Subvastus Approaches Research Articles

Comparable long-term functional outcomes of subvastus and medial parapatellar approach in total knee arthroplasty: A 10-year follow-up study.

Surgeons usually use the medial parapatellar or subvastus approaches for total knee arthroplasty (TKA). The subvastus approach is rapidly gaining recognition to reduce damage to the extensional mechanism and recover faster after surgery. This study compares the long-term outcomes of the conventional medial parapatellar and subvastus approaches in primary TKA during a minimum 10-year follow-up. In a retrospective longitudinal follow-up study from 2008 to 2013, 60 eligible patients for primary TKA were included. The patients were divided into two groups: one undergoing TKA with the subvastus approach (n = 30) and the other with the conventional medial parapatellar approach (n = 30). Postoperatively, the patients were followed up for 10-15 years. Patients were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Society Score (KSS), and Visual Analogue Scale index for pain. The time required to perform an active straight leg raise (SLR) was significantly shorter in the subvastus group (p < 0.001) at early postoperation evaluation. Patients in the subvastus group had lower pain and better knee functional scores at the one-year follow-up (p < 0.05). There was no difference between the two groups regarding duration of hospitalisation, blood loss, operation time, length of the scar, and postoperative complications. Both approaches had similar long-term results regarding pain and functional scores of WOMAC (6.2 ± 1.2 vs. 6.3 ± 1.3, p-value = 0.69) and KSS scores (93.1 ± 6.8 vs. 95.0 ± 3.2, p-value = 0.42). The subvastus approach was associated with a shorter time to achieve active SLR, higher functional scores, and better pain relief at early postoperative evaluations. However, both techniques had similar long-term outcomes in terms of pain and functional scores, as measured by the WOMAC and KSS scales. II.

Prospective comparative study of medial parapatellar and medial subvastus approaches in total knee arthroplasty

Introduction Total knee arthroplasty (TKA) is the treatment of end-stage osteoarthritis in patients who failed to respond to conservative treatment in providing significant pain relief and improving joint function. The medial parapatellar approach (MPP) allows adequate patellar eversion and sufficient knee flexion to expose the knee joint, but the incision through the quadriceps tendon may impair the extensor mechanism of the knee post-operatively. The subvastus approach (SV) completely spares both the quadriceps tendon and muscle and provides adequate exposure of the knee joint for the replacement procedure, SV maintains integrity of the patellar blood supply and reduces post-operative pain resulting in shorter hospital stay.The aim of this prospective study was to compare the results of the medial parapatellar and subvastus approaches in primary total knee arthroplasty (TKA) regarding postoperative pain, recovery of muscle strength, range of knee motion and return to regular daily activities.Materials and Methods Sixty patients underwent TKA at El-Hadara university hospital in Alexandria. The medial parapatellar apphroach (MPP) was performed in 30 patients while the subvastus approach (SV) was used for the other 30 patients. The choice of approach was randomly assigned.Results The statistical analysis of the results at the end of a 6-month follow-up showed that there were no significant differences between the patients in group 1 (MPP) and group 2 (SV) with respect to age, gender, comorbidity, side operated or body mass index (BMI). Regarding the functional knee scores (IKDC, WOMAC), there were no differences at 4 weeks, 3 months and 6 months postoperatively between the two groups. However, we found better outcomes in the SV group regarding the VAS score during the first five postoperative days, earlier quadriceps recovery by assessment of Straight Leg Raising test (SLR), while the operative time was longer in the SV group with less blood collected postoperatively in hemovac drain in the same group.Discussion In our study during the operation via the MPP approach, the index suture positioned at the superomedial border of the patella and the opposite suture on the medial retinacular flap had enabled the surgeon to avoid patellar maltracking during closure of the wound. In the SV group, the L-shaped incision of the medial capsule was considered an efficient landmark for accurate soft tissue closure avoiding the patellar maltracking.Conclusion The subvastus approach offers the advantage of keeping the integrity of quadriceps muscle and the extensor mechanism remains intact post-surgery. It causes less pain and less blood loss postoperatively than the regular parapatellar approach. The patient could recover the knee function in a shorter time with fewer complications, which is greatly in line with the concept of ERAS (Enhanced Recovery After Surgery).

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.

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 effects of medial parapatellar and subvastus bilateral simultaneous approaches in total knee arthroplasty

BackgroundTotal knee arthroplasty is the prevalent surgical intervention being used to treat knee osteoarthritis. Although the medial parapatellar approach is the prominent surgical approach, the parapatellar incision has concerning theoretical risks. The subvastus approach is a less invasive, but less commonly used alternative. The aim of this study is to compare the post-operative outcomes of these two surgical approaches with respect to retropatellar knee pain, knee range of motion, and quadriceps muscle strength at 6 and 12 months post-operation. MethodsIn this randomized controlled trial, 50 patients who suffered from advanced osteoarthritis in both knees underwent simultaneous bilateral total knee arthroplasty, one using the medial parapatellar approach and the other using the subvastus approach. Retropatellar knee pain, quadriceps muscle strength and knee range of motion were assessed pre-operation, as well as at 6 and 12 months post-operation. ResultsThis study found no statistically significant differences in retropatellar knee pain, quadriceps muscle strength, or knee range of motion between the medial parapatellar and subvastus approaches at 6 and 12 months post-operation. ConclusionThe results of this study provide further evidence that the subvastus approach is a comparable alternative to the medial parapatellar approach, but do not indicate any advantages to one over the other. More research is necessary in order to determine if there is an added benefit to the subvastus approach in the short term (<3 months).

A Medial Subvastus Approach for Lateral Unicompartmental Knee Arthroplasty: Technique Description and Early Outcome Results

BackgroundUnicompartmental knee arthroplasty (UKA) treats arthritis involving only one compartment of the knee. Lateral UKA is mainly performed through medial parapatellar or lateral parapatellar approaches to the knee. This technique article introduces a medial subvastus approach to lateral UKA, discusses the clinical rationale behind its use, and offers a preliminary retrospective study on short-term outcomes of lateral UKAs using the lateral vs medial subvastus approaches. MethodsA description of the medial subvastus approach is included. In addition, we reviewed 32 and 30 lateral UKAs performed using the lateral and medial subvastus approaches, respectively. Minimum follow-up duration was 1 year. Knee injury and osteoarthritis outcome score for joint replacement (KOOS, JR) knee scores were used for comparison. ResultsAge and body mass index were similar between the 2 cohorts. Mean KOOS, JR. scores for the subvastus approach group were significantly higher than those for the lateral approach group at 81.41 ± 2.0 for medial subvastus and 74.19 ± 2.9 for lateral (P = .02). One deep infection and 2 revision total knee arthroplasties occurred in the lateral approach group. Neither occurred in the subvastus group. The mean follow-up duration was significantly longer for the lateral approach group than that for the subvastus group at 749 vs 410 days (P < .001). Literature on time-dependence of patient-reported outcomes supports usage of the data, despite follow-up discrepancies. ConclusionsA subvastus approach for lateral UKA may offer improved visualization, easier conversion to total knee arthroplasty, and faster recovery, based on clinical observation. Preliminary results suggest improved short-term knee scores compared to a lateral approach.

Early functional results of the subvastus and medial parapatellar approaches in total knee arthroplasty

Early functional results of the subvastus and medial parapatellar approaches in total knee arthroplasty

Biochemical stress evaluation after medial parapatellar and subvastus approach in total knee replacement.

Even if different surgical approaches for total knee arthroplasty are well known since decades, the standard medial parapatellar incision remains the most common one; general agreement about significant advantages with minimally invasive techniques is lacking. Furthermore, the surgical stress effect on the organism has always been analyzed through blood inflammatory parameters. This study aim was to compare the standard and subvastus approaches, using the salivary cortisol in particular as measure for systemic surgery-related stress. Fifteen operations were performed in a consecutive series; clinical (Knee Society Knee Scoring System., a questionnaire score, range of motion, tourniquet time, intra-operative bleeding) and biochemical factors (salivary and hematic cortisol, C-reactive protein, muscular creatine phosphokinase levels) were evaluated. The final follow-up was at two months after the operation. No significant differences were observed in most of the parameters; however, the subvastus group had a sharper and earlier functional improvement trend than the standard one. On the other side, it increased the CPK levels significantly. In our experience, the medial subvastus approach, firstly associated with greater surgical stress, has then been characterized by a more favorable functional improvement trend. Moreover, the salivary cortisol measurement has proved to be a non-invasive and reliable method to evaluate the systemic surgery-related stress.

Lateral parapatellar and subvastus approaches are superior to the medial parapatellar approach in terms of soft tissue perfusion.

The arthrotomy techniques of knee surgery may cause varying degrees of disruption to the tissue blood supply. The aim of this study was to investigate the effects of the medial parapatellar (MPPa), midvastus (MVa), subvastus (SVa) and lateral parapatellar (LPPa) approaches on regional tissue perfusion of the knee. In this experimental study, a total of 28 female rabbits were applied with four different arthrotomy techniques as Group MPPa, Group MVa, Group SVa and Group LPPa. The blood supply of the tissue around the knee was examined by scintigraphic imaging including the perfusion reserve and T max, and biochemical alteration of the oxidative stress parameters including malondialdehyde (MDA), fluorescent oxidation products (FlOPs), and histopathological findings were evaluated on tissue samples after 3weeks. The perfusion reserve was increased in all four groups compared to the healthy, contralateral knees. In the Group LPPa, the vascularity was significantly increased compared to the Group MPPa (p=0.006). In the examination of biochemical parameters, the increase in MDA levels was statistically significant in the Group MPPa compared with the Group LPPa (p=0.004), and in the Group MVa compared with the Group LPPa (p=0.006). The increase in the value of MDA levels was striking in the Group MPPa and Group MVa compared with the control group (p=0.004, p=0.004, respectively). The increase in another oxidative stress parameter, the tissue FlOPs levels, was statistically significant in the Group MPPa compared with the control group (p=0.035). The LPPa and SVa caused less oxidative stress and less disruption of the muscle blood supply, in biochemical and scintigraphic parameters, compared to the MPPa and MVa. Therefore, in clinical practice, the SVa is preferable to the MPPa and MVa in total knee arthroplasty and the LPPa should be preferred more frequently in selected cases with critical soft tissue viability.

Surgical Approaches in Total Knee Arthroplasty: A Meta-Analysis Comparing the Midvastus and Subvastus to the Medial Peripatellar Approach

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

Postoperative Pain and Contracture Following Total Knee Arthroplasty Comparing Parapatellar and Subvastus Approaches

The purpose of this study was to see if subvastus approach would decrease incidence of postoperative contracture and pain following TKA compared to standard parapatellar approach. Retrospective review of 546 patients in Group A undergoing TKA using parapatellar approach were compared to 255 patients in Group B undergoing subvastus approach. No statistically significant differences regarding OR time, blood loss, BMI, or LOS. Total of 23 (4%) manipulations under anesthesia for contracture in Group A compared to 6 (2%) in Group B (p>0.05). Postoperative pain scores at 6 weeks was greater in Group A, p<0.05. We feel that a subvastus approach minimizes trauma to the extensor mechanism, and therefore decreases the incidence of postoperative pain following TKA.

Increased turn/amplitude parameters following subvastus approach in total knee arthroplasty

To compare the improvement of the vastus medialis component of the quadriceps muscle electrophysiologically after the subvastus and medial parapatellar approaches in total knee arthroplasty (TKA). A total 26 patients that underwent primary unilateral in TKA were included into the study. TKAs were carried out via subvastus approach in 15 patients, while 11 patients were operated via medial parapatellar approach. The electrophysiological evaluations were carried out blindly with regard to the type of the surgical approach before the operation and at 6th week post-operatively. Non-surgical side was also evaluated as a control. Assessments were patellar tendon reflex analysis, motor unit potential analysis and interference pattern analysis (IPA) including turn-amplitude analysis and IPA during maximum contraction. When they were compared to the pre-operative values, "the total mean amplitude" and "the mean turn/sec" parameters were significantly increased in group of subvastus approach (p = 0.017 and p = 0.009, respectively) at the post-operative 6th week. We would not be able to find any difference regarding the other electrophysiological parameters. There was also no significant difference between groups. If there was no significant difference in all the electrophysiological parameters, the increase in turn-amplitude analysis in the group of subvastus approach would be considered as an indicator of a faster functional improvement of knee extensor mechanism in these cases.

A comparison between subvastus and midvastus approaches for staged bilateral total knee arthroplasty:a prospective, randomised study.

This prospective randomised study was undertaken to compare surgical parameters as well as clinical and radiological outcomes of subvastus (SV) to midvastus (MV) approaches in staged bilateral total knee arthroplasty (TKA). Twenty-three patients, aged 55-76 years, who underwent staged bilateral TKAs, were followed up for 6 months. The SV approach was used on one knee and MV approach on the other. We found similar lateral retinacular release rates and patellar resurfacing rates between the two approaches .The SV approached knees had a more significant blood loss and increased operative time compared to the MV approached knees but they achieved significantly earlier active straightleg raises (SLR) postoperatively (p<0.05 for all). The average postoperative pain, flexion, and Knee Society scores were comparable for both approaches. TKA via SV vs. MV approaches provides comparable satisfactory short-term clinical and radiological outcomes, even though there was slightly more difficulty, more blood loss and longer operative times with the SV approach. Total knee arthroplasty, Subvastus approach, Midvastus approach.

A Comparison of Patellar Vascularity Between the Medial Parapatellar and Subvastus Approaches in Total Knee Arthroplasty

A complication of total knee arthroplasty is patellar avascular necrosis. Surgical approaches for total knee arthroplasty include the medial parapatellar approach (MPa) and, less commonly, the subvastus approach (SVa). The argument that SVa retains better patellar vascularity than the MPa was investigated on 20 participants, (SVa, n = 10; MPa, n = 10) 18 months postoperatively. Outcomes were a radionuclide bone imaging technique, a new bone vascularity scale, and an anterior knee pain numerical assessment scale. Results indicated no significant difference between groups on imaging (P = .935), the components of the bone vascularity scale, or anterior knee pain (P > .999). The SVa appears to offer no benefit over the MPa in terms of patellar vascularity or anterior knee pain.

Effects of four different surgical approaches on intra-operative joint gap in posterior-stabilized total knee arthroplasty

The effects of surgical approaches and patellar positions on joint gap measurement during total knee arthroplasty (TKA) remain unclear. We hypothesized that joint gap changes with different knee flexion angles would not be consistent within four different approaches and two different patellar positions. This study enrolled 80 knees undergoing posterior-stabilized TKA. For 60 varus knees, parapatellar, midvastus, and subvastus approaches were used in 20 knees each. For 20 valgus knees, a lateral subvastus approach was used. Component gap length and inclination were measured intra-operatively using a specific tensor device under 40 lb with the patella reduced or shifted laterally, at 0°, 45°, 90°, and 135° of knee flexion. Mean gap lengths at 45° and 90° of knee flexion were significantly larger with the parapatellar approach than with midvastus or lateral subvastus approaches (P < 0.05). Regarding gap inclination, varus angle increased linearly through the entire arc of flexion in all four approaches. When the patella was shifted laterally, gap lengths at 45°, 90°, and 135° were significantly reduced compared with those for the patella reduced in the subvastus approach, whereas gap length was constant in the parapatellar approach, regardless of patellar position. Joint gap kinematics was not consistent within four different approaches and two different patellar positions. Relatively large gaps at 45° and 90° were unique features for the parapatellar approach. Surgeons should be aware that the flexion gap is reduced when the patella is shifted laterally in vastus medialis-preserving approaches such as the subvastus approach. II.

Comparison of the Minimally Invasive and Standard Medial Parapatellar Approaches for Total Knee Arthroplasty: Systematic Review and Meta-Analysis

This systematic literature review analysed the efficacy of minimally invasive subvastus (SV) and midvastus (MV) approaches, compared with the standard medial parapatellar (MP) approach, for total knee arthroplasty. Fixed- and random-effect meta-analyses were performed to pool the results of primary studies assessing the mean difference of each clinical outcome. Length of hospital stay was significantly different between the MP and SV approaches, but not between the MP and MV approaches. Blood loss was significantly higher following MP compared with SV. The number of days to perform a straight-leg raise was significantly longer following MP than either MV or SV. In the first 6 months postsurgery, MV was associated with a better range of motion (ROM) than MP. No significant difference in ROM between MP and SV was apparent at 1 year postsurgery. Quadriceps muscle strength recovered significantly more slowly following MP compared with SV. Future studies should assess the efficacy of the quadriceps-sparing approach and compare minimally invasive approaches, assessing intrinsic postoperative differences.

Comparing Outcomes of Medial Parapatellar and Subvastus Approaches in Total Knee Arthroplasty: A Randomized Controlled Trial

The medial parapatellar (MP) approach in total knee arthroplasty is more common, but the subvastus (SV) approach is less insulting to the quadriceps. Whether the SV approach affords better outcomes was investigated using 90 participants with knee osteoarthritis, randomized to receive either SV or MP approaches and followed for 18 months. The primary outcome was the American Knee Society Score (AKSS); secondary outcomes included pain, knee range, quadriceps lag, Oxford Knee Score, 3-m timed “Up and Go” test, days to straight leg raise, surgeon perceived difficulty, operation duration, and length of stay. Analysis (n = 76) revealed no significant difference in AKSS (P = .076) or other outcomes, except the following: AKSS Functional scores at 12 and 18 months, favoring the MP (P = .032 and P = .028 respectively); surgeon's perceived difficulty, favoring the MP (P = .001); and days to straight leg raise, favoring the SV (P = .044). This study found that the SV approach offers no clinical benefit over the MP approach.

Systematic Review of Medial Parapatellar and Subvastus Approaches in Total Knee Arthroplasty

This systematic review was performed to compare the outcomes of the medial parapatellar and subvastus surgical approaches for total knee arthroplasty. Five studies, published between 1993 and 2001 met the inclusion quality standards for the review. The methodological quality of most studies was poor, and they were not sufficiently homogenous for meta-analysis. We found that the evidence was insufficient to demonstrate a clinical or statistically significant difference between the medial parapatellar and subvastus approaches to total knee arthroplasty across all outcomes. Further trials with robust methodology, objective and functional outcome measures, and follow-up beyond 6 to 12 months are required.

Electromyographic comparison of the mid-vastus and sub-vastus approaches to total knee arthroplasty

Background: To date there has been no study using robust surface electromyographic methods to compare the effect of sub-vastus and mid-vastus approaches to total knee arthroplasty on quadriceps activity. This study was done to ascertain if the sub-vastus technique would result in greater postoperative muscle activity than a vastus splitting approach as measured by electromyography and an earlier achievement of a straight leg raise. Methods: This was a prospective comparative study of the sub-vastus and mid-vastus approaches on vastus medialis and vastus lateralis muscle activity measured by electromyography and time to straight leg raise in 18 patients (7 men and 11 women) after a primary total knee arthroplasty. Results: A statistically significant difference in the number of days taken to achieve straight leg was noted between the mid-vastus and sub-vastus groups (mid-vastus = 2.0 days, 95% CI, 1.43 to 2.56; sub-vastus = 1.25 days, 95% CI, 0.93 to 1.57; P = 0.045). There were no statistical differences (P > 0.05) between the two techniques in electromyography or any of the secondary outcomes at 5 days, 6 weeks and 3 months after surgery. There was no significant correlation (P > 0.05) between the earlier return of straight leg raise in the sub-vastus technique and increased quadriceps activation. Conclusions: This study did not find any statistically significant differences in electromyographic data between the two approaches, suggesting no evidence of denervation of the vastus medialis, although the sub-vastus technique led to an earlier single-leg raise. (C) 2009 Lippincott Williams & Wilkins, Inc

Vastus medialis necrosis secondary to the combination of the subvastus and median parapatellar approaches for implantation of a total knee replacement

We describe a case where a subvastus approach was used for implantation of a primary total knee replacement, which subsequently became infected. Medial parapatellar approaches were then used for the revision surgery at weeks four and twelve after the primary procedure. Vastus medialis necrosis and lateral subluxation of the patella then followed. The patella was centralised electively by performing an open lateral release and semitendinosus tenodesis. This report therefore indicates that combining these two approaches over a short time interval set against a background of haematoma and infection can lead to ischaemic necrosis of the vastus medialis muscle and lateral subluxation of the patella.