Medial Parapatellar Research Articles

Development and validation of a pediatric internationally agreed ultrasound knee synovitis protocol (PIUS-knee) by the PReS imaging working party

ObjectivesTo identify an optimal pediatric musculoskeletal ultrasound (MSUS) protocol for the detection of knee arthritis in patients with juvenile idiopathic arthritis (JIA) including a comparison with existing protocols. Secondary aims were to correlate MSUS-identified B-Mode (BM) and Power Doppler-Mode (PD) synovitis with clinical findings.MethodsConsecutive JIA patients with confirmed knee arthritis after clinical examination underwent a thorough MSUS study protocol which included views identified and consented by the Pediatric Rheumatology european Society (PReS) Imaging Working Party for the detection of synovitis. In total eight views including measurement of the suprapatellar recess were included. Scoring of synovitis followed the pediatric OMERACT criteria (BM and PD severity grading 0 to 3). Interobserver reliability of BM and PD was tested before study begin. Previously published MSUS protocols for knee synovitis were also identified from the literature and their scan protocols compared to identify differences in sensitivity for synovitis according to the number and specific type of views included. Finally, a clinically applicable MSUS protocol for knee synovitis could be proposed.ResultsIn 114 patients with clinically active knee inflammation, BM positivity (grading ≥ 1) was most frequently detected in the suprapatellar longitudinal and transverse scans performed in any positioning (frequency 97–99% in suprapatellar longitudinal in 30° or neutral respectively). PD positivity was however higher in these views performed in 30° flexion compared to neutral. Intrasynovial PD positivity (grading ≥ 1) was most frequently detected in the lateral parapatellar (69%, sensitivity 0.68, specificity 0.98), medial parapatellar (frequency 67%, sensitivity 0.67, specificity 1.0), the longitudinal lateral (68%, sensitivity 0.67, specificity 0.98) and suprapatellar transverse in 30° (frequency 64%, sensitivity 0.64, specificity 1.0). A combination of five views was the most sensitive for BM and PD synovitis. The suprapatellar recess size was analyzed by age and gender. For each group, the recess was wider in knees with arthritis than without (p < 0.001). Interobserver reliability of BM and PD positivity showed 85% agreement, with kappa 0.74 (very good). Three published studies with knee synovitis MSUS protocols were identified, which included a range of 1–3 views. Evaluation of the sensitivity of positive PD findings of each of these protocols reached a range of 53–83%; the highest sensitivity (91%) was achieved with the 5 views as identified by this study. These five views were therefore combined to form the Pediatric Internationally agreed Ultrasound (PIUS) knee protocol.ConclusionBM and PD positivity reliably correlated with the identification of pathological findings in knees of patients with JIA. From an internationally agreed protocol of eight images, a combination of five showed the greatest sensitivity for synovitis. This protocol, termed ‘PIUS-Knee’ performed well when compared to existing protocols.

Mid-vastus approach induces milder short-term effects on postural control compared to parapatellar approach in total knee arthroplasty.

BackgroundMid-Vastus and Medial Parapatellar techniques are used for total knee arthroplasty. Their short-term effects within the first month after surgery are yet unexplored. The purpose of this study was to compare Mid-Vastus and Medial Parapatellar effects on knee strength and balance control, at 5 days, 2 weeks and one month after surgery. It was hypothesized that Mid-Vastus would induce milder effects on the dependent variables due to its less invasive nature. MethodsTwenty females, randomly assigned to either the Mid-Vastus or the Medial Parapatellar group performed knee flexion-extension force and 30 s of bipedal stance before, 5 days, 2 weeks and one month after surgery. Maximum force, weight distribution and travel distance of the Center of Pressure were calculated. FindingsBoth groups showed decreased force output at all post-measurements compared to before surgery. Medial Parapatellar group showcased significantly higher travel distance at the 2 weeks measurement (Z = −2.268, p = .023, |r| = 0.507) compared to before surgery. This result was also imprinted on the travel distance of the non-surgical knee limb in the post (t = 3.259, p = .004, d = 1.456), 2 weeks (Z = −2.570, p = .009, |r| = 0.574) and one month measurement (t = 2.653, p = .016, d = 1.185). InterpretationWhile force is affected for both approaches, Mid-Vastus approach does not affect postural control. Therefore, Mid-Vastus is a less invasive technique compared to Medial Parapatellar. This work highlights the differences between Mid-Vastus and Medial Parapatellar approaches at least until the first month of rehabilitation.

Comparison of short-term radiographic outcomes of medial parapatellar, mini-midvastus, and subvastus surgical approaches in fast-track total knee arthroplasty

Purpose: Due to the difficulties in accessing the knee joint, correct prosthesis placement is of great importance during the implementation of total knee arthroplasty (TKA). This study aimed to compare short-term radiographic X-ray outcomes in patients who underwent fast-track TKA with medial parapatellar (MPP), mini-midvastus (mMV), or subvastus (SV) surgical approaches.&#x0D; Materials and methods: Between 2018 and 2020, 93 patients operated with MPP, mMV, and SV surgical approaches and who had complete data of radiographic outcomes before and sixth-week postoperative were retrospectively analyzed and patients divided into three groups: MPP (n=31), mMV (n=31), and SV (n=31). The alignments of preoperative and sixth-week postoperative X-ray images of the surgical approaches were measured. The operative time of fast-track TKA implementation with MPP, mMV, and SV surgical approaches was recorded.&#x0D; Results: The MPP group had higher preoperative lateral distal femoral angle than the mMV group and a higher preoperative lateral proximal femoral angle than SV group (p=0.018 and p=0.027, respectively). The mMV group had higher postoperative proximal medial tibial angle than SV group (p=0.011). In the postoperative sixth week, the MPP and mMV groups had a lower posterior tibial slope angle than SV group (p=0.001). The MPP approach had significantly shorter operative time than mMV and SV approaches (p=0.001).&#x0D; Conclusion: The outcomes indicate that MPP, mMV, and SV surgical approaches are preferable and feasible in obtaining a satisfactory prosthesis alignment during fast-track TKA. The MPP approach may be preferable because of its shorter operative time and potential advantage in minimizing surgical complication risks.

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

BackgroundNumerous 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. MethodsWe 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. ResultsThe 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. ConclusionQuadriceps-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.

Midvastus Versus Medial Parapatellar Approach in Simultaneous Bilateral Total Knee Arthroplasty

BackgroundThe purpose of this study was to compare the postoperative outcomes over a period of 3 years in patients who underwent bilateral total knee arthroplasty (TKA) using midvastus (MV) versus medial parapatellar (MPP) approaches. MethodsIn this retrospective study, 2 propensity-matched cohorts of patients who underwent simultaneous bilateral TKA via MV (n = 100) and MPP (n = 100) approaches from January 2017 to December 2018 were compared. Surgical parameters compared were surgery time and the incidence of lateral retinacular release (LRR). Clinical parameters including the visual analog score for pain, time for straight leg raise (SLR), range of motion, the Knee Society Score, and the Feller patellar score were assessed in the early postoperative and follow-up periods up to 3 years. Radiographs were evaluated for alignment, patellar tilt, and displacement. ResultsLRR was performed on 17 knees (8.5%) in the MPP group and 4 knees (2%) in the MV group which was significant (P = .03). The time to SLR was significantly lower in the MV group. There was no statistically significant difference in the length of hospital stay between the groups. The visual analog score, range of motion, and Knee Society Score were better in the MV group within 1 month (P < .05), but no statistically significant differences were found later. Patellar scores, radiographic patellar tilt, and displacements were similar at all follow-up periods. ConclusionIn our study, the MV approach had faster SLR, less LRR, and better pain and function scores in the first few weeks after TKA. However, its effect on different patient outcomes has not been sustained at 1 month and further follow-up points. We recommend that surgeons use the surgical approach with which they are most familiar.

Effects of Surgical Approach and Tourniquet Use on Patient-Reported Outcomes Following Total Knee Arthroplasty: A Pilot Randomized Clinical Trial.

Total knee arthroplasty (TKA) is one of the most successful procedures for the treatment of severe knee osteoarthritis. Various surgical approaches have been investigated in the hopes of improving postoperative outcomes. Two include the medial parapatellar (standard) and midvastus. As the midvastus approach does not disrupt the extensor mechanism, it may be advantageous for functional recovery, however length of stay and long-term function are similar between approaches. Tourniquet use during TKA has conflicting results in the literature. We hypothesized that a future trial comparing outpatient versus standard TKA could appropriately use either surgical approach with or without a tourniquet. Therefore, the objective of this pilot randomized trial was to compare postoperative pain, function, quality of life, and satisfaction between patients who underwent a medial parapatellar or midvastus approach for TKA ± tourniquet use. We conducted a randomized trial with a two-by-two factorial design to compare the medial parapatellar to the midvastus surgical approach for TKA ± tourniquet use. The Short Form-12 (SF-12), Western Ontario McMaster Osteoarthritis Index (WOMAC), and Knee Society Score (KSS) were collected at baseline, postoperatively at two, six, 12 weeks, and one year. Eighty-three patients were included. Postoperative WOMAC scores were statistically but not clinically higher at six weeks and three months in favour of no tourniquet use. There were no differences in postoperative WOMAC scores between approaches. Short Form-12 and KSS scores increased in both groups with no significant differences postoperatively (p > 0.05). There were no clinically significant differences in postoperative pain, function, quality of life, or satisfaction between surgical approaches or whether a tourniquet was used. As such, both surgical approaches ± tourniquet use are safe and reliable. We believe a future larger randomized trial could likely incorporate either surgical approach or tourniquet preferences without significant impact on patient reported outcomes.

Evaluation of Patellofemoral Complications by Comparing the Medial Parapatellar and Subvastus Approaches

Total knee arthroplasty (TKA) is considered to be the best method for treating advanced knee osteoarthritis in terms of reducing pain, improving joint functions, and increasing the patient’s quality of life

Comparison of Medial Parapatellar and Transpatellar Tendon Approach in Intramedullary Interlocking Nailing for Tibial Fracture: A Retrospective Analysis

IntroductionTibial fractures are one of the most common traumatic fractures, particularly in automobile accidents. Percutaneous reduction with conventional reduction forceps and un reamed intramedullary nailing, transpatellar, and medial parapatellar tendon approaches are all used, but tibial intramedullary nails are still primarily inserted through a transpatellar tendon splitting or medial parapatellar tendon approach.ObjectiveThe aim and objectives of this study are to assess the mean pain score after nailing for a tibial fracture using a medial parapatellar versus a transpatellar tendon method retrospectively in order to enhance operational planning.Materials and methodsThis is a retrospective study that took place in a UK level 1 trauma center. Data from 60 patients were included between February 2019 and February 2020. An equal number of patients were selected for both approaches to maintain accuracy. The advanced trauma life support (ATLS) protocol was used to handle all of the patients in both groups in order to rule out any other injuries or fractures, after which they were scheduled for surgery after stabilization. They were subsequently evaluated during a three-month follow-up in an outdoor clinic, where they were given a pain score using the visual analogue score (VAS) while moving their knee joints. The mean pain score was differentiated by age, gender, body mass index (BMI), injury side, and injury type.ResultsPatients were divided into groups based on their ages. Patients in the transpatellar tendon group were 32.83±5.13 years old, whereas those in the medial parapatellar tendon group were 31.4 ±5.42 years old. The gender distribution of the patients revealed that the majority of the patients in both groups were male. In both groups, the left side was the most usually affected. The difference between the two groups' mean pain scores at three months was substantially lower in the medial parapatellar approach (p=0.005).ConclusionFor patients having intramedullary nailing for tibial fractures, the medial parapatellar route is associated with a lower mean pain score than the transpatellar route. As a result, we may use this method in these individuals regularly.

Clinical and Radiological Outcomes of Total Knee Arthroplasty Performed with Midvastus and Medial Parapatellar Approaches in Obese Patients.

Background The use of total knee arthroplasty (TKA) for primary osteoarthritis of the knee has remarkably increased recently. We aimed to compare the clinical and radiological outcomes of TKA in obese patients (>30 kg/m2) operated with midvastus (MV) or medial parapatellar (MPP) approaches. Methods This retrospective study was performed using data derived from 80 patients (70 women; 10 men) with an average age of 66.17 ± 5.42 (range: 54 to 77). Patients were allocated into 2 groups as for the type of approach conducted during TKA: group I (n = 41) underwent TKA by MV approach, while the MMP technique was used in group II (n = 39). Results Demographic, clinical, and radiological parameters included age, side of involvement, sex, BMI, diameters of thigh and calf, length of incision, duration of operation, amount of bleeding and transfusion, duration of hospitalization and follow-up, complications, and range of motion, as well as Knee Society Score (KSS) and Knee Society Function Score (KSFS). Patients with a higher BMI (≥35 kg/m2) experienced more profound bleeding and needed more transfusion of erythrocyte suspension. The range of motion was more favorable in groups with BMI <35 kg/m2. The functional outcomes as reflected in KSS and KSFS were much better in patients with BMI <35 kg/m2. Conclusions Our data indicated that obesity can adversely influence the clinical and radiological outcomes after TKA performed by both MV and MPP approaches. A careful analysis of patient characteristics and selection of appropriate operative procedures is critical. Further randomized, controlled trials on larger series must be designed to elucidate the relationship between obesity and therapeutic outcomes after TKA with different approaches.

Does the type of surgical approach affect the clinical outcome of total knee arthroplasty?

BackgroundThe aim of the study was to investigate the issue of medial midvastus (MMV) vs. medial parapatellar (MPP) approaches in total knee arthroplasty (TKA). It was hypothesized that the two surgical approaches would produce significantly different results with respect to patient-reported knee score outcome (hypothesis 1), short-term postoperative range of motion (ROM) (hypothesis 2), long-term postoperative ROM (hypothesis 3) and prosthesis survival (hypothesis 4).MethodsA retrospective comparative study design was applied. Data sets were obtained from the state arthroplasty registry. The Western Ontario and McMaster Universities osteoarthritis index (WOMAC) data were analyzed from preoperative and 1 year postoperatively. The ROM data were analyzed for the time points preoperative, postoperative days 4 and 10 and 1 year.ResultsAvailable were 627 cases (407 MMV vs. 220 MPP) and 1 year postoperatively there were no significant differences between groups regarding the WOMAC scores (hypothesis 1). Early postoperatively on days 4 and 10 after TKA there were no differences between groups (p = 0.305 and p = 0.383, respectively, hypothesis 2). Likewise, ROM did not significantly differ between the groups 1 year after TKA (p = 0.338, hypothesis 3). The 5‑year prosthesis survival did not differ between the groups and showed 94.46% (95% confidence interval, CI 90.69–96.73%) in the MMV group and 94.33% (95% CI 89.96–96.83%) in the MPP group (p = 0.664, hypothesis 4).ConclusionBoth surgical approaches produce equivalent clinical results in terms of early postoperative ROM, late postoperative ROM and 1‑year WOMAC. The same prosthesis survival rates can be expected.

Total diz artroplastisinde subvastus ve medial parapatellar yaklaşımın klinik ve radyolojik sonuçlarının değerlendirilmesi

Introduction: The aim of this study is to compare clinically and radiologically the subvatus (SV) and medial parapatellar (MPP) approaches performed in patients undergoing total knee arthroplasty (TKA) due to severe gonarthrosis. Materials and methods: Patients who underwent TKA between 2015 and 2019 were divided into two groups, SV and MPP, according to the type of approach performed. Demographic, clinical, and surgical information of the patients were evaluated. Knee Society Clinical Rating System (KSS) and visual analogue scale (VAS) scores were used for functional evaluation. AP and lateral orthoroentgenograms and knee radiographs taken at the last follow-up were used for radiological evaluation. Results: The mean duration of surgery and tourniquet was significantly higher in the SV group. (p &lt;.001 and p &lt;.001, respectively). Mean blood loss and number of blood transfusions were significantly higher in the MPP group. (p &lt;.001 and p &lt;.001, respectively). Opiate analgesic need, straight leg raising time and hospitalization time were also significantly higher in the MPP group. (p &lt;.001, p &lt;.001 and p &lt;.001, respectively). Although the KSS, VAS scores, and the range of motion at the first month were better in the SV group, there was no difference between the two groups at 6 and 12 months. Conclusion: According to this study, with the SV approach used for TKA, postoperative blood loss and the need for transfusion decreased, the duration of hospitalization was shortened, postoperative pain was less, and functional scores were better. The only disadvantage is the prolonged operation time

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

BackgroundLow knee awareness after minimally invasive total knee arthroplasty (TKA) has become the ultimate target of a natural-feeling knee that meets patient expectations. The objective of this research was to compare the clinical outcomes of TKA via the mini-midvastus (MMV) approach or the medial parapatellar (MPP) approach, and to evaluate which approach can lead to a better quality of life after surgery.MethodsFrom January 2015 to December 2016, a retrospective cohort study was conducted in 330 patients who underwent TKA via a mini-midvastus (MMV) approach. During this period, we also selected 330 patients who underwent TKA via a medial parapatellar (MPP) approach (MPP group) for comparison. Clinical results were assessed with the visual analog scale score for pain, range of motion, and the Knee Society Score. The Forgotten Joint Score was used to analyze the ability to forget the joint.ResultsThere were significant differences with regard to visual analog scale score, range of motion, and the Knee Society Score until 6 months after surgery between the MMV and MPP groups (p < 0.05), but the differences were not significant at 12 months, 24 months, and 36 months after surgery. However, there were significant differences in the Forgotten Joint Score between the groups during the follow-up period (p < 0.05).ConclusionWhen forgetting the artificial joint after TKA is the ultimate target, better quality of life can be acquired by performing TKA via the MMV approach. In addition, compared with the MPP approach, the MMV approach can offer less pain and a faster recovery.

Effect of the surgical exposure on the early postoperative period after total knee arthroplasty

Total knee arthroplasty has become one of the most successful and safest surgical procedures in orthopedic surgery. Of the many different types of surgical exposure, the most common, so-called medial parapatellar (MP) incision is the cut of the quadriceps tendon, which impairs extensor function. In contrast, subvastus (S) exposure, which spares the extensor apparatus, may promise better healing. The purpose of our prospective observational study at the Orthopedic Clinic of Semmelweis University is to compare the effects of the MP and the S excision on the early postoperative period. The 60 patients enrolled were randomly assigned to two different groups according to the type of intervention. In the study, we measured the effects of the two different methods of surgical exposure on homogeneous patient groups in the early postoperative period based on international literature and the parameters we defined. Visual analog scale (VAS) measured resting and active pain levels for the first 10 days, suggesting a more pronounced difference in active VAS values for the S group. In the case of active VAS, patients in the S group also had significantly less pain on days 2, 3, and 10 than in the MP group. Taking into account the results of the other days, it is in favour of preserving the integrity of the extensor apparatus for improved postoperative functionality. Patients' knee joint range of motion was also measured. On day 1, those in the S group were significantly larger. As the days progress, MP group members catch up with S group during their rehabilitation. Group S patients had an average of 1.944 days to extended leg elevation, which is nearly two days shorter compared to the MP group (p<0.0001). After statistical analysis of data, subvastus exposure appears to be more beneficial in the rehabilitation of the early postoperative period. However, large-scale, multicentre observational studies are required to establish evidence. Orv Hetil. 2020; 161(29): 1208-1214.

Patellofemoral Arthroplasty Surgical Technique: Lateral or Medial Parapatellar Approach

BackgroundPatellofemoral arthroplasty (PFA) is an emerging treatment for patients with isolated patellofemoral compartment osteoarthritis. The medial parapatellar approach is the standard arthrotomy but has been shown in total knee arthroplasty to damage the patellar blood supply and increase postoperative patellar instability. The lateral parapatellar approach is an alternative that may reduce the risk of these outcomes. The purpose of this study is to compare the radiographic measures of patellar tracking and patient-reported outcomes of the medial and lateral parapatellar approaches in PFA. MethodsBetween 2012 and 2019, a retrospective review was performed of 136 knees undergoing PFA at a single institution. Patients were separated by preoperative congruence angle and then surgical approach into 3 cohorts. Preoperative and postoperative patellar tilt and congruence angle were measured. Preoperative and minimum 6-month postoperative patient-reported outcomes scores were collected. ResultsThere were no significant differences in the mean postoperative congruence angle and postoperative patient-reported outcomes among the 3 cohorts. Mean postoperative patellar tilt was normalized only in the abnormal congruence angle/lateral approach group to 2.80° (standard error, 1.85). ConclusionCongruence angle was improved regardless of surgical approach. Patellar tilt was normalized only for the lateral approach in patients with abnormal preoperative congruence angle. There were no significant differences in preoperative and postoperative scores between groups except for preoperative 12-item Short Form Mental Health Survey scores. This study supports that the lateral approach offers improved postoperative patellar tilt compared to a medial approach for PFA while achieving similar patient-reported outcomes.

Can the Surgical Approach to Total Knee Arthroplasty Influence Early Postoperative Outcomes? - A Comparative Study between Trivector and Medial Parapatellar Approaches.

Background:Trivector approach to total knee arthroplasty (TKA) is a quadriceps tendon sparing approach, whereas the medial parapatellar (MPP) approach involves making a longitudinal incision in quadriceps tendon. We postulated that quadriceps-sparing approach such as trivector should make postoperative rehabilitation easier and ultimately reduce the length of hospital stay.Objectives:The aim of the study is to compare the early postoperative outcomes of the TKA performed through the trivector and the MPP approaches.Methodology:We prospectively reviewed the results of 56 consecutive patients operated on by two knee surgeons: one routinely performs trivector and the other an MPP approach. Both the groups consisted of 28 patients each. We looked at operative times, the time taken to perform straight leg raise (SLR), range of movements achieved before discharge, and length of the hospital stay.Results:The mean time taken for performing the surgery through the MPP approach was 56 min, whereas, for the trivector approach, it was 54 min (P = 0.31). The mean time taken to perform SLR in the MPP approach group was 3.5 days, whereas in the trivector group, the meantime taken for SLR was 2.5 days (P = 0.003). The average extension at the time of discharge in the MPP group was 3.8°, and in the trivector group, it was 0.86° (P = 0.007). The average knee flexion at the time of discharge in the MPP group was 84.2°, whereas in the trivector group, it was 86.5° (P = 0.199). The average hospital stay in the MPP group was 5.96 days, whereas in the trivector group, it was 4.84 days (P = 0.11).Conclusions:The trivector approach patients took significantly less time to do SLR and achieved a better range of extension before discharge from the hospital. The patients with trivector approach were discharged early by one day, although it is not statistically significant, it is clinically significant.

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.

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. 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. 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. 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.

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English

Tibial Tubercle Osteotomy vs the Extensile Medial Parapatellar Approach in Revision Total Knee Arthroplasty: Is Tibial Tubercle Osteotomy a Harmful Approach?

BackgroundAs the frequency of total knee arthroplasty (TKA) is increasing, long-term follow-up of patients has become essential, and the frequency of revision total knee arthroplasty (R-TKA) due to the occurrence of various complications has also increased. There is controversy regarding which approach has minimal complications and an adequate visual field in R-TKA. Therefore, we compared the clinical and radiological results between the extensile medial parapatellar (EMP) approach and tibial tubercle osteotomy (TTO) for R-TKA. MethodsBetween March 1, 2000, and December 31, 2015, we compared 35 patients who underwent the EMP approach and 31 who underwent the TTO approach for R-TKA. In this study, the preoperative range of motion (ROM) was an important criterion for the choice of approach in R-TKA. The EMP approach was applied to patients with a ROM above 60°. The TTO approach was applied to patients with knee flexion limited to 0°-30°. We clinically assessed knee ROM, Knee Society scores, and Hospital for Special Surgery scores at the time of the last follow-up. We radiographically measured femorotibial alignment and patellar height. We also examined the complication rates. The average length of the TTO was 1.0 × 2.5 cm × 10 cm. We used 3 or more 3.5-mm half-threaded screws. ResultsThe mean postoperative ROM of the knee joint at the time of the last follow-up was 103° (flexion contracture 5° and further flexion 108°) in the group that underwent the EMP approach and 101° (flexion contracture 4° and further flexion 109°) in the group that underwent the TTO approach. The mean Knee Society scores were 86 (71-96) and 85 (72-94), and the mean Hospital for Special Surgery scores were 82 (70-93) and 83 (68-92) for the 2 groups, respectively, with no statistically significant difference. The mean femorotibial angles were 0.6° (±3.3°) and 0.1° (±2.9°), and the mean Insall-Salvati ratios were 1.0 (±0.34) and 0.8 (±0.14), respectively, with no statistically significant difference. The group that underwent TTO achieved bone union at an average of 11.8 weeks after surgery. In the group that underwent the EMP approach, 2 patients had extensor lag of more than 10°. In the group that underwent TTO, 2 subjects had skin necrosis at the operative site. ConclusionThe clinical and radiological outcomes were similar in the 2 groups after R-TKA. To increase the ROM and obtain adequate exposure, TTO is also considered a useful surgical approach. However, complications related to TTO should be minimized. Level of EvidenceTherapeutic level III, retrospective comparative study.

The Extensile Medial Parapatellar Approach to the Distal Femur and Knee: Anatomic Landmarks and Surgical Technique

This paper describes an extensile surgical approach to the distal femur, which incorporates the medial parapatellar arthrotomy. This extensile exposure serves as an anterior utility approach to the knee, allowing the surgeon access to all aspects of the anterior knee and near circumferential access to the distal femur. Reported indications for access to this region include: tumor resection, difficult primary arthroplasty and revision arthroplasty of the knee, and intra-articular and extra-articular fractures of the distal femur. Despite adequate working knowledge of the standard medial parapatellar approach to the knee, the extensile approach is seldom required and, as a result, orthopedic trainees and practising orthopedic surgeons may not be familiar with the musculotendonous junctions that occur in the quadriceps tendon. This report describes a novel surgical approach and the relevant anatomy through a series of detailed clinical and fresh cadaveric dissections. A previously undescribed anatomic landmark is demonstrated through photographs and cadaveric variation studies, which may help guide the surgeon in defining crucial planes.

Quadriceps-sparing versus traditional medial parapatellar approaches for total knee arthroplasty: a meta-analysis

BackgroundThere is still controversy regarding whether Quadriceps-sparing (QS) approach for total knee arthroplasty (TKA) lead to better earlier recovery as well as compromising low limb alignment and prosthesis position compared with conventional medial parapatellar (MP) approach. To overcome the shortcomings and inaccuracies of single studies, the clinical outcomes and radiographic assessments of QS approach and MP approach were evaluated through meta-analysis.MethodsWe performed this meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A literature search was conducted in the PubMed, EMBase, Cochrane Collaboration Library and Web of Science databases. Our search strategy followed the requirements of the Cochrane Library Handbook. The study selection, data extraction and assessment of methodological quality were independently completed by four authors. And subgroup analysis and publication bias were also performed in the study.ResultsEight prospective randomized controlled trials (RCTs) and eight retrospective studies were identified. Overall meta-analysis and subgroup meta-analysis of RCTs identified the QS approach mainly was associated with increased Knee Society function score beyond 24 months postoperatively (weighted mean difference [WMD] 1.78, P = 0.0004) (WMD 1.86, P = 0.0002), and improved range of motion 1–2 weeks postoperatively (WMD 5.84, P < 0.00001) (WMD 4.87, P = 0.002). Besides, lower visual analogue scale on postoperative day 1 (WMD -0.91, P = 0.02), shorter hospital stay (WMD -0.88, P = 0.02) and shorter incision (extension) (WMD -4.62, P < 0.00001) were indicated in overall meta-analysis. However, surgical and tourniquet time was significantly longer in QS group by both overall and subgroup meta-analysis.ConclusionsQS approach may accelerate early recovery without increasing the risk of malalignment of low limb and malposition of prosthesis.