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Comparison of Quadriceps-Sparing and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials
Accepted Manuscript Comparison of Quadriceps-sparing and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials Gregory S. Kazarian, BA, Matthew Y. Siow, BA, Antonia F. Chen, MD, MBA, Carl A. Deirmengian, MD PII:
S0883-5403(17)30748-9
DOI:
10.1016/j.arth.2017.08.025
Reference:
YARTH 56055
To appear in:
The Journal of Arthroplasty
Received Date: 19 July 2017 Revised Date:
15 August 2017
Accepted Date: 17 August 2017
Please cite this article as: Kazarian GS, Siow MY, Chen AF, Deirmengian CA, Comparison of Quadriceps-sparing and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials, The Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2017.08.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Comparison of Quadriceps-sparing and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials
Gregory S. Kazarian BA1 Matthew Y. Siow BA1 Antonia F. Chen MD, MBA1 Carl A. Deirmengian MD1
Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Corresponding Author: Carl A. Deirmengian, MD Rothman Institute 925 Chestnut St. Philadelphia, PA 19107 P: 267-339-7873 F: 215-503-5651 [email protected]
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Running Title: Quadriceps-sparing and Medial Paraptellar Approaches in TKA
Each author certifies that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
Each author has contributed substantially to the research, preparation, and production of this paper and approves its submission to the Journal of Arthroplasty.
ACCEPTED MANUSCRIPT Comparison of Quadriceps-sparing and Medial Parapatellar Approaches in Total Knee
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Arthroplasty: A Meta-analysis of Randomized Controlled Trials
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Running Title: Quadriceps-sparing and Medial Paraptellar Approaches in TKA
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ABSTRACT
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hopes of improving outcomes associated with the medial parapatellar (MP) approach. There is no clear
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consensus on what advantages, if any, QS provides.
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Background: The quadriceps-sparing (QS) technique for total knee arthroplasty (TKA) was introduced in
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Methods: We performed a meta-analysis of randomized controlled trials (RCTs) comparing the QS and
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MP techniques. Pubmed, Ovid, and Scopus were assessed for relevant literature. Long-term (primary)
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outcomes and short-term (secondary) outcomes from 8 RCTs (579 TKAs) were analyzed using
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OpenMetaAnalyst (2016) software.
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Results: The QS approach did not demonstrate any clinically significant advantages, but was associated
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with statistically and clinically significant increases in the primary outcomes of femoral (OR=4.92,
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p=0.005), tibial (OR=4.34, p=0.01), and mechanical axis outliers (OR=4.77, p=0.004). Secondary
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outcomes assessments demonstrated increased surgical (MD=19.54, p<0.001) and tourniquet time
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(MD=23.30, p<0.001) for QS. While statistically significant advantages for QS were identified in Knee
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Society Function scores at 1.5-3 months (MD=2.31, p=0.004) and 2 years (MD=1.86, p<0.001), these
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were not clinically significant, as they fell well below the roughly 6-point minimal clinically important
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difference for this score.
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Conclusion: According to the highest-level existing literature, the QS approach to TKA fails to
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demonstrate any clinically significant advantages, but shows increased malalignment compared to MP.
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Based on findings from previous studies, this increased incidence of implant malalignment may
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predispose QS patients to early prosthesis failure. Because the QS approach increases the risk of
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malalignment while providing no clear benefit compared to MP, we recommend against the routine use of
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the QS approach in TKA. 2
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Keywords: Total Knee Arthroplasty; Medial-parapatellar Approach; Quadriceps-sparing Approach;
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Outcomes; Meta-analysis
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ACCEPTED MANUSCRIPT Background
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Total knee arthroplasty (TKA) is an extremely successful treatment for patients with end-stage
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osteoarthritis of the knee, and its utilization has grown immensely in recent decades [1-3]. As a result of
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this continued growth, an estimated 3.5 million TKAs will be performed annually by 2030 [4]. While the
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general efficacy of this procedure is largely undisputed among orthopaedic surgeons, there is
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disagreement as to the optimal surgical approach to TKA.
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The QS approach was introduced in an attempt to minimize tissue damage during TKA, and is considered
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one of the least invasive TKA techniques due to its minimal incision size and ability to spare the
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quadriceps muscle and insertion of the vastus medialis [5-9]. While the soft-tissue preservation associated
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with this approach could theoretically offer short- or long-term benefits to the patient, studies assessing
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the QS approach have demonstrated mixed results compared to traditional approaches. Some studies have
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suggested that the QS approach results in decreased need for narcotics, faster recovery times, shorter
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hospital length of stay, decreased blood loss, and improved functional outcomes [10-13]. Other studies,
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however, have demonstrated equivalent outcomes, but an increased risk of implant malalignment with the
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QS approach compared to traditional approaches [11, 14-17]. In concordance with the latter findings, the
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National Advertising Division of the Better Business Bureau recently recommended the discontinuation
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of advertisements describing a faster recovery associated with the QS knee approach, as there was
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insufficient evidence in the literature to support this claim [18].
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In order to determine whether any true statistically or clinically significant differences exist between the
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QS and MP approaches in TKA, we performed a meta-analysis of all available high-quality randomized
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controlled trials (RCTs) comparing these surgical procedures.
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ACCEPTED MANUSCRIPT Materials & Methods
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The current study was performed in accordance with the Preferred Reporting Items for Systematic Review
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and Meta-Analyses (PRISMA) guidelines [19], which established procedures for the rigorous
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performance and reporting of meta-analyses. No external funding was provided for the completion of this
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study.
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85 Database search
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Three different databases were used for the literature review in this meta-analysis: Pubmed, Ovid, and
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Scopus. The “basic search” function of Pubmed was queried using the phrase “medial parapatellar total
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quadriceps sparing knee.” The “Multi-Field-Search” function of the Journals@OvidFullText Database of
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Ovid was queried with the keywords “medial + parapatellar,” “total + knee,” and “quadriceps.” Scopus
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was queried with the keywords “medial parapatellar,” “quadriceps sparing,” and “total knee arthroplasty.”
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This search was performed in January 2017. No temporal limitations were placed on this search.
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The results of our database search were imported into EndNote X7 (Thomas Reuters, 2015). Duplicates
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were eliminated using EndNote X7 as previously described by Bramer et al. [20]. Following duplicate
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removal, two coauthors of this meta-analysis (GSK, MYS) reviewed each of the unique references
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identified in our literature review by title and abstract to assess their applicability to the current study
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according to our inclusion/exclusion criteria (detailed in the proceeding section). Sources not relevant to
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the current study were eliminated. References from relevant sources were screened to identify additional
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potentially relevant resources that were not detected in our database query.
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Inclusion/exclusion criteria
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Prior to the outset of our literature search, two separate inclusion/exclusion criteria were established, one
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to define the standard for clinical studies to be included in this analysis and one to define the standard for 5
ACCEPTED MANUSCRIPT data to be included. Inclusion criteria for clinical studies were as follows: true RCT comparing MP and
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QS approaches in TKA, and available translation in English. Studies were excluded if they were not true
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RCTs or if they did not compare the MP and QS approaches. Inclusion criteria for data were as follows:
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available mean and standard deviation or proportion (or ability to estimate standard deviation using data
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range), data available for ≥ 2 studies. Data was excluded if these descriptive statistics were not provided,
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if fewer than 2 studies included data on a given outcome, or if the data reported on navigation-assisted
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TKA.
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After identifying the literature relevant to this meta-analysis, demographic and outcomes data were
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collected from each study. Demographic data included study sample size, age, and body mass index
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(BMI). Data that fit our inclusion criteria and was available for our analysis included surgical time,
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tourniquet time, intraoperative blood loss, total blood loss, transfusion volume, scar size in extension, scar
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size in flexion, visual analog scale (VAS) pain on day 1, VAS pain on day 3, VAS pain at 2 months,
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Hospital for Special Surgery (HSS) knee score from 2 months, range of motion (ROM) at 1 week, ROM
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at 1-3 months, ROM at 16-24 months, length of stay (LOS), femoral, tibial, and mechanical axis outliers,
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overall femoral, tibial, and mechanical axis alignment, total complications, infection, and KSS Knee and
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Function scores at 1.5-3 and 24 months.
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Primary and secondary outcomes
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Available data comparing QS and MP groups was divided into primary and secondary outcomes based on
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potential for long-term clinical impact. ROM at 16-24 months, KSS Knee and Function scores at 2 years,
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complications, infections, and femoral, tibial, and mechanical axis outliers were selected as primary
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outcomes measures, while all other variables under assessment were considered secondary outcomes.
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Postoperative ROM at 16-24 months was included as a primary outcome because it has a demonstrable 6
ACCEPTED MANUSCRIPT impact on patient satisfaction after TKA [21]. KSS Knee and Function scores were also included as
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primary outcomes, as they are powerful measurement tools with extensive validation in assessing patient
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outcomes [22]. Complications and infection following TKA can have devastating long-term effects on
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patient outcomes, and implant alignment outliers can strongly contribute to early TKA failure and
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revision arthroplasty [23], warranting their inclusion as primary outcomes, as well.
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135 Risk of bias
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Recommendations issued by the Cochrane Handbook for Systematic Reviews were utilized in order to
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assess the quality of each study included in this meta-analysis. Each study was assessed for selection bias
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(random sequence generation and allocation concealment), performance bias (blinding of
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participants/personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete
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outcomes data), reporting bias (selective reporting), and other biases in accordance with the Cochrane
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Handbook for Systematic Reviews [24]. Risk of bias in the aforementioned categories was assessed by
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two authors (GSK, MYS) and designated as “High risk,” “Low risk,” or “Unknown risk.” Discordant
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assessments were settled by a third author (CAD).
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Statistical analysis
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Statistical analysis was performed using OpenMetaAnalyst (2016) software [25]. Dichotomous outcomes,
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including complications, infections, and femoral, tibial, and mechanical axis outliers were assessed using
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a binary effects model. The remaining variables were continuous, and were assessed with a continuous
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effects model. Results of binary effects models are presented as odds ratios (OR) and 95% confidence
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intervals (CI) for comparison of QS and MP groups, while results from continuous effects models are
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presented as mean differences (MD) and 95% CI.
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I2=0%, while high heterogeneity is indicated by I2=100%. Data groups with statistically significant
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(p<0.05) heterogeneity (I2) were assessed using the DerSimonian-Laird random effects model, while a
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fixed-effect inverse variance model was used when heterogeneity was not statistically significant.
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Certain studies included in this meta-analysis provided data ranges (maximum and minimum values)
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rather than standard deviations. In these instances, standard deviation (SD) was estimated as the
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difference between the maximum and minimum values divided by 4 [26], which serves as a conservative
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estimate of SD.
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163 Results
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Database search
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Our database search yielded an initial 303 records. After removal of duplicates, 274 unique records were
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identified. A total of 233 records were excluded based on abstract review, leaving 41 articles for full-text
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review. Following full-text review, 8 RCTs comparing QS to MP approaches were available for meta-
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analysis. The PRISMA flow diagram detailing our literature search is shown in Figure 1.
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Included studies and patient demographics
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Table 1 lists the 8 RCTs included in our analysis, along with sample size, percent of males, average age,
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average BMI, and relevant conclusions for each study. Five of these 8 (62.5%) studies favored the MP
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approach, while 3 (37.5%) favored the QS approach. A total of 579 TKAs were included for analysis,
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with 289 undergoing QS TKA and 290 undergoing MP TKA. Demographic differences were not
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statistically significant between groups. The average age in the QS group was 67.8 (63.5-73.8) years,
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while the average age in the MP group was 67.5 (63.4-73.7) years (p=0.67). The QS group was 21%
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(0.0%-40.0%) male while the MP group was 22.0% (0.0%-47.0%) male (p=0.32). The average BMI was
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similar between groups, as the average BMI was 27.6 (25.2-28.6) kg/m2 in the QS group and 28.4 (25.2-
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29.6) kg/m2 in the MP group (p=0.46).
181 Quality assessment of the included studies is shown in Table 2. One hundred percent of studies were
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randomized, 50% utilized allocation concealment (50% unknown), 50% were blinded to participants and
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personnel (50% unknown), 80% were blinded to outcome assessments (20% unknown), 100% had
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incomplete data outcomes, and 25% selectively reported data (75% unknown). It was impossible to detect
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other biases with the given data (100% unknown).
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Primary outcomes
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Our meta-analysis of primary outcomes demonstrated no differences in favor of QS that were both
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statistically and clinically significant. There were no statistical differences between the QS and MP
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approaches in ROM at 16-24 months (MD=-0.31, 95% CI: [-2.14, 1.51], I2=0.0%, p=0.74), KSS Knee
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scores at 2 years (MD=-0.18, 95% CI: [-1.13, 0.77], I2=24.9%, p=0.71), complications (OR=1.99, 95%
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CI: [0.91, 4.36], I2=0.0%, p=0.09), or infections (OR=1.73, 95% CI: [0.55, 5.49], I2=0.0%, p=0.35). The
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QS group was associated with statically significant increases in femoral angle outliers (OR=4.92, 95% CI:
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[1.62, 14.96], I2=0.0%, p=0.005), tibial angle outliers (OR=4.34, 95% CI: [1.42, 13.29], I2=0.0%,
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p=0.01), and mechanical axis outliers (OR=4.77, 95% CI: [1.66, 13.36], I2=0.0%, p=0.004). While our
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meta-analysis did demonstrate statistically significant differences in KSS Function scores at 2 years in
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favor of QS (MD=1.86, 95% CI: [0.86, 2.85], I2=0.0%, p<0.001), this difference of 1.86 points falls
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below the minimal clinically important difference (MCID) of roughly 6 points [27]. Results are
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summarized in Table 3.
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Secondary outcomes
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statistically and clinically significant. There were statistically and clinically significant differences in
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favor of the MP group in surgical time (MD=19.54, 95% CI: [11.34, 27.74], I2=91.6%, p<0.001) and
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tourniquet time (MD=23.30, 95% CI: [7.50, 39.10], I2=98.8%, p<0.001). While our meta-analysis did
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demonstrate statistically significant differences in KSS Function scores at 1.5-3 months in favor of QS
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(MD=2.31, 95% CI: [0.75, 3.89], I2=66.9%, p=0.004), this difference of 2.31 points once again falls
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below the MCID for KSS [27]. No other statistical differences were detected for any of the secondary
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outcomes under assessment, as demonstrated in Table 4.
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Discussion
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The QS TKA technique was introduced in 2003 by Tria and Coon [28] in hopes of addressing issues
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associated with the MP approach. By avoiding violation of the extensor mechanism and vastus medialis,
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the goal of this approach was to increase the speed of recovery and ROM after TKA. Furthermore, this
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exposure aimed to reduce the extent of patellar de-vascularization [5], which can lead to patellar fracture,
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avascular necrosis, subluxation, dislocation, patellar component loosening, and anterior knee pain [6, 28].
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Various studies, including those assessed in this meta-analysis, have suggested improvements in short-
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and long-term outcomes for the QS approach. These purported advantages include, but are not limited to,
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improvements in KSS score, VAS pain scores, ROM, as well as earlier rehabilitation and activity
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milestones, and others [29-32]. The potential advantages associated with the QS approach, however, come
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at the cost of a smaller incision, which minimizes the surgical viewing window and may increase the
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technical difficulty of this procedure. Not surprisingly, therefore, other studies have shown benefits in
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favor of the MP approach, the most important of which are decreases in the incidence of implant
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alignment outliers [29-31, 33, 34]. Given these discordant findings, we performed a meta-analysis of the
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available RCTs in order to determine the comparative advantages of these procedures.
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differences in favor of the MP approach, but failed to identify any differences that were both statistically
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and clinically significant in favor of QS. We identified large increases in the odds ratios of femoral (4.92),
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tibial (4.34), and mechanical axis outliers (4.77) for the QS approach. As demonstrated by findings in
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Ritter et al. [23], such outliers may be associated with statistically significant increases in implant failure
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rates. Therefore, QS TKA may be associated with a higher risk of implant failure and revision TKA.
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Given the high cost and negative impacts on quality-of-life associated with revision surgery, this
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disadvantage of the QS approach is clinically and financially relevant, and should be strongly considered
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when making determinations of the optimal surgical approach for TKA.
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Our meta-analysis also identified a statistically significant, but clinically insignificant, mean difference of
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1.86 points between the QS and MP groups in terms of KSS function at 2 years. While the MCID has not
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been formally defined by the Knee Society, it has been described as 6.4 (95% CI: [4.4, 8.4]) based on
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regression comparison to satisfaction scores and 6.1 (95% CI: [5.1, 7.1]) via comparison to the Oxford
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Knee Score [27]. Therefore, though the mean difference identified in this meta-analysis was statistically
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significant, it falls well below the threshold for clinical significance according to the MCID cutoff. No
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other long-term primary outcomes demonstrated statistically significant differences between approaches.
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In our assessment of secondary outcomes, we identified statistically and clinically significant differences
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in favor of MP in surgical time and tourniquet, but failed to identify any differences that were both
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statistically and clinically significant in favor of QS. While there is some evidence indicating that
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increased surgical time may increase the rate of surgical site infection following surgery [35], we assessed
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this variable largely from the stand-point of surgeon preference and resource utilization. We believe that
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the roughly 20-minute decrease in surgical time and tourniquet time associated with the MP approach
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makes it preferable from the standpoint of surgeon convenience and operative costs, especially given the
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associated with a statistically significant 2.31-point increase in KSS Function score at 1.5-3 months, this
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again falls well below the MCID of roughly 6.0 points as described above [27], and we do not believe that
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this finding is clinically significant. No other secondary outcomes demonstrated statistically significant
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differences between approaches.
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The findings of our meta-analysis are in partial disagreement with the results and conclusions of a recent
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meta-analysis by Peng et al. [36]. These differences result from disagreement in the studies included in
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our respective meta-analyses, as well as differences in both the interpretation and selection of presented
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data. Though both meta-analyses were designed to include data from RCTs comparing the QS approach to
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the MP approach, it is our opinion that Peng et al. included studies that violated its exclusion criteria, and
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excluded studies that met its inclusion criteria. The inclusion of Shen at al. [10], a study in which results
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from the QS group were compared to an “age-matched and sex-match[ed] cohort,” to serve as the MP
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group, demonstrates a failure to include only true RCTs. The inclusion of Tasker et al. [37], a study in
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which the choice between the “mini-midvastus or subvastus approach [was performed] according to
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surgeon preference” in the QS group, demonstrates both a failure to include only true RCTs and a failure
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to include only studies assessing the true QS approach. Finally, the meta-analysis of Peng et al. did not
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include a study by Chin et al. [38] that qualified for inclusion in this meta-analysis. These deviations led
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to the inappropriate inclusion of two studies that reported results in favor of QS, and the exclusion of a
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study that reported results in favor of MP, biasing results in favor of QS.
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While, both studies identified similar statistically significant differences in short- and long-term KSS
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scores in favor of the QS approach, we drew different conclusions regarding the clinical significance of
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these differences in KSS score. Unlike Peng et al., we do not believe the roughly 2-3 point mean
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differences in KSS score reported in either study bear clinical significance. These differences should not 12
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be reported as a true clinical advantage for the QS approach. Our study is in agreement with Peng et al.
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regarding the statistically and clinically significant decreases in surgical time in favor of the MP approach.
280 Our study results further differ from Peng et al. in that we did not identify differences in VAS pain score
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between groups. We performed an analysis of VAS pain on Days 1 and 2, as well as at 2 months, and
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were unable to detect a difference between the groups. These differences are likely due to the previously
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described issues with adherence to inclusion/exclusion criteria. Regardless of the etiology of this
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difference in findings, the statistically significant of 0.69 point VAS pain difference described by Peng et
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al. falls well below the VAS pain MCID of roughly 2 points [39, 40]. Therefore, decreased pain should
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not be described as a clinical advantage of the QS approach.
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Perhaps the most important difference between our studies is that we were able to gather sufficient data to
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perform an analysis of implant alignment outliers, which was not performed by Peng et al.. We believe
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that the omission of this analysis, which showed large statistically and clinically significant increases in
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the risk of implant malalignment associated with the QS approach, contributed to errant conclusions
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drawn by Peng et al. in favor of the QS approach.
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This meta-analysis had many strengths, including 1) the use of high-quality RCTs as the source of data,
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and 2) assessment of the largest number of outcomes variables of any meta-analysis comparing the QS
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and MP approaches. It also had many weaknesses, including 1) omission of outcomes data that was
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described in fewer than two studies, 2) risk of bias in the included studies, 3) heterogeneity of the
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included data, 4) estimation of standard deviation when only data range was provided, and 5) study cohort
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BMI that may not represent the general population (27.6 kg/m2 and 28.4 kg/m2 in the QS and MP groups,
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respectively). We believe, however, that this active low-BMI population gave the QS approach the
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greatest potential to exhibit its purported benefits. The lack of clinically significant advantages for the QS
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approach in this study helps to demonstrate that it confers no benefit, even in a relatively optimal patient
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population.
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The results of this meta-analysis demonstrate statistically and clinically significant disadvantages for the
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QS approach compared to the MP approach in terms of surgical time, tourniquet time, and incidence of
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femoral, tibial, and mechanical axis outliers. Based on findings from previous studies, the increased
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incidence of implant malalignment associated with QS may predispose patients to early TKA failure.
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Furthermore, the QS approach fails to demonstrate any clinically significant advantage over the MP
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approach in this meta-analysis. Based on these findings, we recommend against the routine use of the QS
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approach in TKA, and also recommend against the suggestion that the QS approach offers the patient any
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clinically significant advantage over the MP approach.
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References 1. Cram P, Lu X, Kates S, Singh J, Li Y, Wolf B. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA 308(12): 1227, 2012 2. Felson D, Lawrence R, Dieppe P, Hirsch R, Helmick C, JM J, Kington R, Lane N, Nevitt M, Zhang Y, Sowers M, McAlindon T, Spector T, Poole A, Yanovski S, Ateshian G, Sharma L, Buckwalter J, Brandt K, Fries J. Osteoarthritis: New Insights. Part 1: The Disease and Its Risk Factors. Annals of Internal Medicine 133(8): 635, 2000 3. Bachmeier C, March L, Cross M, Lapsley H, Tribe K, Courtenay B, Brooks P, Group tACaOP. A comparison of outcomes in osteoarthritis patients undergoing total hip and knee replacement surgery. Osteoarthritis and Cartilage 9: 137, 2001 4. Kurtz S, Ong K, Lau E, Mowat F, M H. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89(4): 780, 2007 5. Niki Y, Mochizuki T, Momohara S, Saito S, Toyama Y, Matsumoto H. Is minimally invasive surgery in total knee arthroplasty really minimally invasive surgery? J Arthroplasty 24(4): 499, 2009 6. Hofmann AA, Plaster RL, Murdock LE. Subvastus (Southern) approach for primary total knee arthroplasty. Clin Orthop Relat Res (269): 70, 1991 7. Scuderi GR, Tenholder M, Capeci C. Surgical approaches in mini-incision total knee arthroplasty. Clin Orthop Relat Res (428): 61, 2004 8. Scuderi G, Tenholder M, Capeci C. Surgical approaches in mini-incision total knee arthroplasty. Clinical orthopaedics and related research 428: 61, 2004 9. Aglietti P, Baldini A, Sensi L. Quadriceps-sparing versus mini-subvastus approach in total knee arthroplasty. Clinical orthopaedics and related research 452: 106, 2006 10. Shen H, Zhang X, Wang Q, Shao J, Jiang Y. Minimally invasive total knee arthroplasty through a quadriceps sparing approach: a comparative study. Zhonghua wai ke za zhi [Chinese journal of surgery] 45(16): 1083, 2007 11. Lin W, Lin J, Horng L, Chang S, Jiang C. Quadriceps-sparing, minimal-incision total knee arthroplasty: a comparative study. The Journal of Arthroplasty 24(7): 1024, 2009 12. Kim J, Lee S, Ha J, Choi H, Yang S, Lee M. The effectiveness of minimally invasive total knee arthroplasty to preserve quadriceps strength: a randomized controlled trial. The Knee 18(6): 443, 2011 13. Pescador D, Moreno A, Blanco J, García I. Long-term analysis of minimally invasive surgery in knee arthroplasty. Acta Ortop Mex 25(6): 353, 2011 14. Gandhi R, Smith H, Lefaivre K, Davey J, Mahomed N. Complications after minimally invasive total knee arthroplasty as compared with traditional incision techniques: a meta-analysis. The Journal of Arthroplasty 26(1): 29, 2011 15. Kim Y, Kim J, Kim D. Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. Bone & Joint Journal 89(4): 467, 2007 16. Chiang H, Lee C, Lin W, Jiang C. Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. Journal of the Formosan Medical Association 111(12): 698, 2012 17. Dayton M, Bade M, Muratore T, Shulman B, Kohrt W, Stevens-Lapsley J. Minimally invasive total knee arthroplasty: surgical implications for recovery. The Journal of Knee Surgery 26(3): 195, 2013 18. NAD Recommends Virtua Health System Discontinue Challenged Claims for ‘Quad-Sparing’ Knee Replacement Surgery. In. ASRC Reviews. 2014 15
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19. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. Open Med 3(3): e123, 2009 20. Bramer WM, Giustini D, de Jonge GB, Holland L, Bekhuis T. De-duplication of database search results for systematic reviews in EndNote. J Med Libr Assoc 104(3): 240, 2016 21. Matsuda S, Kawahara S, Okazaki K, Tashiro Y, Iwamoto Y. Postoperative alignment and ROM affect patient satisfaction after TKA. Clin Orthop Relat Res 471(1): 127, 2013 22. Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott WN. The new Knee Society Knee Scoring System. Clin Orthop Relat Res 470(1): 3, 2012 23. Ritter MA, Davis KE, Meding JB, Pierson JL, Berend ME, Malinzak RA. The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg Am 93(17): 1588, 2011 24. Cochrane Handbook for Systematic Reviews of Interventions. Online Kensaku 35(3): 154, 2014 25. Wallace B, Lajeunesse M, Dietz G, Issa J. Dahabreh, Trikalinos T, Schmid C, Gurevitch J. OpenMEE: Intuitive, open-source software for meta analysis in ecology and evolutionary biology. . In. http://onlinelibrary.wiley.com/doi/10.1111/2041-210X.12708/full. 2016 26. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5: 13, 2005 27. Lee WC, Kwan YH, Chong HC, Yeo SJ. The minimal clinically important difference for Knee Society Clinical Rating System after total knee arthroplasty for primary osteoarthritis. Knee Surg Sports Traumatol Arthrosc, 2016 28. Tria AJ, Jr., Coon TM. Minimal incision total knee arthroplasty: early experience. Clin Orthop Relat Res (416): 185, 2003 29. Lin SY, Chen CH, Fu YC, Huang PJ, Lu CC, Su JY, Chang JK, Huang HT. Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone and Joint Journal 95 B(7): 906, 2013 30. Lin WP, Lin J, Horng LC, Chang SM, Jiang CC. Quadriceps-Sparing, Minimal-Incision Total Knee Arthroplasty. A Comparative Study. Journal of Arthroplasty 24(7): 1024, 2009 31. Kim YH, Kim JS, Kim DY. Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. J Bone Joint Surg Br 89(4): 467, 2007 32. Karpman RR, Smith HL. Comparison of the early results of minimally invasive vs standard approaches to total knee arthroplasty: a prospective, randomized study. J Arthroplasty 24(5): 681, 2009 33. Chiang H, Lee CC, Lin WP, Jiang CC. Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. J Formos Med Assoc 111(12): 698, 2012 34. Chen AF, Alan RK, Redziniak DE, Tria AJ, Jr. Quadriceps sparing total knee replacement. The initial experience with results at two to four years. J Bone Joint Surg Br 88(11): 1448, 2006 35. Peersman G, Laskin R, Davis J, Peterson MG, Richart T. Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS J 2(1): 70, 2006 36. Peng X, Zhang X, Cheng T, Cheng M, Wang J. Comparison of the quadriceps-sparing and subvastus approaches versus the standard parapatellar approach in total knee arthroplasty: a metaanalysis of randomized controlled trials. BMC Musculoskelet Disord 16: 327, 2015 37. Tasker A, Hassaballa M, Murray J, Lancaster S, Artz N, Harries W, Porteous A. Minimally invasive total knee arthroplasty; a pragmatic randomised controlled trial reporting outcomes up to 2 year follow up. Knee 21(1): 189, 2014 38. Chin PL, Foo LS, Yang KY, Yeo SJ, Lo NN. Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty 22(6): 800, 2007
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39. Katz NP, Paillard FC, Ekman E. Determining the clinical importance of treatment benefits for interventions for painful orthopedic conditions. J Orthop Surg Res 10: 24, 2015 40. Tubach F, Ravaud P, Baron G, Falissard B, Logeart I, Bellamy N, Bombardier C, Felson D, Hochberg M, van der Heijde D, Dougados M. Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important improvement. Ann Rheum Dis 64(1): 29, 2005
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Table 1: Summary of studies included in meta-analysis.
Lin [1] Lin [2] Kim [3] Karpman [4] Chiang [5] Chin [6] Xu [7] Matsumoto [8]
QS: 30 MP: 30 QS: 35 MP: 35 QS: 120 MP: 120 QS: 20 MP: 19 QS: 38 MP: 37 QS: 30 MP: 30 QS: 26 MP: 29 QS: 25 MP: 25
% Male 10.0% 10.0% 14.3% 14.3% 22.5% 22.5% 40.0% 47.0% 33.3% 33.3% 20.0% 10.0% 27.0% 38.0% 0.0% 0.0%
Age (years) 69.6 (5.3) 70.2 (6.5) 67.7 (5.0) 68.5 (5.5) 65.4 (11.3) 65.4 (11.3) 73.0 (7.4) 73.0 (5.1) 69.7 (5.3) 69.8 (5.4) 69 (5.8) 63.4 (8.3) 63.5 (8.7) 64.2 (9.3) 73.8 (1.7) 73.7 (1.4)
BMI (kg/m2) 28.1 (4.2) 29.0 (4.2) 26.3 (2.5) 25.9 (2.6) 28.1 (4.25) 28.1 (4.25) 28.0 (4.4) 29 (4.6) 28.6 (3.8) 29.6 (3.5) 27.53 (3.9) 29.44 (4.3) 25.2 (3.4) 25.2 (2.3) -
Relevant Conclusions - QS did not improve short-term clinical or radiographic outcomes. - QS increased varus postoperative alignment. - QS did not improve short-term clinical or radiographic outcomes. - QS increased ST and radiographic outliers. - QS did not improve long-term clinical or radiographic outcomes. - QS increased ST and TT. - QS improved short-term clinical outcomes. - QS did not improve long-term clinical or radiographic outcomes. - QS did not improve short-term clinical outcomes. - QS increased ST and TT. - QS was associated with decreased implant alignment accuracy.
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- QS improved short-term clinical outcomes. - QS did not improve long-term clinical or radiographic outcomes. - QS was associated with smaller surgical incisions.
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Numbers are expressed as mean (standard deviation) (BMI = body mass index; QS = quadriceps-sparing; MP = medial parapatellar; ST = surgical time; TT = tourniquet time).
References
4.
5. 6. 7. 8.
9.
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Lin, W.P., et al., Quadriceps-Sparing, Minimal-Incision Total Knee Arthroplasty. A Comparative Study. Journal of Arthroplasty, 2009. 24(7): p. 1024-1032. Lin, S.Y., et al., Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone and Joint Journal, 2013. 95 B(7): p. 906-910. Kim, Y.H., J.S. Kim, and D.Y. Kim, Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. J Bone Joint Surg Br, 2007. 89(4): p. 467-70. Karpman, R.R. and H.L. Smith, Comparison of the early results of minimally invasive vs standard approaches to total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 2009. 24(5): p. 681-8. Chiang, H., et al., Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. J Formos Med Assoc, 2012. 111(12): p. 698-704. Chin, P.L., et al., Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty, 2007. 22(6): p. 800-6. Xu, J., et al., Total knee arthroplasty: Comparison between quadriceps sparing approach and medial parapatellar approach. Chinese Journal of Tissue Engineering Research, 2013. 17(35): p. 6240-6246. Matsumoto, T., et al., Soft tissue balance measurement in minimal incision surgery compared to conventional total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy, 2011. 19(6): p. 880-886. Cochrane Handbook for Systematic Reviews of Interventions. Online Kensaku, 2014. 35(3): p. 154-155.
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Results Favor? MP MP MP QS MP MP QS QS
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Table 2: Risk of bias.
Lin [2] Kim [3] Karpman [4] Chiang [5] Chin [6] Xu [7] Matsumoto [8]
Allocation concealment
Blinding of participants and personnel Yes
Blinding of outcome assessment Yes
Incomplete outcome data
Selective Reporting
Other Bias
Yes Computer Yes Randomization table Yes Randomization table Yes Computer Yes Computer Yes Randomization table Yes Randomization table Yes -
Sealed envelope Sealed envelope Unknown
Yes
Unknown
Unknown
Unknown
Yes
Yes
Unknown
Unknown
Unknown
Yes
Unknown
Yes
Yes
Unknown
Yes
Yes
Sealed envelope Sealed envelope Unknown
Unknown
Yes
Unknown
Unknown
Yes
Unknown
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Lin [1]
Random sequence generation
Yes
Unknown
Unknown
Yes
Unknown
Unknown
Yes
Yes
Unknown
Yes
Yes
Unknown
Yes
Unknown
Unknown
Unknown
Unknown
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Yes
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Table demonstrates selection bias, performance bias, detection bias, attrition bias, reporting bias, and other biases in accordance with the Cochrane Handbook for Systematic Reviews [9].
References
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5. 6. 7. 8.
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Lin, W.P., et al., Quadriceps-Sparing, Minimal-Incision Total Knee Arthroplasty. A Comparative Study. Journal of Arthroplasty, 2009. 24(7): p. 1024-1032. Lin, S.Y., et al., Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone and Joint Journal, 2013. 95 B(7): p. 906-910. Kim, Y.H., J.S. Kim, and D.Y. Kim, Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. J Bone Joint Surg Br, 2007. 89(4): p. 467-70. Karpman, R.R. and H.L. Smith, Comparison of the early results of minimally invasive vs standard approaches to total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 2009. 24(5): p. 681-8. Chiang, H., et al., Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. J Formos Med Assoc, 2012. 111(12): p. 698-704. Chin, P.L., et al., Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty, 2007. 22(6): p. 800-6. Xu, J., et al., Total knee arthroplasty: Comparison between quadriceps sparing approach and medial parapatellar approach. Chinese Journal of Tissue Engineering Research, 2013. 17(35): p. 6240-6246. Matsumoto, T., et al., Soft tissue balance measurement in minimal incision surgery compared to conventional total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy, 2011. 19(6): p. 880-886. Cochrane Handbook for Systematic Reviews of Interventions. Online Kensaku, 2014. 35(3): p. 154-155.
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Table 3: Primary outcomes. Number of contributing studies
Number QS TKAs
Number MP TKAs
MD or OR (95% CI)
3
193
192
-0.31 (-2.14, 1.51)
2
155
155
2
155
155
4
133
132
4
133
132
3
95
95
4
196
198
8
324
325
Infection
p-value
Heterogeneity
0.736
0.0%
<0.001
0.0%
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1.86 (0.86, 2.85) -0.18 (-1.13, 0.77) 4.92 (1.62, 14.96) 4.34 (1.42, 13.29) 4.77 (1.66, 13.36) 1.99 (0.91, 4.36) 1.73 (0.55, 5.49)
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Outcomes & Demographics ROM 16-24 Months (º) KSS Function 2 years KSS Knee 2 years Femoral Angle Outliers Tibial Angle Outliers Mechanical Axis Outliers Complications
0.709
24.9%
0.005
0.0%
0.010
0.0%
0.004
0.0%
0.087
0.0%
0.352
0.0%
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Italics indicate that ORs were used for comparison, while standard font indicates the use of MD for comparison. Bold indicates a statistically significant p-value (QS = quadriceps-sparing; MP = medial parapatellar; TKA = total knee arthroplasty; MD = mean difference; OR = odds ratio; ROM = range of motion; KSS = Knee Society Score).
References
4.
5. 6. 7. 8.
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Lin, W.P., et al., Quadriceps-Sparing, Minimal-Incision Total Knee Arthroplasty. A Comparative Study. Journal of Arthroplasty, 2009. 24(7): p. 1024-1032. Lin, S.Y., et al., Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone and Joint Journal, 2013. 95 B(7): p. 906-910. Kim, Y.H., J.S. Kim, and D.Y. Kim, Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. J Bone Joint Surg Br, 2007. 89(4): p. 467-70. Karpman, R.R. and H.L. Smith, Comparison of the early results of minimally invasive vs standard approaches to total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 2009. 24(5): p. 681-8. Chiang, H., et al., Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. J Formos Med Assoc, 2012. 111(12): p. 698-704. Chin, P.L., et al., Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty, 2007. 22(6): p. 800-6. Xu, J., et al., Total knee arthroplasty: Comparison between quadriceps sparing approach and medial parapatellar approach. Chinese Journal of Tissue Engineering Research, 2013. 17(35): p. 6240-6246. Matsumoto, T., et al., Soft tissue balance measurement in minimal incision surgery compared to conventional total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy, 2011. 19(6): p. 880-886. Cochrane Handbook for Systematic Reviews of Interventions. Online Kensaku, 2014. 35(3): p. 154-155.
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Table 4: Secondary outcomes.
6
264
265
4
223
222
3
188
187
5
238
3
Heterogeneity
<0.001
91.6%*
<0.001
98.8%*
1.33 (-21.29, 23.95)
0.908
0.0%
236
-17.10 (-61.68, 27.48)
0.452
0.0%
88
86
48.36 (-107.25, 203.97)
0.542
76.0%*
4
195
194
-2.43 (-6.18, 1.32)
0.204
99.7%*
3
184
186
0.053
98.3%*
4
123
121
0.735
0.0%
2
68
67
0.221
0.0%
2
68
0.205
0.0%
2
68
0.126
0.0%
2
58
0.748
19.3%
4
213
4
196
5
5
3
2 2 2
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VAS Pain Month 2 HSS Knee Score at 2-3 months ROM Week 1 (º) ROM 1-3 Months (º) LOS (days) Femoral Angle Alignment (º) Tibial Angle Alignment (º) Mechanical Axis Alignment (º) KSS Function Score 1.5-3 months KSS Knee Score 1.5-3 months SLR at 24 hours (% of patients)
p-value
67 67 56
-1.88 (-3.78, 0.03) -0.07 (-0.48, 0.34) -0.35 (-0.92, 0.21) 0.40 (-0.22, 1.02) -1.80 (-4.12, 0.51) 0.84 (-4.26, 5.92)
211
-0.18 (-1.66, 1.30)
0.811
55.27%
198
-0.28 (-0.90, 0.35)
0.384
64.2%*
249
251
-0.18 (-1.64, 1.28)
0.809
96.0%*
249
251
-0.17 (-1.34, 1.00)
0.779
93.9%*
91
94
1.14 (-.02, 2.30)
0.054
78.2%*
155
155
2.31 (0.75, 3.89)
0.004
66.9%
155
155
0.379
79.7%*
65
65
0.267
0.0%
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VAS Pain Day 3
MD (95% CI) 19.54 (11.34, 27.74) 23.30 (7.50, 39.10)
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No. MP TKAs
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No. QS TKAs
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No. of contributing studies
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Outcomes & Demographics Surgical Time (minutes) Tourniquet Time (minutes) Intraoperative Blood Loss (mL) Total Blood Loss (mL) Transfusion Volume (mL) Scar Size, extension (cm) Scar Size, flexion (cm) VAS Pain Day 1
0.92 (-1.13, 2.98) 1.53 (0.72, 6.26)
*Indicates that that heterogeneity was statistically significant. Bold indicates a statistically significant p-value (QS = quadriceps-sparing; MP = medial parapatellar; TKA = total knee arthroplasty; MD = mean difference; ROM = range of motion; KSS = Knee Society Score; VAS = visual analog scale; HSS = Hospital for Special Surgery; LOS = length of stay; SLR = straight-leg raise).
References 1.
Lin, W.P., et al., Quadriceps-Sparing, Minimal-Incision Total Knee Arthroplasty. A Comparative Study. Journal of Arthroplasty, 2009. 24(7): p. 1024-1032.
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Lin, S.Y., et al., Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone and Joint Journal, 2013. 95 B(7): p. 906-910. Kim, Y.H., J.S. Kim, and D.Y. Kim, Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. J Bone Joint Surg Br, 2007. 89(4): p. 467-70. Karpman, R.R. and H.L. Smith, Comparison of the early results of minimally invasive vs standard approaches to total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 2009. 24(5): p. 681-8. Chiang, H., et al., Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. J Formos Med Assoc, 2012. 111(12): p. 698-704. Chin, P.L., et al., Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty, 2007. 22(6): p. 800-6. Xu, J., et al., Total knee arthroplasty: Comparison between quadriceps sparing approach and medial parapatellar approach. Chinese Journal of Tissue Engineering Research, 2013. 17(35): p. 6240-6246. Matsumoto, T., et al., Soft tissue balance measurement in minimal incision surgery compared to conventional total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy, 2011. 19(6): p. 880-886. Cochrane Handbook for Systematic Reviews of Interventions. Online Kensaku, 2014. 35(3): p. 154-155.
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Figure Legend
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Figure 1. PRISMA flow diagram detailing the literature review.
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S0883-5403(17)30748-9
DOI:
10.1016/j.arth.2017.08.025
Reference:
YARTH 56055
To appear in:
The Journal of Arthroplasty
Received Date: 19 July 2017 Revised Date:
15 August 2017
Accepted Date: 17 August 2017
Please cite this article as: Kazarian GS, Siow MY, Chen AF, Deirmengian CA, Comparison of Quadriceps-sparing and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials, The Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2017.08.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Comparison of Quadriceps-sparing and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials
Gregory S. Kazarian BA1 Matthew Y. Siow BA1 Antonia F. Chen MD, MBA1 Carl A. Deirmengian MD1
Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Corresponding Author: Carl A. Deirmengian, MD Rothman Institute 925 Chestnut St. Philadelphia, PA 19107 P: 267-339-7873 F: 215-503-5651 [email protected]
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Running Title: Quadriceps-sparing and Medial Paraptellar Approaches in TKA
Each author certifies that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
Each author has contributed substantially to the research, preparation, and production of this paper and approves its submission to the Journal of Arthroplasty.
ACCEPTED MANUSCRIPT Comparison of Quadriceps-sparing and Medial Parapatellar Approaches in Total Knee
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Arthroplasty: A Meta-analysis of Randomized Controlled Trials
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Running Title: Quadriceps-sparing and Medial Paraptellar Approaches in TKA
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ABSTRACT
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hopes of improving outcomes associated with the medial parapatellar (MP) approach. There is no clear
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consensus on what advantages, if any, QS provides.
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Background: The quadriceps-sparing (QS) technique for total knee arthroplasty (TKA) was introduced in
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Methods: We performed a meta-analysis of randomized controlled trials (RCTs) comparing the QS and
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MP techniques. Pubmed, Ovid, and Scopus were assessed for relevant literature. Long-term (primary)
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outcomes and short-term (secondary) outcomes from 8 RCTs (579 TKAs) were analyzed using
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OpenMetaAnalyst (2016) software.
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Results: The QS approach did not demonstrate any clinically significant advantages, but was associated
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with statistically and clinically significant increases in the primary outcomes of femoral (OR=4.92,
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p=0.005), tibial (OR=4.34, p=0.01), and mechanical axis outliers (OR=4.77, p=0.004). Secondary
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outcomes assessments demonstrated increased surgical (MD=19.54, p<0.001) and tourniquet time
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(MD=23.30, p<0.001) for QS. While statistically significant advantages for QS were identified in Knee
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Society Function scores at 1.5-3 months (MD=2.31, p=0.004) and 2 years (MD=1.86, p<0.001), these
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were not clinically significant, as they fell well below the roughly 6-point minimal clinically important
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difference for this score.
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Conclusion: According to the highest-level existing literature, the QS approach to TKA fails to
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demonstrate any clinically significant advantages, but shows increased malalignment compared to MP.
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Based on findings from previous studies, this increased incidence of implant malalignment may
27
predispose QS patients to early prosthesis failure. Because the QS approach increases the risk of
28
malalignment while providing no clear benefit compared to MP, we recommend against the routine use of
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the QS approach in TKA. 2
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Keywords: Total Knee Arthroplasty; Medial-parapatellar Approach; Quadriceps-sparing Approach;
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Outcomes; Meta-analysis
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Total knee arthroplasty (TKA) is an extremely successful treatment for patients with end-stage
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osteoarthritis of the knee, and its utilization has grown immensely in recent decades [1-3]. As a result of
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this continued growth, an estimated 3.5 million TKAs will be performed annually by 2030 [4]. While the
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general efficacy of this procedure is largely undisputed among orthopaedic surgeons, there is
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disagreement as to the optimal surgical approach to TKA.
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The QS approach was introduced in an attempt to minimize tissue damage during TKA, and is considered
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one of the least invasive TKA techniques due to its minimal incision size and ability to spare the
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quadriceps muscle and insertion of the vastus medialis [5-9]. While the soft-tissue preservation associated
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with this approach could theoretically offer short- or long-term benefits to the patient, studies assessing
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the QS approach have demonstrated mixed results compared to traditional approaches. Some studies have
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suggested that the QS approach results in decreased need for narcotics, faster recovery times, shorter
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hospital length of stay, decreased blood loss, and improved functional outcomes [10-13]. Other studies,
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however, have demonstrated equivalent outcomes, but an increased risk of implant malalignment with the
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QS approach compared to traditional approaches [11, 14-17]. In concordance with the latter findings, the
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National Advertising Division of the Better Business Bureau recently recommended the discontinuation
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of advertisements describing a faster recovery associated with the QS knee approach, as there was
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insufficient evidence in the literature to support this claim [18].
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In order to determine whether any true statistically or clinically significant differences exist between the
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QS and MP approaches in TKA, we performed a meta-analysis of all available high-quality randomized
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controlled trials (RCTs) comparing these surgical procedures.
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ACCEPTED MANUSCRIPT Materials & Methods
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The current study was performed in accordance with the Preferred Reporting Items for Systematic Review
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and Meta-Analyses (PRISMA) guidelines [19], which established procedures for the rigorous
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performance and reporting of meta-analyses. No external funding was provided for the completion of this
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study.
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85 Database search
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Three different databases were used for the literature review in this meta-analysis: Pubmed, Ovid, and
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Scopus. The “basic search” function of Pubmed was queried using the phrase “medial parapatellar total
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quadriceps sparing knee.” The “Multi-Field-Search” function of the Journals@OvidFullText Database of
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Ovid was queried with the keywords “medial + parapatellar,” “total + knee,” and “quadriceps.” Scopus
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was queried with the keywords “medial parapatellar,” “quadriceps sparing,” and “total knee arthroplasty.”
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This search was performed in January 2017. No temporal limitations were placed on this search.
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The results of our database search were imported into EndNote X7 (Thomas Reuters, 2015). Duplicates
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were eliminated using EndNote X7 as previously described by Bramer et al. [20]. Following duplicate
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removal, two coauthors of this meta-analysis (GSK, MYS) reviewed each of the unique references
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identified in our literature review by title and abstract to assess their applicability to the current study
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according to our inclusion/exclusion criteria (detailed in the proceeding section). Sources not relevant to
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the current study were eliminated. References from relevant sources were screened to identify additional
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potentially relevant resources that were not detected in our database query.
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Inclusion/exclusion criteria
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Prior to the outset of our literature search, two separate inclusion/exclusion criteria were established, one
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to define the standard for clinical studies to be included in this analysis and one to define the standard for 5
ACCEPTED MANUSCRIPT data to be included. Inclusion criteria for clinical studies were as follows: true RCT comparing MP and
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QS approaches in TKA, and available translation in English. Studies were excluded if they were not true
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RCTs or if they did not compare the MP and QS approaches. Inclusion criteria for data were as follows:
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available mean and standard deviation or proportion (or ability to estimate standard deviation using data
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range), data available for ≥ 2 studies. Data was excluded if these descriptive statistics were not provided,
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if fewer than 2 studies included data on a given outcome, or if the data reported on navigation-assisted
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TKA.
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After identifying the literature relevant to this meta-analysis, demographic and outcomes data were
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collected from each study. Demographic data included study sample size, age, and body mass index
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(BMI). Data that fit our inclusion criteria and was available for our analysis included surgical time,
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tourniquet time, intraoperative blood loss, total blood loss, transfusion volume, scar size in extension, scar
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size in flexion, visual analog scale (VAS) pain on day 1, VAS pain on day 3, VAS pain at 2 months,
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Hospital for Special Surgery (HSS) knee score from 2 months, range of motion (ROM) at 1 week, ROM
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at 1-3 months, ROM at 16-24 months, length of stay (LOS), femoral, tibial, and mechanical axis outliers,
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overall femoral, tibial, and mechanical axis alignment, total complications, infection, and KSS Knee and
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Function scores at 1.5-3 and 24 months.
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Primary and secondary outcomes
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Available data comparing QS and MP groups was divided into primary and secondary outcomes based on
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potential for long-term clinical impact. ROM at 16-24 months, KSS Knee and Function scores at 2 years,
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complications, infections, and femoral, tibial, and mechanical axis outliers were selected as primary
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outcomes measures, while all other variables under assessment were considered secondary outcomes.
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Postoperative ROM at 16-24 months was included as a primary outcome because it has a demonstrable 6
ACCEPTED MANUSCRIPT impact on patient satisfaction after TKA [21]. KSS Knee and Function scores were also included as
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primary outcomes, as they are powerful measurement tools with extensive validation in assessing patient
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outcomes [22]. Complications and infection following TKA can have devastating long-term effects on
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patient outcomes, and implant alignment outliers can strongly contribute to early TKA failure and
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revision arthroplasty [23], warranting their inclusion as primary outcomes, as well.
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135 Risk of bias
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Recommendations issued by the Cochrane Handbook for Systematic Reviews were utilized in order to
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assess the quality of each study included in this meta-analysis. Each study was assessed for selection bias
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(random sequence generation and allocation concealment), performance bias (blinding of
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participants/personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete
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outcomes data), reporting bias (selective reporting), and other biases in accordance with the Cochrane
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Handbook for Systematic Reviews [24]. Risk of bias in the aforementioned categories was assessed by
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two authors (GSK, MYS) and designated as “High risk,” “Low risk,” or “Unknown risk.” Discordant
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assessments were settled by a third author (CAD).
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Statistical analysis
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Statistical analysis was performed using OpenMetaAnalyst (2016) software [25]. Dichotomous outcomes,
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including complications, infections, and femoral, tibial, and mechanical axis outliers were assessed using
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a binary effects model. The remaining variables were continuous, and were assessed with a continuous
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effects model. Results of binary effects models are presented as odds ratios (OR) and 95% confidence
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intervals (CI) for comparison of QS and MP groups, while results from continuous effects models are
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presented as mean differences (MD) and 95% CI.
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I2=0%, while high heterogeneity is indicated by I2=100%. Data groups with statistically significant
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(p<0.05) heterogeneity (I2) were assessed using the DerSimonian-Laird random effects model, while a
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fixed-effect inverse variance model was used when heterogeneity was not statistically significant.
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Certain studies included in this meta-analysis provided data ranges (maximum and minimum values)
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rather than standard deviations. In these instances, standard deviation (SD) was estimated as the
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difference between the maximum and minimum values divided by 4 [26], which serves as a conservative
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estimate of SD.
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163 Results
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Database search
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Our database search yielded an initial 303 records. After removal of duplicates, 274 unique records were
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identified. A total of 233 records were excluded based on abstract review, leaving 41 articles for full-text
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review. Following full-text review, 8 RCTs comparing QS to MP approaches were available for meta-
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analysis. The PRISMA flow diagram detailing our literature search is shown in Figure 1.
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Included studies and patient demographics
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Table 1 lists the 8 RCTs included in our analysis, along with sample size, percent of males, average age,
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average BMI, and relevant conclusions for each study. Five of these 8 (62.5%) studies favored the MP
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approach, while 3 (37.5%) favored the QS approach. A total of 579 TKAs were included for analysis,
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with 289 undergoing QS TKA and 290 undergoing MP TKA. Demographic differences were not
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statistically significant between groups. The average age in the QS group was 67.8 (63.5-73.8) years,
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while the average age in the MP group was 67.5 (63.4-73.7) years (p=0.67). The QS group was 21%
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(0.0%-40.0%) male while the MP group was 22.0% (0.0%-47.0%) male (p=0.32). The average BMI was
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similar between groups, as the average BMI was 27.6 (25.2-28.6) kg/m2 in the QS group and 28.4 (25.2-
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29.6) kg/m2 in the MP group (p=0.46).
181 Quality assessment of the included studies is shown in Table 2. One hundred percent of studies were
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randomized, 50% utilized allocation concealment (50% unknown), 50% were blinded to participants and
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personnel (50% unknown), 80% were blinded to outcome assessments (20% unknown), 100% had
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incomplete data outcomes, and 25% selectively reported data (75% unknown). It was impossible to detect
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other biases with the given data (100% unknown).
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Primary outcomes
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Our meta-analysis of primary outcomes demonstrated no differences in favor of QS that were both
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statistically and clinically significant. There were no statistical differences between the QS and MP
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approaches in ROM at 16-24 months (MD=-0.31, 95% CI: [-2.14, 1.51], I2=0.0%, p=0.74), KSS Knee
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scores at 2 years (MD=-0.18, 95% CI: [-1.13, 0.77], I2=24.9%, p=0.71), complications (OR=1.99, 95%
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CI: [0.91, 4.36], I2=0.0%, p=0.09), or infections (OR=1.73, 95% CI: [0.55, 5.49], I2=0.0%, p=0.35). The
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QS group was associated with statically significant increases in femoral angle outliers (OR=4.92, 95% CI:
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[1.62, 14.96], I2=0.0%, p=0.005), tibial angle outliers (OR=4.34, 95% CI: [1.42, 13.29], I2=0.0%,
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p=0.01), and mechanical axis outliers (OR=4.77, 95% CI: [1.66, 13.36], I2=0.0%, p=0.004). While our
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meta-analysis did demonstrate statistically significant differences in KSS Function scores at 2 years in
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favor of QS (MD=1.86, 95% CI: [0.86, 2.85], I2=0.0%, p<0.001), this difference of 1.86 points falls
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below the minimal clinically important difference (MCID) of roughly 6 points [27]. Results are
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summarized in Table 3.
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Secondary outcomes
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statistically and clinically significant. There were statistically and clinically significant differences in
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favor of the MP group in surgical time (MD=19.54, 95% CI: [11.34, 27.74], I2=91.6%, p<0.001) and
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tourniquet time (MD=23.30, 95% CI: [7.50, 39.10], I2=98.8%, p<0.001). While our meta-analysis did
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demonstrate statistically significant differences in KSS Function scores at 1.5-3 months in favor of QS
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(MD=2.31, 95% CI: [0.75, 3.89], I2=66.9%, p=0.004), this difference of 2.31 points once again falls
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below the MCID for KSS [27]. No other statistical differences were detected for any of the secondary
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outcomes under assessment, as demonstrated in Table 4.
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Discussion
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The QS TKA technique was introduced in 2003 by Tria and Coon [28] in hopes of addressing issues
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associated with the MP approach. By avoiding violation of the extensor mechanism and vastus medialis,
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the goal of this approach was to increase the speed of recovery and ROM after TKA. Furthermore, this
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exposure aimed to reduce the extent of patellar de-vascularization [5], which can lead to patellar fracture,
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avascular necrosis, subluxation, dislocation, patellar component loosening, and anterior knee pain [6, 28].
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Various studies, including those assessed in this meta-analysis, have suggested improvements in short-
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and long-term outcomes for the QS approach. These purported advantages include, but are not limited to,
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improvements in KSS score, VAS pain scores, ROM, as well as earlier rehabilitation and activity
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milestones, and others [29-32]. The potential advantages associated with the QS approach, however, come
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at the cost of a smaller incision, which minimizes the surgical viewing window and may increase the
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technical difficulty of this procedure. Not surprisingly, therefore, other studies have shown benefits in
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favor of the MP approach, the most important of which are decreases in the incidence of implant
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alignment outliers [29-31, 33, 34]. Given these discordant findings, we performed a meta-analysis of the
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available RCTs in order to determine the comparative advantages of these procedures.
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differences in favor of the MP approach, but failed to identify any differences that were both statistically
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and clinically significant in favor of QS. We identified large increases in the odds ratios of femoral (4.92),
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tibial (4.34), and mechanical axis outliers (4.77) for the QS approach. As demonstrated by findings in
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Ritter et al. [23], such outliers may be associated with statistically significant increases in implant failure
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rates. Therefore, QS TKA may be associated with a higher risk of implant failure and revision TKA.
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Given the high cost and negative impacts on quality-of-life associated with revision surgery, this
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disadvantage of the QS approach is clinically and financially relevant, and should be strongly considered
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when making determinations of the optimal surgical approach for TKA.
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Our meta-analysis also identified a statistically significant, but clinically insignificant, mean difference of
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1.86 points between the QS and MP groups in terms of KSS function at 2 years. While the MCID has not
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been formally defined by the Knee Society, it has been described as 6.4 (95% CI: [4.4, 8.4]) based on
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regression comparison to satisfaction scores and 6.1 (95% CI: [5.1, 7.1]) via comparison to the Oxford
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Knee Score [27]. Therefore, though the mean difference identified in this meta-analysis was statistically
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significant, it falls well below the threshold for clinical significance according to the MCID cutoff. No
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other long-term primary outcomes demonstrated statistically significant differences between approaches.
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In our assessment of secondary outcomes, we identified statistically and clinically significant differences
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in favor of MP in surgical time and tourniquet, but failed to identify any differences that were both
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statistically and clinically significant in favor of QS. While there is some evidence indicating that
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increased surgical time may increase the rate of surgical site infection following surgery [35], we assessed
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this variable largely from the stand-point of surgeon preference and resource utilization. We believe that
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the roughly 20-minute decrease in surgical time and tourniquet time associated with the MP approach
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makes it preferable from the standpoint of surgeon convenience and operative costs, especially given the
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associated with a statistically significant 2.31-point increase in KSS Function score at 1.5-3 months, this
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again falls well below the MCID of roughly 6.0 points as described above [27], and we do not believe that
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this finding is clinically significant. No other secondary outcomes demonstrated statistically significant
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differences between approaches.
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The findings of our meta-analysis are in partial disagreement with the results and conclusions of a recent
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meta-analysis by Peng et al. [36]. These differences result from disagreement in the studies included in
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our respective meta-analyses, as well as differences in both the interpretation and selection of presented
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data. Though both meta-analyses were designed to include data from RCTs comparing the QS approach to
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the MP approach, it is our opinion that Peng et al. included studies that violated its exclusion criteria, and
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excluded studies that met its inclusion criteria. The inclusion of Shen at al. [10], a study in which results
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from the QS group were compared to an “age-matched and sex-match[ed] cohort,” to serve as the MP
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group, demonstrates a failure to include only true RCTs. The inclusion of Tasker et al. [37], a study in
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which the choice between the “mini-midvastus or subvastus approach [was performed] according to
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surgeon preference” in the QS group, demonstrates both a failure to include only true RCTs and a failure
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to include only studies assessing the true QS approach. Finally, the meta-analysis of Peng et al. did not
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include a study by Chin et al. [38] that qualified for inclusion in this meta-analysis. These deviations led
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to the inappropriate inclusion of two studies that reported results in favor of QS, and the exclusion of a
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study that reported results in favor of MP, biasing results in favor of QS.
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While, both studies identified similar statistically significant differences in short- and long-term KSS
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scores in favor of the QS approach, we drew different conclusions regarding the clinical significance of
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these differences in KSS score. Unlike Peng et al., we do not believe the roughly 2-3 point mean
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differences in KSS score reported in either study bear clinical significance. These differences should not 12
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be reported as a true clinical advantage for the QS approach. Our study is in agreement with Peng et al.
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regarding the statistically and clinically significant decreases in surgical time in favor of the MP approach.
280 Our study results further differ from Peng et al. in that we did not identify differences in VAS pain score
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between groups. We performed an analysis of VAS pain on Days 1 and 2, as well as at 2 months, and
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were unable to detect a difference between the groups. These differences are likely due to the previously
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described issues with adherence to inclusion/exclusion criteria. Regardless of the etiology of this
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difference in findings, the statistically significant of 0.69 point VAS pain difference described by Peng et
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al. falls well below the VAS pain MCID of roughly 2 points [39, 40]. Therefore, decreased pain should
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not be described as a clinical advantage of the QS approach.
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Perhaps the most important difference between our studies is that we were able to gather sufficient data to
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perform an analysis of implant alignment outliers, which was not performed by Peng et al.. We believe
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that the omission of this analysis, which showed large statistically and clinically significant increases in
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the risk of implant malalignment associated with the QS approach, contributed to errant conclusions
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drawn by Peng et al. in favor of the QS approach.
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This meta-analysis had many strengths, including 1) the use of high-quality RCTs as the source of data,
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and 2) assessment of the largest number of outcomes variables of any meta-analysis comparing the QS
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and MP approaches. It also had many weaknesses, including 1) omission of outcomes data that was
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described in fewer than two studies, 2) risk of bias in the included studies, 3) heterogeneity of the
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included data, 4) estimation of standard deviation when only data range was provided, and 5) study cohort
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BMI that may not represent the general population (27.6 kg/m2 and 28.4 kg/m2 in the QS and MP groups,
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respectively). We believe, however, that this active low-BMI population gave the QS approach the
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greatest potential to exhibit its purported benefits. The lack of clinically significant advantages for the QS
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approach in this study helps to demonstrate that it confers no benefit, even in a relatively optimal patient
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population.
305 Conclusions
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The results of this meta-analysis demonstrate statistically and clinically significant disadvantages for the
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QS approach compared to the MP approach in terms of surgical time, tourniquet time, and incidence of
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femoral, tibial, and mechanical axis outliers. Based on findings from previous studies, the increased
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incidence of implant malalignment associated with QS may predispose patients to early TKA failure.
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Furthermore, the QS approach fails to demonstrate any clinically significant advantage over the MP
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approach in this meta-analysis. Based on these findings, we recommend against the routine use of the QS
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approach in TKA, and also recommend against the suggestion that the QS approach offers the patient any
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clinically significant advantage over the MP approach.
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19. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. Open Med 3(3): e123, 2009 20. Bramer WM, Giustini D, de Jonge GB, Holland L, Bekhuis T. De-duplication of database search results for systematic reviews in EndNote. J Med Libr Assoc 104(3): 240, 2016 21. Matsuda S, Kawahara S, Okazaki K, Tashiro Y, Iwamoto Y. Postoperative alignment and ROM affect patient satisfaction after TKA. Clin Orthop Relat Res 471(1): 127, 2013 22. Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott WN. The new Knee Society Knee Scoring System. Clin Orthop Relat Res 470(1): 3, 2012 23. Ritter MA, Davis KE, Meding JB, Pierson JL, Berend ME, Malinzak RA. The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg Am 93(17): 1588, 2011 24. Cochrane Handbook for Systematic Reviews of Interventions. Online Kensaku 35(3): 154, 2014 25. Wallace B, Lajeunesse M, Dietz G, Issa J. Dahabreh, Trikalinos T, Schmid C, Gurevitch J. OpenMEE: Intuitive, open-source software for meta analysis in ecology and evolutionary biology. . In. http://onlinelibrary.wiley.com/doi/10.1111/2041-210X.12708/full. 2016 26. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5: 13, 2005 27. Lee WC, Kwan YH, Chong HC, Yeo SJ. The minimal clinically important difference for Knee Society Clinical Rating System after total knee arthroplasty for primary osteoarthritis. Knee Surg Sports Traumatol Arthrosc, 2016 28. Tria AJ, Jr., Coon TM. Minimal incision total knee arthroplasty: early experience. Clin Orthop Relat Res (416): 185, 2003 29. Lin SY, Chen CH, Fu YC, Huang PJ, Lu CC, Su JY, Chang JK, Huang HT. Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone and Joint Journal 95 B(7): 906, 2013 30. Lin WP, Lin J, Horng LC, Chang SM, Jiang CC. Quadriceps-Sparing, Minimal-Incision Total Knee Arthroplasty. A Comparative Study. Journal of Arthroplasty 24(7): 1024, 2009 31. Kim YH, Kim JS, Kim DY. Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. J Bone Joint Surg Br 89(4): 467, 2007 32. Karpman RR, Smith HL. Comparison of the early results of minimally invasive vs standard approaches to total knee arthroplasty: a prospective, randomized study. J Arthroplasty 24(5): 681, 2009 33. Chiang H, Lee CC, Lin WP, Jiang CC. Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. J Formos Med Assoc 111(12): 698, 2012 34. Chen AF, Alan RK, Redziniak DE, Tria AJ, Jr. Quadriceps sparing total knee replacement. The initial experience with results at two to four years. J Bone Joint Surg Br 88(11): 1448, 2006 35. Peersman G, Laskin R, Davis J, Peterson MG, Richart T. Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS J 2(1): 70, 2006 36. Peng X, Zhang X, Cheng T, Cheng M, Wang J. Comparison of the quadriceps-sparing and subvastus approaches versus the standard parapatellar approach in total knee arthroplasty: a metaanalysis of randomized controlled trials. BMC Musculoskelet Disord 16: 327, 2015 37. Tasker A, Hassaballa M, Murray J, Lancaster S, Artz N, Harries W, Porteous A. Minimally invasive total knee arthroplasty; a pragmatic randomised controlled trial reporting outcomes up to 2 year follow up. Knee 21(1): 189, 2014 38. Chin PL, Foo LS, Yang KY, Yeo SJ, Lo NN. Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty 22(6): 800, 2007
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39. Katz NP, Paillard FC, Ekman E. Determining the clinical importance of treatment benefits for interventions for painful orthopedic conditions. J Orthop Surg Res 10: 24, 2015 40. Tubach F, Ravaud P, Baron G, Falissard B, Logeart I, Bellamy N, Bombardier C, Felson D, Hochberg M, van der Heijde D, Dougados M. Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important improvement. Ann Rheum Dis 64(1): 29, 2005
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Table 1: Summary of studies included in meta-analysis.
Lin [1] Lin [2] Kim [3] Karpman [4] Chiang [5] Chin [6] Xu [7] Matsumoto [8]
QS: 30 MP: 30 QS: 35 MP: 35 QS: 120 MP: 120 QS: 20 MP: 19 QS: 38 MP: 37 QS: 30 MP: 30 QS: 26 MP: 29 QS: 25 MP: 25
% Male 10.0% 10.0% 14.3% 14.3% 22.5% 22.5% 40.0% 47.0% 33.3% 33.3% 20.0% 10.0% 27.0% 38.0% 0.0% 0.0%
Age (years) 69.6 (5.3) 70.2 (6.5) 67.7 (5.0) 68.5 (5.5) 65.4 (11.3) 65.4 (11.3) 73.0 (7.4) 73.0 (5.1) 69.7 (5.3) 69.8 (5.4) 69 (5.8) 63.4 (8.3) 63.5 (8.7) 64.2 (9.3) 73.8 (1.7) 73.7 (1.4)
BMI (kg/m2) 28.1 (4.2) 29.0 (4.2) 26.3 (2.5) 25.9 (2.6) 28.1 (4.25) 28.1 (4.25) 28.0 (4.4) 29 (4.6) 28.6 (3.8) 29.6 (3.5) 27.53 (3.9) 29.44 (4.3) 25.2 (3.4) 25.2 (2.3) -
Relevant Conclusions - QS did not improve short-term clinical or radiographic outcomes. - QS increased varus postoperative alignment. - QS did not improve short-term clinical or radiographic outcomes. - QS increased ST and radiographic outliers. - QS did not improve long-term clinical or radiographic outcomes. - QS increased ST and TT. - QS improved short-term clinical outcomes. - QS did not improve long-term clinical or radiographic outcomes. - QS did not improve short-term clinical outcomes. - QS increased ST and TT. - QS was associated with decreased implant alignment accuracy.
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n
- QS improved short-term clinical outcomes. - QS did not improve long-term clinical or radiographic outcomes. - QS was associated with smaller surgical incisions.
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Study
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Numbers are expressed as mean (standard deviation) (BMI = body mass index; QS = quadriceps-sparing; MP = medial parapatellar; ST = surgical time; TT = tourniquet time).
References
4.
5. 6. 7. 8.
9.
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3.
EP
2.
Lin, W.P., et al., Quadriceps-Sparing, Minimal-Incision Total Knee Arthroplasty. A Comparative Study. Journal of Arthroplasty, 2009. 24(7): p. 1024-1032. Lin, S.Y., et al., Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone and Joint Journal, 2013. 95 B(7): p. 906-910. Kim, Y.H., J.S. Kim, and D.Y. Kim, Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. J Bone Joint Surg Br, 2007. 89(4): p. 467-70. Karpman, R.R. and H.L. Smith, Comparison of the early results of minimally invasive vs standard approaches to total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 2009. 24(5): p. 681-8. Chiang, H., et al., Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. J Formos Med Assoc, 2012. 111(12): p. 698-704. Chin, P.L., et al., Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty, 2007. 22(6): p. 800-6. Xu, J., et al., Total knee arthroplasty: Comparison between quadriceps sparing approach and medial parapatellar approach. Chinese Journal of Tissue Engineering Research, 2013. 17(35): p. 6240-6246. Matsumoto, T., et al., Soft tissue balance measurement in minimal incision surgery compared to conventional total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy, 2011. 19(6): p. 880-886. Cochrane Handbook for Systematic Reviews of Interventions. Online Kensaku, 2014. 35(3): p. 154-155.
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Results Favor? MP MP MP QS MP MP QS QS
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Table 2: Risk of bias.
Lin [2] Kim [3] Karpman [4] Chiang [5] Chin [6] Xu [7] Matsumoto [8]
Allocation concealment
Blinding of participants and personnel Yes
Blinding of outcome assessment Yes
Incomplete outcome data
Selective Reporting
Other Bias
Yes Computer Yes Randomization table Yes Randomization table Yes Computer Yes Computer Yes Randomization table Yes Randomization table Yes -
Sealed envelope Sealed envelope Unknown
Yes
Unknown
Unknown
Unknown
Yes
Yes
Unknown
Unknown
Unknown
Yes
Unknown
Yes
Yes
Unknown
Yes
Yes
Sealed envelope Sealed envelope Unknown
Unknown
Yes
Unknown
Unknown
Yes
Unknown
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Lin [1]
Random sequence generation
Yes
Unknown
Unknown
Yes
Unknown
Unknown
Yes
Yes
Unknown
Yes
Yes
Unknown
Yes
Unknown
Unknown
Unknown
Unknown
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Study
Yes
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Table demonstrates selection bias, performance bias, detection bias, attrition bias, reporting bias, and other biases in accordance with the Cochrane Handbook for Systematic Reviews [9].
References
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5. 6. 7. 8.
9.
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Lin, W.P., et al., Quadriceps-Sparing, Minimal-Incision Total Knee Arthroplasty. A Comparative Study. Journal of Arthroplasty, 2009. 24(7): p. 1024-1032. Lin, S.Y., et al., Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone and Joint Journal, 2013. 95 B(7): p. 906-910. Kim, Y.H., J.S. Kim, and D.Y. Kim, Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. J Bone Joint Surg Br, 2007. 89(4): p. 467-70. Karpman, R.R. and H.L. Smith, Comparison of the early results of minimally invasive vs standard approaches to total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 2009. 24(5): p. 681-8. Chiang, H., et al., Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. J Formos Med Assoc, 2012. 111(12): p. 698-704. Chin, P.L., et al., Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty, 2007. 22(6): p. 800-6. Xu, J., et al., Total knee arthroplasty: Comparison between quadriceps sparing approach and medial parapatellar approach. Chinese Journal of Tissue Engineering Research, 2013. 17(35): p. 6240-6246. Matsumoto, T., et al., Soft tissue balance measurement in minimal incision surgery compared to conventional total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy, 2011. 19(6): p. 880-886. Cochrane Handbook for Systematic Reviews of Interventions. Online Kensaku, 2014. 35(3): p. 154-155.
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Table 3: Primary outcomes. Number of contributing studies
Number QS TKAs
Number MP TKAs
MD or OR (95% CI)
3
193
192
-0.31 (-2.14, 1.51)
2
155
155
2
155
155
4
133
132
4
133
132
3
95
95
4
196
198
8
324
325
Infection
p-value
Heterogeneity
0.736
0.0%
<0.001
0.0%
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1.86 (0.86, 2.85) -0.18 (-1.13, 0.77) 4.92 (1.62, 14.96) 4.34 (1.42, 13.29) 4.77 (1.66, 13.36) 1.99 (0.91, 4.36) 1.73 (0.55, 5.49)
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Outcomes & Demographics ROM 16-24 Months (º) KSS Function 2 years KSS Knee 2 years Femoral Angle Outliers Tibial Angle Outliers Mechanical Axis Outliers Complications
0.709
24.9%
0.005
0.0%
0.010
0.0%
0.004
0.0%
0.087
0.0%
0.352
0.0%
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Italics indicate that ORs were used for comparison, while standard font indicates the use of MD for comparison. Bold indicates a statistically significant p-value (QS = quadriceps-sparing; MP = medial parapatellar; TKA = total knee arthroplasty; MD = mean difference; OR = odds ratio; ROM = range of motion; KSS = Knee Society Score).
References
4.
5. 6. 7. 8.
9.
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Lin, W.P., et al., Quadriceps-Sparing, Minimal-Incision Total Knee Arthroplasty. A Comparative Study. Journal of Arthroplasty, 2009. 24(7): p. 1024-1032. Lin, S.Y., et al., Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone and Joint Journal, 2013. 95 B(7): p. 906-910. Kim, Y.H., J.S. Kim, and D.Y. Kim, Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. J Bone Joint Surg Br, 2007. 89(4): p. 467-70. Karpman, R.R. and H.L. Smith, Comparison of the early results of minimally invasive vs standard approaches to total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 2009. 24(5): p. 681-8. Chiang, H., et al., Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. J Formos Med Assoc, 2012. 111(12): p. 698-704. Chin, P.L., et al., Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty, 2007. 22(6): p. 800-6. Xu, J., et al., Total knee arthroplasty: Comparison between quadriceps sparing approach and medial parapatellar approach. Chinese Journal of Tissue Engineering Research, 2013. 17(35): p. 6240-6246. Matsumoto, T., et al., Soft tissue balance measurement in minimal incision surgery compared to conventional total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy, 2011. 19(6): p. 880-886. Cochrane Handbook for Systematic Reviews of Interventions. Online Kensaku, 2014. 35(3): p. 154-155.
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Table 4: Secondary outcomes.
6
264
265
4
223
222
3
188
187
5
238
3
Heterogeneity
<0.001
91.6%*
<0.001
98.8%*
1.33 (-21.29, 23.95)
0.908
0.0%
236
-17.10 (-61.68, 27.48)
0.452
0.0%
88
86
48.36 (-107.25, 203.97)
0.542
76.0%*
4
195
194
-2.43 (-6.18, 1.32)
0.204
99.7%*
3
184
186
0.053
98.3%*
4
123
121
0.735
0.0%
2
68
67
0.221
0.0%
2
68
0.205
0.0%
2
68
0.126
0.0%
2
58
0.748
19.3%
4
213
4
196
5
5
3
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VAS Pain Month 2 HSS Knee Score at 2-3 months ROM Week 1 (º) ROM 1-3 Months (º) LOS (days) Femoral Angle Alignment (º) Tibial Angle Alignment (º) Mechanical Axis Alignment (º) KSS Function Score 1.5-3 months KSS Knee Score 1.5-3 months SLR at 24 hours (% of patients)
p-value
67 67 56
-1.88 (-3.78, 0.03) -0.07 (-0.48, 0.34) -0.35 (-0.92, 0.21) 0.40 (-0.22, 1.02) -1.80 (-4.12, 0.51) 0.84 (-4.26, 5.92)
211
-0.18 (-1.66, 1.30)
0.811
55.27%
198
-0.28 (-0.90, 0.35)
0.384
64.2%*
249
251
-0.18 (-1.64, 1.28)
0.809
96.0%*
249
251
-0.17 (-1.34, 1.00)
0.779
93.9%*
91
94
1.14 (-.02, 2.30)
0.054
78.2%*
155
155
2.31 (0.75, 3.89)
0.004
66.9%
155
155
0.379
79.7%*
65
65
0.267
0.0%
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VAS Pain Day 3
MD (95% CI) 19.54 (11.34, 27.74) 23.30 (7.50, 39.10)
RI PT
No. MP TKAs
SC
No. QS TKAs
M AN U
No. of contributing studies
EP
Outcomes & Demographics Surgical Time (minutes) Tourniquet Time (minutes) Intraoperative Blood Loss (mL) Total Blood Loss (mL) Transfusion Volume (mL) Scar Size, extension (cm) Scar Size, flexion (cm) VAS Pain Day 1
0.92 (-1.13, 2.98) 1.53 (0.72, 6.26)
*Indicates that that heterogeneity was statistically significant. Bold indicates a statistically significant p-value (QS = quadriceps-sparing; MP = medial parapatellar; TKA = total knee arthroplasty; MD = mean difference; ROM = range of motion; KSS = Knee Society Score; VAS = visual analog scale; HSS = Hospital for Special Surgery; LOS = length of stay; SLR = straight-leg raise).
References 1.
Lin, W.P., et al., Quadriceps-Sparing, Minimal-Incision Total Knee Arthroplasty. A Comparative Study. Journal of Arthroplasty, 2009. 24(7): p. 1024-1032.
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Lin, S.Y., et al., Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone and Joint Journal, 2013. 95 B(7): p. 906-910. Kim, Y.H., J.S. Kim, and D.Y. Kim, Clinical outcome and rate of complications after primary total knee replacement performed with quadriceps-sparing or standard arthrotomy. J Bone Joint Surg Br, 2007. 89(4): p. 467-70. Karpman, R.R. and H.L. Smith, Comparison of the early results of minimally invasive vs standard approaches to total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 2009. 24(5): p. 681-8. Chiang, H., et al., Comparison of quadriceps-sparing minimally invasive and medial parapatellar total knee arthroplasty: a 2-year follow-up study. J Formos Med Assoc, 2012. 111(12): p. 698-704. Chin, P.L., et al., Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty, 2007. 22(6): p. 800-6. Xu, J., et al., Total knee arthroplasty: Comparison between quadriceps sparing approach and medial parapatellar approach. Chinese Journal of Tissue Engineering Research, 2013. 17(35): p. 6240-6246. Matsumoto, T., et al., Soft tissue balance measurement in minimal incision surgery compared to conventional total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy, 2011. 19(6): p. 880-886. Cochrane Handbook for Systematic Reviews of Interventions. Online Kensaku, 2014. 35(3): p. 154-155.
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Figure Legend
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Figure 1. PRISMA flow diagram detailing the literature review.
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