Is Minimally Invasive Surgery in Total Knee Arthroplasty Really Minimally Invasive Surgery?

doi:10.1016/j.arth.2008.04.002

The Journal of Arthroplasty

Volume 24, Issue 4, June 2009, Pages 499-504

https://doi.org/10.1016/j.arth.2008.04.002 Get rights and content

Abstract

Minimization of soft-tissue damage is one of the primary purposes behind the application of minimally invasive surgery (MIS) in total knee arthroplasty (TKA). A consecutive series of 147 TKAs were enrolled in the present study, with 96 MIS-TKAs using 11 quadriceps-sparing, 46 subvastus, 32 midvastus, and 7 parapatellar approaches and 51 conventional TKAs using 22 subvastus, 9 midvastus, and 20 parapatellar approaches. Serum levels of creatinine phosphokinase, myoglobin, aldolase, lactate dehydrogenase, glutamic oxaloacetic transaminase, and creatinine were measured on postoperative days 0, 1, 2, 4, 7, and 14. Postoperative rising index (RI) was expressed as a proportion of the preoperative value. When RIs were compared between MIS-TKA and conventional TKA, no significant differences were found for any enzymes. Interestingly, the midvastus approach displayed the highest RIs for creatinine phosphokinase and myoglobin between the 4 vastus-splitting approaches. Consequently, degree of muscle damage was equivalent between MIS-TKA and conventional TKA, whereas types of vastus-splitting approach appeared closely related to muscle damage.

Section snippets

Materials and Methods

This study initially examined 158 knees from 143 consecutive patients who underwent primary TKA between September 2004 and December 2006. Of these, 11 patients did not receive postoperative laboratory testing on a routine basis as required by our study protocol, as 1 patient developed acute deep infection, 1 patient experienced symptomatic pulmonary embolism, and 9 patients refused multiple blood tests within 2 weeks postoperatively. These 11 knees from 11 patients were therefore excluded from

Time Course for Serum Levels of Muscle-Related Enzymes

Serum levels of CPK and myoglobin showed a sharp single peak on postoperative day 1, whereas aldolase, LDH, and GOT displayed 2 peaks on postoperative days 1 and 7 (Fig. 1). On further observation, aldolase displayed 2 major peaks, whereas LDH and GOT exhibited a first minor peak and a second major peak. Creatinine remained unchanged for 14 days postoperatively. RI_peak was thus defined as the value on postoperative day 1 for CPK and myoglobin, on postoperative day 7 for LDH and GOT, and on

Discussion

The concept of QS has been developed to avoid damage to the quadriceps muscle and suprapatellar pouch in the knee joint and to enhance early rehabilitation 1, 3. Medial parapatellar arthrotomy is limited to the superior pole of the patella to expose the knee and displace the patella laterally without eversion. However, performing this QS approach is difficult without causing damage to the VMO because the inferior edge of the VMO reportedly inserts at or near the midpole of the patella in most

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Cited by (48)

Iatrogenic Bone and Soft Tissue Trauma in Robotic-Arm Assisted Total Knee Arthroplasty Compared With Conventional Jig-Based Total Knee Arthroplasty: A Prospective Cohort Study and Validation of a New Classification System
2018, Journal of Arthroplasty
The objective of this study was to compare macroscopic bone and soft tissue injury between robotic-arm assisted total knee arthroplasty (RA-TKA) and conventional jig-based total knee arthroplasty (CJ-TKA) and create a validated classification system for reporting iatrogenic bone and periarticular soft tissue injury after TKA.
This study included 30 consecutive CJ-TKAs followed by 30 consecutive RA-TKAs performed by a single surgeon. Intraoperative photographs of the femur, tibia, and periarticular soft tissues were taken before implantation of prostheses. Using these outcomes, the macroscopic soft tissue injury (MASTI) classification system was developed to grade iatrogenic bone and soft tissue injuries. Interobserver and Intraobserver validity of the proposed classification system was assessed.
Patients undergoing RA-TKA had reduced medial soft tissue injury in both passively correctible (P < .05) and noncorrectible varus deformities (P < .05); more pristine femoral (P < .05) and tibial (P < .05) bone resection cuts; and improved MASTI scores compared to CJ-TKA (P < .05). There was high interobserver (intraclass correlation coefficient 0.92 [95% confidence interval: 0.88-0.96], P < .05) and intraobserver agreement (intraclass correlation coefficient 0.94 [95% confidence interval: 0.92-0.97], P < .05) of the proposed MASTI classification system.
There is reduced bone and periarticular soft tissue injury in patients undergoing RA-TKA compared to CJ-TKA. The proposed MASTI classification system is a reproducible grading scheme for describing iatrogenic bone and soft tissue injury in TKA.
RA-TKA is associated with reduced bone and soft tissue injury compared with conventional jig-based TKA. The proposed MASTI classification may facilitate further research correlating macroscopic soft tissue injury during TKA to long-term clinical and functional outcomes.
Anatomical Features of the Descending Genicular Artery to Facilitate Surgical Exposure for the Subvastus Approach—A Cadaveric Study
2018, Journal of Arthroplasty
Citation Excerpt :
The SVA was first described in the German literature by Erkes [14] in 1929 and was popularized for TKA by Hofmann et al [8] in 1991. The SVA was considered to be the more “anatomic” technique because it preserved the extensor mechanism and minimized vascular damage to the knee [15,16]. The SVA could provide better pain relief with lower opioid consumption and quick recovery with earlier straight leg raising and with greater knee flexion [4,17].
The purpose of this cadaveric study was to clarify the proximal limit for the subvastus approach (SVA) in total knee arthroplasty to decrease potential vascular injury.
Seventy embalmed knees underwent a modified SVA using a 14-cm oblique medial incision. Anatomical features of the descending genicular artery (DGA) were investigated with regard to variation, distance of the vessels from surgical landmarks, and sex differences.
The DGA was identified in 62 knees (89%), while it was absent in 8 knees (11%); in the latter, the articular, saphenous, and muscular branches arose separately from the femoral artery. The mean distances from the tibial tuberosity and medial joint line to the origin of the DGA were 15.5 ± 1.6 cm and 12.6 ± 1.6 cm, respectively. Both distances were significantly longer in males than in females (P < .01, respectively). A strong positive correlation was found between the distance from the tibial tuberosity to the origin of the DGA and the distance from the medial joint line to the origin of the DGA (Spearman's correlation coefficient, R² = 0.72, P < .01). A weak positive correlation was found between the distance from the tibial tuberosity to the origin of the DGA and lower leg length (R² = 0.13, P < .01). No vascular injuries were observed in this surgical exposure.
The DGA showed several variations and was absent 11% of the time. An oblique medial incision within 14 cm from the tibial tuberosity followed by arthrotomy is considered a safe zone for the SVA.
Comparison of Quadriceps-Sparing and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials
2018, Journal of Arthroplasty
The quadriceps-sparing (QS) technique for total knee arthroplasty (TKA) was introduced to improve outcomes associated with the medial parapatellar (MP) approach. There is no clear consensus on what advantages, if any, QS provides.
We performed a meta-analysis of randomized controlled trials (RCTs) comparing the QS and MP techniques. PubMed, Ovid, and Scopus were assessed for relevant literature. Long-term (primary) outcomes and short-term (secondary) outcomes from 8 RCTs (579 TKAs) were analyzed using OpenMetaAnalyst (2016).
The QS approach did not demonstrate clinically significant advantages, but was associated with statistically and clinically significant increases in the primary outcomes of femoral (odds ratio [OR] 4.92, P = .005), tibial (OR 4.34, P = .01), and mechanical axis outliers (OR 4.77, P = .004). Secondary outcome assessments demonstrated increased surgical (mean differences [MD] 19.54, P < .001) and tourniquet time (MD 23.30, P < .001) for QS. Although statistically significant advantages for QS were identified in Knee Society Function scores at 1.5-3 months (MD 2.31, P = .004) and 2 years (MD 1.86, P < .001), these were not clinically significant (fell below the 6-point minimal clinically important difference).
The QS approach to TKA fails to demonstrate clinically significant advantages, but shows increased malalignment. This increased incidence of implant malalignment may predispose QS patients to early prosthesis failure. Because the QS approach may increases the risk of malalignment while providing no clear benefit compared to MP, we recommend against the routine use of the QS TKA approach.
Comparison of postoperative morbidity between simultaneous bilateral and staged bilateral total knee arthroplasties: Serological perspective and clinical consequences
2014, Journal of Arthroplasty
Citation Excerpt :
Blood testing was performed and serum levels of hemoglobin, C-reactive protein (CRP), creatine phosphokinase (CPK), and d-dimer were measured at baseline and on PODs 1, 2, 4, 7, and 14. CPK index was expressed as a proportion of the preoperative value, as reported previously [15]. Total blood loss was determined as the intraoperative blood loss plus volume from drain until 48 h postoperatively.
The present study compared simultaneous and two-staged (stages 1 and 2 with 8-month interval on average) bilateral TKAs in terms of postoperative serological status and clinical consequences. The decrease in hemoglobin over 2 weeks postoperatively was similar between groups. C-reactive protein levels and creatine phosphokinase index peaking on day 2 were significantly higher in the simultaneous group than in either staged group (P < 0.05). Incidence of DVT on day 7 tended to be higher in the simultaneous group, but the difference was not significant. Considering the approximately 8-month interval and 2-month earlier functional recovery with stage 2 TKAs, 6 months were saved with the simultaneous bilateral TKA group. Collectively, simultaneous bilateral TKA is likely to offer a safe and effective procedure in appropriate clinical settings involving anti-bleeding and anti-venous thromboembolism prophylaxis.
Minimally invasive total knee arthroplasty; a pragmatic randomised controlled trial reporting outcomes up to 2year follow up
2014, Knee
We present a prospective, randomised, multi-surgeon, controlled trial comparing minimally invasive (MIS) and standard approach total knee arthroplasty (TKA).
Participants underwent unilateral TKA. Patients were randomised to Bristol, quadriceps sparing MIS or standard medial parapatellar approaches. Length of stay with secondary outcome measures including knee range of movement, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) and American Knee Society Score (KSS) up to 2 years. Radiographic and post operative assessment was blinded.
86 patients (92 knees) participated in the study. Mean operative time between MIS and control groups was 95.5 (95% CI 90.0–101.0) and 94.8 (95% CI 88.2–101.4) minutes respectively. Mean readiness for discharge was shorter in the MIS group 4.5 ± 1.5 (95% CI, 4.1–4.9) days versus 5.9 ± 2.7 (95% CI, 5.1–6.7) days amongst controls (p = 0.004). Patients in the MIS group had fewer complications (p = 0.003). One patient developed a deep vein thrombosis (DVT) and one required revision surgery, both in the control group.
83 patients completed follow up to 2 years (40 MIS, 43 controls). Range of movement and other outcome measures improved up to 1 year post-operatively with no statistically significant differences between MIS and controls. We found no evidence of radiographic loosening in either group at the 2 year follow up.
MIS offers reduced length of stay and fewer complications for patients following TKR without evidence of component mal-alignment. Our findings of fewer systemic complications in MIS TKR patients warrant further future study.
Level 1
The use of tourniquet is useful in terms of blood loss and soft tissue damage in arthroscopic anterior cruciate ligament reconstruction: a retrospective study
2023, Scientific Reports

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Original ArticleIs Minimally Invasive Surgery in Total Knee Arthroplasty Really Minimally Invasive Surgery?

Abstract

Section snippets

Materials and Methods

Time Course for Serum Levels of Muscle-Related Enzymes

Discussion

J Mol Cell Cardiol

Chest

Minimal incision total knee arthroplasty: early experience

Clin Orthop

Surgical approaches in mini-incision total knee arthroplasty

Clin Orthop

Advancements in minimally invasive total knee arthroplasty

Orthopaedics

Minimally invasive total knee arthroplasty

J Bone Joint Surg

Minimally invasive total knee replacement through a mini-midvastus incision: an outcome study

Clin Orthop

Skeletal muscle damage during tourniquet-induced ischaemia

Eur J Appl Physiol

Original Article
Is Minimally Invasive Surgery in Total Knee Arthroplasty Really Minimally Invasive Surgery?