Minimally Invasive Total Knee Arthroplasty
In addition to conventional surgical approaches, total knee arthroplasty (TKA) may be done by means of minimally invasive surgery (MIS). Minimally invasive TKA (MIS-TKA) is often portrayed in the lay community and press as involving a small skin incision. Actually, MIS-TKA is defined by limited soft-tissue and bony dissection. MIS-TKA was developed after the description of unicondylar knee arthroplasty. [1, 2]
Conventional TKA is a successful operation for patients suffering from arthritis of the knee, with a reported complication rate of less than 2% and an implant survivorship of 95% at 10 years. The aim of MIS-TKA is to decrease postoperative pain and shorten the rehabilitation period.
MIS-TKA is used as an alternative to conventional TKA. However, there are conflicting data on whether MIS-TKA is an acceptable replacement for or even an improvement on conventional TKA, and no definitive answer to this question is available at present.
No absolute contraindications exist for MIS-TKA; this procedure is defined by limited soft-tissue and bony dissection. Conventional TKA is probably a more suitable choice for the following patients [3, 4, 5] :
Complication prevention measures recommended for MIS-TKA are exactly the same as those recommended for conventional TKA and should include the following:
Early series comparing MIS-TKA with conventional TKA reported successful outcomes. [6, 7] A randomized controlled trial (RCT) showed significantly shorter hospital stays after MIS-TKA than after conventional TKA.  In a retrospective review of 48 knees, MIS-TKA patients were able to complete an active straight leg raise earlier than conventional TKA patients could.  A similar conclusion was reached in a study comparing computer-assisted approaches.  A case-control study comparing 32 knees after conventional TKA and after MIS-TKA reported mean Knee Society Scores (KSS) of 94 and 96 and mean functional scores of 90 and 99, respectively. 
An RCT that investigated extensor and flexor muscle function after conventional TKA and MIS-TKA found that the MIS-TKA group had a higher knee extensor peak torque at 3, 6, and 12 months postoperatively.  Similarly, another RCT found that the MIS-TKA group had greater hamstring and quadriceps strength at 4 weeks after surgery; however, this difference was not observed at 12 weeks, and no benefit was documented with regard to longer-term strength or functional performance. 
Another prospective RCT, which compared conventional TKA with MIS-TKA by using an accelerometer, found that MIS-TKA patients were significantly more active on all postoperative days and that MIS-TKA patients achieved 80% of their preoperative acceleration in about half of the time that conventional TKA patients took to reach this level.  Additionally, a systematic review of 13 randomized controlled trials found that the mean KSS at 6 and 12 weeks postoperatively was higher in the MIS-TKA group but that this difference was lost at 6 months. 
Conflicting conclusions demonstrate why there is still no consensus regarding either the noninferiority or the superiority of MIS-TKA as compared with conventional TKA. A prospective RCT found that as expected, incisions were significantly shorter in the MIS-TKA group, but there were no significant differences in the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Oxford Knee Score (OKS), the KSS, and the Short Form (SF)-12 score at 6-week, 1-year, 2-year, and 5-year follow-up evaluations in comparison with conventional TKA. 
A meta-analysis of 30 RCTs examined short- to midterm results (< 36 months) for MIS-TKA as compared with conventional TKA.  Evaluating a total of 2500 TKAs, the authors concluded that the MIS-TKA group had better outcomes with respect to KSS, range of motion, days to straight leg-raise, and total blood loss. However, this benefit was associated with longer operating and tourniquet times, as well as wound-healing complications. Overall, though, there were no significant differences with regard to radiographic evaluation of component positioning with MIS-TKA and conventional TKA.
An RCT that evaluated medium-term results demonstrated that at a mean of 6 years’ follow-up, there were no differences between MIS-TKA and conventional TKA in terms of pain, function, malalignment, or revision rates. 
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Derek F Amanatullah, MD, PhD Assistant Professor, Department of Orthopedic Surgery, Stanford University School of Medicine
Derek F Amanatullah, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, American Medical Association, California Orthopedic Association, International Cartilage Repair Society, Orthopaedic Research Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Stanford University<br/>Received research grant from: OREF; OTCF; Stryker; Zimmer-Biomet; Roam Robotics<br/>Have a 5% or greater equity interest in: Arthrology Designs (DBA: PlantarTech), Arthrology Consulting, Ankaa Safe Assets<br/>Received income in an amount equal to or greater than $250 from: Stryker; Exactech; Ethicon<br/>Patents: Dynamic Tension Plantar Fasciitis Splint; Cool Cut Cast Saw, Modular Total Knee, Augmented Reality Arthroplasty; Surgical Instrument Visualization System for: Honoraria: WebMD.
Sahitya K Denduluri, MD Resident Physician, Department of Orthopedic Surgery, Stanford Hospital
Disclosure: Nothing to disclose.
Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates
Disclosure: Nothing to disclose.
Paul E Di Cesare, MD
Disclosure: Nothing to disclose.
Minimally Invasive Total Knee Arthroplasty
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