Total knee replacement through a mini-mid-vastus approach

Abstract

The results of total knee replacement over the past 30 years have been excellent. The operation has been shown to relieve pain and increase the ability of patients to function and participate in activities of daily living. Over and above this these results have been shown to be longlasting, with many ten and fifteen year follow up studies in the peer reviewed literature [1-3] using a variety of implant designs. Traditionally, these primary total knee replacements have been performed through a median parapatellar incision. The incision extended proximally for several inches into the junction between the rectus tendon and the vastus medialis muscle. The suprapatellar bursa was extensively opened, the knee was hyper-flexed and the patella was everted. All of this was done through a skin incision that normally measured somewhere between 15 and 18 cm in length. Despite our excellent long-term results using this type of surgical exposure we did note, however, that the recuperation was prolonged. Patients often had difficulty regaining flexion. Physical therapy requirements were often intensive with patient's not able to normally resume their activities of daily living for about three or more months after surgery. Over the past 10 to 15 years, minimally invasive approaches have been used to treat a variety of other surgical conditions including chronic gallbladder disease, torn anterior cruciate ligaments, ruptured ovarian cysts, and median nerve compression in the carpal tunnel. The premise in all of those surgeries had been that by limiting the amount of disruption of the deep tissues during the surgery the recuperative time could be sped up, blood loss could be diminished, and postoperative pain could be decreased. Orthopaedic surgeons conjectured whether similar type outcomes could be obtained if we could perform primary knee replacements to more limited exposures. Could we perform the surgery by not extensively disrupting the quadriceps musculature and suprapatellar pouch and still obtain adequate exposure for proper component position and ligament balancing? Would the results of doing this be less pain at the surgery, a faster recuperation, and possibly less blood loss? Bearing all of this in mind, however, had to still perform the surgery in a manner which enabled us to properly expose the important anatomic features so as to minimize the chance of inadvertent damage to bony capsular, vascular or neurological structures. © 2007 Springer Medizin Verlag Heidelberg.