The history of total joint replacement has demonstrated
continuous evolution. With the development of total knee
arthroplasty since 1974 the field of knee arthroplasty has
undergone many changes. With the introduction of minimally
invasive surgery for total knee arthroplasty (TKA) both interest
and suspicion have aroused. Amidst this controversy the aim of
the present study was to review the current literature on
Minimally Invasive Total Knee Arthroplasty (MITKA) and to
provide an overview of the field of minimally invasive surgery
for total knee arthroplasty.
Material and method: A comprehensive search of PubMed,
Medline, Cochrane, CINAHL, and Embase was performed. The initial
search revealed 82 articles out of which 14 articles were in
language other than English and hence were excluded. This
resulted in inclusion of 68 studies in the current review.
Results: Though studies on minimally invasive knee
arthroplasty have shown the same consistent trends of reduced
pain, quicker rehabilitation and good patient satisfaction,
component alignment remains an unanswered issue and although
early series with computer navigation look promising, the need
further randomised controlled trials remains.
Whilst there is no doubt there is a future in minimally
invasive TKA, its introduction to the surgical community must be
undertaken responsibly not just by the orthopaedic community but
also by orthopaedic manufacturers.
Invasive; total knee replacement
in surgery is not new and should not be unexpected. The history
of total joint replacement has demonstrated continuous
evolution. The relatively high complication rates associated
with early prostheses and techniques eventually led to the
improvement of implants and refinement of the surgical
procedures. Gradual adoption of these improvements and their
eventual diffusion into the surgical community led to improved
success and increased rates of implantation1.
the development of total knee arthroplasty since 1974 the field
of knee arthroplasty has undergone many changes 2, 3.
Despite outstanding results 4, 5 many patients
experience a tremendous amount of pain and impaired quadriceps
muscle function in the short term that may lead to prolonged
rehabilitative efforts until full recovery 6. Mizner
et al 7analyzed 40 patients who underwent unilateral
followed by rehabilitation, including 6 weeks of outpatient
physical therapy. In their study, patients experienced
significant worsening of range of motion, quadriceps strength,
and performance on functional tests 1 month after surgery. Of
all physical measures assessed, quadriceps muscle strength
showed the greatest decline and was the most highly correlated
measure associated with functional performance at all testing
sessions. Likewise, Silva and colleagues 8 assessed
quadriceps muscle strength by measuring isometric extension peak
torque in 32 knees more than 2 years after TKA. The mean
isometric extension peak torque values in their patients were
reduced by up to 30.7% (P = .01) and the isometric flexion peak
torque values were, on average, 32.2% lower than those from
the introduction of minimally invasive surgery for unicondylar
knee arthroplasty by Repicci in early 1990s and its subsequent
acceptance globally 9, 10, 11, along with the attempt
to reduce quadriceps muscle strength loss and improve early
clinical outcome (reduced pain, reduced length of
hospitalization, and earlier return to full function) following
total knee replacement, minimally invasive quadriceps-sparing
techniques have become increasingly popular 11, 12, 13.
However since its introduction for total knee arthroplasty (TKA)
both interest and suspicion have aroused.
have suggested faster recovery times, less pain and improved
cosmoses for their patients 15, 16. Critics cite the
reduced visualization as a risk for poorer component placement
which could compromise long term survivorship for short term
this controversy the aim of the present study was to review the
current literature on Minimally Invasive Total Knee Arthroplasty
(MITKA) and to provide an overview of the field of minimally
invasive surgery for total knee arthroplasty.
search of PubMed, Medline, Cochrane, CINAHL, and Embase
databases was performed using the key words minimally
invasive total knee replacement, mini-incision knee surgery,
minimally invasive surgery and total knee replacement. All
articles relevant to the subject were retrieved, and their
bibliographies thoroughly reviewed for further references.
Studies in language other than English
The initial search revealed 82 articles
out of which 14 articles were in language other than English and
hence were excluded. This resulted in inclusion of 68 studies in
the current review.
The exact definition
of MIS as related to total knee arthroplasty is open to debate.
Historically, minimally invasive total knee arthroplasty was
defined as an incision length of < 14 cm. However, the length
of the incision was not the primary influence on potential
postoperative benefits to the patient and thus several other
factors were included in this definition. Those are: 1. the
amount of soft-tissue dissection (including muscle, ligament,
and capsular damage). 2. Patellar retraction or eversion. 3.
Tibiofemoral dislocation 15, 16, 18. Hence minimally
invasive surgery should not be considered to be a cosmetic
procedure but rather one that addresses patient’s concerns
with regard to postoperative pain and slow rehabilitation.
of Minimally Invasive Total Knee Arthroplasty
The indications for the surgery are much more restrictive than the
standard TKA. Many of MITKA reports have listed strict selection
criteria for this procedure. Patient weight (>100 kg), body
mass index (BMI >40), knee deformity(not more than 10°
of anatomic varus,15° of anatomic valgus and a 10°
flexion contracture), age(>80 years), previous open knee
surgery, inflammatory arthropathy, preoperative knee range of
motion (flexion <90° ), patella baha have all
been reported as selection criteria used to limit which patients
could undergo an MIS procedure13, 14, 16, 19, 20, 21, 22,
23, 24, 27.Controversy however still exists whether these
criteriae need to be strictly adhered to with some studies
stating that this need not be the case 25
while others stating it as the most
common pitfall 21.
Several MIS TKA techniques
have been described: mini-arthrotomy, mini-midvastus, medial
quad-sparing, mini-subvastus and mini-lateral approach. The
mini-arthrotomy technique uses a smaller medial parapatellar
arthrotomy than a traditional medial parapatellar arthrotomy
does 19, 26. The mini-midvastus technique has an
arthrotomy that extends 2 cm or more into the vastus medialis
muscle 13, 18, 21,27,28,29. The medial quad-sparing
approach uses a more medial incision and avoids a quadriceps
arthrotomy 22, 23, 24, 30. The mini-subvastus
approach, which is an evolution of the subvastus technique of
Hoffman et al 31, uses an anterior approach and a
quad-sparing arthrotomy 28. The lateral approach
extends from the proximal end of patella laterally and extends
between distally between the tibial tuberosity and Gerdy’s
tubercle 30. All MIS TKA techniques avoid everting
A) Medial Approach
The Vastus medialis
Obliques (VMO) is the only muscle of the quadriceps muscle group
that can prevent lateral displacement of patella when the knee
is actively extended 31. A midvastus approach may cut
the nerve branch from the vastus medialis longus (VML) to VMO.
Retinacular branches to the medial capsule are devided when the
incision extends proximally to the patella. The articular branch
of the descending genicular artery always follow the nerve
branch(when it exists) from the saphenous nerve. A long medial para patellar approach may injure the
saphenous nerve to the VMO, thus preventing full rehabilitation
following TKA32. Thus the aim of MISTKA is to
minimize the damage to VMO and to preserve maximum quadriceps
function which in turn favours better and early rehabilitation 34,
35. Also as most conventional TKA was performed through a
medial approach, a logical step towards introduction of MITKA
was to become aware of its instrumentations and principles
through a medial approach.
B) Lateral Approach
One of the main advantages
of the lateral approach is that the quadriceps muscle is totally
spared so VMO is immediately available for rehabilitation.
Additionally, maintaining the medial control of the patella
limits lateral tracking of the patella. With the lateral
approach, the infrapatellar branch of the saphenous nerve and
the medial articular branch of the saphenous nerve that
accompanies the descending branch of medial genicular artery may
be completely avoided as medial side of the knee is not exposed.
Also damage to the superior medial and superior medial genicular
artery is more easily avoided.
Lateral release are easier
to perform through a lateral MIS approach which in turn allows
for a more accurate measurement of tibial bone resection in varus knees
30, 36, 37.
protocols and post operative management
In the excellent symposium on minimally invasive arthroplasty by the
Journal of Bone and Joint Surgery38, Dr. Jay Berry
stated, “Often overlooked in the discussion of minimally
invasive arthroplasty is the role that an integrated program of
anaesthesia and accelerated rehabilitation that is instituted
with minimally invasive methods may play in facilitating shorter
hospital stays.” Early success of a surgical procedure has
been shown to depend on anaesthesia protocols; pain management
protocols; and early physical therapy protocols 39, 40.
Several studies have focused attention to this aspect of patient
management and have suggested the need for development of
special anaesthetic and rehabilitation protocols specifically
for MITKA to expedite recovery and hence justify the true role
of mini incision in total knee arthroplasty 40, 41,
to many patients, a smaller incision is clearly not the reason
why they may perform better. The minimisation of soft tissue
dissection/disruption, lack of patella eversion and in situ bone
cutting techniques to minimise articular dislocations are
clearly more important in producing improved outcomes. MITKA
being a relatively “young” procedure, majority of the
studies have reported on early results only.
A) Blood Loss: Majority of
studies comparing Minimally Invasive surgery with conventional
total knee arthroplasty have shown significantly less blood loss
(exception is study
by Laskin et al in 2004 which reported higher blood loss in
MITKA group 21 )and decrease in post
op haemoglobin in the MITKA group 12, 37, 43, 44, 45.
B) Tourniquet time: Review of literature suggested that majority of
studies tend to report longer tourniquet time with this
procedure 13, 43, 46, 47, but as the experience of
the operating surgeon with MITKA increases the tourniquet time
gradually decreases 20, 48, 49.
C) Post operative pain: Post operative pain relief is variably reported
in literature in comparison to standard TKA. While most of the
studies report lower post op pain in the MITKA series 20,
46, 50 (exception is a prospective randomised control
trial by Karachalios et
al 43 which report higher pain with MITKA), studies
scrutinising this factor in detail report no difference in pain
with the passage of time17.
Duration of Hospital stay:
With the ever increasing pressure both on Orthopaedic surgeons
and the managerial staff to produce high volume surgery, total
knee arthroplasty is being considered to join the list of
out-patient procedures. Majority of the comparative studies
reporting on in patient stay duration shows lesser duration of
hospital stay in patients with MITKA as compared to standard
procedure 20, 48, 52. Berger et al 51 reports
discharging 99% of the patients after 24 hours, this he
attributes to development of a comprehensive pathway for minimally invasive surgical technique. In this
study they suggest that addressing and alleviating the patient's
apprehension about outpatient TKA is the key stone of early
Range of motion: Majority of studies comparing MITKA with
conventional arthroplasty report better range of motion in MITKA
group 13, 20, 43, 52 however
several studies following this parameter over time report no
difference in the two groups from as little as 2 weeks post
operatively 21, 43, 50, 53. The finding that has been
consistent however has been the quick regain in quadriceps
strength and earlier achievement of first 90 range of motion 28,
43, 53, 54.
Complications: Component alignment remains an unanswered issue with
some studies showing high rates of malalignment 17, 43, 68.
healing has been reported in number of series 43, 52, 55
possibly due to excessive retraction during the procedure.
Other complications like deep vein thrombosis, peroneal
nerve palsy, superficial and deep infections, patellar fracture,
patellar tendon rupture, periprosthetic fracture etc has also
been reported 12, 37, 43, 48, 52, 53, 55, 56. Also some studies have reported conversion of the mini
approach to standard approach when visualisation became
difficult especially in obese patients or patients with sever
deformity 43, 56, 57, 58.
The current debate
regarding the value of minimally invasive surgery extends beyond
the demonstrated or potential clinical benefits of these
procedures. Economic considerations of patients, surgeons,
hospitals, and tax- payers are prominent factors in this debate
and will continue to influence the adoption of minimally
invasive surgical procedures. Studies focusing there attention
to MITKA economy have found the need for high quality studies to
support superior economical consideration of this procedure over
standard approach 57, 58.
of computer navigation
Computer navigation with
minimally invasive procedures is evolving rapidly. There is
however little information on the feasibility of computer
navigation when using a minimally invasive approach for total
knee arthroplasty, during which the anatomic landmarks for
registration may be obscured. Majority of studies using computer
navigation for MITKA have reported the main advantage of this
technique over conventional total knee arthroplasty to be
improved postoperative radiographic alignment without much
difference in clinical results 59, 60, 61, 62, 63.
There is however a word of
caution when using navigation with MITKA because of their
associated anomalies (these technologies sometimes return
incorrect information during surgical procedures) 63.
Hence although promising, the initial clinical experience is
limited and needs to be supported by further, prospective
It has been previously shown that two of the greatest concerns for
patients prior to total joint arthroplasty are pain and length
of recovery 64. Minimally invasive knee arthroplasty
certainly appears to address these concerns with early series
showing the same consistent trends of reduced pain, quicker
rehabilitation and good patient satisfaction scores. Component
alignment remains an unanswered issue and although early series
with computer navigation look promising, the need further
randomised controlled trials remains. Also VMO constant insertion ( which formed the basis of medial
approach to MITKA) at the midpoint of the patella 65
has been challenged 66.
Whilst there is no doubt there is a future in minimally invasive
TKA, its introduction to the surgical community must be
undertaken responsibly not just by the orthopaedic community but
also by orthopaedic manufacturers. Currently NICE considers the
evidence on the procedures safety and efficacy inadequate for it
to be undertaken without special arrangements for consent and
for audit and research. It further defines the importance of
training and has asked to British Orthopaedic Association to
produce standards for training 67.
the future of minimally invasive TKA will require a complete
change of visualization (improved surgical approaches,
single-incision or multi-incision approaches), access (tissue
expanders, endoscopic visualization), instrumentation (smaller
and less bulky), and implants (downsized implants with reduced
fixation keels, modular implants) with longer follow up studies
to prove its worth.
L F.The history of hip surgery. In: Callaghan J J, Rosenberg
A G and Rubash H E, Editors, The adult hip. Lippincott,
Philadelphia, 1998: 4.
J, Ranawat CS, Scott WN, Walker P. Total condylar knee
replacement: Preliminary report. Clin Ortho 1976;
Insall J, Tria AJ, Scott WN. The total condylar knee
prosthesis: The first five years. Clin Orthop 1979; 145:
EM, Meding JB, Faris PM, Ritter MA. Long-term
followup of nonmodular total knee replacements, Clin Orthop
2004; 404: 34-39.
FF Sr. Long-term followup after mobile-bearing total knee
replacement, Clin Orthop 2002; 403: 40-50.
P, Hall GM, Peerbhoy D, Shenkin A, Parker C. Recovery from
hip and knee arthroplasty: patients' perspective on pain,
function, quality of life, and well-being up to 6 months
postoperatively. Arch Phys Med Rehabil 2001; 82: 360-366.
RL, Petterson SC, Snyder-Mackler L.Quadriceps strength and
the time course of functional recovery after total knee
arthroplasty. J Orthop Sports Phys Ther 2005; 35: 424-436.
M, Shepherd E F, Jackson W O, Pratt J A, McClung C D,
Schmalzried T P.
strength after total knee arthroplasty. J Arthroplasty 2003;
A J, Webb J, Topf H, Dodd CA, Goodfellow JW, Murray DW.
Rapid recovery after oxford unicompartmental
arthroplasty through a short incision. J Arthroplasty
2001; 16: 970–976.
J N , Flecher X. Minimally invasive unicompartmental
knee arthroplasty. The Knee 2004; 11: 341–347.
J L, Price AJ, Breard D J, Dodd C A F , Murray D W.
Minimally Invasive Oxford unicompartmental knee
arthroplasty: functional results at 1 year and the effect of
surgical inexperience. The Knee 2004; 11: 363–367.
A J, Coon T M. Minimal incision total knee arthroplasty:
Clin Orthop 2003; 416:185-190.
S B, Cook S, Beksac B.Minimally invasive total knee
replacement through a mini midvastus approach: a comparative
study. Clin Orthop 2004; 428: 68 -73.
GR, Tenholder M, Capeci C. Surgical approaches in
mini-incision total knee arthroplasty, Clin Orthop 2004;
RS, Beksac B, Phongjunakorn A, Pittors K, Davis J, Shim JC,
Pavlov H, Petersen M. Minimally invasive total knee
replacement through a mini-midvastus incision: An outcome
study. Clin Orthop 2004; 428: 774–781.
P M, Mont M A, McMahon M, Ragland P S, Kester M.
Minimally Invasive Total Knee Arthroplasty. J Bone
Joint Surg 2004; 86-A: 26–32.
D F, Dennis D A. Mini-incision total knee arthroplasty
can increase risk of component malalignment. Clin Orthop
2005; 440: 77–81.
PM, Mon M A, Kester M A. Minimally invasive total knee
arthroplasty: a 10-feature evolutionary approach. Orthop
Clin North Am 2004; 35: 217-226.
G R, Tria A J Jr. Minimal incision total knee arthroplasty.
In: G.R. Scuderi and A.J. Tria, Editors, MIS of the Hip and
the Knee: a Clinical Perspective, Springer-Verlag, New York,
CM, Stepanian JD. The impact of minimally invasive surgical
techniques on early range of motion after primary total knee
arthroplasty. J Arthroplasty 2008; 23: 10-18
S, Alan R K, Tria A J Jr. (2006) Minimally Invasive
Quadriceps-Sparing Posterior Stabilized Total Knee
Arthroplasty Operative Techniques in Orthopaedics 16,
A J Jr. (2004) Minimally invasive total knee arthroplasty:
the importance of instrumentation, Orthop Clin North Am, 35,
A J Jr. (2003) Advancements in minimal invasive total knee
arthroplasty, Orthopedics, 26, 859–863.
Y J, Tanavalee A, Chan A P H et al., Minimally invasive
surgery for total knee arthroplasty. In: G.R. Scuderi and
A.J. Tria, Editors, MIS of the Hip and the Knee: a Clinical
Perspective, Springer–Verlag, New York (2004), p. 160.
W C, Diesfeld P J, LeMarr A, Reedy M E. (2007)Applicability
of the mini-subvastus total knee arthroplasty technique:
ananalysis of 725 cases with mean 2-year follow-up. J Surg
Orthop Adv, 131-137.
R, Tria A J Jr. (2004) Minimal incision total knee
arthroplasty. In: G.R. Scuderi and A.J. Tria, Editors, MIS
of the Hip and the Knee: a Clinical Perspective, Springer-Verlag,
R S. (2003) New techniques and concepts in total knee
replacement, Clin Orthop, 416, 151-153.
Scuderi G R, Tenholder M, Capeci C (2004). Surgical
approaches in mini-incision total knee arthroplasty. Clin
Orthop, 428, 61-67.
P M, Neal D J, Kester M A. (2003)Minimal incision total knee
arthroplasty using the suspended leg technique, Orthopedics,
P M. (2004) Minimally invasive total knee arthroplasty—midvastus
approach. In: J.H. Hozack and M. Krisman, Editors, Minimally
Invasive Total Joint Arthroplasty, Springer-Verlag, New
E M, Justin D F.(2004) Minimally invasive total knee
replacement: principles and technique, Orthop Clin North Am,
Hoffmann A A, Plaster R L, Murdock L E.(1991) Subvastus
(southern) approach for primary total knee arthroplasty,
AY, Lee FL, Wong PK, Wong CY, Yeung SS.(2001) Effects of
knee joint angles and fatigue on the neuromuscular control
of vastus medialis oblique and vastus lateralis muscle in
humans. Eur J Appl Physiol, 84, 36-41.
R E Jr, Trinidad G, Buck WR.(1999) Midvastus approach in
total knee arthroplasty: a description and a cadaveric study
determining the distance of the popliteal artery from the
patellar margin of the incision. J Arthroplasty, 14,
S C, Marascalco R, Hughston JC.(1983) Disruption of the
vastus medialis obliquus with medial knee ligament injuries.
Am J Sports Med, 11, 427-431.
I, Araç S, Sahinoğlu K, Birvar K.(1992) The
innervation of vastus medialis obliquus. J Bone Joint Surg
(Br), 74, 624.
M A, Bonutti P M, Chauhan S K et al. Lateral approach to
total knee arthroplasty: minimal soft tissue invasion. In:
W.J. Hozack, M. Krismer and M. Nogler et al., Editors,
Minimally invasive total joint arthroplasty, Springer
Medizin Verlag, Heidelberg (2004), p. 151.
TM, Bonutti PM, Ulrich SD, Fatscher T, Marker DR, Mont
MA.(2007)Minimally invasive lateral approach to total knee
arthroplasty.J Arthroplasty, 22, 21-26.
D J, Berger R, Callaghan J et al. (2003)
Symposium—minimally invasive total hip arthroplasty, J
Bone Joint Surg Am 85, 2235. (REPEAT)
R. MIS-2 hip arthroplasty.(2004) Lecture at Emerging
Techniques in Hip and Knee Arthroplasty not a publisher
S, Buchheit K, Deirmengian C, Berger RA.(2006) Perioperative
protocols for minimally invasive total knee arthroplasty. J
Knee Surg, 19, 129-132.
GR. (2006) Preoperative planning and perioperative
management for minimally invasive total knee arthroplasty.
Am J Orthop, 35, 4-6.
DG, Mann K.(2007) Minimal Incision Protocols for Anesthesia,
Pain Management, and Physical Therapy With Standard
Incisions in Hip and Knee Arthroplasties The Effect on Early
Outcomes. J Arthroplasty, 22, 20-25.
T, Giotikas D, Roidis N, Poultsides L, Bargiotas K, Malizos
KN.(2008) Total knee replacement performed with either a
mini-midvastus or a standardapproach: A prospective
randomised clinical and radiological trial..J Bone Joint
Surg (Br), 90, 584-591.
RA, Deirmengian CA, Della Valle CJ, Paprosky WG, Jacobs JJ,
Rosenberg AG.(2006) A technique for minimally invasive,
quadriceps-sparing total knee arthroplasty. J Knee Surg, 19,
M, Clarke HD, Scuderi GR. (2005) Minimal-incision total knee
arthroplasty: the early clinical experience. Clin Orthop,
Y, Miura H, Matsuda S, Okazaki K, Iwamoto Y. (2007)
Minimally invasive versus standard approach in total knee
arthroplasty. Clin Orthop, 463, 144-150.
FR, Bonutti PM, Hozack WJ et al (2007).Clinical experience
using a minimally invasive surgical approach for total knee
arthroplasty: early results of a prospective randomized
study compared to a standard approach. J Arthroplasty, 22,
NS. (2006) Minimally invasive technique in total knee
arthroplasty--history, tips, tricksand pitfalls. Injury, 37,
A, Thiengwittayaporn S, Itiravivong P.(2005) Results of the
136 consecutive minimally invasive total knee
arthroplasties.J Med Assoc Thai, 88, 74-78.
HT, Su JY, Chang JK, Chen CH, Wang GJ.(2007) The early
clinical outcome of minimally invasive quadriceps-sparing
total kneearthroplasty: report of a 2-year follow-up. J
Arthroplasty, 22, 1007-1012.
RA, Sanders S, Gerlinger T, Della Valle C, Jacobs JJ,
Rosenberg AG. (2005)Outpatient total knee arthroplasty with
a minimally invasive technique.J Arthroplasty, 20, 33-38.
WC, Diesfeld PJ, Reedy ME, LeMarr AR.(2008) Mini-subvastus
approach for total knee arthroplasty.J Arthroplasty,
T, Ongnamthip P, Karnchanalerk K, Udombuathong P. (2008)
Comparative study between 2 cm limited quadriceps exposure
minimal invasive surgery and conventional total knee
arthroplasty in quadriceps function: prospective randomized
controlled trial. J Med Assoc Thai, 91, 203-207
DS, Lee HK, Hwang SY, Park JU.(2006) Blood loss after
navigation-assisted minimally invasive total knee
arthroplasty. Orthopedics, 29, 152-154.
A, Thiengwittayaporn S, Itiravivong P.(2007)Progressive
quadriceps incision during minimally invasive surgery for
total knee arthroplasty: the effect on early postoperative
ambulation. J Arthroplasty, 22, 1013-1018.
RA, Sanders S, D'Ambrogio E, Buchheit K, Deirmengian C,
Paprosky W,Della Valle CJ, Rosenberg AG. Minimally invasive
quadriceps-sparing TKA: results of a comprehensive pathway
foroutpatient TKA. J Knee Surg. 2006 Apr;19(2):145-8
P, Baldini A, Sensi L. (2006) Quadriceps-sparing versus
mini-subvastus approach in total knee arthroplasty. Clin
Orthop, 452, 106-111.
KJ, Beringer D. (2007) Economic considerations in minimally
invasive total joint arthroplasty. Clin Orthop, 463, 20-25.
TM. (2006) The economic impact of minimally invasive total
knee arthroplasty. Am J Orthop, 35, 33-35.
AQ, Yeo SJ, Yang KY, Lo NN, Chia KU, Chong HC. (2008)
Computer-assisted minimally invasive total knee arthroplasty
compared with standard total knee arthroplasty. A
prospective, randomized study. J Bone Joint Surg (Am), 90,
JK, Song EK, Yoon TR, Park SJ, Bae BH, Cho SG.(2007)
Comparison of functional results with navigation-assisted
minimally invasive and conventional techniques in bilateral
total knee arthroplasty. Comput Aided Surg, 12, 189-193.
Laskin (2003) New techniques and concepts in total knee
replacement, Clin Orthop 416, 151-153.
JK, Song EK.(2006) Navigation-assisted less invasive total
knee arthroplasty compared with conventional total knee
arthroplasty: a randomized prospective trial. J Arthroplasty,
AJ Jr (2006).The evolving role of navigation in minimally
invasive total knee arthroplasty. Am J Orthop, 35, 18-22.
RT, McGrory B J, Berry D J, Becker W M, Harmsen W S.(1999)
Patients' concerns prior to undergoing total hip and total
knee arthroplasty, Mayo Clin Proc, 74, 978–982.
MW, Meneghini RM, Trousdale RT. (2006) Anatomy of the
extensor mechanism in reference to quadriceps-sparing TKA,
Clin Orthop, 452, 102-105.
G, Nunn T, Allen RA, Forrester AW, Gregori A. (2008)
Variation of the Vastus Medialis Obliquus Insertion and its
Relevance to Minimally Invasive Total Knee Arthroplasty A
Cadaver and Magnetic Resonance Imaging Study. J Arthroplasty.
2008, 23, 600-604.
WC, Diesfeld PJ, Reedy ME, Lemarr AR. Surgical accuracy with
the mini-subvastus total knee arthroplasty a computer
tomography scan analysis of postoperative implant alignment.
J Arthroplasty, 23, 543-549.