TKA: Mini-midvastus approach yields better short-term outcomes vs. parapatellar approach .
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2014;2(14):6 PLoS One. 2014 May 20;9(5):e95311. doi: 10.1371/journal.pone.0095311. eCollection 2014.18 randomized controlled trials (937 patients; 1093 TKAs) comparing the mini-midvastus and parapatellar approaches in patients undergoing total knee arthroplasty (TKA) were included in this meta-analysis. The purpose of this review was to compare these two treatment approaches with respect to postoperative pain, function and complications. Pooled data indicated that, although associated with a significantly longer operative time, the mini-midvastus approach yielded significantly better pain scores and range of motion at 1-2 weeks post-operation, compared to the parapatellar approach. Furthermore, both groups exhibited similar Knee Society Scores, rates of lateral retinacular release, blood loss, straight leg raise, hospital stay and postoperative complications.
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Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
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Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
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Why was this study needed now?
In an attempt to minimize pain and promote recovery in total knee arthroplasty (TKA) minimally-invasive techniques have been adopted for this type of surgical procedure. Traditionally, minimally-invasive TKA (MIS TKA) has been performed using either a subvastus or quadriceps-sparing approach; however, these techniques involve small surgical fields and longer operative times. As a result, the mini-midvastus approach was proposed to address some of these concerns. As several high-quality trials have compared these techniques to date, this meta-analysis was needed to compare the clinical efficacy and safety of mini-midvastus and standard parapatellar approach in patients undergoing TKA.
What was the principal research question?
With respect to clinical efficacy and safety, how does the mini-midvastus approach compare to the parapatellar approach in patients undergoing total knee arthroplasty?
- 18 randomized controlled trials (937 patients; 1093 TKAs) were included in this meta-analysis.
- With respect to Knee Society Scores (KSS), there were no significant between-group differences at 6 weeks (MD 5.15 [95% CI -3.36 to 13.66]; p=0.24), 3 months (MD 0.55 [-1.14 to 2.50]; p=0.59), 6 months (MD -2.15 [-5.92 to 1.62]; p=0.26), or 1 year (MD 0.66 [-0.68 to 1.99]; p=0.33) post-operation.
- VAS scores were found to be significantly lower in the mini-midvastus group versus the parapatellar group at 1-2 weeks post-operation (MD -0.20 [95% CI -0.29 to 0.11]; p<0.01). There were no between-group differences at any other time point: 3 days (p=0.42), 6 weeks (p=0.22), 3 months (p=0.82) and 6 months (p=0.80) post-operation.
- ROM was significantly higher using the mini-midvastus approach compared to the parapatellar approach at 1-2 weeks post-operation (MD 7.45 [95% CI 3.26 to 11.64]; p<0.05). There were no between-group differences at any other time point: 6 weeks (p=0.36), 3 months (p=0.46) and 6 months (p=0.47).
- The mini-midvastus approach was associated with a significantly longer operative time compared to the parapatellar approach (MD 11.64 [95% CI 5.50 to 17.78]; p<0.05).
- There was no significant difference between groups in lateral retinacular release (p=0.12), blood loss (p=0.33), straight leg raise (p=0.13), hospital stay (p=0.79), total complications (p=0.88), wound infection (p=0.64) or deep vein thrombosis (p=0.22).
What should I remember most?
Although associated with a significantly longer operative time, the mini-midvastus approach in total knee arthroplasty (MIS TKA) yielded significantly better pain scores and range of motion in the short-term (i.e. 1-2 weeks post-operation), compared to the parapatellar approach. These outcomes were statistically similar between groups at 6 weeks, 3 months and 6 months post-operation. Furthermore, both groups exhibited similar Knee Society Scores, rates of lateral retinacular release, blood loss, straight leg raise, hospital stay and postoperative complications.
How will this affect the care of my patients?
The results from this study suggest that, despite longer operative times, the mini-midvastus approach in total knee arthroplasty (TKA) is associated with superior range of motion and pain scores in the short-term (i.e. 1-2 weeks postoperatively), when compared to the parapatellar approach. As heterogeneity among studies was significant for some analyses, additional research is required to confirm these results.
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