The lateral and medial approach in total arthroplasty for valgus knee: a meta-analysis of current literature

Comparative Analysis of Outcomes of Lateral Versus Medial Approach in the Total Knee Arthroplasty for Valgus Deformity: A Systematic Review and Meta-analysis

Background

Valgus knee deformity poses great challenges in total knee arthroplasty (TKA) and requires precision in balancing of soft tissue and implant component positioning. The surgical approach used for TKA has a determinantal impact on intraoperative soft tissue balancing, postoperative knee function, and complications. We executed a systematic review and meta-analysis of current literature, which included a maximum number of studies with quantitative analysis of all possible outcomes to substantiate the current evidence of the advantage of lateral versus medial approach in TKA for valgus knee deformity.

Methodology

We performed a meticulous primary electronic search across PubMed, Emabse, Scopus, and Cochrane Library databases, and looked for the comparative studies that evaluated the medial versus lateral approach in TKA for valgus knees. Statistical analyses were executed with RevMan-5.4.1.

Results

On the evaluation of four randomized controlled trials (RCTs), two prospective and five retrospective comparative studies, our analysis revealed a better functional outcome in terms of Knee Society Score [MD 2.24, 95% CI 0.42, 4.05; p = 0.02] with the medial approach. However, comparable results were observed for two approaches with regard to Knee Society Function [MD 0.69, 95% CI - 1.77, 3.15; p = 0.58], knee flexion range of motion (ROM) [MD 3.30, 95% CI - 1.34, 7.95; p = 0.16], overall complications [OR 0.60, 95% CI 0.27,1.34; p = 0.22], wound-related complications, infection, nerve injury, periprosthetic fracture, post-operative valgus, blood loss, duration of surgery, postoperative pain, and patellar tilt for TKA in valgus knee.

Conclusion

Evidence from the currently available published data suggests that the lateral approach, compared to the medial approach in TKA for the valgus knee, does not show clear superiority.

Total knee arthroplasty for knee osteoarthritis associated with abnormal patellar tendon deformity: a case report

There have been no earlier reports of knee osteoarthritis with valgus knee deformity in which the patellar tendon infiltrates the tibial bone marrow instead of attaching to the tibial tubercle. This case report describes a total knee arthroplasty (TKA) performed for the treatment of a primary knee osteoarthritis resulting from a valgus knee joint position attributed to an abnormality of the patellar ligament attachment. During a TKA, the tendon tissue in the tibial medullary canal interfered with the reamer used to prepare for the stem extensions needed to improve the fixation of the component on the tibia, which had a cortical defect. The arthroplasty succeeded, and good clinical results have been maintained over the 3 years since the surgery. Surgeons should consider careful preoperative examinations by magnetic resonance imaging or CT when an abnormal bone defect is observed at the tibial tubercle on plain X-ray images.

Lateral versus medial approach for total knee arthroplasty for valgus knee deformity shows comparable functional outcomes, hip-knee-ankle angle values, and complication rates: a meta-analysis of comparative studies

INTRODUCTION

The aim of this meta-analysis of comparative studies was to update the current evidence on functional and radiographic outcomes and complications between medial and lateral approaches for total knee arthroplasty (TKA) for valgus knee deformity.

MATERIALS AND METHODS

The PubMed, MEDLINE, Scopus, and the Cochrane Central databases were used to search keywords and a total of ten studies were included. The methodological quality of the included studies was assessed. Data extracted for quantitative analysis included the Knee Society score (KSS), range of motion (ROM), surgical time, hip-knee-ankle angle (HKA), and number and types of complications. Random- and fixed-effect models were used for the meta-analysis of pooled mean differences (MDs) and odds ratios (ORs). The Mantel-Haenszel method was adopted.

RESULTS

A total of 1008 patients were identified, of whom 689 and 319 underwent TKA for valgus knee deformity with lateral and medial approach, respectively. The mean age was 70 ± 9.5 and 67.3 ± 9.6 years for the lateral and medial approaches, respectively. The mean follow-up was 37.8 ± 21.9 and 45.9 ± 26.7 months for the lateral and medial approach groups, respectively. Significantly higher functional outcomes were found for the medial approach, as measured by the postoperative KSS (MD = 1.8, 95% CI [0.48, 3.12], P = 0.007) and flexion ROM (MD = 3.12, 95% CI [0.45, 5.79], P = 0.02). However, both of these differences were lower than the minimal clinically important difference. Comparable surgical time and postoperative HKA angle values (MD = 0.22, 95% CI [- 0.30, 0.75], P = 0.40) between the two surgical approaches were found. The incidence of periprosthetic joint infections, fractures, transient peroneal nerve injuries, and deep vein thrombosis was comparable.

CONCLUSION

This meta-analysis of comparative studies showed that when lateral and medial approaches are used for total knee arthroplasty for valgus knee deformity, comparable functional outcomes in terms of the KSS and ROM, surgical time, and postoperative hip-knee-ankle angle values can be expected. Similar rates of periprosthetic joint infection, fracture, and peroneal nerve injury were also found.

LEVEL OF EVIDENCE

I.

PROSPERO REGISTRATION NUMBER ID

CRD42023392807.

Lateral or Medial Parapatellar Surgical Approach to the Valgus Osteoarthritic Knee? A Retrospective Single-Center Study

Aims: Total knee arthroplasty in patients with fixed valgus deformity is a demanding procedure. The aim of this study was to compare the clinical results of using the lateral approach [LA] versus the medial approach [MA] in the treatment of fixed valgus knee deformities. Methods: This single-center study compared the results of 143 consecutive patients with fixed valgus deformity (mean 21.55° valgus, mean age 68.2 years) undergoing LA Total Knee Arthroplasty [TKA] to 50 patients (mean 16.58° valgus, mean age 67.2 years) undergoing MA TKA. The mean follow-up period was 5.1 years (2−10 years). Data was collected from operative notes, routine postoperative visits, and radiological findings. Apart from a radiological evaluation, patients were clinically assessed both pre- and postoperatively using the Knee Society Score [KSS]. Descriptive statistics together with the Kolmogorov-Smirnov test, the Student’s t-test for independent samples, and the Mann-Whitney U test were used. The level of significance in this study was α = 0.05. Results: In the LA group, the KSS Knee was significantly higher than in the MA group [85.31 vs. 77.42, respectively, p-value < 0.001]. The difference was also in the KSS total but with no statistical significance [155.17 vs. 149.22, p-value 0.087]. The surgery time in the LA group was shorter than in the MA group [81 vs. 91 min, respectively, p-value—0.002]. The complication rate after surgery was higher in the MA group than in the LA group (14% vs. 9%, respectively). Conclusions: The lateral approach is a good alternative to the standard medial parapatellar approach in the treatment of fixed valgus knee deformities. A higher postoperative KSS Knee, shorter surgery time, and similar complication rate make the lateral approach a valuable option for treating patients with osteoarthritis and fixed valgus knee deformity.

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.