Minimally Invasive Total Knee Arthroplasty: The journey so far

Anil Khanna

Abstract:

Introduction: The history of total joint replacement has demonstrated continuous evolution. With the development of total knee arthroplasty since 1974 the field of knee arthroplasty has undergone many changes. With the introduction of minimally invasive surgery for total knee arthroplasty (TKA) both interest and suspicion have aroused. Amidst this controversy the aim of the present study was to review the current literature on Minimally Invasive Total Knee Arthroplasty (MITKA) and to provide an overview of the field of minimally invasive surgery for total knee arthroplasty. 
Material and method: A comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase was performed. The initial search revealed 82 articles out of which 14 articles were in language other than English and hence were excluded. This resulted in inclusion of 68 studies in the current review.
Results: Though studies on minimally invasive knee arthroplasty have shown the same consistent trends of reduced pain, quicker rehabilitation and good patient satisfaction, component alignment remains an unanswered issue and although early series with computer navigation look promising, the need further randomised controlled trials remains.
Conclusion: Whilst there is no doubt there is a future in minimally invasive TKA, its introduction to the surgical community must be undertaken responsibly not just by the orthopaedic community but also by orthopaedic manufacturers.

J.Orthopaedics 2009;6(1)e9

Keywords:

Minimally Invasive; total knee replacement

Introduction:

Innovation in surgery is not new and should not be unexpected. The history of total joint replacement has demonstrated continuous evolution. The relatively high complication rates associated with early prostheses and techniques eventually led to the improvement of implants and refinement of the surgical procedures. Gradual adoption of these improvements and their eventual diffusion into the surgical community led to improved success and increased rates of implantation¹.

With the development of total knee arthroplasty since 1974 the field of knee arthroplasty has undergone many changes ^{2, 3}. Despite outstanding results ^{4, 5} many patients experience a tremendous amount of pain and impaired quadriceps muscle function in the short term that may lead to prolonged rehabilitative efforts until full recovery ⁶. Mizner et al ⁷analyzed 40 patients who underwent unilateral TKA followed by rehabilitation, including 6 weeks of outpatient physical therapy. In their study, patients experienced significant worsening of range of motion, quadriceps strength, and performance on functional tests 1 month after surgery. Of all physical measures assessed, quadriceps muscle strength showed the greatest decline and was the most highly correlated measure associated with functional performance at all testing sessions. Likewise, Silva and colleagues ⁸ assessed quadriceps muscle strength by measuring isometric extension peak torque in 32 knees more than 2 years after TKA. The mean isometric extension peak torque values in their patients were reduced by up to 30.7% (P = .01) and the isometric flexion peak torque values were, on average, 32.2% lower than those from control subjects.

With the introduction of minimally invasive surgery for unicondylar knee arthroplasty by Repicci in early 1990s and its subsequent acceptance globally ^{9, 10, 11}, along with the attempt to reduce quadriceps muscle strength loss and improve early clinical outcome (reduced pain, reduced length of hospitalization, and earlier return to full function) following total knee replacement, minimally invasive quadriceps-sparing techniques have become increasingly popular ^{11, 12, 13}. However since its introduction for total knee arthroplasty (TKA) both interest and suspicion have aroused.

Proponents have suggested faster recovery times, less pain and improved cosmoses for their patients ^{15, 16}. Critics cite the reduced visualization as a risk for poorer component placement which could compromise long term survivorship for short term gain ¹⁷.

Amidst this controversy the aim of the present study was to review the current literature on Minimally Invasive Total Knee Arthroplasty (MITKA) and to provide an overview of the field of minimally invasive surgery for total knee arthroplasty.

Materials and Methods:

A comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases was performed using the key words minimally invasive total knee replacement, mini-incision knee surgery, minimally invasive surgery and total knee replacement. All articles relevant to the subject were retrieved, and their bibliographies thoroughly reviewed for further references.

Exclusion criteria

Studies in language other than English were excluded.

The initial search revealed 82 articles out of which 14 articles were in language other than English and hence were excluded. This resulted in inclusion of 68 studies in the current review.

Definition of MITKA

The exact definition of MIS as related to total knee arthroplasty is open to debate. Historically, minimally invasive total knee arthroplasty was defined as an incision length of < 14 cm. However, the length of the incision was not the primary influence on potential postoperative benefits to the patient and thus several other factors were included in this definition. Those are: 1. the amount of soft-tissue dissection (including muscle, ligament, and capsular damage). 2. Patellar retraction or eversion. 3. Tibiofemoral dislocation ^{15, 16, 18}. Hence minimally invasive surgery should not be considered to be a cosmetic procedure but rather one that addresses patient’s concerns with regard to postoperative pain and slow rehabilitation.

Indication of Minimally Invasive Total Knee Arthroplasty

The indications for the surgery are much more restrictive than the standard TKA. Many of MITKA reports have listed strict selection criteria for this procedure. Patient weight (>100 kg), body mass index (BMI >40), knee deformity(not more than 10° of anatomic varus,15° of anatomic valgus and a 10° flexion contracture), age(>80 years), previous open knee surgery, inflammatory arthropathy, preoperative knee range of motion (flexion <90° ), patella baha have all been reported as selection criteria used to limit which patients could undergo an MIS procedure^{13, 14, 16, 19, 20, 21, 22, 23, 24, 27}.Controversy however still exists whether these criteriae need to be strictly adhered to with some studies stating that this need not be the case  ²⁵ while others stating it as the most common pitfall ²¹.

Surgical Technique

Several MIS TKA techniques have been described: mini-arthrotomy, mini-midvastus, medial quad-sparing, mini-subvastus and mini-lateral approach. The mini-arthrotomy technique uses a smaller medial parapatellar arthrotomy than a traditional medial parapatellar arthrotomy does ^{19, 26}. The mini-midvastus technique has an arthrotomy that extends 2 cm or more into the vastus medialis muscle ^{13, 18, 21,27,28,29}. The medial quad-sparing approach uses a more medial incision and avoids a quadriceps arthrotomy ^{22, 23, 24, 30}. The mini-subvastus approach, which is an evolution of the subvastus technique of Hoffman et al ³¹, uses an anterior approach and a quad-sparing arthrotomy ²⁸. The lateral approach extends from the proximal end of patella laterally and extends between distally between the tibial tuberosity and Gerdy’s tubercle ³⁰. All MIS TKA techniques avoid everting the patella.

Rational of approaches

A) Medial Approach

The Vastus medialis Obliques (VMO) is the only muscle of the quadriceps muscle group that can prevent lateral displacement of patella when the knee is actively extended ³¹. A midvastus approach may cut the nerve branch from the vastus medialis longus (VML) to VMO. Retinacular branches to the medial capsule are devided when the incision extends proximally to the patella. The articular branch of the descending genicular artery always follow the nerve branch(when it exists) from the saphenous nerve.  A long medial para patellar approach may injure the saphenous nerve to the VMO, thus preventing full rehabilitation following TKA³². Thus the aim of MISTKA is to minimize the damage to VMO and to preserve maximum quadriceps function which in turn favours better and early rehabilitation ^{34, 35}. Also as most conventional TKA was performed through a medial approach, a logical step towards introduction of MITKA was to become aware of its instrumentations and principles through a medial approach.

B) Lateral Approach

One of the main advantages of the lateral approach is that the quadriceps muscle is totally spared so VMO is immediately available for rehabilitation. Additionally, maintaining the medial control of the patella limits lateral tracking of the patella. With the lateral approach, the infrapatellar branch of the saphenous nerve and the medial articular branch of the saphenous nerve that accompanies the descending branch of medial genicular artery may be completely avoided as medial side of the knee is not exposed. Also damage to the superior medial and superior medial genicular artery is more easily avoided.

Lateral release are easier to perform through a lateral MIS approach which in turn allows for a more accurate measurement of  tibial bone resection in varus knees ^{30, 36, 37}. 

Anaesthetic protocols and post operative management

In the excellent symposium on minimally invasive arthroplasty by the Journal of Bone and Joint Surgery^38, Dr. Jay Berry stated, “Often overlooked in the discussion of minimally invasive arthroplasty is the role that an integrated program of anaesthesia and accelerated rehabilitation that is instituted with minimally invasive methods may play in facilitating shorter hospital stays.” Early success of a surgical procedure has been shown to depend on anaesthesia protocols; pain management protocols; and early physical therapy protocols ^{39, 40}. Several studies have focused attention to this aspect of patient management and have suggested the need for development of special anaesthetic and rehabilitation protocols specifically for MITKA to expedite recovery and hence justify the true role of mini incision in total knee arthroplasty ^{40, 41, 42}.

Results of MITKA

Although appealing to many patients, a smaller incision is clearly not the reason why they may perform better. The minimisation of soft tissue dissection/disruption, lack of patella eversion and in situ bone cutting techniques to minimise articular dislocations are clearly more important in producing improved outcomes. MITKA being a relatively “young” procedure, majority of the studies have reported on early results only.

A) Blood Loss:  Majority of studies comparing Minimally Invasive surgery with conventional total knee arthroplasty have shown significantly less blood loss (exception is  study by Laskin et al in 2004 which reported higher blood loss in MITKA group ²¹ )and decrease in post  op haemoglobin in the MITKA group ^{12, 37, 43, 44, 45}.

B) Tourniquet time: Review of literature suggested that majority of studies tend to report longer tourniquet time with this procedure ^{13, 43, 46, 47}, but as the experience of the operating surgeon with MITKA increases the tourniquet time gradually decreases ^{20, 48, 49}.

C) Post operative pain: Post operative pain relief is variably reported in literature in comparison to standard TKA. While most of the studies report lower post op pain in the MITKA series ^{20, 46, 50} (exception is a prospective randomised control trial by Karachalios et al ⁴³ which report higher pain with MITKA), studies scrutinising this factor in detail report no difference in pain with the passage of time¹⁷.

D) Duration of Hospital stay: With the ever increasing pressure both on Orthopaedic surgeons and the managerial staff to produce high volume surgery, total knee arthroplasty is being considered to join the list of out-patient procedures. Majority of the comparative studies reporting on in patient stay duration shows lesser duration of hospital stay in patients with MITKA as compared to standard procedure ^{20, 48, 52}. Berger et al ⁵¹ reports discharging 99% of the patients after 24 hours, this he attributes to development of a comprehensive pathway for minimally invasive surgical technique. In this study they suggest that addressing and alleviating the patient's apprehension about outpatient TKA is the key stone of early discharge.

E) Range of motion: Majority of studies comparing MITKA with conventional arthroplasty report better range of motion in MITKA group ^{13, 20, 43, 52}  however several studies following this parameter over time report no difference in the two groups from as little as 2 weeks post operatively ^{21, 43, 50, 53}. The finding that has been consistent however has been the quick regain in quadriceps strength and earlier achievement of first 90 range of motion ^{28, 43, 53, 54}.

G) Complications: Component alignment remains an unanswered issue with some studies showing high rates of malalignment ^{17, 43, 68}.  Delayed wound healing has been reported in number of series ^{43, 52, 55} possibly due to excessive retraction during the procedure.  Other complications like deep vein thrombosis, peroneal nerve palsy, superficial and deep infections, patellar fracture, patellar tendon rupture, periprosthetic fracture etc has also been reported ^{12, 37, 43, 48, 52, 53, 55, 56}.  Also some studies have reported conversion of the mini approach to standard approach when visualisation became difficult especially in obese patients or patients with sever deformity ^{43, 56, 57, 58}.

Economical aspects

The current debate regarding the value of minimally invasive surgery extends beyond the demonstrated or potential clinical benefits of these procedures. Economic considerations of patients, surgeons, hospitals, and tax- payers are prominent factors in this debate and will continue to influence the adoption of minimally invasive surgical procedures. Studies focusing there attention to MITKA economy have found the need for high quality studies to support superior economical consideration of this procedure over standard approach ^{57, 58}.

Role of computer navigation

Computer navigation with minimally invasive procedures is evolving rapidly. There is however little information on the feasibility of computer navigation when using a minimally invasive approach for total knee arthroplasty, during which the anatomic landmarks for registration may be obscured. Majority of studies using computer navigation for MITKA have reported the main advantage of this technique over conventional total knee arthroplasty to be improved postoperative radiographic alignment without much difference in clinical results ^{59, 60, 61, 62, 63}.

There is however a word of caution when using navigation with MITKA because of their associated anomalies (these technologies sometimes return incorrect information during surgical procedures) ⁶³. Hence although promising, the initial clinical experience is limited and needs to be supported by further, prospective analysis.

Conclusion :

It has been previously shown that two of the greatest concerns for patients prior to total joint arthroplasty are pain and length of recovery ⁶⁴. Minimally invasive knee arthroplasty certainly appears to address these concerns with early series showing the same consistent trends of reduced pain, quicker rehabilitation and good patient satisfaction scores. Component alignment remains an unanswered issue and although early series with computer navigation look promising, the need further randomised controlled trials remains.  Also VMO constant insertion ( which formed the basis of medial approach to MITKA) at the midpoint of the patella ⁶⁵  has been challenged ⁶⁶.

Whilst there is no doubt there is a future in minimally invasive TKA, its introduction to the surgical community must be undertaken responsibly not just by the orthopaedic community but also by orthopaedic manufacturers. Currently NICE considers the evidence on the procedures safety and efficacy inadequate for it to be undertaken without special arrangements for consent and for audit and research. It further defines the importance of training and has asked to British Orthopaedic Association to produce standards for training ⁶⁷.

Thus the future of minimally invasive TKA will require a complete change of visualization (improved surgical approaches, single-incision or multi-incision approaches), access (tissue expanders, endoscopic visualization), instrumentation (smaller and less bulky), and implants (downsized implants with reduced fixation keels, modular implants) with longer follow up studies to prove its worth.

Reference :

1. Peltier L F.The history of hip surgery. In: Callaghan J J, Rosenberg A G and Rubash H E, Editors, The adult hip. Lippincott, Philadelphia, 1998: 4.

2. Insall J, Ranawat CS, Scott WN, Walker P.  Total condylar knee replacement: Preliminary report. Clin Ortho 1976; 120:149-154.
   Insall J, Tria AJ, Scott WN. The total condylar knee prosthesis: The first five years. Clin Orthop 1979; 145: 68-77.

3. Keating EM, Meding JB, Faris PM, Ritter MA.   Long-term followup of nonmodular total knee replacements, Clin Orthop 2004; 404: 34-39.

4. Buechel FF Sr. Long-term followup after mobile-bearing total knee replacement, Clin Orthop 2002; 403: 40-50.

5. Salmon P, Hall GM, Peerbhoy D, Shenkin A, Parker C. Recovery from hip and knee arthroplasty: patients' perspective on pain, function, quality of life, and well-being up to 6 months postoperatively. Arch Phys Med Rehabil 2001; 82: 360-366.

6. Mizner RL, Petterson SC, Snyder-Mackler L.Quadriceps strength and the time course of functional recovery after total knee arthroplasty. J Orthop Sports Phys Ther 2005; 35: 424-436.

7. Silva M, Shepherd E F, Jackson W O, Pratt J A, McClung C D, Schmalzried T P.

8. Knee strength after total knee arthroplasty. J Arthroplasty 2003; 18: 605-611.

9. Price A J, Webb J, Topf H, Dodd CA, Goodfellow JW,  Murray DW.  Rapid recovery after oxford unicompartmental arthroplasty through a short incision.  J Arthroplasty 2001; 16: 970–976.

10. Argenson J N , Flecher X.  Minimally invasive unicompartmental knee arthroplasty. The Knee 2004; 11: 341–347.

11. Rees J L, Price AJ,  Breard D J, Dodd C A F , Murray D W.  Minimally Invasive Oxford unicompartmental knee arthroplasty: functional results at 1 year and the effect of surgical inexperience. The Knee 2004; 11: 363–367.

12. Tria A J, Coon T M. Minimal incision total knee arthroplasty: early experience. Clin Orthop 2003; 416:185-190.

13. Haas S B, Cook S, Beksac B.Minimally invasive total knee replacement through a mini midvastus approach: a comparative study. Clin Orthop 2004; 428: 68 -73.

14. Scuderi GR, Tenholder M, Capeci C. Surgical approaches in mini-incision total knee arthroplasty, Clin Orthop 2004; 428: 61-67.

15. Laskin RS, Beksac B, Phongjunakorn A, Pittors K, Davis J, Shim JC, Pavlov H, Petersen M. Minimally invasive total knee replacement through a mini-midvastus incision: An outcome study. Clin Orthop 2004;  428: 774–781.

16. Bonutti P M, Mont M A,  McMahon M, Ragland P S, Kester M.  Minimally Invasive Total Knee Arthroplasty. J Bone Joint Surg 2004; 86-A: 26–32.

17. Dalury D F, Dennis D A.  Mini-incision total knee arthroplasty can increase risk of component malalignment. Clin Orthop 2005; 440: 77–81.

18. Bonutti PM, Mon M A, Kester M A. Minimally invasive total knee arthroplasty: a 10-feature evolutionary approach. Orthop Clin North Am 2004; 35: 217-226.

19. Scuderi G R, Tria A J Jr. Minimal incision total knee arthroplasty. In: G.R. Scuderi and A.J. Tria, Editors, MIS of the Hip and the Knee: a Clinical Perspective, Springer-Verlag, New York, 2004, 175–186.

20. McAllister CM, Stepanian JD. The impact of minimally invasive surgical techniques on early range of motion after primary total knee arthroplasty. J Arthroplasty 2008; 23: 10-18

21. M S, Alan R K, Tria A J Jr. (2006) Minimally Invasive Quadriceps-Sparing Posterior Stabilized Total Knee Arthroplasty Operative Techniques in Orthopaedics 16, 170-176.

22. Tria A J Jr. (2004) Minimally invasive total knee arthroplasty: the importance of instrumentation, Orthop Clin North Am, 35, 227-234.

23. Tria  A J Jr. (2003) Advancements in minimal invasive total knee arthroplasty, Orthopedics, 26, 859–863.

24. Choi Y J, Tanavalee A, Chan A P H et al., Minimally invasive surgery for total knee arthroplasty. In: G.R. Scuderi and A.J. Tria, Editors, MIS of the Hip and the Knee: a Clinical Perspective, Springer–Verlag, New York (2004), p. 160.

25. Schroer W C, Diesfeld P J, LeMarr A, Reedy M E. (2007)Applicability of the mini-subvastus total knee arthroplasty technique: ananalysis of 725 cases with mean 2-year follow-up. J Surg Orthop Adv, 131-137.

26. Scuderi R, Tria A J Jr. (2004)  Minimal incision total knee arthroplasty. In: G.R. Scuderi and A.J. Tria, Editors, MIS of the Hip and the Knee: a Clinical Perspective, Springer-Verlag, New York,175–186.

27. Laskin R S. (2003) New techniques and concepts in total knee replacement, Clin Orthop, 416, 151-153.

28. G.R. Scuderi G R, Tenholder M, Capeci C (2004). Surgical approaches in mini-incision total knee arthroplasty. Clin Orthop, 428, 61-67.

29. Bonutti P M, Neal D J, Kester M A. (2003)Minimal incision total knee arthroplasty using the suspended leg technique, Orthopedics, 26, 899-903.

30. Bonutti P M. (2004) Minimally invasive total knee arthroplasty—midvastus approach. In: J.H. Hozack and M. Krisman, Editors, Minimally Invasive Total Joint Arthroplasty, Springer-Verlag, New York, 139.

31. Goble E M, Justin D F.(2004) Minimally invasive total knee replacement: principles and technique, Orthop Clin North Am, 35, 235-245.

32. 31. Hoffmann A A, Plaster R L, Murdock L E.(1991) Subvastus (southern) approach for primary total knee arthroplasty, Clin Orthop,269,70-77.

33. Chan AY, Lee FL, Wong PK, Wong CY, Yeung SS.(2001) Effects of knee joint angles and fatigue on the neuromuscular control of vastus medialis oblique and vastus lateralis muscle in humans. Eur J Appl Physiol, 84, 36-41.

34. Cooper R E Jr, Trinidad G, Buck WR.(1999) Midvastus approach in total knee arthroplasty: a description and a cadaveric study determining the distance of the popliteal artery from the patellar margin of the incision. J Arthroplasty, 14, 505-508.

35. Hunter S C, Marascalco R, Hughston JC.(1983) Disruption of the vastus medialis obliquus with medial knee ligament injuries. Am J Sports Med, 11, 427-431.

36. Günal I, Araç S, Sahinoğlu K, Birvar K.(1992) The innervation of vastus medialis obliquus. J Bone Joint Surg (Br), 74, 624.

37. Mont M A, Bonutti P M, Chauhan S K et al. Lateral approach to total knee arthroplasty: minimal soft tissue invasion. In: W.J. Hozack, M. Krismer and M. Nogler et al., Editors, Minimally invasive total joint arthroplasty, Springer Medizin Verlag, Heidelberg (2004), p. 151.

38. Seyler TM, Bonutti PM, Ulrich SD, Fatscher T, Marker DR, Mont MA.(2007)Minimally invasive lateral approach to total knee arthroplasty.J Arthroplasty, 22, 21-26.

39. Berry D J, Berger R, Callaghan J et al. (2003) Symposium—minimally invasive total hip arthroplasty, J Bone Joint Surg Am 85, 2235. (REPEAT)

40. Berger R. MIS-2 hip arthroplasty.(2004) Lecture at Emerging Techniques in Hip and Knee Arthroplasty not a publisher Atlanta.

41. Sanders S, Buchheit K, Deirmengian C, Berger RA.(2006) Perioperative protocols for minimally invasive total knee arthroplasty. J Knee Surg, 19, 129-132.

42. Scuderi GR. (2006) Preoperative planning and perioperative management for minimally invasive total knee arthroplasty. Am J Orthop, 35, 4-6.

43. Nuelle DG, Mann K.(2007) Minimal Incision Protocols for Anesthesia, Pain Management, and Physical Therapy With Standard Incisions in Hip and Knee Arthroplasties The Effect on Early Outcomes. J Arthroplasty, 22, 20-25.

44. Karachalios T, Giotikas D, Roidis N, Poultsides L, Bargiotas K, Malizos KN.(2008) Total knee replacement performed with either a mini-midvastus or a standardapproach: A prospective randomised clinical and radiological trial..J Bone Joint Surg (Br), 90, 584-591.

45. Berger RA, Deirmengian CA, Della Valle CJ, Paprosky WG, Jacobs JJ, Rosenberg AG.(2006) A technique for minimally invasive, quadriceps-sparing total knee arthroplasty. J Knee Surg, 19, 63-70.

46. Tenholder M, Clarke HD, Scuderi GR. (2005) Minimal-incision total knee arthroplasty: the early clinical experience. Clin Orthop, 440, 67-76.

47. Tashiro Y, Miura H, Matsuda S, Okazaki K, Iwamoto Y. (2007) Minimally invasive versus standard approach in total knee arthroplasty. Clin Orthop, 463, 144-150.

48. Kolisek FR, Bonutti PM, Hozack WJ et al (2007).Clinical experience using a minimally invasive surgical approach for total knee arthroplasty: early results of a prospective randomized study compared to a standard approach. J Arthroplasty, 22, 8-13.

49. Shankar NS. (2006) Minimally invasive technique in total knee arthroplasty--history, tips, tricksand pitfalls. Injury, 37, 25-30

50. Tanavalee A, Thiengwittayaporn S, Itiravivong P.(2005) Results of the 136 consecutive minimally invasive total knee arthroplasties.J Med Assoc Thai, 88, 74-78.

51. Huang HT, Su JY, Chang JK, Chen CH, Wang GJ.(2007) The early clinical outcome of minimally invasive quadriceps-sparing total kneearthroplasty: report of a 2-year follow-up. J Arthroplasty, 22, 1007-1012.

52. Berger RA, Sanders S, Gerlinger T, Della Valle C, Jacobs JJ, Rosenberg AG. (2005)Outpatient total knee arthroplasty with a minimally invasive technique.J Arthroplasty, 20, 33-38.

53. Schroer WC, Diesfeld PJ, Reedy ME, LeMarr AR.(2008) Mini-subvastus approach for total knee arthroplasty.J Arthroplasty, 23,19-25.

54. Chotanaphuti T, Ongnamthip P, Karnchanalerk K, Udombuathong P. (2008) Comparative study between 2 cm limited quadriceps exposure minimal invasive surgery and conventional total knee arthroplasty in quadriceps function: prospective randomized controlled trial. J Med Assoc Thai, 91, 203-207

55. Eum DS, Lee HK, Hwang SY, Park JU.(2006) Blood loss after navigation-assisted minimally invasive total knee arthroplasty. Orthopedics, 29, 152-154.

56. Tanavalee A, Thiengwittayaporn S, Itiravivong P.(2007)Progressive quadriceps incision during minimally invasive surgery for total knee arthroplasty: the effect on early postoperative ambulation. J Arthroplasty, 22, 1013-1018.

57. Berger RA, Sanders S, D'Ambrogio E, Buchheit K, Deirmengian C, Paprosky W,Della Valle CJ, Rosenberg AG. Minimally invasive quadriceps-sparing TKA: results of a comprehensive pathway foroutpatient TKA. J Knee Surg. 2006 Apr;19(2):145-8

58. Aglietti P, Baldini A, Sensi L. (2006) Quadriceps-sparing versus mini-subvastus approach in total knee arthroplasty. Clin Orthop, 452, 106-111.

59. Bozic KJ, Beringer D. (2007) Economic considerations in minimally invasive total joint arthroplasty. Clin Orthop, 463, 20-25.

60. Coon TM. (2006) The economic impact of minimally invasive total knee arthroplasty. Am J Orthop, 35, 33-35.

61. Dutton AQ, Yeo SJ, Yang KY, Lo NN, Chia KU, Chong HC. (2008) Computer-assisted minimally invasive total knee arthroplasty compared with standard total knee arthroplasty. A prospective, randomized study. J Bone Joint Surg (Am), 90, 2-9.

62. Seon JK, Song EK, Yoon TR, Park SJ, Bae BH, Cho SG.(2007) Comparison of functional results with navigation-assisted minimally invasive and conventional techniques in bilateral total knee arthroplasty. Comput Aided Surg, 12, 189-193.

63. R.S. Laskin (2003) New techniques and concepts in total knee replacement, Clin Orthop 416, 151-153.

64. Seon JK, Song EK.(2006) Navigation-assisted less invasive total knee arthroplasty compared with conventional total knee arthroplasty: a randomized prospective trial. J Arthroplasty,  21, 777-782.

65. Tria AJ Jr (2006).The evolving role of navigation in minimally invasive total knee arthroplasty. Am J Orthop, 35, 18-22.

66. Trousdale RT, McGrory B J, Berry D J, Becker W M, Harmsen W S.(1999) Patients' concerns prior to undergoing total hip and total knee arthroplasty, Mayo Clin Proc, 74, 978–982.

67. Pagnano MW, Meneghini RM, Trousdale RT. (2006) Anatomy of the extensor mechanism in reference to quadriceps-sparing TKA, Clin Orthop, 452, 102-105.

68. Holt G, Nunn T, Allen RA, Forrester AW, Gregori A. (2008) Variation of the Vastus Medialis Obliquus Insertion and its Relevance to Minimally Invasive Total Knee Arthroplasty A Cadaver and Magnetic Resonance Imaging Study. J Arthroplasty. 2008, 23, 600-604.

69. www.nice.org.uk/page.aspx?o=222345.

70. Schroer WC, Diesfeld PJ, Reedy ME, Lemarr AR. Surgical accuracy with the mini-subvastus total knee arthroplasty a computer tomography scan analysis of postoperative implant alignment. J Arthroplasty, 23, 543-549.

This is a peer reviewed paper 

Please cite as: Anil Khanna: Minimally Invasive Total Knee Arthroplasty: The journey so far

J.Orthopaedics 2009;6(1)e9

URL: http://www.jortho.org/2009/6/1/e9

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