of the patients' soft tissues determined preoperatively. A simple mathematical model has been developed to calculate the inherent length and 'spare' length of the hamstring and quadriceps muscle groups in 28 patients undergoing limb lengthening procedures. The range of knee motion was recorded preoperatively and loss of movement recorded during follow-up. The results show a strong correlation between predicted 'spare' length of quadriceps and loss of knee flexion. An association was noted between loss of knee extension and the straight leg raise and correlation of knee extension and the spare length of the hamstrings. The straight leg raise test, and calculation of spare quadriceps length using our formula, as part of the preoperative assessment, can help predict which patient is at risk of a reduced range of motion of the knee.     

Navigation-assisted less invasive total knee arthroplasty compared with conventional total knee arthroplasty: a randomized prospective trial

The purpose of this study was to evaluate the hypothesis that a less invasive (LIS) surgical technique using a navigation system would promote rapid recovery and improve alignment compared with conventional technique in total knee arthroplasty (TKA). This study compared 49 navigation-assisted LIS TKAs with 53 conventionally performed TKAs using a medial parapatellar arthrotomy with patellar eversion. Navigation-assisted LIS TKA used a shorter skin incision, a midvastus approach without patella eversion, and a navigation system. Navigation-assisted LIS TKA had better pain scores, shorter times to achieve 90 degrees flexion and straight leg raise, and a smaller extension lag during the very early postoperative period. However, there were no differences between the groups 2 weeks postoperatively. There were no differences in mean prosthetic alignment between the 2 groups, but the navigation-assisted LIS group had fewer "outliers" than the conventionally performed TKA group.     

Outcome of subvastus approach in elderly nonobese patients undergoing bilateral simultaneous total knee arthroplasty: A randomized controlled study

Background:

Subvastus approach in total knee arthroplasty (TKA) spares the quadriceps and may assist in faster rehabilitation. The present randomised controlled study was conducted to determine if the subvastus approach results in early recovery, faster mobilization, shorter hospital stay, and improved function.

Materials and Methods:

100 patients undergoing simultaneous bilateral TKA were randomized into two groups: subvastus group and medial parapatellar group. The patients were assessed clinically using VAS, time to straight leg raise, ability to stand with walker, ability to use a commode chair, ability to climb stairs, flexion at discharge, and day of discharge. Perioperative blood loss and duration of surgery were also compared. The patient were kept on same pain management and physiotherapy protocol. The evaluation was done at day 0,1,3 and at discharge. Statistical analyses tested the null hypotheses of no differences in patients treated with either group at 95% significance level (P < 0.05).

Results:

The VAS score was significantly lower in subvastus group on day 1 and day 3. Also mean hospital stay was 2.04 days less in subvastus group. Patients with subvastus approach were able to perform straight leg raising 0.44 days earlier. Though time to stand with walker was same for both groups, the ability to use commode chair, and climb stairs was significantly early (P < 0.05) in the subvastus group. The average flexion at the time of discharge in subvastus and parapatellar group were 100.8 and 96.8°, respectively. The mean perioperative blood loss in subvastus group and parapatellar group were 343 ml and 372 ml, respectively. Average surgical time required for subvastus approach and parapatellar approach were 108.5 and 94.3 min, respectively.

Conclusions:

Subvastus approach produce appreciably less pain and faster mobilization due to lesser insult to quadriceps, thus assisting in early rehabilitation, shorter hospital stay, less expenditure, and more patient satisfaction.     

Decreased range of motion following acute versus chronic anterior cruciate ligament reconstruction

Eighty patients with acute anterior cruciate ligament (ACL) reconstruction were compared to 80 patients with chronic ACL reconstruction. Before reconstruction, all patients had 0 degrees-120 degrees active motion, performed a straight leg raise without loss of extension, and demonstrated good quadriceps control. At 3 months, 4 acute patients had decreased range of motion (<10 degrees-120 degrees), but none at 6 or 12 months, and did not require repeat surgery. One chronic patient had decreased range of motion at 3 and 6 months and 1 patient had decreased range of motion at 1 year; both patients required operative intervention. Using these specific preoperative criteria, no increased incidence of decreased range of motion was found when an ACL reconstruction was performed within 3 weeks of injury.     

EMG Biofeedback as Treatment for Patellofemoral Pain Syndrome*

Patellofemoral pain syndrome may be classified as a dysfunction of the patella's ability to track in the femoral groove. This study identifies an effective treatment approach for patellofemoral pain syndrome. The approach integrates the concept of improved patellar tracking through selective enhancement of the vastus medialis oblique muscle with conventional exercise regimens for patellofemoral pain syndrome. Six patellofemoral pain syndrome patients were enrolled in a three-phase electromyographic biofeedback and exercise program: 1) biofeedback orientation and instruction in isometric quadriceps contractions, straight leg raises, and a home program; 2) biofeedback training for vastus medialis oblique enhancement with isometric quadriceps contractions, straight leg raises, terminal knee extensions, and progressive resistive exercises; and 3) incorporation of increased vastus medialis oblique activity in functional patterns of movement. All six patients learned to alter their vastus medialis oblique activity through the use of this treatment approach. The alteration of vastus medialis oblique activity resulted in an apparent change in the patellofemoral forces and a concomitant decrease in the patients' complaints of pain. These patients were able to return to pain-free functional activities in only six to nine treatment sessions within a 4- to 6-week period. The use of electromyographic biofeedback coupled with a graded exercise program is an efficient and effective treatment approach for patellofemoral pain syndrome patients.J Orthop Sports Phys Ther 1984;6(2):95-103.     

Clinical comparison of the midvastus and medial parapatellar surgical approaches.

The medial parapatellar approach and the midvastus approach are the two most commonly used surgical approaches in total knee replacement. This study compared surgical and clinical parameters associated with both surgical approaches in primary total knee replacement. One hundred nine patients who underwent bilateral primary total knee replacements had a medial parapatellar approach to one knee and a midvastus approach to the opposite knee. The prosthetic design and physical therapy were identical in all 109 patients. The patients and physical therapists were blinded to the type of approach used on each knee. The comparison included the surgical parameters of difficulty of exposure, surgical time, incidence of lateral retinacular release, and total blood loss. The clinical parameters of pain, range of motion, ability to perform a straight leg raise, and complications were compared at 8 days, 6 weeks and 6 months. The comparison between the two surgical approaches showed a statistically significant difference in four parameters, all of which favored the midvastus approach. The patients who had the midvastus approach required fewer lateral retinacular releases, had less pain at 8 days, had less pain at 6 weeks, and had a higher incidence of ability to straight leg raise at 8 days. There was no statistical difference between the two surgical approaches in all other surgical and clinical parameters. There was no increased difficulty of exposure using the midvastus approach when compared with the medial parapatellar approach even in patients with severe varus or valgus deformities. Notably, all clinical parameters were equal at 6 months. From a clinical standpoint, the midvastus approach had an advantage over the medial parapatellar approach because the patients had significantly less pain and had the ability to straight leg raise at 8 days. Because the managed care environment dictates a shorter hospital stay, patients who have the midvastus surgical approach have less pain and earlier control of the operative leg, and may be discharged from the hospital earlier. However, the clinical results at 6 months based on the patient's pain relief, range of motion, and ability to straight legraise were identical between the two surgical approaches.     

Patellar tendon rupture repair using Dall-Miles cable

Ten patients underwent patellar tendon repair with end-to-end suture technique and medial and lateral retinacular repair, as well as reinforcement with a Dall-Miles cable through the patella and tibial tubercle. The cable was tensioned at 60 degrees of flexion to allow immediate range of motion to at least 100 degrees of flexion and to protect the repair from undue tension while healing. Accurate tendon length was obtained from a lateral radiograph of the noninvolved knee in 60 degrees of flexion. Patients were allowed to bear full weight as tolerated postoperatively. A knee immobilizer was worn for approximately 2 weeks when adequate muscular control of the leg was attained. The cable was removed 6-8 weeks postoperatively, at which time range of motion equal to the opposite extremity was sought. Full extension was obtained by 1 week postoperatively. Average postoperative knee flexion was 88 degrees at 2 weeks, 112 degrees at 1 month, 133 at 3 months, and 138 degrees at 6 months compared to flexion of 141 degrees in the noninvolved knee. Mean quadriceps muscle strength 1 year postoperatively was 72%+/-11% of the noninvolved leg. No patient had patella infera or rerupture after surgery. Repair of a patellar tendon rupture with end-to-end techniques reinforced with a Dall-Miles cable allows immediate rehabilitation without the need for prolonged immobilization. This technique allows restoration of full range of motion early postoperatively and enables patients to regain adequate quadriceps strength.     

Quadriceps and patellar tendon rupture

Ruptures of the patellar and/or quadriceps tendon are rare injuries that require immediate repair to re-establish knee extensor continuity and to allow early motion. We evaluated 36 consecutive patients with quadriceps or patellar tendon rupture between 1993 and 2000. There were 37 primary ruptures, 3 reruptures, 21 quadriceps and 19 patellar tendon ruptures. Follow up examination (>24 months postoperatively) included the patient's history, assessment of risk factors, clinical examination of both knees, isometric muscle strength measurements and three specific knee scores, Hospital for Special Surgery Score, Knee Society Score and Turba Score, and a short form SF-36. We evaluated 29 patients (26 men) with 33 ruptures (16 patellar tendon, 17 quadriceps tendon). Seven patients were lost to follow up. We found no difference between the range of motion and muscle strength when the injured leg was compared to the non-injured leg. Risk factors did not influence the four scores, patient satisfaction, pain, muscle strength or range of motion. Multiple injured patients had a significant reduction in muscle strength and circumference, however patient satisfaction did not differ to the non-multiple injured patient group.     

Semiextended approach for intramedullary nailing via a patellar eversion technique for tibial-shaft fractures: Evaluation of the patellofemoral joint

Intramedullary nail fixation is a common treatment for tibial-shaft fractures, and it offers a better functional prognosis than other conservative treatments. Currently, the primary approach employed during intramedullary nail insertion is the semiextended position is the suprapatellar approach, which involves a vertical incision of the quadriceps tendon Damage to the patellofemoral joint cartilage has been highlighted as a drawback associated with this approach. To avoid this issue, we perform surgery using the patellar eversion technique and a soft sleeve. This method allows the articular surface to be monitored during intramedullary nail insertion. We arthroscopically assessed the effect of this technique on patellofemoral joint cartilage. The patellar eversion technique allows a direct view and protection of the patellofemoral joint without affecting the patella. Thus, damage to the patellofemoral joint cartilage can be avoided.     

Short-term recovery after anterior cruciate ligament reconstruction: a prospective comparison of three autografts

Sixty-four patients with three different autografts were prospectively evaluated following anterior cruciate ligament (ACL) reconstruction for motion return, thigh girth, quadriceps activity, assistive device usage, and duration of pain medication usage. The quadriceps tendon group achieved knee extension sooner than the patellar tendon group. The hamstring group used assistive devices for less time than the patellar tendon group. The quadriceps group required less pain medication than either of the groups. There are significant differences in short-term pain medication requirements and restoration of function among patients following ACL reconstruction using different autografts.     

Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft

BACKGROUND: Surgical reconstruction of the anterior cruciate ligament (ACL) is indicated in the ACL-deficient knee with symptomatic instability and multiple ligaments injuries. Bone patellar tendon-bone and the hamstring tendon generally have been used. In the present study, we describe an alternative graft, the quadriceps tendon-patellar bone autograft, by using arthroscopic ACL reconstruction. METHODS: From March of 1996 through March of 1997, a quadriceps tendon-patellar bone autograft was used in 12 patients with ACL injuries. RESULTS: After 15 to 24 months of follow-up, the clinical outcome for those patients with this graft have been encouraging. Ten patients could return to the same or a higher level of preinjury sports activity. According to the International Knee Documentation Committee rating system, 10 of the 12 patients had normal or nearly normal ratings. Recovery of quadriceps muscle strength to 80% of the normal knee was achieved in 11 patients in 1 year. CONCLUSION: The advantages of the quadriceps tendon graft include the following: the graft is larger and stronger than the patellar tendon; morbidity of harvest technique and donor site is less than that of patellar tendon graft; there is little quadriceps inhibition after quadriceps harvest; there is quicker return to sports activities with aggressive rehabilitation. A quadriceps tendon-patellar autograft is a reasonable alternative to ACL reconstruction in patients who are not suitable for either a bone-patellar tendon-bone autograft or a hamstring tendon autograft.     

Additional Peripheral Nerve Block to Periarticular Injection Has No Benefit for Patients Undergoing TKA: A Factorial Propensity Score–Matched Analysis Comparing Four Multimodal Analgesic Techniques

BackgroundControversy remains over what and how many analgesic techniques are required as the most effective multimodal pain regimen in total knee arthroplasty (TKA). This study aimed to evaluate the effect of additional analgesic methods combined with periarticular injection (PAI) analgesia for TKA.MethodsUsing retrospective cohort data, patients undergoing TKA with spinal anesthesia and PAI were divided into 4 groups. Group A (control) comprised 66 patients; group B (73 patients) had additional adductor canal block; group C (70 patients) obtained additional femoral nerve block, and group D (73 patients) received additional adductor canal block and intrathecal morphine. Propensity score matching was applied to compare visual analog scale (VAS) for pain intensity, cumulative morphine use (CMU), knee flexion angle, straight leg raise, length of hospital stay, and postoperative nausea and vomiting.ResultsThere was no significant difference regarding VAS and morphine use, when either group B or C was compared with group A. Group D had significantly lower VAS than groups A, B, and C during the first 24 hours after surgery and required significantly less CMU than groups A and B. However, the pain score of group D increased afterward, with significantly longer length of hospital stay than groups A and B. There was no difference in straight leg raise among the groups.ConclusionAdditional peripheral nerve block to PAI provides no benefit for patients undergoing TKA. Adjuvant intrathecal morphine could significantly reduce the VAS and CMU in the acute postoperative period; however, rebound pain with prolonged hospital stays was observed.