Sub-vastus approach versus the medial parapatellar approach in primary total knee: a randomised controlled trial [ISRCTN44544446]

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Abstract

Background

Thirty thousand knee replacements are performed annually in the UK. There is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We planned a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function.

Methods

Patients undergoing primary total knee arthroplasty at the local NHS Trust are to be recruited into the study. Patients are to be randomised into either the subvastus or medial parapatellar approache to knee arthroplasty. The primary outcome measures will be the American Knee Society and WOMAC Scores. The secondary outcome measures will be patient based measures of EuroQol and SF-36. All outcomes will be measured pre-operatively, 1, 6, 12 and 52 weeks post-operatively. We will also review pain intensity using a pain and analgesia diary. Ease of surgical exposure and complications will also be analysed.

Discussion

Evidence is lacking concerning the best surgical approach to the knee joint for patients undergoing primary total knee replacement. This pragmatic randomised trial tests the hypothesis that the sub-vastus approach is significantly superior to the standard medial parapatellar approach in terms of short and long term knee function.

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Most cited references 19

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Comparison of the subvastus and paramedian surgical approaches in bilateral knee arthroplasty.

Bruce Fauré, James Benjamin, Betsy Lindsey … (1993)

A prospective randomized study was performed on 20 patients undergoing one-stage bilateral knee arthroplasty. One knee was exposed using a standard median parapatellar arthrotomy and the other knee with a subvastus arthrotomy. All patients underwent quantitative strength testing before surgery and at 1 week, 1 month, and 3 months after surgery. The knees were also evaluated for range of motion, and patients, who were blinded as to the approach used, completed questionnaires at each evaluation period as to their preference, if any, regarding knee pain and level of function. There was no difference in the range of motion between knees exposed with the paramedian or subvastus arthrotomy at any time period. The subvastus knees demonstrated significantly greater strength at the 1-week and 1-month intervals, but there was no strength difference at the 3-month interval. There were more lateral releases performed in the paramedium knees, and three minor complications were related to the subvastus approach. Patients who expressed a preference chose the subvastus knee 4:1 over the paramedian knee. The subvastus approach offers a reasonable alternative to the paramedian arthrotomy and preserves greater quadriceps strength in the early postoperative period.

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Resurfacing of the patella in total knee arthroplasty. A prospective, randomized, double-blind study.

M Milicić, Chad Myers, Scott A Waldman … (1997)

During a two-year period, eighty-nine patients who were scheduled to have a total knee arthroplasty for the treatment of degenerative osteoarthrosis were randomly assigned to one of two groups: resurfacing of the patella or retention of the patella. All patients received the same posterior cruciate-sparing prosthesis, and all operations were performed by, or under the direct supervision of, one of us. Three patients died in the early postoperative period. The remaining eighty-six patients (118 knees; fifty-eight that had had resurfacing of the patella and sixty that had not) formed the study group. They were followed for a mean of thirty months (range, twenty-four to forty-four months). Evaluation was performed with use of the clinical scoring system of The Knee Society, a patient-satisfaction questionnaire, specific questions regarding patellofemoral symptoms and function, and radiographs. All clinical evaluations were performed by the same research nurse, without the involvement of a physician, in a blinded manner (neither the nurse nor the patient had knowledge of whether the patella had been resurfaced). Preoperatively, the mean Knee Society score, on a scale ranging from 0 to 200 points, was 89.7 points (range, 33 to 132 points); postoperatively, this score improved to a mean of 172.7 points (range, 98 to 200 points). With the numbers available for study, we could detect no significant difference between the knees that had had patellar resurfacing and those that had not with regard to the over-all score (p = 0.63), the subscore for pain (p = 0.56), or the subscore for function (p = 0.77). We also could detect no difference between the treatment groups, with the numbers available, with regard to patient satisfaction or the responses to questions involving the function of the patellofemoral joint, including the ability to exit from an automobile, to rise from a chair, and to climb stairs. Thirty-two patients had bilateral total knee replacement with resurfacing of the patella in one knee and retention of the patella in the other. These patients expressed no clear preference for either knee. Eight (13 per cent) of the sixty knees that had not had resurfacing were painful anteriorly compared with four (7 per cent) of the fifty-eight that had; this was not a significant difference (p = 0.38), with the numbers available. The anterior pain that was noted postoperatively was predominantly of new onset; it had not been observed preoperatively in three of the four knees that had had resurfacing or in four of the eight that had not. No additional treatment options were offered to the patients who had anterior pain in the knee after resurfacing. However, six (10 per cent) of the sixty knees that had not had resurfacing had it subsequently, because of anterior pain in the knee, after the twelfth postoperative month (range, fifteen to thirty-nine months). The pain decreased in four of these knees. Thus, total knee arthroplasty with retention of the patella yielded clinical results that were comparable with those after total knee arthroplasty with patellar resurfacing, but it was associated with a 10 per cent prevalence of the need for subsequent resurfacing. The prevalence of anterior pain after total knee arthroplasty was not influenced by whether or not the patella had been resurfaced. The postoperative clinical scores, the postoperative development of anterior pain, and the need for subsequent resurfacing were not predicted by the presence of preoperative anterior pain, obesity, or the grade of chondromalacia observed intraoperatively. Because of the short duration of follow-up, these results should be considered preliminary. Additional follow-up is planned.

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Subvastus approach for total knee arthroplasty: a prospective, randomized, and observer-blinded trial.

G S Roysam, Holly D. Oakley (2001)

A prospective, randomized, and blinded trial was conducted with 89 consecutive primary knee arthroplasties comparing standard medial parapatellar arthrotomy with the subvastus approach. All patients received the same prosthesis (Insall-Burstein II) inserted by one surgeon using an identical technique with the only difference being the approach. The parapatellar approach (group I) was used in 43 knees, and in the remaining 46 knees the subvastus approach (group II) was used. Assessment revealed significantly earlier return of straight-leg raise (3.2 days vs 5.8 days, P <.001), lower consumption of opiates in the first week (78 mg vs 102 mg, P <.001), less blood loss (527 mL vs 748 mL, P <.001), and greater knee flexion at 1 week (78 degrees vs 55 degrees, P <.001) in group II (subvastus approach). The subvastus approach offers early advantages over the standard parapatellar arthrotomy. It preserves the integrity of the vastus medialis and peripatellar plexus of vessels. We advise its wider use in primary total knee arthroplasty.

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Author and article information

Journal

Journal ID (nlm-ta): Trials

Title: Trials

Publisher: BioMed Central (London )

ISSN (Electronic): 1745-6215

Publication date Collection: 2006

Publication date (Electronic): 31 July 2006

Volume: 7

Page: 23

Affiliations

[1 ]University of Keele, Keele University Medical School, Thornburrow Drive, Hartshill, Stoke-on-Trent, Staffordshire, ST4 7QB, UK

[2 ]University Hospital of North Staffordshire NHS Trust, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK

[3 ]Newcastle-under-Lyme Primary Care NHS Trust, Civic Offices, Merrial Street, Newcastle-under-Lyme, ST5 2AZ, UK

[4 ]University of Limerick, Dept. of Mathematics & Statistics, University of Limerick, Limerick, Ireland

Article

Publisher ID: 1745-6215-7-23

DOI: 10.1186/1745-6215-7-23

PMC ID: 1553468

PubMed ID: 16879744

SO-VID: 7d75ca8d-a1fb-4fb5-9713-9b954d9c8a4c

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Sub-vastus approach versus the medial parapatellar approach in primary total knee: a randomised controlled trial [ISRCTN44544446]

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Abstract

Background

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Discussion

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Most cited references 19

Comparison of the subvastus and paramedian surgical approaches in bilateral knee arthroplasty.

Resurfacing of the patella in total knee arthroplasty. A prospective, randomized, double-blind study.

Subvastus approach for total knee arthroplasty: a prospective, randomized, and observer-blinded trial.

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