Mini-midvastus versus mini-medial parapatellar approach for minimally invasive total knee arthroplasty: outcomes pendulum is at equilibrium

Calipered Kinematically Aligned Medial Unicompartmental Knee Arthroplasty: A Surgical Technique

This study presents a surgical technique for kinematically aligned medial unicompartmental knee arthroplasty with the MOTO (Medacta Corporate, Switzerland) partial knee implant. This technique aims to replicate the native medial femoral and tibial morphology by providing caliper-verified bone resections and kinematic alignment principles. The paper provides a comprehensive overview of the surgical steps and discusses the implications for implant longevity.

Compare the Quadriceps Activity between Mini-Midvastus and Mini-Medial Parapatellar Approach in Total Knee Arthroplasty with Electromyography

Background: The comparison between the mini-midvastus (mini-MV) and mini-parapatellar (mini-MPP) approach in total knee arthroplasty (TKA) remains a subject of debate. The present study compared quadriceps activation, pain levels, and clinical outcomes between the two approaches; quadricep activation was assessed using surface electromyography (sEMG). Methods: This retrospective cross-sectional study comprised a total of 78 patients aged between 50 and 85 years with primary osteoarthritis. Patients were divided into a mini-MV (n = 38) group and a mini-MPP (n = 40) group according to the surgical approach. Results: The two groups exhibited no significant differences in sEMG for the vastus medialis (VM) or rectus femoris (RF) at the follow-up time points, with the exception that the mini-MV group exhibited superior strength of RF during extensions at the 2-week follow-up. However, the mini-MPP group had superior Western Ontario and McMaster Universities Index (WOMAC) total and function scores at the 2- and 6-week follow-ups. The mini-MPP group also had superior WOMAC stiffness scores at the 2-week follow-up. The two groups did not differ significantly in terms of pain levels or morphine consumption. Conclusions: The sEMG data of quadriceps muscle would not differ significantly between the mini-MV and mini-MPP approaches for TKA. Moreover, the mini-MPP approach may yield superior WOMAC scores when compared with the mini-MV approach.

Mid-vastus total knee arthroplasty for medial osteoarthritis recovers gait balance control better than lateral parapatellar approach three months post-surgery

Total knee arthroplasty (TKA) approaches affect recovery outcomes, with different levels of residual loss of muscle strength and functional deficits. The current study compared the gait balance control in older individuals 3 months after TKA via the lateral parapatellar approach (LPPA) and mid-vastus approach (MVA) in terms of the inclination angle (IA) of the center of pressure (COP) to the body's center of mass (COM) vector, and the rate of change of IA (RCIA). In a gait laboratory, 12 patients with severe medial knee osteoarthritis who had undergone bilateral TKA via LPPA and 12 via MVA were evaluated and compared against 12 healthy controls for their balance control during gait 3 months after surgery. The participants' kinematic data and ground reaction forces were measured synchronously using an 8-camera motion capture system and three forceplates, respectively, from which the COM, COP, IA and RCIA were calculated using a 13-body-segment model. The LPPA group showed significantly greater sagittal IA during DLS (p < 0.01) but less sagittal and frontal RCIA throughout the gait cycle (p < 0.04) compared to controls. The MVA showed better recovery in the balance control with most IA and RCIA variables similar to those of the healthy controls throughout the gait cycle. The patients with LPPA walked with a compromised balance control throughout the gait cycle while the MVA group showed close-to-normal balance control with a slight decrease in sagittal RCIA during SLS. The current between-approach findings were likely related to the differences in the muscles involved during surgery, suggesting that MVA may be a better choice than LPPA when taking short-term gait balance control into consideration.

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).

Comparing the Water-Tight Closure of Barbed and Conventional Suture Under Static and Dynamic Conditions in an Ex-Vivo Human Knee Arthrotomy Model

Background

Barbed suture has become popular for closure of the arthrotomy and overlying tissues in total knee arthroplasty. STRATAFIX Symmetric PDS Knotless Tissue Control Device, a unique and novel barbed suture, with barbs formed integral to the suture core provides greater suture strength than the more common cut barbed suture designs. It is the only barbed suture commercially available with an indication in high tension areas, such as fascia. The purpose of this study was to evaluate the use of this novel barbed suture in the formation of a water-tight arthrotomy closure, using a continuous suture pattern, compared to conventional Coated VICRYL (polyglactin 910) Suture, using an interrupted suture pattern, in a cadaveric knee arthrotomy.

Methods

Twenty fresh-frozen cadaver knees underwent randomization to provide donor-paired matching of the knee arthrotomy closures using barbed suture in a continuous pattern or conventional suture in an interrupted pattern. Each specimen underwent 5 phases of testing that included 1) predynamic static leak testing; 2) dynamic motion leak testing; 3) postdynamic static leak testing; 4) suture release static leak testing; and 5) postsuture release dynamic motion leak testing, to assess the fluid leak rate.

Results

Under the initial static conditions, watertightness was similar for the 2 types of sutures. However, in all subsequent phases of testing, continuous barbed suture created a better watertight closure than interrupted conventional suture.

Conclusions

In this study, it was observed that closure of a knee arthrotomy using the novel barbed suture provided improved watertightness compared to conventional interrupted closure under dynamic conditions and suture release.

Does surgical approach affect patient outcomes of total knee arthroplasty?

BACKGROUND

Surgical approaches for total knee arthroplasty (TKA) include the medial parapatellar (MPA), subvastus (SV), midvastus (MV), and lateral parapatellar approach (LPA); it remains unclear which approach is superior.

METHODS

Patients having undergone TKA at our institution were retrospectively organized into matched groups according to surgical approach (MPA, MV, SV, or LPA). Outcomes between the groups were compared using the Short-Form 12 (SF-12), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Society Score (KSS), and range of motion (ROM) up to 2 years postoperative.

RESULTS

Sixty-eight MV patients, 8 SV patients, and 4 LPA patients were matched with groups of MPA patients. There was no difference in outcomes between the MPA and MV groups up to 2 years. The SV group had significantly higher SF-12 Physical Composite Score (PCS; p = 0.036) and WOMAC stiffness score (p = 0.014) at 2 years, but significantly lower flexion at 1 year (p = 0.022) than the MPA group. The LPA group had significantly lower SF-12 PCS (p = 0.011) and WOMAC function scores (p = 0.022) at 1 year than the MPA group.

CONCLUSION

There was no significant difference between the MPA and MV approach. The SV approach had some improved long-term outcomes over the MPA aproach (SF-12 and WOMAC), but had significantly lower flexion at 1 year. The LPA group showed inferior outcomes than the MPA group but had more severe valgus preoperative deformity (p = 0.024). Further studies are required to investigate the potential benefit of quadriceps-sparing approaches.

Comparison of minimally invasive approaches and standard median parapatellar approach for total knee arthroplasty: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND: Minimally invasive total knee arthroplasty (TKA) has been actively advertised by the orthopedic industry. The purpose of this network meta-analysis was to comprehensively compare the effectiveness of four minimally invasive surgery (MIS) approaches and the medial parapatellar (MPP) approach to improve the American Knee Society Score (KSS) in primary TKA. MATERIALS AND METHODS: Studies were comprehensively searched on PubMed, Embase, Cochrane Library (CENTRAL), Web of Science and Science Direct up to June 2018 with a major focus on the outcome of KSS. Risk of bias was assessed using the Cochrane risk of bias tool. Quality assessment was performed using the GRADE system. Both pair-wise and network meta-analyses are calculated to comprehensively compare the effectiveness of four MIS and TKA approaches. RESULTS: Eleven trials with 1025 knees undergoing TKA were included. Our analysis showed that both MPP and MIS approaches provided improvement in terms of short-term (four-eight weeks) total, objective and functional KSS. The network-meta analysis revealed that MIS approaches showed a trend towards superior KSS improvement over standard MPP approaches. However, statistical advantages were only observed in the mini-MPP group for functional KSS compared to the conventional MPP and quadriceps-sparing (QS) groups. CONCLUSIONS: Evidence shows that MIS TKA approaches are effective alternatives to MPP approaches. However, orthopedic surgeons should be cautiously optimistic about minimally invasive TKA in terms of KSS improvement.

Quadriceps muscle group function and after total knee arthroplasty-asystematic narrative update

BACKGROUND

This article systematically summarizes the present evidences, published in the last 20 years, regarding the pre- and post-operative factors, which may influence recovery of the function of the quadriceps muscle group following total knee arthroplasty (TKA). We following the PRISMA methodology, including meta-analyses and high-level evidence studies (prospective trials, and, when unavailable, retrospective studies).

SOURCES OF DATA

Pubmed and Cochrane databases: 582 articles were identified and 54 of them were selected.

AREAS OF AGREEMENT

Tourniquets inflated at high pressure exert a detrimental effect on the quadriceps muscle group. Faster quadriceps recovery takes place using mini-invasive approaches, an eight-week rehabilitation period including balance training and the use of nutraceuticals.

AREAS OF DISAGREEMENT

Pre-habilitation and pre-operative factors, analgesic methods and different TKA implants.

GROWING POINTS AND AREAS TIMELY FOR DEVELOPING RESEARCH

Telerehabilitation seems a cost-effective tool for rehabilitation after TKA. Patients' optimization protocols before TKA should include standardized nutraceuticals intake.

Does mini-midvastus approach have an advantageous effect on rapid recovery protocols over medial parapatellar approach in total knee arthroplasty?

Objectives

This study aims to compare the effects of mini- midvastus (MMV) versus medial parapatellar (MPP) approach on rapid recovery protocols during total knee arthroplasty (TKA).

Patients and methods

This prospective, randomized, single- blinded study was performed in 54 patients (4 males, 50 females; mean age 64.1±6.4 years) diagnosed as primary knee osteoarthritis and planned for unilateral TKA between May 2018 and March 2019. Patients were randomly assigned as MMV (1 male, 26 females; mean age 65±6.4 years) and MPP (3 males, 24 females; mean age 63.2±6.3 years) groups. Rapid recovery TKA protocol and discharge criteria were assembled and all patients were evaluated preoperatively, and at postoperative first and third months. Length of hospital stay (LOS) was recorded for all patients. Hemoglobin and hematocrit values, radiologic assessment of alignment, knee range of motion (ROM), quadriceps muscle strength, Visual Analog Scale (VAS), 30-sec chair-stand test, stair-climb test, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Short Form-36 (SF-36) were used for evaluations by blinded observers.

Results

There was no significant difference in demographic variables between two groups. Operative time in MMV Group (78.1±2.7 min) was significantly longer than the MPP Group (65.9±2.6 min) (p<0.0005). LOSs in the MMV and MPP Groups were 27.6±3.1 hours and 29.1±6.7 hours with no significant difference. There was no statistically significant difference in postoperative measurements between groups in hemoglobin and hematocrit values, radiologic alignment of components, knee ROM, VAS, 30-sec chair-stand test, stair-climb test, WOMAC, KOOS, and SF-36 evaluations (p>0.05). In terms of quadriceps muscle strength gain, we could not find any difference between groups in pre- and postoperative difference of changes (p>0.05).

Conclusion

With the use of contemporary rapid recovery protocols during TKA, MMV approach had no superiority over MPP approach when quadriceps muscle strength, LOS, pain, function, and quality of life were assessed. Longer operative time in the MMV approach compared to MPP approach may be considered as a disadvantage.

Mini-midvastus versus medial parapatellar approach in total knee arthroplasty: difference in patient-reported outcomes measured with the Forgotten Joint Score

Background

Low knee awareness after minimally invasive total knee arthroplasty (TKA) has become the ultimate target of a natural-feeling knee that meets patient expectations. The objective of this research was to compare the clinical outcomes of TKA via the mini-midvastus (MMV) approach or the medial parapatellar (MPP) approach, and to evaluate which approach can lead to a better quality of life after surgery.

Methods

From January 2015 to December 2016, a retrospective cohort study was conducted in 330 patients who underwent TKA via a mini-midvastus (MMV) approach. During this period, we also selected 330 patients who underwent TKA via a medial parapatellar (MPP) approach (MPP group) for comparison. Clinical results were assessed with the visual analog scale score for pain, range of motion, and the Knee Society Score. The Forgotten Joint Score was used to analyze the ability to forget the joint.

Results

There were significant differences with regard to visual analog scale score, range of motion, and the Knee Society Score until 6 months after surgery between the MMV and MPP groups (p < 0.05), but the differences were not significant at 12 months, 24 months, and 36 months after surgery. However, there were significant differences in the Forgotten Joint Score between the groups during the follow-up period (p < 0.05).

Conclusion

When forgetting the artificial joint after TKA is the ultimate target, better quality of life can be acquired by performing TKA via the MMV approach. In addition, compared with the MPP approach, the MMV approach can offer less pain and a faster recovery.

Minimally Invasive Total Knee Arthroplasty: Does Surgical Technique Actually Impact the Outcome?

A surgical approach to total knee arthroplasty has been at the forefront of many conversations. Surgeons used the medial parapatellar approach for its familiarity of anatomy, reliability, and ability to convert to a more extensile approach. This article reviews the current literature and information regarding the effect of surgical approach on patients' outcomes. The results of the limited medial parapatellar, subvastus, midvastus, and quadriceps-sparing approaches were analyzed. All techniques can provide adequate exposure with successful outcomes. It is recommended that a surgeon perform the approach with which they are most comfortable, because that will likely yield the best patient outcome.

Better outcomes after mini-subvastus approach for primary total knee arthroplasty: a Bayesian network meta-analysis

Introduction

Alternatives to the classical medial parapatellar (MPP) approach for total knee arthroplasty (TKA) include the mini-medial parapatellar (MMPP), mini-subvastus (MSV), mini-midvastus (MMV) and quadriceps-sparing (QS) approaches. The best approach has been not fully clarified. The purpose of the present study was to conduct a Bayesian network meta-analysis comparing these approaches.

Materials and methods

The present analysis was carried out according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of healthcare interventions. The databases search was performed in October 2019. All clinical trials comparing two or more approaches for primary TKA were considered for inclusion. The baseline comparability was evaluated through the analysis of variance (ANOVA) test. The statistical analysis was performed through the STATA software/MP. A Bayesian hierarchical random-effects model analysis was adopted in all the comparisons.

Results

Data from 52 articles (4533 patients) were collected. The mean follow-up was 20.38 months. With regard to diagnosis, gender, age and BMI, adequate baseline comparability was detected. The MSV approach ranked better concerning clinical scores (the lowest visual analogic scale, the higher KSS and KSFS) and functional outcomes (the shortest straight leg raise, the greatest degree of flexion and range of motion). Concerning perioperative data, the MSV evidenced the shortest hospital stay, while the MPP the shortest surgical duration and lowest estimated blood loss.

Conclusion

According to the main findings of the present study, the mini-subvastus approach for total knee arthroplasty demonstrated superior overall compared to the other approaches. Orthopaedic surgeons should consider this approach in the light of the evidence and limitations of this Bayesian network meta-analysis.

Comparable outcomes in mini-midvastus versus mini-medial parapatellar approach in total knee arthroplasty: a meta-analysis and systematic review

BACKGROUND

Minimally invasive surgery (MIS) techniques in total knee arthroplasties (TKA) have gained popularity over conventional techniques due to benefits of hastened recovery and reduced complications. There are a variety of MIS techniques available and two most common techniques currently employed are the mini-midvastus (mMV) and mini-medial parapatellar (mMPP) approaches. This meta-analysis aims to compare the clinical outcomes and peri-operative parameters between mMV and mMPP in TKA in order to determine the presence of a superior technique.

METHODS

A multi-database search was performed according to PRISMA guidelines. Data from studies comparing clinical outcomes and peri-operative parameters between mMV and mMPP approaches in TKA were extracted and analysed.

RESULTS

A total of five randomized controlled trials were included for analysis, consisting of 190 mMV and 189 mMPP knees. Clinically unimportant differences were noted in blood loss and surgical time between the groups (5 mL less blood loss and 7 min less surgical time in mMV, P < 0.001). There was no statistically significant difference between both groups for Knee Society Score at 1 and 2 years, range of motion at 1 and 2 years, incision length or incidence of lateral retinacular release (all non-significant, P > 0.05).

CONCLUSION

The mMV and mMPP MIS TKA approaches have equivalent clinical outcomes. Despite a statistically significant longer operative time and higher mean blood loss in mMV than mMPP approach, clinically significant difference was not demonstrated. Both mMV and mMPP MIS techniques are reliable and safe to perform in TKA.

Risk of bias and the reporting of surgeons' experience in randomized controlled trials of total hip and total knee arthroplasty: A systematic review

RATIONALE, AIMS, AND OBJECTIVES

The potential bias introduced by surgeons' lack of comparable, relevant experience when performing the procedures in different arms of randomized controlled trials (RCTs) is arguably not well-managed or reported. The aim of this work was to review the frequency and nature with which surgeons' relevant experience is reported in RCTs of total hip (THA) and total knee arthroplasty (TKA), and to relate this to other risk of bias domains for this study design.

METHODS

A systematic review of RCTs comparing different minimally invasive procedures for TKA and comparisons of THA and hemiarthroplasty (HA). We searched MEDLINE, EMBASE, Science Citation Index, The Cochrane Library, Conference Proceedings Citation Index-Science (CPCI-S), Current Controlled Trials, and Clinical Trials.gov.

RESULTS

Seventy-five relevant RCTs were identified, 65 RCTs comparing minimally invasive with standard or other minimally invasive approaches to TKA, and 10 for THA compared with HA. Risk of bias based on the reported details of surgeons' relevant experience was categorized as low, high, or unclear. There was a clear distinction before and after 2009, with a substantial decrease in trials at high or unclear risk of bias after this date. There were no strong associations between this domain and other, standard risk of bias domains for RCTs.

CONCLUSION

The surgeons' relevant experience in an evaluated procedure is often poorly reported but has improved since 2009. The variable is not adequately captured by any other risk of bias domain. Future work should concentrate on conducting research on a much larger sample of studies and in procedures other than knee and hip arthroplasty.

No Difference in Outcomes 12 and 24 Months After Lower Extremity Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

A better understanding of how patient-reported outcome measures (PROMs) change after total knee and hip arthroplasties (TKA and THA) is needed to support the minimum arbitrary follow-up of 24-months required by orthopedic journals. Therefore, our purpose was to perform a systematic review and meta-analysis of the THA and TKA literature to determine if equivalence exists between 12- and 24-month outcomes data.

METHODS

A search was performed using the PubMed and EMBASE databases for primary and revision THA and TKA studies reporting PROMs data at both 12 and 24 months. Reports on PROMs for TKA and THAs were included for meta-analysis to detect statistical differences at 12 and 24 months.

RESULTS

A total of 15 reports from 9 TKA (n = 1564) and 6 THA (n = 740) reports were analyzed. The mean change between 12 and 24 months for Knee Society Score was 0.15 absolute points (95% confidence interval [CI]: 0.97-1.06, P = .13) and for Western Ontario and McMaster Universities Osteoarthritis index was 0.50 absolute points (95% CI: 0.94-1.07, P = .49). The mean change between 12 and 24 months for Harris Hip Score was 2.01 absolute points (95% CI: 0.94-1.1, P = .22) and for short form was 0.02 absolute points (95% CI: 0.92-1.08, P = .94).

CONCLUSION

No different outcomes were found within THA and TKA for 4 PROMs at 12- and 24-month follow-up. Although the findings from this study do not alleviate the need for collecting data from longer follow-up periods, there may not be additional value in collecting short-term outcomes data in routine practice at both 1 and 2 years.

Lateral parapatellar and subvastus approaches are superior to the medial parapatellar approach in terms of soft tissue perfusion

PURPOSE

The arthrotomy techniques of knee surgery may cause varying degrees of disruption to the tissue blood supply. The aim of this study was to investigate the effects of the medial parapatellar (MPPa), midvastus (MVa), subvastus (SVa) and lateral parapatellar (LPPa) approaches on regional tissue perfusion of the knee.

METHODS

In this experimental study, a total of 28 female rabbits were applied with four different arthrotomy techniques as Group MPPa, Group MVa, Group SVa and Group LPPa. The blood supply of the tissue around the knee was examined by scintigraphic imaging including the perfusion reserve and T _max, and biochemical alteration of the oxidative stress parameters including malondialdehyde (MDA), fluorescent oxidation products (FlOPs), and histopathological findings were evaluated on tissue samples after 3 weeks.

RESULTS

The perfusion reserve was increased in all four groups compared to the healthy, contralateral knees. In the Group LPPa, the vascularity was significantly increased compared to the Group MPPa (p = 0.006). In the examination of biochemical parameters, the increase in MDA levels was statistically significant in the Group MPPa compared with the Group LPPa (p = 0.004), and in the Group MVa compared with the Group LPPa (p = 0.006). The increase in the value of MDA levels was striking in the Group MPPa and Group MVa compared with the control group (p = 0.004, p = 0.004, respectively). The increase in another oxidative stress parameter, the tissue FlOPs levels, was statistically significant in the Group MPPa compared with the control group (p = 0.035).

CONCLUSION

The LPPa and SVa caused less oxidative stress and less disruption of the muscle blood supply, in biochemical and scintigraphic parameters, compared to the MPPa and MVa. Therefore, in clinical practice, the SVa is preferable to the MPPa and MVa in total knee arthroplasty and the LPPa should be preferred more frequently in selected cases with critical soft tissue viability.

Mid-term survivorship of cruciate-retaining versus posterior-stabilized total knee arthroplasty using modular mini-keel tibial implants

Background

Reports of diverse outcomes in modular mini-keel tibial componentry for total knee arthroplasty (TKA) have raised concerns about early aseptic loosening. Cruciate-retaining (CR) prostheses, using mini-keel implants, have yet to be reported and compared to posterior-stabilizing (PS) designs.

Methods

A retrospective, case-matched study of 91 consecutive TKAs (n = 46 CR; n = 45 PS prostheses), using modular mini-keel tibial componentry with a 45-mm drop down stem extension, was conducted. The Knee Society Score functional survey, radiographic analysis including alignment and periprosthetic radiolucency, TKA prosthesis longevity, and surgical complications were reported and compared between CR and PS groups.

Results

The Knee Society Score at 5-year follow-up averaged 81.67 ± 11.97 and 80.12 ± 14.16 in the CR and PS groups, respectively (p = 0.29). The femorotibial angle averaged 5.85° ± 2.62° and 5.85° ± 3.27° valgus in the CR and PS groups, respectively (p = 0.60). The average tibial component angle was 0.46° ± 1.6° and 0.61° ± 1.3° varus in the CR and PS groups, respectively (p = 0.30); posterior inclination averaged 2.28° ± 2.36° and 1.93° ± 2.72° in the CR and PS groups, respectively (p = 0.51). Radiolucency was noted in 17 zones of the CR group and in 9 zones of the PS group (p = 0.24). Three TKAs required further surgery: one locking plate fixation for a periprosthetic tibial fracture (PS group) and two revision TKAs (one CR infection and one PS fracture).

Conclusion

Modular mini-keel tibial components showed good reliability and results with both CR and PS prostheses in minimally invasive surgery TKA.

Mini-subvastus versus medial parapatellar approach for total knee arthroplasty: a prospective randomized controlled study

PURPOSE

Whether minimally invasive total knee arthroplasty (MIS-TKA) could offer better and faster recovery without the deviation of post-operative prosthesis position and limb alignment is still controversial. This prospective and randomized study was conducted to compare the clinical and radiological outcomes between patients who underwent the mini-subvastus approach of MIS-TKA and those who underwent the medial parapatellar approach of traditional TKA.

METHODS

Fifty patients, including 50 knees, who required TKA due to osteoarthritis were randomized to the mini-subvastus group (group I) or the medial parapatellar group (group II). All patients accepted the same method of anaesthesia, equal support therapy and identical rehabilitation exercise after surgery. The evaluation system included operation time, tourniquet time, blood loss, skin incision length in flexion, straight leg raising time, the time of lower limb muscle strength up to grade 4, the time of walking with aid or without aid, the time of walking up and down the stairs, the active flexion angle, range of movement (ROM), the Knee Society Scores (KSS), visual analogue score for pain (VAS), hospital stays and radiographic outcomes.

RESULTS

The mini-subvastus approach offered smaller skin incision length in flexion, but at the cost of operation time (P < 0.001). No significant difference was found in tourniquet time and blood loss. The patients in group I could achieve straight leg raising, the lower limb muscle strength up to grade 4, walking with or without aid, and walking up and down the stairs earlier (P < 0.001). The active flexion angle, ROM, VAS and KSS in group I were superior to those in group II until six months post-operatively (P < 0.001), but the differences was not apparent at 12 months post-operatively. More importantly, there was no significant difference between the two groups on radiological outcomes (P > 0.05).

CONCLUSIONS

The mini-subvastus approach could offer faster recovery, less pain and shorter hospital stays without compromising the principles of proper prosthesis position and limb alignment compared with the medial parapatellar approach.

Clinical Considerations for the Use Lower Extremity Arthroplasty in the Elderly

There is an increase in the aging population that has led to a surge of reported cases of osteoarthritis and a greater demand for lower extremity arthroplasty. This article aims to review the current treatment options and expectations when considering lower extremity arthroplasty in the elderly patient with an emphasis on the following subjects: (1) updated clinical guidelines for the management of osteoarthritis in the lower extremity, (2) comorbidities and risk factors in the surgical patient, (3) preoperative evaluation and optimization of the surgical patient, (4) surgical approach and implant selection, and (5) rehabilitation and life after lower extremity arthroplasty.

Soft-tissue damage during total knee arthroplasty: Focus on tourniquet-induced metabolic and ionic muscle impairment

PURPOSE

Advantages of tourniquet use in TKA include benefits for surgeons and patients, varying from a bloodless operation site to a reduced intervention time. The time under ischemia and the reperfusion period are crucial phases for affected soft-tissue, most commonly the extensor mechanism.

CASE REPORTS

documented its impact on soft-tissue, ranging from necrotic muscle damage to systemic inflammation. Recently, research regarding tourniquet application patterns discuss clinical outcome parameters in the context of soft-tissue damage, excluding the underlying pathophysiological mechanisms.

METHODS

This review summarizes the molecular aspects of soft-tissue damage occurring during tourniquet application in TKA with special focus on ischemia/reperfusion injury. Recent meta-analyses and original trials were reviewed for data on muscle damage and are presented.

CONCLUSION

Although underlying pathomechanisms are well known and presented, clinical orthopedic research has so far not addressed this issue. In context of physical training, positive effects regarding postoperative recovery might be possible if more attention is paid to prepare involved muscle preoperatively to TKA (prehabilitation).

Computer-assisted total knee arthroplasty using mini midvastus or medial parapatellar approach technique: A prospective, randomized, international multicentre trial

Background

Despite the growing evidence in the literature there is still a lack of consensus regarding the use of minimally invasive surgical technique (MIS) in total knee arthroplasty (TKA).

Methods

A prospective, randomized, international multicentre trial including 69 patients was performed to compare computer-assisted TKA (CAS-TKA) using either mini-midvastus (MIS group) or standard medial parapatellar approach (conventional group).

Patients from 3 centers (Maastricht, Zwickau, Adelaide) with end-stage osteoarthritis of the knee were randomized to either an MIS group with dedicated instrumentation or a conventional group to receive cruciate retaining CAS-TKA without patella resurfacing. The primary outcome was to compare post operative pain and range of motion (ROM). The secondary outcome was to measure the duration of surgery, blood loss, chair rise test, quadriceps strength, anterior knee pain, Knee Society Score (KSS),WOMAC scores, mechanical leg axis and component alignment.

Results

Patients in the MIS group (3.97 ± 2.16) had significant more pain at 2 weeks than patients in the conventional group (2.77 ± 1.43) p = 0.003. There was no significant difference in any of the other primary outcome parameters. Surgery time was significantly longer (p < 0.001) and there were significantly higher blood loss (p = 0.002) in the MIS group as compared to the conventional group. The difference of the mean mechanical leg alignment between the groups was not statistically significant (–0.43° (95 % CI –1.50 – 0.64); p = 0.43).

There was no significant difference of component alignment between the two surgical groups with respect to flexion/extension (p = 0.269), varus/valgus (p = 0.653) or rotational alignment (p = 0.485) of the femur component and varus valgus alignment (p = 0.778) or posterior slope (p = 0.164) of the tibial component.

Conclusion

There was no advantage of the MIS approach compared to a conventional approach CAS-TKA in any of the primary outcome measurements assessed, however the MIS approach was associated with longer surgical time and greater blood loss. MIS-TKA in combination with computer navigation is safe in terms of implant positioning.

Trial registration number

ClinicalTrials.gov NCT02625311 8 December 2015

The Patient's Perception Does Not Differ Following Subvastus and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Simultaneous Bilateral Randomized Study

This simultaneous bilateral randomized study investigated whether patients would perceive the difference between the subvastus approach (SVA) and the medial parapatellar approach (MPA) after total knee arthroplasty (TKA). In 50 patients scheduled to undergo same-day bilateral TKA, one knee was randomly assigned to SVA and the other to MPA. Patient-reported measures (pain, Western Ontario McMaster University Osteoarthritis Index score, and side preference) and physician-assessed measures (isokinetic muscle strength, range of motion, and Knee Society score) were compared. No differences were observed in the patient-reported measures and physician-assessed measures, with the exception of greater quadriceps strength at postoperative 1 week in knees that underwent SVA. Patients receiving contemporary perioperative management after same-day bilateral TKA do not perceive any difference between knees that underwent SVA or MPA.

Comparison of the quadriceps-sparing and subvastus approaches versus the standard parapatellar approach in total knee arthroplasty: a meta-analysis of randomized controlled trials

Background

The quadriceps-sparing and subvastus approaches are two of the most commonly used minimally-invasive approaches in total knee arthroplasty (TKA). However, the conclusion among studies still remains controversial. The purpose of this meta-analysis was to compare the clinical efficacy of the subvastus and quadriceps-sparing approaches with the standard parapatellar approach in TKA.

Methods

Randomized controlled trials (RCTs) comparing the quadriceps-sparing or subvastus approach with the standard parapatellar approach was identified in the databases of PubMed, the Cochrane library, EMBASE and Web of Science up to July 2014. Two authors extracted the following data: the basic characteristics of patients, the methodological quality and clinical outcomes from the included RCTs independently. RevMan 5.2.7 software was used for meta-analysis.

Results

A total of 19 RCTs (1578 patients) were included for meta-analysis. The results suggested that the quadriceps-sparing approach showed better outcomes in knee society score (KSS) and visual analog score (VAS), but this approach required a longer operative time than the standard parapatellar approach. There were no differences in total complications, wound infection, deep vein thrombosis, blood loss and hospital stay between the quadriceps-sparing and standard approaches. The subvastus approach showed better outcomes in VAS, knee range of motion (ROM), straight leg raise and lateral retinacular release than the standard parapatellar approach. There were no differences in KSS, total complication, wound infection, deep vein thrombosis, blood loss and hospital stay between the quadriceps-sparing and standard approaches.

Conclusions

The current evidence showed that, when compared with the standard parapatellar approach, the quadriceps-sparing approach was associated with better outcomes in KSS and VAS but required a longer operative time, and the subvastus approach was associated with better outcomes in VAS, ROM, straight leg raise and lateral retinacular release.

Optimal patellar alignment with minimally invasive approaches in total knee arthroplasty after a minimum five year follow-up

PURPOSE

Patellofemoral syndrome is still a common complication after total knee arthroplasty (TKA). However, the effects of specific surgical approaches on patellar tracking and alignment remain incompletely understood. In this study, we compared patellar alignment in patients who underwent TKA via three different techniques.

METHODS

A total of 96 patients who completed a minimum follow-up of five years were involved in three groups: 30 patients were treated with the traditional medial parapatellar approach (MPP group), 35 patients were treated with the mini-medial parapatellar approach (MMP group) and 31 were treated with a quadriceps-sparing approach (QS group). Radiographic data for patellar alignment and clinical results were compared.

RESULTS

Patellar tilt and patellar displacement at the final follow-up evaluation differed significantly among the three groups [P < 0.01, analysis of variance (ANOVA)]. The MMP and QS groups exhibited more proper patellar alignment than the MPP group. The clinical results did not differ significantly among the groups (P > 0.05, ANOVA). In addition, there were no correlations between postoperative patellar alignment and clinical scores.

CONCLUSIONS

The results of this study indicate that TKA performed using minimally invasive approaches yields superior patellar alignment compared to the traditional MPP approach.

Minimally invasive midvastus versus standard parapatellar approach in total knee arthroplasty: a meta-analysis of randomized controlled trials

Objective

Minimally invasive midvastus approach (mini-midvastus) has been widely used in total knee arthroplasty (TKA). However, the clinical effects still remains controversial. This meta-analysis was based on randomized controlled trials (RCTs) aiming to quantitatively analyze the clinical efficacy of mini-midvastus versus standard parapatellar approach in TKA.

Methods

This meta-analysis was performed according to the PRISMA guidelines. A literature search for the eligible RCTs was carried out in the databases of PubMed, the Cochrane library, EMBASE and Web of Science. Two independent reviewers independently completed the study selection, data extraction, and the assessment of methodological quality. Meta-analysis was conducted by the RevMan 5.2 software.

Results

A total of 18 RCTs (937 patients with 1093 TKAs) published from 2007 to 2013 were included. The meta-analysis suggested that the mini-midvastus approach significantly improved knee range of motion (ROM) and decreased visual analog score (VAS) at postoperative 1–2 weeks (p<0.05), and there were no statistical differences in terms of knee society score (KSS) (6 weeks to 1 year), VAS (6 weeks to 6 months), ROM (6 weeks to 6 months), lateral retinacular release, blood loss, straight leg raise, hospital stay and postoperative complications between the mini-midvastus and standard parapatellar approach (p>0.05). However, the operative time was significantly longer when performing the mini-midvastus group than the parapartellar approach (p<0.05).

Conclusion

This meta-analysis found that compared with the standard parapatellar approach, the mini-midvastus approach had early advantages in the VAS and ROM, but had the disadvantage in the operative time.

Level of Evidence

Therapeutic study Level I.