Minimally invasive total knee replacement: techniques and results

Abstract

In this review, we outlined the definition of minimally invasive surgery (MIS) in total knee replacement (TKR) and described the different surgical approaches reported in the literature. Afterwards, we went through the most recent studies assessing MIS TKR. Next, we searched for potential limitations of MIS knee replacement and tried to answer the following questions: Are there selective criteria and specific patient selection for MIS knee surgery? If there are, then what are they? After all, a discussion and conclusion completed this article. There is certainly room for MIS or at least less invasive surgery for appropriate selected patients. Nonetheless, there are differences between approaches. Mini-medial parapatellar is easy to master, quick to perform and potentially extendable, whereas mini-subvastus and mini-midvastus are trickier and require more caution related to risk of haematoma and vastus medialis oblique (VMO) nerve damage. Current evidence on the safety and efficacy of mini-incision surgery for TKR does not appear fully adequate for the procedure to be used without special arrangements for consent and for audit or continuing research. There is an argument that a sudden jump from standard TKR to MIS TKR, especially without computer assistance such as navigation, patient-specific instrumentation or robotic, may breach a surgeon's duty of care towards patients because it exposes patients to unnecessary risks. As a final point, more evidence is required on the long-term safety and efficacy of this procedure which will give objective shed light on real benefits of MIS TKR.

Keywords: Less invasive surgery; Minimally invasive surgery; Total knee arthroplasty; Total knee replacement.

Fig. 1

Conventional approaches of Langenbeck (left) and Insall (right)

Fig. 2

From left to right: (1) mini-medial parapatellar approach which is basically a small conventional approach without cutting the quads; (2) MIS Quad-sparing approach which is straight above the patella, (3) mini-midvastus approach which goes through the vastus medialis approach (VM); (4) mini-subvastus approach which goes under the VM

Fig. 3

Field of view of the mini-parapatellar approach

Fig. 4

Example of tibial plateau with small keel fitting into minimally invasive surgical (MIS) approach

Fig. 5

National Joint Registry (NJR) in England reporting MIS Total Knee Arthroplasty (TKA) between 2005 and 2014

Fig. 6

Minimally invasive total knee arthroplasty using computer-assisted navigation technology