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The Mini-Incision Mid-Vastus Approach for Total Knee Arthroplasty

Der Midvastus-Zugang mit kurzer Muskelinzision zur Implantation von Kniegelenkendoprothesen

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Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Abstract

Objective

Rapid functional recovery and improved range of motion after total knee arthroplasty (TKA) without compromising implant position.

Indications

Osteoarthritis of the knee requiring TKA.

Contraindications

Preoperative flexion < 80°.

Flexion contracture > 20°.

Body mass index > 40 kg/m2.

Fixed valgus deformity > 15°.

Relative: previous open surgery on the knee; systematic steroids (skin fragility); tall muscular males.

Surgical Technique

Straight skin incision over the medial third of the patella from 2 cm proximal to the patella, and then to the level of the tibial tuberosity. Extension of capsular incision 2 cm into the vastus medialis muscle from a point 2 cm proximal to the patella. Deep incision around the medial border of the patella and distally to the level of the tibial tuberosity. The patella is displaced laterally but is not everted in flexion. Knee flexion and extension as necessary to move the soft-tissue surgical window for proximal or distal exposure. Hyperflexion of the knee only for insertion of the tibial component.

Postoperative Management

Knee flexion exercises extension/flexion 0-0-70° using continuous passive motion the day after surgery. Weight bearing to tolerance allowed at 1st day after surgery (walker, two crutches). Thrombosis prophylaxis.

Results

69 patients with 74 TKAs done through the mini-incision mid-vastus approach were available with a minimum 1-year follow-up. A control group was evaluated retrospectively including 52 patients with 57 total knee replacements in which a standard medial parapatellar arthrotomy with patella eversion was used. At all clinical evaluations flexion and the ability to climb stairs were significantly superior in the mid-vastus group indicating a faster recovery and return to functional activities. There were no complications and the radiographic evaluation found no implant or limb malalignment, or signs of early loosening.

Zusammenfassung

Operationsziel

Schnellere Wiederherstellung der Kniegelenkfunktion mit verbesserter Beweglichkeit nach Implantation einer Kniegelenkprothese mit sicherer Implantatpositionierung.

Indikationen

Implantation von Knieendoprothesen bei Gonarthrose.

Kontraindikationen

Präoperative Flexion < 80°.

Beugekontraktur > 20°.

Body-Mass-Index > 40 kg/m2.

Kontrakte Valgusdeformität > 15°.

Relativ: Vorherige Arthrotomie des Kniegelenks; systemische Steroideinnahme (Hautfragilität); grosse muskelstarke Männer.

Operationstechnik

Gerader Hautschnitt, über dem medialen Drittel der Patella beginnend, 2 cm proximal der Patella bis zur Tuberositas tibiae. Tiefe mediale parapatellare Inzision der Kapsel von der Tuberositas tibiae bis 2 cm proximal der oberen medialen „Patellaecke“, Erweiterung der Inzision über 2 cm im Faserverlauf des Musculus vastus medialis. Die Patella wird lateralisiert, aber nicht vollständig evertiert. Notwendigenfalls wird durch Beugung und Streckung des Gelenks das Weichteilfenster zur besseren Darstellung nach proximal und distal verlagert. Eine überspitzwinklige Beugung des Gelenks ist nur zur Einbringung der tibialen Komponente notwendig.

Weiterbehandlung

Krankengymnastische Übungsbehandlung mit CPM-(„continuous passive motion-)Schienen-Anwendung (Extension/Flexion 0-0-70°) und schmerzadaptierte Vollbelastung am 1. postoperativen Tag (Gehwagen, zwei Unterarmgehstützen). Thromboseprophylaxe.

Ergebnisse

Von 74 Kniegelenkprothesen (69 Patienten), die über einen Midvastus-Zugang mit verkürzter Muskelinzision implantiert wurden, wurde das Ergebnis nach mindestens 1 Jahr evaluiert und mit einer Kontrollgruppe verglichen (57 Kniegelenkprothesen, 52 Patienten), bei der eine mediale parapatellare Standardarthrotomie mit vollständiger Patellaeversion verwendet wurde. Die klinischen Ergebnisse der Midvastus-Gruppe bestätigten zu allen Untersuchungszeitpunkten eine signifikant bessere Flexion und Fähigkeit, Treppen zu steigen, was eine schnellere Wiederherstellung der Kniegelenkfunktion und Rückkehr zu funktionellen Aktivitäten bedeutet. Komplikationen traten nicht auf, und die radiologischen Untersuchungen zeigten keine Implantatfehllagen, keine Achsfehlstellungen oder Anzeichen für frühzeitige Implantatlockerungen.

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Authors and Affiliations

  1. Department of Orthopedics, University of Ulm, Ulm, Germany

    Markus Flören & Heiko Reichel

  2. The Division of Arthroplasty, Hospital for Special Surgery, New York, NY, USA

    Jack Davis & Richard S. Laskin

  3. Orthopädische Universitätsklinik, Universität Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany

    Markus Flören

Authors
  1. Markus Flören
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  2. Heiko Reichel
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  3. Jack Davis
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  4. Richard S. Laskin
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Correspondence to Markus Flören.

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Flören, M., Reichel, H., Davis, J. et al. The Mini-Incision Mid-Vastus Approach for Total Knee Arthroplasty. Orthop Traumatol 20, 534–543 (2008). https://doi.org/10.1007/s00064-008-1509-2

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  • DOI: https://doi.org/10.1007/s00064-008-1509-2

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