Comparisons of the Efficacy and Safety of Total Knee Arthroplasty by Different Surgical Approaches: A Systematic Review and Network Meta‐analysis

The purpose of this network meta‐analysis was to investigate the efficacy and safety of total knee arthroplasty (TKA) considering seven different surgical approaches. Four databases (PubMed, Cochrane Library, EMBASE, Web of Science) were searched for clinical randomized controlled trials (RCTs) involving TKA with different surgical approaches. STATA 14.0 was used to construct network maps and publication bias graphs and conduct inconsistency tests, network meta‐analyses, and surface under the cumulative ranking (SUCRA) calculations. A total of 51 RCTs involving 4061 patients and 4179 knees from 18 countries were included. Among the seven surgical approaches, the midvastus approach (MV) was the top choice to reduce tourniquet use time, the subvastus approach (SV) had the shortest operation time, the mini‐midvastus approach (Mini‐SV) was associated with the least amount of time to achieve straight leg raise (SLR) after surgery, the mini‐medial parapatellar approach (Mini‐MP) reduced postoperative pain effects, and the medial parapatellar approach (MP) was the best approach to improve range of motion (ROM). Excluding the quadriceps‐sparing approach (QS), which was not compared, the use of the mini‐midvastus (Mini‐MV) may shorten the hospital stay. There were no significant differences in blood loss, postoperative complications, American Knee Society Score (AKSS) objective, or AKSS functional between the seven surgical approaches (P > 0.05).     

Comparative Efficacy of the Different Surgical Approaches in Total Knee Arthroplasty: A Systematic-Review and Network Meta-Analysis

BackgroundSeveral surgical approaches including midvastus, subvastus, mini-parapatellar, quadriceps-sparring (QS) and parapatellar are currently used to perform total knee arthroplasty (TKA). Since none of published study exhibited a simultaneous comparison of all of them, a network meta-analysis has been conducted to compare the most widely used knee surgical approaches regarding the improvement of functional outcomes and the range of motion (ROM).MethodsRandomised controlled trials (RCTs) comparing TKA approaches were searched in electronic databases, major orthopedics journals, and oral communications, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform until May 1st, 2020. Two reviewers independently selected trials and extracted data. The primary outcomes were functional scores at 6 months post-surgeryevaluated by KSS and WOMAC, and the ROM.ResultsSixty RCTs involving 5042 patients with 5107 TKA were included. No significant differences between different approaches were found for the KSS assessment or the WOMAC at 6 months. The mean of ROM at 6 months post-surgery were higher in the subvastus group than in all the others surgical approaches. The difference of ROM with subvastus approach was 7.3° (95% CI ?14.1 to ?0.1) with the midvastus approach, 11.1° (95% CI ?18.7 to ?2.8) with mini-parapatellar, 8.9° (95% CI ?14.2 to ?3.1) with standard parapatellar, and 9.2° (95% CI ?16.1 to ?1.8) with QS.ConclusionNo differences were found in functional outcomes over short or medium terms but subvastus seemed to increase the ROM at 6 months post-surgery. Until or unless future studies can demonstrate a long-term benefit, based on these results all studied surgical approaches to perform a TKA are equal.Level of EvidenceNetwork meta-analysis. Level 1.     

Subvastus and medial parapatellar approaches in TKA: comparison of functional results

The purpose of this study was to compare the clinical results of total knee arthroplasty (TKA) in the early and late postoperative period using subvastus and medial parapatellar approach. A prospective randomized controlled study was conducted in a group of 169 patients (180 TKAs) with 2-year follow-up. Patients were divided into a study group (97 TKAs) with a subvastus approach and a control group (83 TKAs) with a parapatellar approach. Assessment of the results of both operating approaches was based on functional, clinical Knee Society Score, and pain (visual analog scale). Patients in the subvastus group achieved full active extension, better range of motion, and better Knee Society Score results at 12 days, 6 weeks, and 12 weeks earlier than patients in the medial parapatellar group. They also had less pain at 12 days. No statistically significant differences existed between assessed end points in both groups at 24- and 52-weeks, and 24-months postoperatively. The subvastus approach has given patients better early clinical results; however, at longer follow-up, both groups had similar outcomes. The potential benefits of the subvastus approach are: protection of the extensor mechanism from damage, less risk of damaging the blood supply to the patella, earlier clinical recovery, and less pain in the early postoperative period. The subvastus approach is an alternative to the standard medial parapatellar approach in TKA. It can be used with equally good results, especially taking into consideration positive clinical aspects in the early postoperative period.     

Is Minimally Invasive Surgery in Total Knee Arthroplasty Really Minimally Invasive Surgery?

Minimization of soft-tissue damage is one of the primary purposes behind the application of minimally invasive surgery (MIS) in total knee arthroplasty (TKA). A consecutive series of 147 TKAs were enrolled in the present study, with 96 MIS-TKAs using 11 quadriceps-sparing, 46 subvastus, 32 midvastus, and 7 parapatellar approaches and 51 conventional TKAs using 22 subvastus, 9 midvastus, and 20 parapatellar approaches. Serum levels of creatinine phosphokinase, myoglobin, aldolase, lactate dehydrogenase, glutamic oxaloacetic transaminase, and creatinine were measured on postoperative days 0, 1, 2, 4, 7, and 14. Postoperative rising index (RI) was expressed as a proportion of the preoperative value. When RIs were compared between MIS-TKA and conventional TKA, no significant differences were found for any enzymes. Interestingly, the midvastus approach displayed the highest RIs for creatinine phosphokinase and myoglobin between the 4 vastus-splitting approaches. Consequently, degree of muscle damage was equivalent between MIS-TKA and conventional TKA, whereas types of vastus-splitting approach appeared closely related to muscle damage.     

Comparison of early postoperative rehabilitation outcome following total knee arthroplasty using different surgical approaches and instrumentation

PURPOSE: To assess early postoperative rehabilitation outcome following computer-assisted total knee arthroplasty (TKA) or standard instrumentation TKA using a medial parapatellar or subvastus approach. METHODS: A prospective controlled trial of 70 consecutive patients undergoing TKA with a low contact stress rotating platform prosthesis was conducted. Patients were randomised to receive surgery with either computer navigation or standard instrumentation. A medial parapatellar or subvastus approach was used according to the surgeons' preference. Outcome measures included preoperative knee function, intra-operative factors, and postoperative rehabilitation. RESULTS: Duration of surgery was significantly longer when using computer navigation; however, operating time decreased with greater experience. A higher incidence and duration of early postoperative quadriceps dysfunction was associated with computer-assisted TKA through the medial parapatellar approach than through the subvastus approach or TKA performed with standard instrumentation. No patient who received surgery through the subvastus approach had a lag of more than 20 degrees, at 48 hours postoperatively, regardless of the instrumentation used. CONCLUSION: Computer-assisted TKA through a medial parapatellar approach was associated with delayed recovery of the quadriceps during early postoperative rehabilitation. This was due to the additional quadriceps dissection required to place the femoral tracking array. The subvastus approach is therefore recommended for computer-assisted TKA.     

Surgical approaches in mini-incision total knee arthroplasty

Mini-incision total knee arthroplasty can be accomplished through versions of exposures used in standard total knee arthroplasty. Modifications of the medial parapatellar, subvastus, and midvastus approaches are presented, and potential advantages and disadvantages of each approach are reviewed. When making the transition to smaller incisions and arthrotomies, the medial parapatellar seems to be the most versatile. The ability to do a total knee arthroplasty through a mini incision, and ultimately the success of the procedure, will depend on appropriate patient selection.     

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.     

Strength and voluntary activation of quadriceps femoris muscle in total knee arthroplasty with midvastus and subvastus approaches

To determine and compare the influence of 2 different approaches on quadriceps femoris muscle function in total knee arthroplasty (TKA), 20 patients (14 women, 6 men) with bilateral knee osteoarthritis underwent a 1-stage bilateral TKA. Surgical approaches (subvastus, midvastus) were performed by a random selection. Measurements of quadriceps voluntary activation and maximal voluntary contraction were estimated by a twitch interpolation technique before, 3 and 6 months after TKA. Knee pain was quantified by the Lewis Score. There was no difference between the 2 approaches at 3 and 6 months after TKA with regard to maximal voluntary contraction (P = 0.84, F = 0.041) and voluntary activation (P = .863, F = 0.031). In the subvastus group was a significantly higher knee pain until 6 months after surgery (P = .02). The subvastus approach for TKA does not provide any advantages compared with the midvastus approach with respect to the quadriceps femoris muscle strength in the early postoperative period. Furthermore, the subvastus approach caused significantly more pain postoperatively.     

Postoperative Pain and Contracture Following Total Knee Arthroplasty Comparing Parapatellar and Subvastus Approaches

The purpose of this study was to see if subvastus approach would decrease incidence of postoperative contracture and pain following TKA compared to standard parapatellar approach. Retrospective review of 546 patients in Group A undergoing TKA using parapatellar approach were compared to 255 patients in Group B undergoing subvastus approach. No statistically significant differences regarding OR time, blood loss, BMI, or LOS. Total of 23 (4%) manipulations under anesthesia for contracture in Group A compared to 6 (2%) in Group B (p > 0.05). Postoperative pain scores at 6 weeks was greater in Group A, p < 0.05. We feel that a subvastus approach minimizes trauma to the extensor mechanism, and therefore decreases the incidence of postoperative pain following TKA.     

Minimally invasive total knee arthroplasty using a cruciate-retaining knee system: A 3–5 year study with comparison to a standard approach

Background/PurposeMinimally invasive surgery (MIS) for total knee arthroplasty (TKA) is a recent development. Most published studies of the procedure report on early experience, and have emphasized early recovery and good outcomes in the first 3 months to 1 year.MethodsThis retrospective study compared 121 TKA done through a minimally invasive midvastus approach with 50 TKA done using a standard medial parapatellar approach, and assessed the results at a minimum follow-up of 3–5 years. A cemented U2 cruciate-retaining knee (United, Taipei, Taiwan) was used in both patient groups.ResultsThe postoperative mean knee score and function score were 95.3 (range, 69–110) and 82.3 (range, 20–100) respectively in the MIS TKA group, compared to 94 (range, 78–00) and 82 (range, 30–100) for the control group (standard approach). The postoperative Knee Society scores did not differ significantly between the two groups. The postoperative mean range of motion was 113.8° (range, 70–145°) in the MIS TKA group compared with 105.1° (range, 40–130°) for the control group, and the difference was significant (p < 0.05). There was no difference in postoperative coronal X-ray alignment between the two groups, neither were there any outliers in the component alignment and component size in the MIS TKA group. There were three knees (2%) with anterior femoral notching in the MIS TKA group compared to no knee notching for the control group.ConclusionThough the MIS TKA was technically demanding, the outcomes at 3–5 years’ follow-up were at least as good as those obtained with the standard medial parapatellar TKA procedure.     

Systematic Review of Medial Parapatellar and Subvastus Approaches in Total Knee Arthroplasty

This systematic review was performed to compare the outcomes of the medial parapatellar and subvastus surgical approaches for total knee arthroplasty. Five studies, published between 1993 and 2001 met the inclusion quality standards for the review. The methodological quality of most studies was poor, and they were not sufficiently homogenous for meta-analysis. We found that the evidence was insufficient to demonstrate a clinical or statistically significant difference between the medial parapatellar and subvastus approaches to total knee arthroplasty across all outcomes. Further trials with robust methodology, objective and functional outcome measures, and follow-up beyond 6 to 12 months are required.     

Subvastus versus medial parapatellar approach in total knee arthroplasty

The subvastus approach for total knee replacement was compared with the standard medial parapatellar approach in terms of postoperative knee scores and quadriceps strength. Two groups of patients with similar characteristics were formed: the first group consisted of 12 knees of 9 patients who were implanted via the medial parapatellar approach, and for the second group the subvastus approach was used in 10 knees of 10 patients. The groups' knee scores and quadriceps strength were compared preoperatively and postoperatively at week 6, months 3 and 6. The knee scores improved similarly in both groups, but the change was more pronounced in the subvastus group. Quadriceps strength was greater in the subvastus group at postoperative week 6, but there was no significant difference between the groups in months 3 and 6. It was concluded that although the subvastus approach offers greater quadriceps strength in the early postoperative period, it has no significant advantage in this aspect over the medial parapatellar approach.     

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.     

A midvastus muscle-splitting approach for total knee arthroplasty

This study presents a modification of the medial parapatellar surgical approach for total knee arthroplasty. This approach separates the vastus mediatis muscle in the direction of its fibers beginning at the superior pole of the patella. One hundred eighteen consecutive total knee arthroplasty cases, performed by a single surgeon, were randomized prospectively to receive a medial parapatellar or midvastus muscle-splitting surgical approach. The frequency of lateral retinacular releases was recorded, patellar tilt and translation were measured, and quadriceps strength was tested. The midvastus muscle-splitting approach provided excellent exposure to all knees. Patellar stability and quadriceps strength were equivalent for the two approaches. It is concluded that the midvastus muscle-splitting approach is an efficacious alternative to the medial parapatellar approach for primary total knee arthroplasties.     

Muscle torques in total knee arthroplasty with subvastus and parapatellar approaches

The current study was designed to compare muscle torques when using the subvastus and parapatellar approaches for unilateral total knee arthroplasty. Twelve female patients had unilateral total knee arthroplasty with the subvastus approach from January 1997 to June 1998. The historic control group consisted of 16 female patients who had unilateral total knee arthroplasty with the parapatellar approach from July 1994 to January 1997. Six and 12 months after surgery, a Cybex dynamometer was used to measure isometric and isokinetic muscle strength. Two parameters were used to compare the two approaches, the first parameter was the difference in peak torque between the surgically treated knee and the baseline value for the healthy knee, and the second parameter was the hamstring to quadriceps peak-torque ratio, again using the value for the healthy knee as baseline. The subvastus approach resulted in an initial higher peak torque in the quadriceps 6 months after surgery, but this difference became insignificant 12 months postoperative. Using the subvastus approach, the hamstring to quadriceps peak-torque ratio reached the normal range (0.50-0.80) sooner than was the case using the parapatellar approach. There is a phenomenon of cross adaptation of the untreated knee to the surgically treated knee, and knees operated on by the subvastus approach showed functional recovery at an earlier date than those operated on by the parapatellar approach.     

Subvastus and medial parapatellar approaches in total knee arthroplasty

This retrospective study compared the outcome of two consecutive groups of patients having primary total knee arthroplasty. The arthroplasties were performed in the first group (169 arthroplasties in 143 patients) from 1988 to 1992 using a medial parapatellar approach, and in the second group (167 arthroplasties in 148 patients) from 1992 to 1996 using a subvastus approach. The patient outcomes were evaluated at 6 months, and were based on clinical and radiographic measures, occurrence of intraoperative lateral retinacular release, and incidence of postoperative patellar subluxation. There were no significant differences between the two groups for range of motion, Knee Society knee and function scores, and stair climbing ability. The patella tracked centrally in significantly more knees with the subvastus approach (139 of 167 knees, 83%) than with the parapatellar approach (107 of 169 knees, 63%). There were significantly fewer knees in the subvastus group requiring a lateral retinacular release (62 of 167 knees, 37%), compared with the parapatellar group (113 of 169 knees, 67%). The authors concluded that the subvastus approach led to improved patellar tracking and stability. Although the surgical and rehabilitative protocols were identical for both groups, the results may have been affected by changing circumstances during the 9-year period of the study.     

Comparison of the modified subvastus and medial parapatellar approaches in total knee arthroplasty

In this paper, we evaluated the difference between the modified subvastus approach and the medial parapatellar approach in total knee arthroplasty(TKA). We assessed the time of active straight-leg raise (SLR) post-operatively and the range of flexion of the operated knee at the tenth post-operative day, 6 weeks and 6 months, 12 months and 3 years. We investigated the degree of the patellar tilt and subluxation 24 months post-operatively. The patients who underwent the modified subvastus approach performed active SLR earlier (mean 0.5 days) than the medial parapatellar approach patients (mean 2.2 days). Knee flexion was better at the tenth post-operative day in the modified subvastus approach group compared to the medial parapatellar approach group. There was no statistical difference between the two groups with regard to the patellar tilt and subluxation. We conclude that the modified subvastus approach is recommendable in primary TKA.

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Résumé  Nous avons évalué la différence entre l’abord médial para patellaire et l’abord modifié subvastus lors de la mise en place d’une prothèse totale du genou. Nous avons apprécié le temps de récupération post-opératoire de l’extension active du genou et le degré de flexion de celui-ci à 10 jours, 6 semaines, 6, 12 et 36 mois. Nous avons également exploré les complications rotuliennes, notamment subluxations à 24 mois. Les patients ayant bénéficié d’un abord subvastus récupèrent une extension active plus précoce (en moyenne de 0,5 jours), contre 2,2 jours pour l’abord médian. L’amélioration de la flexion du genou est également meilleure à 10 jours post-opératoire dans ce groupe. Il n’y a pas de différence significative entre ces deux groupes en ce qui concerne les problèmes rotuliens. Nous pensons que l’abord subvastus est à recommander dans la mise en place d’une prothèse totale du genou.

     

The effect of surgical approaches and tourniquet application on patellofemoral tracking in total knee arthroplasty

The purpose of this study was to assess the influences of surgical approaches and tourniquet application on the lateral retinacular tension (LRT). Single-setting bilateral total knee arthroplasty was performed in 10 patients, and the medial parapatellar and midvastus approaches were randomly performed on each knee using tourniquet application. The LRT was measured using the buckle transducer before and after each approach. Next, the tourniquet was deflated and the measurement was repeated. After the parapatellar approach, LRT was significantly decreased. Conversely, no significant change was seen after the midvastus approach with the tourniquet inflated. However, in the midvastus approach, LRT was significantly decreased after tourniquet deflation. We concluded that both the parapatellar and midvastus approaches influence patellar tracking and LRT.     

股肌下结合微斜切入路全膝关节置换术治疗膝外翻

目的评估股肌下结合微斜切入路(SMOC)实施人工全膝关节置换术治疗膝关节外翻畸形的可行性及早期临床效果。 方法回顾性分析2015年4月至2017年10月在青岛大学附属医院关节外科50例(60膝)行初次人工膝关节置换术治疗并获得完整随访的膝外翻患者，排除年龄> 85岁、既往膝关节手术史及身体质量指数> 30 kg/m²的患者。男13例，女37例，年龄平均(60±8)岁。诊断为类风湿性关节炎42例52膝，骨关节炎5例5膝，创伤性关节炎3例3膝。采用SMOC入路行人工全膝关节置换术患者25例(31膝)，内侧髌旁入路者25例(29膝)。记录并比较两组患者的术前一般资料、血红蛋白、视觉模拟评分法(VAS)、美国特种外科医院(HSS)评分、膝关节被动活动度(ROM)、外翻角度；手术时间、术中出血量、外侧支持带松解率、术后2 d血红蛋白含量、术后引流量、输血率、直腿抬高时间、辅助镇痛药物使用情况、术后下肢力线、髌股适合角；24 h VAS，以及术后1周HSS评分及膝关节ROM，独立样本t检验或卡方检验比较分析两组差异。 结果术前一般资料两组无差异(P>0.05)，随访期间无感染及假体松动等并发症。术后外翻膝均得到矫正，两组在手术时间、术中出血量、术后引流量、术后2 d血红蛋白含量、输血率、术后下肢力线、髌股适合角方面两组差异无统计学意义(P>0.05)；SMOC组在直腿抬高时间(t＝10.500，P<0.01)、外侧支持带松解率(χ² ＝5.711，P<0.05)、辅助镇痛药使用(χ² ＝9.934，P<0.01)方面优于内侧髌旁入路。术后24 h VAS评分SMOC组低于髌旁组(t＝10.540，P<0.001)、1周HSS评分(t＝8.110，P<0.001)及ROM(t＝2.085，P<0.05)，SMOC组低于髌旁组。 结论利用SMOC入路全膝置换术可有效治疗膝外翻畸形，与髌旁入路相比，髌外侧支持带松解率更低，可获得更快速的近期康复效果。     

Mini-Midvastus Versus Mini-Medial Parapatellar Approach for Minimally Invasive Total Knee Arthroplasty : Outcomes Pendulum Is at Equilibrium

Comparisons between mini-midvastus (mMV) and mini-medial parapatellar approach (mMPP) for total knee arthroplasty (TKA) have reported variable results. We compared two approaches with minimum two year follow up. Forty consecutive patients who underwent staged bilateral TKA were prospectively randomized for mMPP approach in one knee and mMV approach in the other. Clinical parameters (muscle strength, pain, ROM, Knee Society Score) and surgic.l parameters (duration of surgery, blood loss, lateral releases) were assessed at 2, 6, 12 weeks and 6, 12, 24 months postoperatively. Clinical outcomes revealed inconsistent pattern of differences at various intervals. Surgical outcomes were not different. There were no major differences in outcomes between the two approaches. We recommend someone use surgical approach with which they are most familiar.