Minimally Invasive Total

Knee Arthroplasty
Does Surgical Technique Actually Impact
the Outcome?
Jason P. Mora, DOa, Giles R. Scuderi, MDb,*

KEYWORDS
 Minimally invasive surgery  Total knee arthroplasty  Medial parapatellar  Quad sparing
 Mini medial parapatellar  Midvastus  Subvastus  Outcomes

KEY POINTS
 There are various minimally invasive surgical approaches for performing a total knee
arthroplasty, including the limited medial parapatellar, subvastus, midvastus, and quadriceps-
sparing approaches.
 When comparing the conventional medial parapatellar approach with minimally invasive
techniques, there may be a benefit to range of motion and Knee Society scores in the early
postoperative period.
 The benefits quickly even out and there seem to be no significant difference in outcomes
between the approaches in the late postoperative period.
 All approaches are proven to be successful; our recommendation is for a surgeon to perform the
approach with which they are most comfortable, because that should yield the best patient
outcome.

INTRODUCTION and decrease blood loss, thus decreasing a pa-

tient’s time to postoperative recovery of func-
Currently, the topic of surgical approach for to- tion.1 Historically, these techniques were
tal knee arthroplasty (TKA) has been at the fore- developed for the performance of unicompart-
front of many conversations. Traditionally, mental knee arthroplasty. Repicci and col-
surgeons used the medial parapatellar approach leagues1 were able to popularize the minimally
for its familiarity of anatomy, reliability, and abil- invasive approach after favorable early results
ity to easily convert to a more extensile from their series of unicompartmental knee
approach. Over the years, surgeons have tried arthroplasties performed through a 10-cm skin
to modify or improve surgical approaches to incision and limited medial capsular arthrotomy.
positively impact both intraoperative outcomes Recently, there has been interest in analyzing
and postoperative function. In the early 1990s, the validity of the hypothetical improvements in
surgeons began developing minimally invasive outcome and function with less invasive surgery.
surgical (MIS) techniques to improve patient out- Numerous studies have examined the various
comes by minimizing dissection to potentially commonly used surgical approaches and evalu-
decrease the amount of soft tissue disruption ated their effect on clinical outcomes. The

a
Adult Reconstruction, Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell, Northwell Health Or-
thopaedic Institute at MEETH, 210 East 64th Street, 4th Floor, New York, NY 10065, USA; b Adult Reconstruction,
Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell, 130 East 77th Street, 11th Floor, New York, NY
10075, USA
* Corresponding author.
E-mail address: [email protected]

Orthop Clin N Am 51 (2020) 303–315

https://doi.org/10.1016/j.ocl.2020.02.009
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304 Mora & Scuderi

long-term benefits of each MIS approach have exposure, the medial parapatellar arthrotomy
been scrutinized to compare the accuracy of can easily be extended or incorporated into
implant placement, fixation, postoperative more extensile approaches (Fig. 1).
complication, and ultimately functional
outcome. MINIMALLY INVASIVE APPROACHES
The current medical climate relies heavily on Quadriceps-Sparing Approach
bundle payments, cost effectiveness, and pa- In the early 2000s, the quadriceps-sparing
tient outcomes, and, as a result, surgeons must approach was developed. The impetus of its
evaluate all aspects of patient care. Moreover, development was to create a true anatomic
some patients are increasingly inquiring about approach without violation of the extensor
a surgeon’s ability and willingness to perform a mechanism. This approach begins with a 10-cm
TKA through a particular surgical approach us- anterior skin incision. Then, a mini parapatellar
ing advanced technologies. Therefore, it is capsular incision is made starting at the superior
important for surgeons to be able to thoroughly pole of the patella and continuing to 2 cm distal
discuss with patients the benefits and pitfalls to to the tibial joint line.4 The differentiating factor
all surgical approaches as they pertain to a pa- of this approach is that it does not violate any fi-
tient’s recovery and ultimate outcome. The pur- bers of the quadriceps muscle. This approach
pose of this article is to review the most current was initially popular in performing unicompart-
literature available and compare how surgical mental knee arthroplasty with the use of mini-
approaches, whether it is traditional or minimally mally invasive instruments.5 The quadriceps-
invasive techniques, impact postoperative sparing approach was later adopted by some
outcomes. surgeons to perform TKA. Without having to
further disrupt soft tissue planes, patients may
TRADITIONAL APPROACH have an easier recovery and decreased blood
Medial Parapatellar Arthrotomy loss plus increased range of motion (ROM).1
The traditional medial parapatellar arthrotomy To perform this technique, companies began
has been the workhorse for TKA for many de- developing smaller specialized surgical instru-
cades. Since its beginning, when it was originally ments, including retractors, alignment guides,
described by von Langenbeck to its modifica- and cutting blocks, to perform the surgery within
tions by Sir Robert Jones and John Insall, it has a smaller operative field with the same accuracy
proven to be a reliable approach.2 It provides in bone preparation and implant position as with
adequate visualization for implantation of a total a conventional approach.6 Early on, surgeons
knee prosthesis with appropriate alignment,
size, and balance.
This approach gains access into the knee joint
by making an incision approximately 8 to 10 cm
proximal to the superior pole of the patella. The
incision incorporates a small sleeve of the medial
quadriceps tendon to displace the vastus medi-
alis medially and extensor mechanism with the
patella laterally. As the quadriceps tendon inci-
sion is brought distally to the patella, there are
some variations to the approach. Although
some surgeons prefer to come around the
medial border of the patella with a curvilinear
incision, Insall preferred a vertical incision
directly over the medial border of the patella
and subperiosteally dissecting the medial
capsule from the medial border of the patella.
The medial arthrotomy is then continued distally
along the medial edge of the patella tendon
adjacent to the tibial tubercle.3
Once the arthrotomy is made, visualization of
the suprapatellar pouch and infrapatellar fat pad
is achieved. With retraction, knee flexion, and
lateral subluxation of the patella, the knee joint Fig. 1. Traditional medial parapatellar arthrotomy.
is exposed. With a stiff knee and limited Red dashed line signifies incision.

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 Minimally Invasive Total Knee Arthroplasty 305

quickly appreciated the learning curve for this flap at the lower border of the vastus medialis
technique as many failures were being discov- muscle (VMO). The VMO has an insertion that
ered, which seemed to be attributable to tech- is found at a 50 angle to the midbody of the pa-
nical errors.1 However, through repetition and tella.9 The arthrotomy begins along the medial
advances in instrumentation, some surgeons border of the patella tendon from its insertion
have adopted this technique in very select pa- at the tibial tubercle and extends proximally to
tients. Patient selection and surgeon experience the insertion of the VMO at the medial patella
play an important role when choosing this border. The incision is then continued in a
approach. Iatrogenic complications such as medial direction along the lower border of the
collateral ligament rupture, cement retention, muscular belly of the VMO. The VMO and pa-
and patella tendon avulsions all decrease with tella tendon are retracted laterally and as the
advanced surgical experience (Fig. 2).7 knee is brought to 90 of flexion the patella is
subluxed laterally, exposing the knee joint. To
Mini Subvastus Approach facilitate exposure the suprapatella plica is
Historically, the subvastus approach has been incised (Fig. 3).
recognized as a reasonable approach for most
primary TKA. This approach was typically done Mini Midvastus Approach
through an anterior midline skin incision. Modifi- With the extensile limitations that are inherent to
cations have been made to gain the necessary the subvastus approach and the difficulty of the
exposure without extensive skin incisions.8 How- quadriceps-sparing approach, some surgeons
ever, owing to the maintained integrity of the have used a midvastus approach for its potential
proximal medial muscular sleeve, many surgeons ease.10 This approach has been seen as a fine
have abandoned this approach for revision middle ground between the medial parapatellar
reconstructive procedures because of its limited and the subvastus approaches for primary
extensile exposure.1 TKA.11 An anterior midline skin incision provides
The approach uses a straight anterior midline exposure to the extensor mechanism with sub-
skin incision. The subcutaneous dissection is car- cutaneous dissection. The arthrotomy begins
ried out down to the retinacular capsular layer, along the medial border of the patella tendon
exposing the extensor mechanism. The differ- from its insertion at the tibial tubercle and ex-
ence from the traditional medial parapatellar tends proximally to the insertion of the VMO at
approach lies within its deep incision. The deep the medial patella border. Visualization of the
subcutaneous layer is developed as a medial superior medial border of the patella is

Fig. 2. Quadriceps-sparing arthrotomy. Red dashed Fig. 3. Mini subvastus arthrotomy. Red dashed line
line signifies incision. signifies incision.

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306 Mora & Scuderi

paramount, because you must find the insertion patella, leaving a small sleeve of quadriceps
fibers of the VMO.1 An incision is made parallel tendon attached to the VMO.1 The arthrotomy
with the fibers of the VMO directed from the su- is continued along the medial border of the pa-
perior medial border of the patella into and tella and patella tendon continuing down the
along the muscle fibers. As the knee is brought tibial tubercle.
into flexion and the patella subluxed laterally, To further facilitate exposed if needed, the
the knee joint is exposed as the fibers of the incision of both skin and arthrotomy can be
VMO split. The degree of proximal muscle split easily extended to gain adequate exposure.
provides exposure to the knee joint (Fig. 4). The learning curve for this approach was quanti-
fied by King and colleagues1 and found to be
Limited Medial Parapatellar Arthrotomy approximately 50 TKA performed by high-
The limited medial parapatellar arthrotomy has volume surgeons. However, owing to the ability
evolved from the traditional arthrotomy by to easily extend the incision, this procedure has
limiting the amount of dissection or incision proved to be a friendly approach for surgeons.
into the quadriceps tendon. This procedure re-
lies on the same soft tissue landmarks and tissue CLINICAL OUTCOMES
planes as the traditional approach. The limited Early Versus Late Recovery
parapatellar arthrotomy takes advantage of the After reviewing the most recent literature and
anatomy with selective position of retractors gathering the clinical outcomes, the reports
and allows creation of a mobile window to gain remain consistent (Table 1). A systematic review
access into the knee joint.1 The purpose of the by Bourke and colleagues12 showed no differ-
limited approach is to minimize the skin incision ence in clinical outcomes when comparing the
and minimize the length of the arthrotomy to medial parapatellar and subvastus approaches.
only what is required for visualization and appro- These findings were similar to the quadriceps-
priate placement of the implants. sparing techniques as well. No difference was
An anterior midline incision is made; however, found with respect to early recovery when
the incision spans from just proximal to the supe- comparing quad-sparing and mini subvastus
rior pole of the patella and continues distantly to approach.13
the tibial tubercle. Subcutaneous dissection ex- Yao and colleagues14 reported on the ability
poses the capsular retinacular layer. A medial to regain quadriceps strength when comparing
parapatellar arthrotomy is created beginning 2 the mini subvastus and traditional medial para-
to 4 cm proximal to the superior pole of the patellar approaches. They found that patients
treated with the mini subvastus approach were
able to perform a straight leg raise faster than
the control group. However, strength recovery
was not exponential and quickly plateaued after
2 weeks postoperatively.
Some studies have attempted to discover
benefits when comparing different MIS tech-
niques. Bonutti and colleagues8 reported on a
prospective, randomized, controlled trial of
bilateral TKA with one side having a midvastus
and the other having a subvastus. There was
no difference observed between the 2 ap-
proaches. Cho and colleagues15 reported on a
comparison of a mini midvastus group with a
mini medial parapatellar and found that quadri-
ceps force was stronger in the mini midvastus
group when compared with the limited medial
parapatellar group at 6 weeks. Interestingly,
the more limited medial parapatellar group
had greater quadriceps recovery than the mini
midvastus group during the first 6 weeks to 3
months. This difference was not evident over
time; at 1 year postoperatively, both groups
Fig. 4. Mini midvastus arthrotomy. Red dashed line had no significant differences in quadriceps
signifies incision. strength.

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 Table 1
Summary of clinical outcomes
Length of Incision and
Early vs Late Recovery ROM KS Scores Cosmesis Duration of Surgery
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Bourke et al showed no Obaid-ur-Rahman and Obaid-ur-Rahman and Smith et al demonstrated Peng et al in a meta-
difference comparing Amin found greater Amin reported higher a significantly smaller analysis reported an
medial parapatellar ROM in a quadriceps- KS scores in the length of the skin increase in the
and subvastus sparing approach. quadriceps-sparing incision in the MIS duration of surgery
approach group when compared groups (10–13 cm in (>18 minutes for MIS).
with the conventional the MIS groups
approach at 1 mo and and >13 cm in the
3 mo but no conventional group).
differences after 3 mo.
Yao et al found the mini Yao et al also found early Peng et al showed Yao et al in a meta- Yao et al found a longer
subvastus group was ROM improvements in improvements in KS analysis noted that skin duration of surgery in
able to perform an SLR their MIS group. At 1 scores for the incision for the mini mini subvastus
faster than the control and 3 d, the mini quadriceps-sparing subvastus approach approach compared
group in <2 wk subvastus group had group compared with was significantly with the conventional
postoperatively improved ROM, but the conventional shorter than the medial parapetallar.
this difference group at 3 mo and 2 y. conventional group.

Minimally Invasive Total Knee Arthroplasty

normalized by 14 d. No subsequent
differences.
Bonutti et al reported no Peng et al found Bourke et al found no Kye-Youl Cho et al meta- Xu et al reported that
difference between improvements in ROM differences with analysis reported the MIS surgical
midvastus and at 1 wk and 12 mo in respect to long-term length of the skin techniques take longer
subvastus approaches the mini subvastus clinical benefits incision was then a conventional
group. However, there between medial significantly shorter in medial parapatellar
were no differences parapatellar the MIS group arthrotomy
thereafter. arthrotomy or the compared with the
subvastus approach. limited medial
parapatellar group.
Kye-Youl Cho et al found Kye-Youl Cho et al found Kye-Youl Cho et al found — Li et al found also found
that quadriceps force no difference no statistical difference longer surgical times in
was stronger in the comparing ROM between the MIS or MIS.
mini midvastus group between MIS and the the limited medial
when compared with limited medial parapatellar.
the limited medial parapatellar
(continued on next page)

307
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Mora & Scuderi
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Table 1
(continued )
Length of Incision and
Early vs Late Recovery ROM KS Scores Cosmesis Duration of Surgery
parapatellar group at
6 wk
Heekin and Fokin Xu et al who found Nestor et al only found — —
showed no clinical increased ROM with better quadriceps
differences between mini midvastus strength at 3 wk
the mini midvastus approach in the first postoperatively
group and the limited 2 wk only. between medial
medial parapatellar parapatellar
group arthrotomy and mini
midvastus approaches.
Khakha et al reviewed — Unwin et al found no — —
MIS computer assisted difference in pain
TKA with conventional control or functional
computer assisted scores between MIS
TKA, and found early techniques and
improvement in conventional
quadriceps strength approach.
and functional scores
at 2 y with MIS but at
5 y there was no
difference
— — Kazarian et al only — —
showed improved KSS
from 1 to 3 mo
postoperatively in the
quadriceps-sparing
group compared with
the conventional
approach.
 Length of Hospital Stay Radiographic Outcomes Blood Loss Pain Control Wound Complications Deep Vein Thrombosis
Obaid-ur-Rahman and Gandhi et al reported Peng et al showed no Peng et al found a Peng et al found no Peng et al their meta-
Amin showed that no difference in statistical differences difference at 1 wk in differences in wound analysis found no
length of say in the component or limb between the VAS ( 0.69) when complications differences in the
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hospital was alignment when quadriceps-sparing comparing between the incidence of DVT in the
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statistically shorter in comparing MIS TKA and standard groups quadriceps-sparing quadriceps-sparing quadriceps-sparing
the MIS group when with standard medial with respect to blood patients with and conventional group compared with
compared with the parapatellar loss. conventional medial parapatellar the medial
traditional medial approaches. approaches approaches. parapatellar group.
parapatellar
(3.2–5.8 d)
Peng et al showed no Yuan et al revealed that Yao et al reported no Yao et al only found Li et al in a meta-analysis —
correlation between the quadriceps- differences in blood improvements at 1 found an overall
MIS quadriceps- sparing approach has a loss comparing MIS and 3 d in the mini increase in wound
sparing technique or risk of radiographic with conventional. subvastus group healing complications
conventional with outliers. However, no compared with the in the MIS groups
respect to hospital definitive differences conventional group compared with the
length of stay. were found. conventional medial
parapatellar groups.
Yao et al found no Yao et al in a radiographic Kye-Youl Cho et al also Xu et al meta-analysis — —

Minimally Invasive Total Knee Arthroplasty

difference in hospital analysis found no found no difference in found that pain control
stay when comparing differences in hip–knee blood loss when was improved in the
the mini subvastus angle, femoral angle, comparing the mini early postoperative
group with the tibial angle, femoral midvastus with the period (1–2 wk only) in
conventional prosthesis flexion angle, limited medial the mini midvastus
approach. and posterior slope parapatellar patients.
angle of the tibial arthrotomy.
plateau in a comparison
of the mini subvastus
approach and medial
parapatellar.
(continued on next page)

309
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Mora & Scuderi
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Table 1
(continued )
Length of Hospital Stay Radiographic Outcomes Blood Loss Pain Control Wound Complications Deep Vein Thrombosis
— Kye-Youl Cho et al found Li et al in a meta-analysis — — —
no differences in found a decrease in
radiographic total blood loss in the
outcomes when MIS group when
comparing mini compared with medial
midvastus group and parapatellar
the shortened medial
parapatellar group
— Unwin et al found no — — — —
radiographic
differences at 6 y
postoperatively
between MIS
approach and
conventional
approach.
 Minimally Invasive Total Knee Arthroplasty 311

Heekin and Fokin16 further analyzed the com- quadriceps-sparing group when compared with
parison between the mini midvastus group and the conventional approach at 1 and 3 months.
the limited medial parapatellar arthrotomy. Additionally, they found that patients who un-
They reported on 40 patients who underwent derwent a quadriceps-sparing approach were
bilateral TKA with a limited medial parapatellar quicker to return to independent walking.18
on one side and mini midvastus on the other However, there were no differences in the func-
side. Their findings showed no clinical differ- tional KS scores after 3 months. A meta-analysis
ences between the approaches. They further from Peng and colleagues19 showed significant
went on to comment that the decision for improvements in KS scores for the quadriceps-
choosing an approach should be based on the sparing group when compared with the conven-
surgeon’s comfort level.16 tional group at 3 months and 2 years. Yet, at 4 to
The possible advantages for MIS techniques 6 weeks there were no differences between the
in computer-assisted navigated cases have also 2 groups. It is difficult to determine why there
been evaluated. Khakha and colleagues17 were increases in KS scores only at 3 months
reviewed the outcome comparing MIS computer and then 2 years.
assisted TKA with conventional computer assis- Conversely, Bourke and colleagues21
ted TKA, and they found an early improvement compared outcomes on 90 patients undergoing
in quadriceps strength and functional scores at bilateral TKA with either the standard medial
2 years with the MIS approach, although at parapatellar arthrotomy or the subvastus
5 years there was no difference. approach and found no differences with respect
to long-term clinical benefits. They were only
Range of Motion able to demonstrate better KS scores at 12
Several authors have attempted to identify po- and 18 months. Similarly, when Cho and col-
tential benefits in postoperative ROM between leagues15 reviewed KS functional scores, there
the various MIS approaches. Obaid-ur-Rahman was no statistical difference between the MIS
and Amin18 found the ROM greater in patients or the limited medial parapatellar arthrotomy.
who underwent a quadriceps-sparing approach. Nestor and colleagues22 reviewed 27 patients
Yao and colleagues14 also found early ROM im- undergoing bilateral TKA with the standard
provements in their MIS group. At 1 and medial parapatellar arthrotomy or mini midvas-
3 days, patients in the mini subvastus group tus approach and found that the MIS approach
had improved ROM, but this normalized by had better quadriceps strength at 3 week post-
14 days postoperatively. operatively. No differences were found in any
Peng and colleagues19 were also able to other outcome measures. Similarly, Unwin and
display significant improvements in ROM at 1 colleagues23 found that there was no difference
week and 12 months in the mini subvastus in pain control or functional scores with their MIS
group. However, all other follow-up visits before techniques compared with the conventional
1 year post operatively showed no difference as approach. A meta-analysis from Kazarian and
compared with the traditional approach. Cho colleagues24 showed improved KS scores at 1
and colleagues15 found no difference when to 3 months postoperatively in the quadriceps-
comparing ROM between the MIS approach sparing group compared with the conventional
and the limited medial parapatellar arthrotomy. approach. After 3 months, no additional benefit
These findings were also consistent with the re- was seen between the 2 groups. In reviewing
sults from the meta-analysis by Xu and col- these reported studies, we believe that the over-
leagues,20 who found significantly increased all consensus shows no definitive improvement
ROM with the mini midvastus approach in the in KS scores when comparing MIS and conven-
first 2 weeks. However, after 2 weeks there tional approaches.
was no difference in ROM. In summarizing all
these reports, it seems that there may be an Length of Incision and Cosmesis
advantage to MIS approaches in the first few There is an impression that a small skin incision
weeks after surgery, but by 3 months the ROM with MIS TKA would be more appealing to pa-
seems to be similar. tients. Although cosmesis is rather subjective,
several authors have attempted to investigate
Knee Society Scores the effect of the surgical approach on the skin
Several studies have reviewed the functional incision. A meta-analysis by Smith and col-
outcomes between the traditional and MIS ap- leagues25 demonstrated a significantly smaller
proaches. Obaid-ur-Rahman and Amin reported length of the skin incision in the MIS groups.
higher Knee Society (KS) scores in the Lengths of incisions varied with each study

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312 Mora & Scuderi

ranging from 10 to 13 cm in the MIS groups and the mini subvastus group with the conventional
more than 13 cm in the conventional group. approach group. After reviewing the literature,
Additionally, they found greater ROM in the surgical arthrotomy does not affect the length
MIS; however, no other clinical or radiographic of stay after TKA.
differences were seen. Yao and colleagues14
noted that their skin incision for the mini subvas- Radiographic Outcomes
tus approach showed to be significantly shorter Accurate positioning of the components and
than the conventional group. Cho and col- limb alignment are paramount in TKA. The surgi-
leagues15 reported the length of the skin incision cal approach should not jeopardize these pa-
was significantly shorter in the MIS group rameters. A meta-analysis by Gandhi and
(9.6 cm) compared with the limited medial para- colleagues27 reported on complications be-
patellar group (11 cm). To our knowledge, no tween MIS TKA on standard medial parapatellar
studies have evaluated the patients’ perceptions approaches and they found no difference in
of their surgical incisions. component or limb alignment. A meta-analysis
by Yuan and colleagues28 revealed that the
Duration of Surgery quadriceps-sparing approach has a risk of radio-
Many surgeons that have reservations toward graphic outliers. compared with the conven-
MIS approaches have raised concerns about tional medial parapatellar approach, there
the potential for MIS to increase the operative were statistical differences in hip–knee angle,
time. Peng and colleagues19 in a meta-analysis coronal tibial component angle, and femoral
reported an increase in the duration of surgery. notch. No differences were seen with the coro-
The mean difference in operative time between nal femoral angle. These radiographic outliers
the MIS and standard approach was, on may certainly lead to component malalignment
average, 18 minutes longer. Yao and col- and malposition. Yao and colleagues14 in a
leagues14 also compared the duration of surgery radiographic analysis found no differences in
for the mini subvastus approach and the conven- hip–knee angle, femoral angle, tibial angle,
tional medial parapatellar and they found the femoral prosthesis flexion angle, and posterior
mini subvastus group had a significantly longer slope angle of the tibial plateau in a comparison
duration of surgery. Xu and colleagues20 found of the mini subvastus approach and medial para-
an average increase of operative time of patellar arthrotomy. Comparably, other studies
11.64 minutes in the mini midvastus compared appreciated no differences in radiographic out-
with medial parapatellar. The length of tourni- comes when comparing the mini midvastus
quet time has also been seen in studies to be group and the shortened medial parapatellar
significantly longer in the mini midvastus group group.15 Midterm data from Unwin and col-
compared with the limited medial parapatellar leagues23 echoed these findings at 6 years post-
group.15 Other investigators have found that operatively with no differences in the
MIS techniques may take longer then a conven- radiographic alignment between their MIS
tional medial parapatellar arthrotomy.20,26 approach and conventional approach. Overall,
the literature shows no difference in radio-
Length of Hospital Stay graphic outcomes between approaches.
With the advent of rapid recovery programs and
same-day TKA, there is a great deal of discussion COMPLICATIONS
of all aspects of patient care to improve unnec- Blood Loss
essary costs and added financial burden on the Reports have found consistent results with
patient. Although many variables go into the respect to blood loss when comparing MIS and
length of stay, there have been some investiga- standard approaches. Peng and colleagues19
tions into the surgical technique and surgical showed no statistical differences between the
approach. Obaid-ur-Rahman and Amin18 quadriceps-sparing and standard groups with
showed that length of say in the hospital was sta- respect to blood loss. This finding was also
tistically shorter, 3.2 days in the MIS group when noted by Yao and colleagues.14 Cho and col-
compared with 5.8 days in the traditional medial leagues15 found no difference in blood loss
parapatellar group. Peng and colleagues,19 when comparing the mini midvastus with the
conversely, showed no correlation between the limited medial parapatellar arthrotomy.
MIS quadriceps-sparing technique or a conven- Conversely, Li and colleagues26 in a meta-
tional technique with respect to hospital length analysis found a decrease in total blood loss in
of stay. Likewise, Yao and colleagues14 found the MIS group when compared with medial par-
no difference in hospital stay when comparing apatellar. The majority of the literature shows no

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 Minimally Invasive Total Knee Arthroplasty 313

difference in blood loss when comparing MIS SUMMARY

with conventional arthrotomies. Of note, in the
meta-analyses, there was use of a tourniquet in Throughout the history of TKA, we have
the majority of studies. However, some never continued to improve on the efficiency of the
stated whether they used a tourniquet or not. procedure. Even with the evolution of various
MIS approaches, the traditional medial parapa-
tellar approach remains a well-documented, suc-
Pain Control cessful surgical approach. No alternative
Peng and colleagues19 found a difference at approach to the knee has been able to success-
1 week in visual analogue scale (VAS) scores fully prove its superiority to the medial parapa-
when comparing quadriceps-sparing patients tellar. Nevertheless, many other TKA
with conventional approaches. There was a approaches have not been definitively found to
decrease, on average, of 0.69 in VAS scores be inferior to the conventional approach. This
for the quadriceps-sparing group at the 1- list includes the quadriceps-sparing, midvastus,
week mark, but there were no differences at 4 subvastus, or limited medial parapatellar
to 6 weeks. Yao and colleagues14 found that, arthrotomies. All have been proven to be
at 1 and 3 days, patients in the mini subvastus acceptable approaches when performing a
group had improved VAS score when TKA. The data available over the past 2 decades
compared with the conventional group. Howev- remain consistent regarding the comparison of
er, this finding normalized in the subsequent MIS with conventional total knee approaches.
days. Additionally, the mini subvastus cohort There seems to be no definitive benefit to early
in the study by Peng and colleagues19 dis- postoperative function. Although some studies
played improved VAS scores for patients at show a benefit in the first couple of weeks post-
the 1-year mark between compared with the operatively, ultimately within the first few
conventional group. months the outcomes are comparable.8,12,14–17
Xu and colleagues20 in a meta-analysis When evaluating ROM, MIS techniques seem
echoed theses findings and found that pain con- to have a potential advantage compared with
trol was statistically improved ( 0.20 VAS) in the the conventional approach. Some authors found
early postoperative period (1–2 weeks) in the a significant increase in ROM in the quadriceps-
mini midvastus patients. However, no subse- sparing and mini subvastus approaches. Still,
quent pain differences were seen on VAS scores this improvement seemed to only be present in
after 2 weeks. the first few weeks after surgery.15,18–20 Func-
tional outcomes displayed a similar distribution
Wound Complications of findings. Again, the MIS quadriceps-sparing
With regard to incisional healing and infection technique has better improvement in KS scores
rates, Peng and colleagues19 found no differ- in the immediate to early postoperative period;
ences in wound complications between the however, those results seemed to level out within
quadriceps-sparing and conventional medial the first 3 to 6 months postoperatively. Only 2
parapatellar approaches. Similarly, no differ- studies were able to show benefits in KSS scores
ences were demonstrated when comparing the beyond 1 year postoperatively.15,18,19,21,22,24
mini subvastus group to the conventional The length of the incision was very consistent
group.19 In contrast, Li and colleagues26 in a across all studies. MIS techniques consistently
meta-analysis found an overall increase in wound proved to have smaller skin incisions compared
healing complications in the MIS groups with conventional groups. However, there seems
compared with the conventional medial parapa- to be no influence on surgical outcome. Addi-
tellar groups. Although the literature shows no tionally, to our knowledge there are no studies
statistical difference, there may be a potential that examine patients’ perception of their inci-
for wound healing complications. sions while comparing approaches.14,18
Effects on the duration of surgery seem to be
Deep Vein Thrombosis almost unanimous; most of the current literature
There are not many reports on the incidence of available shows that the duration of surgery is pro-
deep vein thrombosis with MIS approaches. longed with MIS techniques compared with tradi-
However, Peng and colleagues19 in a their tional exposures. There are a few studies that
meta-analysis found no differences in the inci- contend these findings and report that there is
dence of deep vein thrombosis in the no difference in surgical time. However, it should
quadriceps-sparing group when compared with be noted that these reports were done in centers
the medial parapatellar arthrotomy group. with a high volume by well-experienced surgeons.

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314 Mora & Scuderi

Their findings, although valid, raise questions as 7. Jackson G, Waldman BJ, Schaftel EA. Complica-
to their reproducibility in lower volume tions following quadriceps-sparing total knee
institutions.14,19,20,26 arthroplasty. Orthopedics 2008;31(6):547.
Even with rapid recovery programs and same 8. Bonutti PM, Zywiel MG, Ulrich SD, et al.
day TKA, there is no observed advantage to MIS A comparison of subvastus and midvastus ap-
approaches. Although some reports have shown proaches in minimally invasive total knee arthro-
a decreased length of stay with MIS approaches, plasty. J Bone Joint Surg Am 2010;92(3):575–82.
others have reported no difference. Addition- 9. Pagnano MW, Meneghini RM, Trousdale RT. Anat-
ally, there seem to be many factors that influ- omy of the extensor mechanism in reference to
ence a patient’s length of stay and it is difficult quadriceps-sparing TKA. Clin Orthop Relat Res
to come to a consensus with many confounding 2006;452(452):102–5.
variables at different institutions.14,18,19 10. Laskin RS, Beksac B, Phongjunakorn A, et al. Mini-
With the introduction of MIS techniques, a mally invasive total knee replacement through a
valid concern was raised about the potential in- mini-midvastus incision: an outcome study. Clin
crease in radiographic outliers with the potential Orthop Relat Res 2004;428:74–81.
for early failure. With experience and meticulous 11. Engh GA, Holt BT, Parks NL. A midvasus muscle-
technique, there is no difference in the incidence splitting approach for total knee arthroplasty.
of radiographic outliers. However, Yuan and col- J Arthroplasty 1997;12(3):322–31.
leagues28 cautioned surgeons on the potential 12. Bourke MG, Buttrum PJ, Fitzpatrick PL, et al. Sys-
risk for more outliers in the quadriceps-sparing tematic review of medial parapatellar and subvas-
approach.14,23,27 tus approaches in total knee arthroplasty.
Overall, the use of both MIS and standard ap- J Arthroplasty 2010;25(5):728–34.
proaches prove to be acceptable in TKA. Neither 13. Aglietti P1, Baldini A, Sensi L. Quadriceps-sparing
has proved to be superior or inferior to the other. versus mini-subvastus approach in total knee
The decision to perform an MIS or standard arthroplasty. Clin Orthop Relat Res 2006;452:
approach remains with a surgeon’s preference. 106–11.
With experience all techniques have been suc- 14. Yao Y, Kang P, Xue C, et al. A prospective random-
cessful. Our recommendation is that surgeons ized controlled study of total knee arthroplasty via
choose a surgical approach that is most appro- mini-subvastus and conventional approach. Zhong-
priate for the patient. Factors such as pathologic guo Xiu Fu Chong Jian Wai Ke Za Zhi 2018;32(2):
deformity, preoperative ROM, prior surgery and 162–8.
incisions, along with the diagnosis influence the 15. Cho K-Y, Kim K-I, Umrani S, et al. Better quadriceps
chosen surgical approach. The outcome of TKA recovery after minimally invasive total knee arthro-
goes beyond the surgical approach. plasty. Knee Surg Sports Traumatol Arthrosc 2014;
22(8):1759–64.
16. Heekin RD, Fokin AA. Mini-midvastus versus mini-
DISCLOSURE
medial parapatellar approach for minimally invasive
The authors have nothing to disclose. total knee arthroplasty: outcomes pendulum is at
equilibrium. J Arthroplasty 2014;29(2):339–42.
17. Khakha RS, Chowdhry M, Norris M, et al. Five-year
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