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Surgical Techniques   |    
Comparison of the Vastus-Splitting and Median Parapatellar Approaches for Primary Total Knee Arthroplasty: A Prospective, Randomized StudySurgical Technique
Matthew J. Kelly, MD1; Mustasim N. Rumi, MD2; Milind Kothari, DO3; Michael A. Parentis, MD4; Katrina J. Bailey, PT3; William M. Parrish, MD3; Vincent D. PellegriniJr., MD5
1 20415 Stable Lane, Waynesville, MO 65583
2 Orthopaedic Associates of Central Texas, 16020 Park Valley Drive, Round Rock, TX 78746
3 Departments of Neurology (M.K.), Physical Therapy (K.J.B.), and Orthopaedics and Rehabilitation (W.M.P.), The Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA 17033
4 The Knee Center of Western New York, 100 Corporate Way, Suite 12, Amherst, NY 14226
5 Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Suite S 11 B, Baltimore, MD 21201. E-mail address: vpellegrini@umoa.umm.edu
View Disclosures and Other Information
DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedics and Rehabilitation, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 88-A, pp. 715-720, April 2006

The Journal of Bone and Joint Surgery, Incorporated
JBJS Essential Surgical Techniques, 2007 Mar 01;89(2 suppl 1):80-92. doi: 10.2106/JBJS.F.01190
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Abstract

BACKGROUND:

A vastus-splitting approach for total knee arthroplasty has been advocated to preserve function of the extensor mechanism and to decrease the prevalence of lateral release. Critics have claimed that there is greater blood loss and compromised exposure in large patients who are managed with this approach. The purpose of the present study was to compare vastus-splitting and median parapatellar approaches for primary total knee arthroplasty.

METHODS:

Forty-two consecutive patients (fifty-one knees) undergoing primary total knee arthroplasty were randomized to treatment with a median parapatellar or vastus-splitting approach. The interval of the vastus muscle split was marked with radiopaque vascular clips. Surgical data, functional parameters, and preoperative and postoperative electromyograms were assessed.

RESULTS:

Early (six-month) and intermediateterm (five-year) follow-up showed no differences in functional parameters, tourniquet time, or the frequency of patellar resurfacing. Significantly more lateral releases (p < 0.01) and greater blood loss (p = 0.03) occurred in the median parapatellar group. Nine (43%) of twenty-one knees in the vastus-splitting group had abnormal electromyographic findings at six months postoperatively, whereas all patients in the median parapatellar group had normal findings. Seven knees with abnormal electromyographic findings at six months had normal findings when restudied at five years; in each of these knees, the vastus split had been developed bluntly. The other two knees with abnormal findings at six months had had sharp dissection for the muscle split. Both of these knees had chronic changes, one with changes indicative of reinnervation and the other with ongoing denervation, but neither demonstrated functional compromise.

CONCLUSIONS:

The vastus-splitting approach offers a viable alternative to the median parapatellar approach for primary total knee arthroplasty that reduces the need for lateral retinacular release without impairment of quadriceps function. Electromyographic abnormalities in the quadriceps muscle have no functional consequence and most likely represent reversible neurapraxic injury that may be avoided by blunt dissection in the vastus medialis muscle.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Vincent D. Pellegrini, Jr., M.D.
    Posted on May 04, 2007
    Dr. Pellegrini et al. respond to Dr. Merchant
    Dept. of Orthopaedics, University of Maryland School of Medicine, Baltiimore, MD 21201

    We thank Dr. Merchant for correctly identifying our error as it relates to patellofemoral imaging of the knee. We concur with his comments and, indeed, customarily perform patellofemoral imaging with the knee in 30 degrees of flexion to more sensitively identify lateral subluxation of the patella. The patellar view presented in our paper does not reflect our usual practice.

    We appreciate Dr Merchant's efforts in bringing this inadvertent misrepresentation to our attention as well as that of the readership of The Journal.

    Alan C. Merchant, M.D.
    Posted on April 06, 2007
    Patellofemoral Joint Radiographs
    Clinical Professor, Stanford University, Stanford, CA

    To The Editor:

    The otherwise excellent article, "Comparison of the Vastus-Splitting and Median Parapatellar Approaches for Primary Total Knee Arthroplasty: A Prospective, Randomized Study. Surgical Technique" by Matthew J. Kelly, et al. was marred by an error in the legend of Figure 1. The axial view radiograph of the knee was mislabeled as "a Merchant radiograph of the patella".

    The shape and appearance of the distal femur on the film demonstrates that it is really a Settegast view. This technique requires the knee to be acutely flexed well beyond 90° drawing the patella, which might otherwise be severely subluxed laterally at the trochlear level, into the intercondylar space to articulate with the distal, or weight bearing surface, of the femoral condyles.

    Conversely, the "Merchant" axial view radiograph is exposed with both knees flexed no more than 45°, showing the patella's true relationship to the trochlea.(1,2)

    This may seem to be a minor point, but if the surgeon is not aware that the patella is subluxed laterally prior to surgery, he or she may not take sufficient measures to correct that subluxation during surgery. Many postoperative patellofemoral complications can be avoided if the surgeon is aware of this problem before surgery.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated .

    References:

    1. Merchant AC, Mercer RL, Jacobsen RH, Cool CR: Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg 56A:1391–1396, 1974.

    2. Merchant AC: Patellofemoral imaging. Clin Orthop 389:15–21, 2001.

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