Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Minimally Invasive Total Knee Arthroplasty Technique

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

Minimally Invasive Approaches to Total Knee Arthroplasty

In minimally invasive total knee arthroplasty (MIS-TKA), the midline skin incision is approximately twice the length of the patella (ie, 6-14 cm), and a parapatellar arthrotomy is performed (see the image below).

Midline skin incision is performed. Mini-incision Midline skin incision is performed. Mini-incision is approximately twice length of patella, 6-14 cm (blue); conventional incision is longer (red extensions).

A curvilinear medial skin incision extending from the superior pole of the patella to the tibial joint line provides better exposure for varus knees. A curvilinear lateral skin incision extending from the superior pole of the patella to the tibial joint line provides better exposure for valgus knees.[15] If necessary, a second lateral incision may be made from the lateral femoral epicondyle to just above the Gerdy tubercle.[7]

A limited median parapatellar arthrotomy is favored (see the image below). This familiar approach facilitates a natural transition from conventional TKA to MIS-TKA.[4] MIS-TKA limits the proximal extension into the quadriceps tendon to 2-4 cm and still allows sufficient lateral subluxation of the patella. Patellar eversion should be avoided.[16] Because of the unique incisions of specific minimally invasive procedures, converting to a standard median parapatellar arthrotomy can be problematic and may require an entirely new incision.

Parapatellar arthrotomy is performed (ie, median p Parapatellar arthrotomy is performed (ie, median parapatellar, midvastus, subvastus, or lateral) to access knee joint and perform arthroplasty.

Other options for the arthrotomy include the midvastus, subvastus, and lateral approaches.[6, 17, 18, 19] A midvastus approach involves cutting 1-3 cm of the vastus medialis obliquus (VMO). However, the VMO is the only muscle that prevents lateral displacement of the patella when the knee is actively extended.[13]

A subvastus arthrotomy avoids disturbing the quadriceps mechanism but may make it difficult to evert the patella. However, with satisfactory dissection and smaller instrumentation, patellar translation alone is sufficient. The quadriceps-sparing technique is essentially a subvastus approach with no patellar translation; it necessitates modified instrumentation. Both the subvastus approach and the quadriceps-sparing approach often provide limited visibility of the lateral tibial condyle and have longer learning curves for the surgeon.[16]

A randomized, double-blind study by Tomek et al compared a quadriceps-sparing (QS) subvastus approach to TKA with medial parapatellar arthrotomy (MPPA).[20] The investigators found that the QS technique yielded no significant advantages over the MPPA technique in terms of either time to recovery of knee function or opioid utilization; however, QS patients reported slightly lower mean pain scores at rest on postoperative day 1 and during activity on postoperative day 3.

Another randomized study, by Wegrzyn et al, compared the gait of patients 2 months after a subvastus arthrotomy or an MPPA and found no differences between the groups with respect to outcome scores, activity scores, patient milestone diary of activities, isometric quadriceps strength, or gait parameters.[21] There was a marginally higher speed of stair ascent in the subvastus arthrotomy.

The lateral approach is a newly described technique for MIS-TKA that involves an incision through the iliotibial band. It often requires computer navigation. Advantages of the lateral approach include the following[7] :

  • It obviates the need for an intramedullary guide for femoral component positioning
  • It does not violate the quadriceps mechanism
  • It permits eversion of the patella
  • It does not dislocate the knee joint

A possible disadvantage of the lateral arthrotomy is the reduced access to the tibia and the posteromedial soft tissue attachments that results from the position of the incision approximately 7 mm lateral to the tibial tubercle.[13]

Although the limited skin incision and arthrotomy hinder simultaneous visualization of every component of the joint, the mobile window concept allows all portions of the joint to be visualized during MIS-TKA—but not at the same time. Accordingly, the surgeon must be vigilant to avoid placing undue stress on the soft tissue through aggressive retraction.

MIS-TKA is facilitated by 10-35° of flexion.[22] In addition, gravity can be used to assist in visualizing the knee joint and minimizing soft-tissue trauma through what is known as the suspended leg technique. By flexing the hip to 20-30° and allowing the knee 90-100° of flexion, the target portion of the knee can be manipulated into the surgical field.

Familiarity with techniques of soft-tissue and bony manipulation is essential for a successful MIS-TKA, but the specific techniques used may vary, depending on the surgical approach used.[14]

Patellar capsular release enhances the lateral mobility of the patella and the exposure of the anterior knee joint. Subluxation or retraction of the patella results in minimal postoperative quadriceps dysfunction as compared with the complete patellar eversion used in conventional TKA.[23] Joint dislocation is avoided during bone cuts to prevent capsular damage, which affects postoperative recovery.

Progressive bone cuts increase the volume of available surgical space through which to operate. They may be done in either of the following sequences[6, 13] :

  • First the tibia, then the femur, and finally the patella
  • First the patella (if it is to be resurfaced), then the distal femur, then the tibia, and finally the remaining femur

Even when this tactic is used, however, surgeons may need to complete bone cuts freehand and remove bone piecemeal after the initial osteotomy.

After the procedure, the patient should be followed at the same time intervals that would be appropriate for a conventional TKA. Clinical and radiographic examinations should be done at 6 weeks, 3 months, and 6 months and then yearly for the life of the TKA to monitor for aseptic loosening and late infection.

Next

Complications

The more difficult surgical approaches required for MIS-TKA are associated with a prolonged surgical learning curve. This learning curve can affect operating time, as well as infection rate.[24, 25, 26] In addition, the limited visibility inherent in MIS-TKA exacerbates the technical difficulty of performing accurate osseous cuts and can result in cement retention. Otherwise, the complications of MIS-TKA are similar to those of conventional TKA. Infection, aseptic loosening, implant malposition, and arthrofibrosis remain potential complications.

To prevent deep venous thrombosis ,as well as pulmonary embolism, patients should be on an appropriate anticoagulation regimen, as recommended by the American Academy of Orthopaedic Surgeons.

MIS-TKA is unlikely to result in any improvement in component survivorship. Attempts to determine whether it yields any significant improvements in postoperative knee function or long-term component longevity have yielded conflicting reports.[27]

MIS-TKA may not actually be atraumatic to the knee. One study found that serum levels of creatinine phosphokinase, myoglobin, aldolase, lactate dehydrogenase, glutamic oxaloacetic transaminase, and creatinine were equal in conventional TKA and MIS-TKA soft tissues.[28] Another study found no differences between conventional TKA and MIS-TKA with regard to preoperative and postoperative C-reactive protein (CRP) or interleukin (IL)-6 levels.[11]

As a result of the high cost of the new instruments required, the significant potential for complications, and the substantial learning curve, MIS-TKA is currently recommended only for high-volume surgeons who receive specialized training.[15]

Previous
 
 
Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

References
  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].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.