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Minimally Invasive Total Knee Arthroplasty

  • Author: Derek F Amanatullah, MD, PhD; Chief Editor: Erik D Schraga, MD  more...
Updated: Apr 30, 2015


In addition to conventional surgical approaches, total knee arthroplasty (TKA) may be done by means of minimally invasive surgery (MIS). Minimally invasive TKA (MIS-TKA) is often portrayed in the lay community and press as involving a small skin incision. Actually, MIS-TKA is defined by limited soft tissue and bony dissection. MIS-TKA was developed after the description of unicondylar knee arthroplasty.[1, 2]

Conventional TKA is a successful operation for patients suffering from arthritis of the knee with a reported complication rate of less than 2% and an implant survivorship of 95% at 10 years. The aim of MIS-TKA is to decrease postoperative pain and shorten the rehabilitation period.


Indications and Contraindications

MIS-TKA is used as an alternative to conventional TKA. However, there are conflicting data on whether MIS-TKA is an acceptable replacement for or even an improvement on conventional TKA, and no definitive answer to this question is available at present.

No absolute contraindications exist to MIS-TKA; this procedure is defined by limited soft tissue and bony dissection. Conventional TKA is probably a more suitable choice for the following patients[3, 4, 5] :

  • Patients with a body mass index (BMI) greater than 40 kg/m 2
  • Patients with severe fixed valgus deformity
  • Patients with severe osteoporosis
  • Patients who have previously undergone knee arthrotomy
  • Patients with rheumatoid arthritis

Technical Considerations

Complication prevention measures recommended for MIS-TKA are exactly the same as those recommended for conventional TKA and should include the following:

  • Appropriate preoperative screening and clearance
  • Preoperative templating and planning
  • Preoperative administration of antibiotics as recommended by the American Academy of Orthopaedic Surgeons


Early series comparing MIS-TKA with conventional TKA reported successful outcomes.[6, 7] In a retrospective review of 48 knees, MIS-TKA patients were able to complete an active straight leg raise earlier than conventional TKA patients could.[8] A case-control study comparing 32 knees after conventional TKA and after MIS-TKA reported mean Knee Society Scores (KSS) of 94 and 96 and mean functional scores of 90 and 99, respectively.[9]

A randomized, double-blinded trial that investigated extensor and flexor muscle function after conventional TKA and MIS-TKA found that the MIS-TKA group had a higher knee extensor peak torque at 3, 6, and 12 months postoperatively.[10]

Another prospective randomized trial, which compared conventional TKA with MIS-TKA by using an accelerometer, found that MIS-TKA patients were significantly more active on all postoperative days and that MIS-TKA patients achieved 80% of their preoperative acceleration in about half of the time that conventional TKA patients took to reach this level.[11]

A systematic review of 13 randomized controlled trials found that the mean KSS at 6 and 12 weeks postoperatively was higher in the MIS-TKA group but that this difference was lost at 6 months.[12]

Contributor Information and Disclosures

Derek F Amanatullah, MD, PhD Assistant Professor, Department of Orthopaedic Surgery, Stanford University School of Medicine

Derek F Amanatullah, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, Orthopaedic Research Society, American Association of Hip and Knee Surgeons, California Orthopedic Association, International Cartilage Repair Society

Disclosure: Received honoraria from Sanofi for message board participation; Received honoraria from Medscape for manuscript preparation; Received intellectual property rights from Dynamic Tension Plantar Fasciitis Splint for patent pending; Received intellectual property rights from Cool Cut Cast Saw Blade for patent pending.


Paul E Di Cesare, MD 

Paul E Di Cesare, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

  1. Repicci JA, Eberle RW. Minimally invasive surgical technique for unicondylar knee arthroplasty. J South Orthop Assoc. 1999 Spring. 8(1):20-7; discussion 27. [Medline].

  2. Romanowski MR, Repicci JA. Minimally invasive unicondylar arthroplasty: eight-year follow-up. J Knee Surg. 2002 Winter. 15(1):17-22. [Medline].

  3. Laskin RS. Minimally invasive total knee arthroplasty: the results justify its use. Clin Orthop Relat Res. 2005 Nov. 440:54-9. [Medline].

  4. Scuderi GR, Tenholder M, Capeci C. Surgical approaches in mini-incision total knee arthroplasty. Clin Orthop Relat Res. 2004 Nov. 61-7. [Medline].

  5. Hernandez-Vaquero D, Noriega-Fernandez A, Suarez-Vazquez A. Total knee arthroplasties performed with a mini-incision or a standard incision. Similar results at six months follow-up. BMC Musculoskelet Disord. 2010 Feb 6. 11:27. [Medline]. [Full Text].

  6. Tria AJ Jr, Coon TM. Minimal incision total knee arthroplasty: early experience. Clin Orthop Relat Res. 2003 Nov. 185-90. [Medline].

  7. Bonutti PM, Mont MA, McMahon M, Ragland PS, Kester M. Minimally invasive total knee arthroplasty. J Bone Joint Surg Am. 2004. 86-A Suppl 2:26-32. [Medline].

  8. Watanabe T, Muneta T, Ishizuki M. Is a minimally invasive approach superior to a conventional approach for total knee arthroplasty? Early outcome and 2- to 4-year follow-up. J Orthop Sci. 2009 Sep. 14(5):589-95. [Medline].

  9. Laskin RS, Beksac B, Phongjunakorn A, et al. Minimally invasive total knee replacement through a mini-midvastus incision: an outcome study. Clin Orthop Relat Res. 2004 Nov. 74-81. [Medline].

  10. Kim JG, Lee SW, Ha JK, Choi HJ, Yang SJ, Lee MY. The effectiveness of minimally invasive total knee arthroplasty to preserve quadriceps strength: A randomized controlled trial. Knee. 2010 Sep 10. [Medline].

  11. Tsuji S, Tomita T, Fujii M, Laskin RS, Yoshikawa H, Sugamoto K. Is minimally invasive surgery-total knee arthroplasty truly less invasive than standard total knee arthroplasty? A quantitative evaluation. J Arthroplasty. 2010 Sep. 25(6):970-6. [Medline].

  12. Cheng T, Feng JG, Liu T, Zhang XL. Minimally invasive total hip arthroplasty: a systematic review. Int Orthop. 2009 Dec. 33(6):1473-81. [Medline]. [Full Text].

  13. Goble EM, Justin DF. Minimally invasive total knee replacement: principles and technique. Orthop Clin North Am. 2004 Apr. 35(2):235-45. [Medline].

  14. Bonutti PM, Mont MA, Kester MA. Minimally invasive total knee arthroplasty: a 10-feature evolutionary approach. Orthop Clin North Am. 2004 Apr. 35(2):217-26. [Medline].

  15. Tria AJ Jr. Minimally invasive total knee arthroplasty: the importance of instrumentation. Orthop Clin North Am. 2004 Apr. 35(2):227-34. [Medline].

  16. Lee DH, Choi J, Nha KW, Kim HJ, Han SB. 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. Knee Surg Sports Traumatol Arthrosc. 2011 Jan. 19(1):66-73. [Medline].

  17. Engh GA, Holt BT, Parks NL. A midvastus muscle-splitting approach for total knee arthroplasty. J Arthroplasty. 1997 Apr. 12(3):322-31. [Medline].

  18. Engh GA, Parks NL. Surgical technique of the midvastus arthrotomy. Clin Orthop Relat Res. 1998 Jun. 270-4. [Medline].

  19. Berger RA, Sanders S, Gerlinger T, Della Valle C, Jacobs JJ, Rosenberg AG. Outpatient total knee arthroplasty with a minimally invasive technique. J Arthroplasty. 2005 Oct. 20(7 Suppl 3):33-8. [Medline].

  20. Tomek IM, Kantor SR, Cori LA, Scoville JM, Grove MR, Morgan TS, et al. Early Patient Outcomes After Primary Total Knee Arthroplasty with Quadriceps-Sparing Subvastus and Medial Parapatellar Techniques: A Randomized, Double-Blind Clinical Trial. J Bone Joint Surg Am. 2014 Jun 4. 96(11):907-915. [Medline]. [Full Text].

  21. Wegrzyn J, Parratte S, Coleman-Wood K, Kaufman KR, Pagnano MW. The John Insall award: no benefit of minimally invasive TKA on gait and strength outcomes: a randomized controlled trial. Clin Orthop Relat Res. 2013 Jan. 471(1):46-55. [Medline]. [Full Text].

  22. Reid JB 3rd, Guttmann D, Ayala M, Lubowitz JH. Minimally invasive surgery-total knee arthroplasty. Arthroscopy. 2004 Oct. 20(8):884-9. [Medline].

  23. Mahoney OM, McClung CD, dela Rosa MA, Schmalzried TP. The effect of total knee arthroplasty design on extensor mechanism function. J Arthroplasty. 2002 Jun. 17(4):416-21. [Medline].

  24. Kashyap SN, Van Ommeren JW, Shankar S. Minimally invasive surgical technique in total knee arthroplasty: a learning curve. Surg Innov. 2009 Mar. 16(1):55-62. [Medline].

  25. Lubowitz JH, Sahasrabudhe A, Appleby D. Minimally invasive surgery in total knee arthroplasty: the learning curve. Orthopedics. 2007 Aug. 30(8 Suppl):80-2. [Medline].

  26. King J, Stamper DL, Schaad DC, Leopold SS. Minimally invasive total knee arthroplasty compared with traditional total knee arthroplasty. Assessment of the learning curve and the postoperative recuperative period. J Bone Joint Surg Am. 2007 Jul. 89(7):1497-503. [Medline].

  27. Cheng T, Liu T, Zhang G, Peng X, Zhang X. Does minimally invasive surgery improve short-term recovery in total knee arthroplasty?. Clin Orthop Relat Res. 2010 Jun. 468(6):1635-48. [Medline]. [Full Text].

  28. Niki Y, Mochizuki T, Momohara S, Saito S, Toyama Y, Matsumoto H. Is minimally invasive surgery in total knee arthroplasty really minimally invasive surgery?. J Arthroplasty. 2009 Jun. 24(4):499-504. [Medline].

Midline skin incision is performed. Mini-incision is approximately twice length of patella, 6-14 cm (blue); conventional incision is longer (red extensions).
Parapatellar arthrotomy is performed (ie, median parapatellar, midvastus, subvastus, or lateral) to access knee joint and perform arthroplasty.
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