Subvastus versus medial parapatellar approach in total knee arthroplasty: meta-analysis

Functional Outcome of Subvastus versus Medial Parapatellar Approaches for Total Knee Replacement in Patients with Knee Osteoarthritis: A Prospective Cohort Study

Background

Subvastus approach and medial parapatellar approach are two major approaches for total knee replacement (TKR). There is no global consensus on the superiority of either approach in terms of functional outcomes.

Objective

The present study aimed to evaluate the functional outcome of TKR through subvastus approach and medial parapatellar approach by using patient-reported scores at 3-, 6-, and 12-month post-operative follow-ups.

Methods

This prospective cohort follow-up study included patients with knee osteoarthritis who underwent elective primary TKR either through the subvastus or medial parapatellar approaches at King Abdullah Medical City, Makkah city, Kingdom of Saudi Arabia, from January 2019 to December 2022. Scores from the self-reported Oxford Knee Score (OKS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were compared in the two groups of patients at 3-, 6-, and 12-month post-operative follow-ups.

Results

A total of 98 patients were included, of which 37 underwent TKR through the subvastus approach and 61 through the medial parapatellar approach. There was an overall significant change over time in both WOMAC and OKS scores (P < 0.001). Patients who underwent the subvastus approach had significantly higher mean of WOMAC and OKS than patients with the medial parapatellar approach at the 3- and 6-month follow-ups (P < 0.05), but not at the 12-month follow-up.

Conclusions

For TKR, the medial parapatellar approach results in better functional outcomes at the 3- and 6- month follow-up periods compared with the subvastus approach.

Immunohistochemical analysis of the quadriceps femoris muscle before and after total knee arthroplasty

BACKGROUND

The number of total knee arthroplasties (TKA) has increased steadily with the aging of the population. This surgical procedure is recognized for its success in pain relief and restoration of knee function. However, decreased quadriceps femoris (QF) muscle strength after TKA is frequently observed but with unknown etiology. Evidence suggests that the location of the operative incision (i.e., surgical access) can influence QF muscle structure and function. The present study aimed to assess the fiber type composition, structure and assembly of the QF's vastus medialis (VM) and vastus lateralis (VL) muscles before and after TKA.

METHODS

Muscle biopsies (VM and VL muscles) were collected from patients previously submitted to TKA via the medial parapatellar route and undergoing TKA revision (main group, n = 9) and patients with osteoarthrosis (OA) who were due to undergo TKA (control group: n = 18). The biopsied muscle tissue was prepared, stored, and then sectioned in a cryostat at -25 °C. The tissue sections were evaluated using routine staining techniques in pathological anatomy and histochemistry.

RESULTS

The normal mosaic pattern of the medial and lateral knee muscles was observed in the main and control groups, with no evidence of peripheral nerve damage. Notably, 88.9 % of the patients exhibited mild to severe VL atrophy, while only 11.1 % of patients in the control group presented this feature (P < 0.001).

CONCLUSIONS

The medial parapatellar incision for TKA surgical access does not generate definitive morphological changes in the VM and VL muscle fibers but may contribute to VL atrophy.

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).

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.

Lateral subvastus approach: A cadaveric examination of its potential for total knee arthroplasty

BACKGROUND

Lateral approaches to total knee arthroplasty (TKA) provide good surgical exposure and may provide greater ease of soft tissue balancing in patients with a valgus deformity; however, little is known about the versatility in non-valgus knees. The present study evaluated if a lateral subvastus approach can achieve adequate surgical exposure while maintaining less soft tissue damage compared with the medial parapatellar approach in knees without any significant deformity.

METHODS

Using paired fresh-frozen cadaveric knees, the present study provides the first specimen-matched, side-by-side comparison of the lateral subvastus approach to the standard medial parapatellar approach to TKA. Ten knees were selected to undergo a lateral subvastus approach; the contralateral knee had a medial parapatellar approach as control. Incision length, surgical exposure and iatrogenic soft tissue damage were compared between the two approaches.

RESULTS

The lateral subvastus approach was successfully performed using an incision length that was not different from that used in the medial parapatellar approach (p > 0.05). The resultant surgical exposure was comparable between approaches (p > 0.05). The risk of the approach included tearing of the vastus lateralis fibers, and/or abrasion of the iliotibial tract/patellar ligament.

CONCLUSIONS

The lateral subvastus approach to TKA provided a comparable method to the standard medial parapatellar approach. Despite adequate exposure, the approach did risk soft tissue injury. Caution needs to be exercised to reduce the risk of iatrogenic injury to the vastus lateralis and surrounding ligaments. The successful implementation in this cadaveric study substantiates the need for further consideration of this approach in clinical practice.

A Modified Under-Vastus Approach for Knee Arthroplasty with Anatomical Repair of Soft Tissue

The under-vastus approach (UVA) is a modification of the conventional subvastus approach for knee arthroplasty. Our modified UVA allows the muscles to be spared while offering good exposure of the operative field and facilitating anatomical repair of the capsule and fascia. A medial parapatellar incision is made and the vastus medialis fascia is incised along the same line. The muscle belly is not incised but detached from the surrounding fascia and retracted laterally. The suprapatellar pouch capsule is then laterally incised under the vastus muscles. The patella can then be easily retracted laterally and adequate exposure is possible. After the procedure, both capsule and fascia can be anatomically repaired. We use this approach for all primary arthroplasties in our practice. There has been no case in which an additional muscle incision was required, and there were no intraoperative complications. The modified UVA allows for excellent exposure of the operative field as well as muscle retention in both primary total and unicompartmental knee arthroplasties.

[A prospective randomized controlled study of total knee arthroplasty via mini-subvastus and conventional approach]

Objective

To compare the clinical and radiographic results between primary total knee arthroplasty (TKA) via mini-subvastus or conventional approach through a prospective randomized controlled study.

Methods

Ninety-four patients (104 knees) undergoing primary TKA between January 2011 and April 2012 were evaluated and randomly divided into 2 groups. Forty-six patients (52 knees) underwent TKA via conventional approach (conventional approach group), and 48 patients (52 knees) underwent TKA via mini-subvastus approach (mini-subvastus approach group). In these patients, 45 cases (51 knees) in conventional approach group and 45 cases (49 knees) in mini-subvastus approach group were followed up and recruited in the final analysis. There was no significant difference in age, gender, body mass index, sides, osteoarthritis grading, American Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, visual analogue scale (VAS), range of motion (ROM) of knee between 2 groups ( P>0.05). The clinical indexes were recorded and analyzed, including the operation time, length of incision, total blood loss, blood transfusion after operation, hospital stay time, the time of performing straight leg raise, incision condition, VAS score, ROM of knee, HSS score, and KSS score, hip-knee-ankle angle (HKA), femoral anatomic axis and the femoral prosthesis joint angle (femoral angle), tibia anatomic axis and tibial prosthesis joint angle (tibial angle), femoral prosthesis flexion angle (FPFA), and posterior slope angle (PSA) of the tibial plateau.

Results

All patients were followed up. The average follow-up time was 66.4 months (range, 60.0-72.5 months) in conventional approach group and 65.6 months (range, 60.0-71.2 months) in mini-subvastus approach group. Compared with the conventional approach group, the incision of mini-subvastus approach group shortened, the operation time prolonged, and the time when patients started straight leg raise exercises was earlier; showing significant differences between 2 groups ( P<0.05). There was no significant difference in hospital stay time, total blood loss, and numbers of blood transfusion between 2 groups ( P>0.05). The complication rate was 8.2% (4/49) in mini-subvastus approach group and 0 in conventional approach group, showing no significant difference between 2 groups ( P=0.054). At 1 and 3 days, the VAS and the ROM of knee in mini-subvastus approach group were significantly better than those in conventional approach group ( P<0.05); but there was no significant difference in above indexes between 2 groups at 14 day ( P>0.05). There was no significant difference in HSS and KSS scores between 2 groups at the 1, 3, 6, 12 months and 3, 5 years ( P>0.05). X-ray film showed no aseptic loosening in all cases. There was no significant difference in the measured values and incidence of abnormal patient of HKA, femoral angle, tibial angle, FPFA, and PSA at last follow-up between 2 groups ( P>0.05).

Conclusion

TKA via mini-subvastus approach is helpful to the early function recovery of knee, but the long-term effectiveness is consistent with TKA via conventional approach. As the limited exposure, TKA via mini-subvastus spproach may has high risk of operative complications.

Medial parapatellar approach leads to internal rotation of tibial component in total knee arthroplasty

PURPOSE

The purpose of this study was to investigate if the type of approach [medial parapatellar approach (MPA) versus lateral parapatellar approach with tibial tubercle osteotomy (LPA)] influences rotation of femoral and/or tibial component and leg axis in total knee arthroplasty (TKA). It was the hypothesis that MPA leads to an internally rotated tibial TKA component.

METHODS

This study included 200 consecutive patients in whom TKA was performed using either a parapatellar medial (n = 162, MPA) or parapatellar lateral approach with tibial tubercle osteotomy (n = 38, LPA). All patients underwent clinical follow-up, standardized radiographs and computed radiography (CT). TKA components' position and the whole leg axis were assessed on 3D reconstructed CT scans (sagittal, coronal and rotational). Mean values of TKA component position and the whole leg alignment of both groups were compared using a t test. The tibial component was graded as internally rotated (<3° of external rotation (ER)), neutral rotation (equal or between 3° and 6° of ER) and externally rotated (>6° ER). The femoral component was graded as internally rotated [>3° of internal rotation (IR)], neutral rotation (equal or between -3° IR and 3° of ER) and externally rotated (>3° ER).

RESULTS

There was no significant difference in terms of whole leg axis after TKA between both groups (MPA: 0.2° valgus ± 3.4; LPA: 0.0° valgus ± 3.5). Means of tibial component rotation were 2.7° ER ± 6.1 (MPA) and 7.6° ER ± 5.4 (LPA). Patients of group LPA presented a significantly less internally rotated (LPA: 18.4%; MPA: 48.8%) and more externally rotated (LPA: 52.6%; MPA: 22.8%) tibial component (p < 0.001). No significant differences were seen for the femoral component position, tibial valgus/varus and tibial slope.

CONCLUSION

The type of approach (medial versus lateral) significantly influenced tibial TKA component rotation. It appears that a MPA tends to internally rotate the tibial TKA component and a LPA tends to externally rotate the tibial TKA. The anterior cortex should not be used as landmark for tibial TKA component placement when using the lateral approach with tibial tubercle osteotomy.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Minimally invasive versus conventional approaches in total knee replacement/arthroplasty: A review of the literature

Background

Life expectancy lengthening and aging of population resulted in dramatically increase of patients with osteoarthritis. Total knee arthroplasty is widely used as the gold standard in order to relieve pain, correct deformity and restore function. A contemporary and controversial topic, is that of minimally invasive surgery for TKA. The minimally invasive approaches are based on the concept that they don't violate the extensor mechanism, resulting in earlier functional recovery, shorter hospital stay and enhanced patients' overall satisfaction. The most commonly used MIS approaches in TKA are the subvastus, midvastus and the quadriceps sparing. There is a debate regarding the efficacy and safety of these methods.

Objective

In this article we will review the current literature (randomized controlled trials and systematic reviews/meta-analyses) on MIS compared to traditional approach and analyse their clinical safety, efficacy and long-term results.

Design

Comparison of well-designed studies have tried to demonstrate the advantages/disadvantages, the clinical results and the complications of the MIS approaches compared to the MPP approach.

Results

MIS approaches seem to provide advantages in the immediate post-operative period accompanied by increased reports of complications. Consequently, further investigation based on large well-designed studies with long-term results are warranted to further clarify MIS effectiveness/safety.

Medial subvastus versus the medial parapatellar approach for total knee replacement: A systematic review and meta-analysis of randomized controlled trials

Twenty randomized controlled trials comprising 1893 primary total knee replacements were included in this review.

The subvastus approach conferred superior results for mean difference (MD) in time to regain an active straight leg raise (1.7 days, 95% confidence interval [CI] 1.0 to 2.3), visual analogue score for pain on day one (0.8 points on a scale out of 10, 95% CI 0.2 to 1.4) and total range of knee movement at one week (7°, 95% CI 3.2 to 10.7). The subvastus approach also resulted in fewer lateral releases (odds ratio 0.4, 95% CI 0.2 to 0.7) and less peri-operative blood loss (MD 57 mL, 95% CI 10.5 to 106.4) but prolonged surgical times (MD 9.7 min, 95% CI 3.9 to 15.6).

There was no difference in Knee Society Score at six weeks or one year, or the rate of adverse events including superficial or deep infection, deep vein thrombosis or knee stiffness requiring manipulation under anaesthesia.

This review demonstrates evidence of early post-operative benefits following the subvastus approach with equivalence between approaches thereafter.

Cite this article: EFORT Open Rev 2018;3:78-84. DOI: 10.1302/2058-5241.3.170030.

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).

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.

Surgical approaches in total knee arthroplasty: a meta-analysis comparing the midvastus and subvastus to the medial peripatellar approach

Subvastus, midvastus and medial parapatellar approaches are the most popular approaches in total knee arthroplasty (TKA). However, the superior approach in TKA still remains controversial. We therefore conducted a meta-analysis to quantitatively compare the midvastus and subvastus approaches to the medial parapatellar approach in TKA. A total of 32 randomized controlled trials (RCTs) with 2451 TKAs in 2129 patients were included in this study. The meta-analysis suggested that, when compared with the medial parapatellar approach, the midvastus approach showed better outcomes in pain and knee range of motion at postoperative 1-2weeks but also was associated with longer operative time; the subvastus approach showed better outcomes in knee range of motion at postoperative 1week, straight leg raise and lateral retinacular release.

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.

Fast-track knee arthroplasty -- status and future challenges

BACKGROUND

Fast-track programs have been developed for different surgical procedures leading to higher patient satisfaction and lower morbidity. This concept has been extended to knee arthroplasty in recent years. The purpose of this narrative review was to discuss the different aspects of fast-track knee arthroplasty.

METHOD

Both authors searched the contemporary literature on minimally invasive knee arthroplasty and review articles on fast-track surgery aiming to summarize recent developments.

RESULTS

Length of stay after knee arthroplasty is influenced by preoperative risk factors, anaesthetic and surgical techniques, pain, orthostatic intolerance, cognitive function, sleep disturbances, bleeding and anaemia and finally muscle function and rehabilitation.

CONCLUSIONS

Fast-track surgery reduces the length of stay and the morbidity after knee arthroplasty.

CLINICAL RELEVANCE

Optimisation of pre-, per- and postoperative pathway for knee arthroplasty reduces morbidity after this type of surgery and results in shorter length of stay.