Better quadriceps recovery after minimally invasive total knee arthroplasty

Subvastus Approach Supporting Fast-Track Total Knee Arthroplasty Over the Medial Parapatellar Approach: A Systematic Review and Network Meta-Analysis

BACKGROUND

Numerous surgical approaches are being used to perform total knee arthroplasty (TKA). This systematic review and network meta-analysis aimed to compare surgical approaches used in TKA regarding postoperative outcomesat different time points.

METHODS

We performed a literature search from medical database inception until October 2, 2021. We searched for randomized controlled trials (RCTs) investigating patients undergoing TKA and comparing at least 2 surgical approaches regarding early postsurgical clinical outcomes (range of motion [ROM], pain on a visual analog scale, and Knee Society Score [KSS]). We included 33 RCTs in our networks. Using paired and network meta-analysis, we calculated pooled mean differences (MDs) with 95% CIs by comparing surgical approaches to the medial parapatellar method.

RESULTS

The subvastus (SV) method performed the best on days 1 (MD = 6.99; CI: 1.08; 12.89), 3 (MD = 8.00; CI: 2.08; 13.92), 4 (MD = 27.01; CI: 18.09; 35.92), and 6 (MD = 27.22; CI: 18.38; 36.07) for ROM improvement. Regarding the decrease in pain, the mini SV approach offered significantly lower pain values on days 1 (MD = -1.98; CI: -2.93; -1.03), 3 (MD = -0.85; CI: -1.49; -0.22), and 7 (MD = -1.90; CI: -2.23; -1.57). The differences decreased as time passed. Furthermore, the SV and mini-SV methods performed the best regarding total, knee and function KSS.

CONCLUSION

Quadriceps-sparing approaches, especially the SV and mini-SV, are superior to the other approaches in the early postsurgical period, but the differences decrease as time passes.

Minimally invasive medial femoral approach to total knee arthroplasty improves short-term outcomes compared to the standard medial parapatellar approach: a systematic review and meta-analysis

OBJECTIVE

The aim of this study is to conduct a comprehensive evaluation of the effectiveness of the medial parapatellar approach via the vastus medialis obliquus muscle in comparison with the standard medial parapatellar approach for total knee arthroplasty, using a systematic approach.

METHODS

A computer search was conducted on PubMed, EMBASE, Medline, Cochrane libraries, and Web of Science databases to comprehensively collect randomized controlled studies on minimally invasive (MMV) approaches for knee arthroplasty, specifically the vastus and medial parapatellar (MP) approaches. Two authors independently screened the literature based on inclusion and exclusion criteria, evaluated the quality of the included studies using the Cochrane systematic review method, and performed a meta-analysis using RevMan 5.3 software.

RESULTS

A total of twelve randomized controlled studies were ultimately included, comprising 788 knees. The small incision medial femoral muscle approach (MMV) group consisted of 398 cases, while the traditional parapatellar approach (MP) group consisted of 390 cases. Data analysis showed that in the comparison of KSS, VAS, and ROM score at 3 months after surgery, MMV approach was superior to MP approach [MD = 2.89, 95%CI (0.33, 5.46), P = 0.03], [MD = - 0.22, 95%CI (- 0.36, - 0.09), P = 0.001], and [MD = 1.08, 95%CI (0.04, 2.12), P = 0.04]. However, there was no significant difference in the postoperative KSS, VAS, and ROM score between the MMV and MP approaches at 6 and 12 months after surgery. The operation time of the MMV group was longer than that of the MP group [MD = 8.98, 95%CI (4.64, 13.32), P < 0.0001], and the number of days of straight leg raising after surgery was shorter in the MMV group than in the MP group [MD = - 1.91, 95%CI (- 3.45, - 0.37), P = 0.01], with statistically significant differences. There was no significant difference in the lateral support band release rate [OR = 0.72, 95%CI (0.23, 2.28), P = 0.58], length of hospital stay [MD = 0.07, 95%CI (- 0.18, 0.31), P = 0.58], postoperative complications [MD = 0.62, 95%CI (0.33, 1.18), P = 0.15], and intraoperative blood loss [MD = 70.50, 95%CI (- 57.51, 198.72), P = 0.28].

CONCLUSION

Most of the approaches have similar length of stay and incidence of complications compared to standard approaches. However, the minimally invasive midvastus approach has shown potential to improve short-term outcomes.

STUDY REGISTRATION

PROSPERO registration number CRD42023410583.

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).

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.

Better outcomes after minimally invasive surgeries compared to the standard invasive medial parapatellar approach for total knee arthroplasty: a meta-analysis

PURPOSE

Minimally invasive surgery (MIS) for total knee arthroplasty (TKA) is often marketed as being able to speed up healing times over standard invasive surgery (SIS) through the medial parapatellar approach. The advantages of these minimally invasive approaches, however, are not yet definitively established. A meta-analysis of studies comparing peri-operative and post-operative differences and long-term complications of MIS versus SIS for TKA was conducted.

METHODS

This meta-analysis was conducted following the PRISMA guidelines. The Pubmed, Google Scholar, Scopus, and Embase databases were accessed in September 2020. All clinical trials comparing minimally-invasive versus standard approaches for TKA were considered. Only studies reporting quantitative data under the outcomes of interest were included. Methodological quality assessment was performed using the PEDro appraisal score.

RESULTS

This meta-analysis covers a total of 38 studies (3296 procedures), with a mean 21.3 ± 24.3 months of follow-up. The MIS group had shorter hospitalization times, lower values of total estimated blood loss, quicker times of straight-leg raise, greater values for range of motion, higher scores on the Knee Society Clinical Rating System (KSS) and its related Function Subscale (KSFS). Pain scores, anterior knee pain and revision rate were similar between MIS and SIS. SIS allowed a quicker surgical duration.

CONCLUSION

The present meta-analysis encourages the use of minimally invasive techniques for total knee arthroplasty. However, MIS TKA is technically demanding and requires a long learning curve.

LEVEL OF EVIDENCE

III, meta-analysis of clinical trials.

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.

Different Factors Conduct Anterior Knee Pain Following Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

A systematic review and meta-analysis was performed to investigate the risks associated with anterior knee pain (AKP) following primary total knee arthroplasty (TKA).

METHODS

A computerized search was performed of the following databases: MEDLINE, Embase, and Cochrane Central (published prior to July 2017). A total of 37 studies, which included 1641 cases of AKP and 168,090 TKAs, were included in the meta-analysis.

RESULTS

A subgroup analysis revealed that compared with those without the following medical conditions, patients who had an infrapatellar fat pad excision and more than 12 months of follow-up (odds ratio [OR] 12.58, 95% confidence interval [CI] 3.245-48.781) were more likely to have AKP after TKA. Circumpatellar electrocautery (>12 months: OR 0.50, 95% CI 0.326-0.760; ≤12 months: OR 0.59, 95% CI 0.408-0.867) and patellar resurfacing (OR 0.25, 95% CI 0.131-0.485) may decrease the risk of AKP. Other factors, including the prosthesis bearing type (mobile bearing or fixed bearing) and the approach (midvastus compared with the medial parapatellar approach), were not significant risk factors for AKP.

CONCLUSION

The use of strategies such as patellar denervation and patellar resurfacing in primary TKA is recommended because they are safe and result in good clinical outcomes in preventing AKP. Caution should be taken when using an infrapatellar fat pad excision, because there is an increased risk of AKP at long-term follow-up (>12 months). Future studies should investigate these different strategies to confirm the underlying mechanisms and help prevent the occurrence of AKP after TKA. The timing of AKP onset remains unclear and requires further research.

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.

Anterior vs Posterior Periarticular Multimodal Drug Injections: A Randomized, Controlled Trial in Simultaneous Bilateral Total Knee Arthroplasty

BACKGROUND

Currently, various techniques are used to overcome postoperative pain after total knee arthroplasty. A local analgesic infiltration with periarticular multimodal drug injection (PMDI) is favorable because of its simplicity, safety, and efficacy. The present study compared the efficacy of a PMDI at the anterior vs posterior compartments.

METHODS

Forty-six patients were randomized to receive the PMDI at either the anterior or posterior compartment, with the contralateral knee receiving the PMDI at the opposite compartment. The PMDI injected to the posterior capsule, medial and lateral meniscal remnant, was defined as the posterior compartment injection, whereas the injection to the medial retinaculum, quadriceps muscle, pes anserinus, and retropatellar fat pad was defined as the anterior compartment injection. Pain scores at rest, knee flexion angle, quadriceps function, and drainage blood loss were evaluated in both groups.

RESULTS

The anterior PMDI group had significantly lower pain scores at rest during 96 hours postoperatively. On the day of discharge, 19 patients (41.3%) favored the knee with the anterior PMDI, which was superior to 9 patients (19.6%) who favored the knee with the posterior PMDI. The anterior PMDI demonstrated a superior recovery of quadriceps function during the same period, but there was no significant difference in terms of other parameters.

CONCLUSION

The PMDI at the anterior compartment can reduce pain after total knee arthroplasty with potentially better quadriceps function compared with that in the PMDI at the posterior compartment. We recommend infiltrating the anterior compartment with a greater amount of PMDI than the posterior compartment.

Knee Extensor Strength and Gait Characteristics After Minimally Invasive Unicondylar Knee Arthroplasty vs Minimally Invasive Total Knee Arthroplasty: A Nonrandomized Controlled Trial

BACKGROUND

In light of the existing lack of evidence, it was the aim of this study to compare gait characteristics and knee extensor strength after medial unicondylar knee arthroplasty (MUKA) with those after total knee arthroplasty (TKA), given the same standardized minimally invasive surgery (MIS) approach in both groups.

METHODS

Patients scheduled for MIS-MUKA or MIS-TKA as part of clinical routine were invited to participate. A posterior cruciate ligament-retaining total knee design was used for all MIS-TKA. A 3-dimensional gait analysis was performed preoperatively with a VICON system and at 8 weeks postoperative to determine temporospatial parameters, ground reaction forces, joint angles, and joint moments. At the same 2 times, isokinetic tests were performed to obtain peak values of knee extensor torque. A multivariate analysis of variance was conducted and included the main effects time (before and after surgery) and surgical group and the group-by-time interaction effect.

RESULTS

Fifteen MIS-MUKA patients and 17 MIS-TKA patients were eligible for the final analysis. The groups showed no differences regarding age, body mass index, sex, side treated, or stage of osteoarthritis. We determined neither intergroup differences nor time × group interactions for peak knee extensor torque or any gait parameters (temporospatial, ground reaction forces, joint angles, and joint moments).

CONCLUSION

It is concluded that MUKA is not superior to TKA with regard to knee extensor strength or 3-dimensional gait characteristics at 8 weeks after operation. As gait characteristics and knee extensor strength are only 2 of the various potential outcome parameters (knee scores, activity scores…) and quadriceps strength might take a longer time to recover, our findings should be interpreted with caution.

Factors for Assessing the Effectiveness of Early Rehabilitation after Minimally Invasive Total Knee Arthroplasty: A Prospective Cohort Study

The effectiveness of current rehabilitation programs is supported by high-level evidence from the results of randomized controlled trials, but an increasing number of patients are not discharged from the hospital because of the schedule of the critical path (CP). The present study aimed to determine which factors can be used to assess the effectiveness of early rehabilitation. We enrolled 123 patients with medial knee osteoarthritis (OA) who had undergone unilateral minimally invasive total knee arthroplasty for the first time. The following factors were assessed preoperatively: the maximum isometric muscle strength of the knee extensors and flexors, maximum knee and hip joint angle, pain, 5-m maximum walking speed, sex, age, body mass index, exercise habits, Kellgren-Lawrence grade, femorotibial angle, failure side (bilateral or unilateral knee OA), and functional independence measure. We re-evaluated physical function (i.e., muscle strength, joint angle, and pain) and motor function (5-m maximum walking speed) 14 days postoperatively. Changes in physical function, motor function (5-m maximum walking speed), and number of days to independent walking were used as explanatory variables. The postoperative duration of hospitalization (in days) was used as the dependent variable in multivariate analyses. These analyses were adjusted for sex, age, body mass index, exercise habits, Kellgren-Lawrence grade, femorotibial angle, failure side, and functional independence measure. The duration of hospitalization was significantly affected by the number of days to independent walking (p < 0.001, β = 0.507) and a change in the 5-m maximum walking speed (p = 0.016, β = -0.262). Multiple regression analysis showed that the radiographic knee grade (p = 0.029, β = 0.239) was a significant confounding factor. Independent walking and walking speed recovery were considered to reduce the duration of hospitalization. Therefore, these indices can be used to assess the effectiveness of early rehabilitation.

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.