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TKA: Mini-midvastus approach yields better short-term outcomes vs. parapatellar approach
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July 2014
TKA: Mini-midvastus approach yields better short-term outcomes vs. parapatellar approach
Study Type:Therapy
OE Level Evidence:1
Journal Level of Evidence:1
Minimally Invasive Midvastus versus Standard Parapatellar Approach in Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials
PLoS One. 2014 May 20;9(5):e95311. doi: 10.1371/journal.pone.0095311. eCollection 2014.Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
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.
Publication Funding Details
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Funding:
Non-funded
Conflicts:
None disclosed
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
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)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Introduction
4/4
Accessing Data
4/4
Analysing Data
3/4
Results
3/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
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?
Study Characteristics
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Data Source:
PubMed (1950-Oct 2013), EMBASE (1974-Oct 2013), Cochrane Library (issue 9, 2013), and Web of Science (1980-Oct 2013) were searched. A manual search of the reference lists of all relevant articles was also performed. Furthermore, Google Scholar was also searched.
Index Terms:
The following search strategies were used for this meta-analysis: (1) Arthroplasty, Replacement, Knee [Mesh] OR knee arthroplasty OR knee replacement; (2) parapatellar OR standard OR conventional; (3) midvastus OR mini-midvastus OR vastus splitting; and (4) #1 AND #2 AND #3.
Study Selection:
Study selection was performed independently by two reviewers. Studies were included if they: (1) were randomized controlled trials; (2) included adult patients undergoing primary TKA; and (3) compared the mini-midvastus approach to the standard parapatellar approach.
Data Extraction:
Data extraction was performed independently by two reviewers, with disagreements being resolved through discussion. The primary outcomes were Knee Society Scores (KSS) and Visual Analog Scale (VAS) scores for pain. Secondary outcomes included knee range of motion (ROM), operative time, lateral retinacular release, blood loss, straight leg raise, hospital stay, and postoperative complications (i.e. total complications, deep vein thrombosis, and wound infection).
Data Synthesis:
Meta-analysis was performed using Review Manager 5.2 software. For continuous and dichotomous outcomes, mean differences (MD) and odds ratios (OR) were calculated, respectively, along with corresponding 95% confidence intervals (CI). Heterogeneity was assessed by performing the X-squared test and by computing the I-squared statistic. When heterogeneity was significant (i.e. I-squared>50%), a random-effects model was used to pool the data. Conversely, when heterogeneity was not significant (i.e. I-squared 50% or less), a fixed-effects model was used.
What were the important findings?
- 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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