Mini-midvastus Approach Research Articles

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).

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.

Analysis of learning curve of minimally invasive total knee arthroplasty: A single surgeon's experience with 4017 cases over a 9-year period.

To evaluate a single surgeon's experience with minimally invasive total knee arthroplasty (MIS-TKA) and report the 9-year learning curve and trends in clinical outcomes based on assessment of surgical skills, radiographic alignments, and patient's function scores. This retrospective study included a total of 4107 knees from 3403 patients undergoing bilateral or unilateral MIS-TKA between March 2004 and February 2013. MIS-TKA was performed through a modified mini-midvastus approach. Postsurgical care regime was standardized for all patients. Data of consecutive 3-month intervals were collected and compared for changes of trends in outcomes over time, including tourniquet time, intraoperative complications, radiographic alignment, the Knee Society Score (KSS), and functional scores. Significant increase in the number of cases undergoing MIS-TKA per 3-month interval over the study period was observed. As surgeon's experience increased over time, tourniquet time was decreased from an average of 70 minutes to approximately 35 minutes. A total of 65 (1.68%) intraoperative complications were recorded and the frequencies were in a significant decreasing trend. The rate of malalignment was in a decreasing trend and steady desired alignment (6°) was achieved at the 15th three-month interval. KSS and function scores increased from 87.4 to 91.5 and 92.6 to 96.8, respectively. Although a surgeon may become competent with MIS-TKA and achieved the preliminary learning curve within one year, experience accumulation continuously improved technical proficiency in MIS-TKA. This study confirmed significant improvements in surgical skills, postoperative alignment, and patients' function over time.

Does Obesity Affect Clinical and Radiological Outcomes in Minimally Invasive Total Knee Arthroplasty? Minimum 5-Year Follow-up of Minimally Invasive TKA in Obese Patients.

BackgroundThe aim of this study was to evaluate the clinical and radiological outcomes of minimally invasive total knee arthroplasty (MIS-TKA) in obese patients.MethodsWe examined the records of 371 cases of MIS-TKA performed using the mini-midvastus approach from January 2006 to December 2006. According to body mass index (BMI), the cases were classified into group A (BMI < 25 kg/m2, 114 knees), group B (25 kg/m2 ≤ BMI < 30 kg/m2, 179 knees), and group C (BMI ≥ 30 kg/m2, 78 knees). Clinical outcomes were measured with the Hospital for Special Surgery Score and Knee Society Score. Radiological evaluation included measurements of knee alignment.ResultsMIS-TKA was performed on all patients. The skin incision size in group A, group B, and group C was 8.2 ± 0.8 cm, 8.3 ± 0.8 cm, and 8.5 ± 0.9 cm, respectively, and the operation time was 86.4 ± 10.4 minutes, 85.9 ± 11.3 minutes, and 89.0 ± 11.4 minutes, respectively, indicating no significant difference among the groups (p > 0.05). There was no difference in terms of the accuracy of the tibial implant alignment, with 97.6%, 95.2%, and 93.4% of each group showing 90° ± 3° varus angulation (p > 0.05). With respect to the accuracy of the femorotibial angle, 93.9%, 94.6%, and 90.2% of each group had 6° ± 3° valgus angulation, with group C demonstrating the lowest level of accuracy (p < 0.05). The preoperative range of motion and Knee Society Score of group C were less than those of groups A and B (p < 0.05), but there was no notable difference among groups at the postoperative 3-month and 1-year follow-ups (p > 0.05).ConclusionsMIS-TKA in obese patients showed satisfactory clinical and radiological results without significant difference in surgical results compared to nonobese patients.

Using a non-invasive secure skin closure following total knee arthroplasty leads to fewer wound complications and no patient home care visits compared to surgical staples

BackgroundSuperficial wound complications occur in up to 10% of total knee arthroplasty (TKA) procedures and have been associated with periprosthetic joint infection. The ideal material for TKA closure should offer: 1) fast intraoperative application, 2) minimal wound complications and 3) removable by patients without assistance. We evaluated a novel, non-invasive, removable skin closure system for TKA to determine its effect on wound complications. MethodsWe prospectively evaluated 221 consecutive TKA patients who received skin closure using a non-invasive zipper-like system (‘Zip’; Zip 16 Surgical Skin Closure System; Zipline Medical). All procedures were performed by a single surgeon using the mini-midvastus approach. Patients received two weeks of rivaroxaban postoperatively. Demographics, comorbidities, in-hospital complications and six-week wound evaluation were recorded. Data was compared to a cohort of 1001 patients from the same surgeon who received staples for closure and coumadin for thromboprophylaxis. ResultsZip patients had a significantly higher BMI (p=0.001), incidence of diabetes (p=0.035) and smoking (p=0.005). Zip patients removed dressings themselves and did not report problems with dressing care. Rate of readmission for wound-related complications was significantly lower in the Zip closure group (p=0.045). Overall readmission rates were similar between groups. ConclusionsIn our experience, the Zip 16 Surgical Skin Closure System is easy to apply, avoids home care and has produced fewer wound complications compared to staples. Results have been positive despite the study cohort having a higher number of diabetic patients and using an anticoagulant associated with a higher risk of wound complications.

Minimally Invasive Midvastus versus Standard Parapatellar Approach in Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

ObjectiveMinimally 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.MethodsThis 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.ResultsA 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).ConclusionThis 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 EvidenceTherapeutic study Level I.

Better quadriceps recovery after minimally invasive total knee arthroplasty

The proponents of minimally invasive total knee arthroplasty (TKA) have reported better functional recovery than conventional TKA. In most of the previous studies, the results were shown with the relatively subjective methods. We investigated the objective results with a dynamometry in this prospective randomized study. It was hypothesized that minimally invasive TKA would have a better and earlier recovery of quadriceps force in terms of the objective numeric data. Sixty-six TKAs were prospectively randomized into two groups. Thirty-three knees underwent minimally invasive TKA using mini-midvastus approach and 33 knees underwent conventional TKA using medial parapatellar approach. The quadriceps force was assessed using a dynamometer. The data were collected preoperatively and at postoperative 6 weeks, 3 months, 6 months and 1 year consecutively. The mean of quadriceps force in minimally invasive TKA group at postoperative 6 weeks was greater than conventional TKA after removing the covariate (preoperative quadriceps force) with analysis of covariance (P = 0.002), but thereafter, the difference was not significant till 1 year. Meanwhile, with repeated measures analysis of variance, conventional TKA group had greater quadriceps recovery than minimally invasive TKA group during postoperative 6 weeks to 3 months (P = 0.035). The proportion of patients unable to recover the quadriceps force to their preoperative levels by 1 year postoperatively was similar in two groups. Minimally invasive TKA has benefit in quadriceps recovery at earlier rehabilitation period although catch-up recovery in conventional TKA was accelerated from the postoperative 6 weeks to 3 months. It may support the concept of early return to full activity after minimally invasive TKA, and patients might get back early to normal life.

L’accesso mini-midvastus modificato in chirurgia protesica del ginocchio

The main goals of minimally invasive surgery (MIS) TKA are to minimize surgical trauma, decrease postoperative pain, and improve the rehabilitation and early functional recovery after surgery. To minimize soft tissue damage, several surgical approaches have been suggested, including the mini-parapatellar approach, the mini-subvastus approach and the mini-midvastus approach. We prefer the mini-midvastus approach because it preserves the extensor mechanism, with an acceptable joint view. Some authors showed that the mini-midvastus approach provides the best clinical outcomes at 1 and 3 months when compared with other minimally invasive and standard approaches. On the other hand, the 43% of patients who underwent a vastus-splitting approach presented electromyographic alterations after surgery, due to muscle damage. For this reason we will describe in this article a modified mini-midvastus technique.

Differences between Midvastus and Subvastus TKA Surgical Approaches in the Tasks of Sitting and Standing

The mini-midvastus (MV) approach to total knee arthroplasty (TKA) minimizes damage to the extensor mechanism; however, the mini-subvastus (SV) approach is designed to avoid such damage. Quadriceps weakness following TKA can have a significant impact on the activities of daily living, particularly stand-to-sit down (STSD) and sit-to-stand up (STSU) activities. Fifty-three subjects diagnosed with primary osteoarthritis and scheduled to undergo TKA were randomized to receive an MV or SV surgical approach and were given identical postoperative orders. Compared with age-matched controls, the SV group had a quicker return of normal peak knee extension moment during STSU, whereas the MV group had a quicker return of normal movement patterns in hip, knee, and ankle parameters during STSD yet represented the higher functioning subjects as more MV subjects had difficulty completing the task as instructed. Considering both movements are required for daily living, neither surgical group was found to have a significant advantage over the other in functional outcome through 6 months post-TKA.

Mini-midvastus versus mini-medial parapatellar approach in total knee arthroplasty: a prospective, randomized study

To date, no English literature has evaluated the short-term results of the mini-medial parapatellar approach compared with the mini-midvastus approach. This prospective, randomized study was performed to compare the short-term results of total knee arthroplasty using either a mini-midvastus or a mini-medial parapatellar approach. We reported the clinical and radiological results of 89 patients who had primary total knee arthroplasties with minimally invasive techniques using either a mini-midvastus or a mini-medial parapatellar approach. The mini-midvastus approach was used on 45 patients (group I) and a mini-medial parapatellar approach on 44 patients (group II). Skin incision length, tourniquet time, incidence of lateral retinacular release, total blood loss, straight leg raising time, visual analogy scale score, alignment of the knee, component position, and complication of each group were examined. Knee Society scores, range of motion were compared at 7days, 6weeks, 3months, and 6months postoperatively. The mean tourniquet time was 68min in group I, significantly longer than 56min for group II. However, comparisons of postoperative knee scores and function scores between both approaches did not yield a significant difference in outcome. No significant difference was found with respect to total blood loss, visual analogy scale score, straight-leg-raising test, range of motion or radiographic findings. Based on these results, we believe that the early results are similar between mini-midvastus and mini-medial parapatellar approach, ultimately the selection of the surgical approach will depend on the surgeon's experience and preference.

Custom-fit minimally invasive total knee arthroplasty: effect on blood loss and early clinical outcomes

Recently, new custom-fit pin guides in total knee arthroplasty (TKA) have been introduced. Use of these guides may reduce operating time. Use of the guides combined with the absence of intramedullary alignment jigs may lead to reduced blood loss and improved early outcomes. Our aim was to evaluate blood loss and early clinical outcomes in patients undergoing minimally invasive TKA using custom-fit magnetic resonance imaging (MRI)-based pin guides. A prospective study in 80 patients was carried out. Patients were divided randomly into 2 equal groups. In one group, intramedullary alignment jigs were used. In the second group, custom-fit MRI-based pin guides were used. All patients received the same cemented posterior-stabilized implant through a mini-midvastus approach. The volume in the drain bottles was recorded after 48 h. Hb loss was estimated by subtracting the postoperative from the preoperative Hb level. Transfusion requirements and surgical time were recorded. Outcome measures were Knee Society Scores (KSS), knee flexion, knee swelling and pain. There was lower mean drainage of blood in the custom-fit group (391 ml vs. 603 ml; p < 0.0001). There was no difference in estimated loss of Hb (3.6 g/dl vs. 4.1 g/dl; n.s.) and in transfusion requirements (7.5 % vs. 10 %; n.s.). Surgical time was reduced in the custom-fit group (12 min less; p = 0.001). KSS measured at week 2, 6 and 12 showed no significant difference between groups. Knee flexion measured on days 7, 10 and at week 6, 12 and knee swelling and pain measured on days 1, 3, 10 and at week 6, 12 showed no significant difference between groups. Using custom-fit pin guides reduces blood drainage, but not the estimated Hb loss in minimally invasive TKA and does not affect transfusion rate. Surgical time is reduced. There is no effect on the early clinical outcomes. Therapeutic study, Level I.

Mini-midvastus Versus Medial Parapatellar Approach in TKA: Muscle Damage and Inflammation Markers

The purpose of this prospective study was to analyze the biochemical markers of muscle damage and inflammation in patients treated with the mini-midvastus approach or the medial parapatellar approach for total knee arthroplasty. Of 60 patients who underwent unilateral total knee arthroplasty, 30 were treated with the mini-midvastus approach (MMV group) and 30 were treated with the medial parapatellar approach (MPP group). Serum creatine kinase, myoglobin, lactate dehydrogenase, glutamic oxaloacetic transaminase, C-reactive protein, interleukin-6, and interleukin-1β levels were measured preoperatively, immediately postoperatively (except for C-reactive protein level), and on postoperative days 1, 2, and 3. Student's t test, Pearson's chi-square test, and Fisher's exact test were used to compare the outcomes between the 2 groups. Compared with the MPP group, a significant increase in serum creatine kinase level existed in the MMV group on postoperative days 2 (P=.08) and 3 (P=.09) and cumulatively (P=.02). However, significantly elevated C-reactive protein and interleukin-6 levels existed in the MPP group.According to the serum creatine kinase levels, the mini-midvastus approach has no superiority over the medial parapatellar approach in terms of sparing muscle and may cause more muscle damage. Further study is warranted to determine the correlation between biochemical markers and functional deficits.

A prospective randomised study of minimally invasive midvastus total knee arthroplasty compared with standard total knee arthroplasty

IntroductionProposed advantages of minimally invasive surgery include shorter hospital stay, less blood loss, and a greater range of motion but potential concerns are raised about both prolonged learning curves and a compromise in exposure leading to implant malposition. Patients and methodsThis powered study evaluates the outcomes of 80 patients randomised to have mini-midvastus (MMV) approach or standard medial parapatellar (MPP) approach. Rehabilitation protocols and discharge criteria were standardised. Patients were discharged home directly, capable of safe independent care. Validated outcome measures were recorded post-operatively at intervals up to 1year. Independent, blinded review of post-operative x-rays was obtained. ResultsLength of stay was similar in the MMV and MPP groups (median 3.73days vs. 3.75days). No statistically significant differences were detected in either the demographic data or any intra-operative variable apart from blood loss and incision length. No statistically significant difference in clinical outcome measures (Oxford/Knee Society Scores) or radiographic analysis was observed. ConclusionThe MMV approach does not appear to confer any clinically significant benefit apart from a smaller surgical scar, compared to the MPP surgical technique.Level of evidence I: randomised control trial.R.E.C. 040301.

Critical Review of Minimally Invasive Approaches in Knee Arthroplasty

Despite high survivorship for total knee arthroplasty, many reports have described low patient-satisfaction rates. Standard parapatellar approaches have been linked with decreased quadriceps muscle strength, which may in turn lead to prolonged rehabilitation and altered kinematics. Although technically demanding, minimally invasive techniques offer the potential for shorter recovery times and improved strength. Our purpose was to compare perioperative factors, the clinical and radiographic outcomes, complications, and survivorship of several minimally invasive approaches to each other and to the conventional medial parapatellar approach. A total of 23 level I or II studies were reviewed. There were no statistically significant differences in perioperative factors, clinical or radiographic outcomes, survivorship, or complication rates between patients the various minimally invasive approaches to a standard approach. The only significant difference observed was in recovery of quadriceps muscle function (shorter in patients who had a minimally invasive approach). The minimally invasive lateral approach had more complications than the other minimally invasive approaches. The mini-midvastus approach had the best clinical outcomes at 1 and 3 months when compared with other minimally invasive approaches and standard approaches. The mini-subvastus approach had the lowest rate of complications, overall. Further multicenter randomized trials are needed to determine the minimally invasive approach that best improves outcomes while minimizing complications.

Difference in Stair Negotiation Ability Based on TKA Surgical Approach

Several surgical approaches for total knee arthroplasty (TKA) have been developed to minimize soft-tissue trauma and expedite functional recovery. A group of 61 subjects undergoing computer-navigated, minimally invasive TKA were randomized to receive a mini-parapatellar, standard parapatellar, mini-midvastus (MV), or mini-subvastus approach. Before and after treatment, subjects were asked to negotiate stairs in a self-selected manner. This study used the manner of stair negotiation (i.e., use of handrail, step-over-step, step-by-step) as a proxy for functional ability. Subjects who received TKA through a mini-MV approach demonstrated a significantly lower level of function at 2 and 4 months. If early functional recovery is a goal of TKA, surgeons should be cautious when considering the mini-MV approach, which was found to be inferior to other approaches in this study.

Minimally Invasive Total Knee Arthroplasty with Mini-midvastus Approach

Minimally Invasive Total Knee Arthroplasty with Mini-midvastus Approach

MIS-QS-TKAの短期成績

MIS-QS-TKAの短期成績

Mini-Midvastus vs Standard Medial Parapatellar Approach: A Prospective, Randomized, Double-Blinded Study in Patients Undergoing Bilateral Total Knee Arthroplasty

The purpose of this study was to determine whether the mini-midvastus approach to total knee arthroplasty (TKA) results in differences in quadriceps muscle strength as well as previously cited advantages in a double blind prospective randomized trial. Twenty-seven patients (54 TKAs) scheduled for bilateral TKA were randomized to undergo mini-midvastus approach on one knee and standard approach on the other. Incision lengths were the same. Postoperative strength was determined by isokinetic and isometric peak torque testing. Range of motion, pain Visual analog scale, side-preference, and gait analysis were assessed preoperatively and postoperatively. The only significant difference in strength testing was increased isokinetic and isometric extension torque at 3 weeks postoperatively for the mini-midvastus approach. No differences between the mini-midvastus and standard approach were observed for stride length, stance time, pain Visual analog scale, or knee range of motion. The mini-midvastus approach has limited benefit compared to the standard approach for TKA.

No difference in early functional outcomes for mini-midvastus and limited medial parapatellar approaches in navigation-assisted total knee arthroplasty: a prospective randomized clinical trial

Patients desire less pain and faster recovery of range of knee motion after total knee arthroplasty (TKA). While minimal invasive surgery (MIS) TKA appears to meet these needs, concerns exist regarding component malpositioning. Navigation systems can reduce the incidence of component misalignment. The present prospective randomized study compared limited medial parapatellar (LMPP) and mini-midvastus (MMV) approaches in 30 patients who had bilateral simultaneous primary TKAs. Each patient underwent LMPP on one knee and MMV on the other. Both approaches were navigation-assisted. We primarily analyzed postoperative pain (using visual analog scores), range of knee motion, and hospital for special surgery (HSS) scores in the first 6 postoperative months (i.e., the early postoperative period), and secondarily analyzed perioperative parameters and radiographic outcomes. The LMPP and MMV approaches were found to be similar in terms of pain measured at postoperative 3 days, 1, 2 weeks, 1, 3, and 6 months (P = NS). Similarly, the 2 approaches were found to be similar in terms of range of motion measured at 1, 2 weeks, 1, 3, and 6 months (P = NS), and in terms of HSS scores measured at 1, 3, and 6 months (P = NS). There were also no differences between groups in terms of total blood loss, approach preferred by patients, and radiographic component positioning. The present study found that navigation-assisted MMV and navigation-assisted LMPP resulted in similar outcomes in terms of pain, ROM, HSS score, and radiologic outcomes over the first six postoperative months. We recommend the LMPP approach over the MMV approach in navigation-assisted MIS TKA because it is more familiar to surgeons and is easier to convert to the conventional approach where necessary.

A Comparison of Subvastus and Midvastus Approaches in Minimally Invasive Total Knee Arthroplasty

The mini-subvastus and the mini-midvastus approaches are among the most common alternatives to the medial parapatellar approach for total knee arthroplasty. The purpose of this study was to compare the early clinical outcomes of these two approaches. In this prospective, randomized study of fifty-one patients who underwent bilateral total knee arthroplasty, the mini-subvastus approach was used in one knee and the mini-midvastus approach, in the contralateral knee. There were forty-two women and nine men who had a mean age of seventy years at the time of the index arthroplasties, and they were followed for two years postoperatively. Clinical outcome was assessed and compared with use of the Knee Society pain and function scores, the straight-leg-raising test, range of motion, and isokinetic strength testing. Operating time and blood loss for each approach were also compared. In addition, patients were surveyed concerning which knee they preferred. Comparisons of postoperative Knee Society scores between both approaches at the time of the two-year follow-up did not yield a significant difference in outcome. Isokinetic strength testing at twelve weeks postoperatively revealed no significant differences in muscle strength, with a mean extensor peak torque-to-body weight ratio of 0.14 Nm/kg for both groups. No significant difference was found with respect to total blood loss, straight-leg-raising test, range of motion, or patient preference. There was no clinically relevant difference in operative times between the two approaches. The minimally invasive subvastus and midvastus approaches for total knee arthroplasty were both associated with excellent short-term clinical results. Some surgeons believe that the subvastus approach completely avoids damage to the quadriceps mechanism and therefore would be associated with improved muscle function. This prospective series did not identify a substantive difference between the two approaches. We believe that the decision between these surgical approaches should be based on surgeon preference and experience.