Download PDF
J Knee Surg
DOI: 10.1055/a-2796-8160
Original Article

Is the Mini-Midvastus Approach for Total Knee Arthroplasty Any Better in Reducing Blood Loss and Hospital Stay?

Authors

  • Ahmet Can Erdem

    1   Department of Orthopedics and Traumatology, Bezmialem Vakif University, İstanbul, Turkey

  • Mehmet Erdem

    2   Private Practice, Bursa, Turkey

  • Necmettin Turgut 

    3   Department of Orthopedics and Traumatology, Başkent University, Adana Turgut Noyan Training and Research Center, Adana, Turkey

  • Levent Bayam

    4   Department of Orthopedics and Traumatology, Medipol University, Istanbul, Turkey

  • Fevzi Sağlam

    5   Department of Orthopedics and Traumatology, Sakarya University, Sakarya, Turkey

  • Muhammed Fatih Serttaş

    6   Department of Orthopedics and Traumatology, Kocaeli City Hospital, Kocaeli, Turkey

Funding Information None.
Further Information
   Permissions and Reprints

Abstract

Total knee arthroplasty (TKA) is a widely used surgical intervention for advanced osteoarthritis, with evolving surgical techniques aiming to reduce blood loss and hospital stay. The minimally invasive midvastus (MMV) approach is hypothesized to minimize soft tissue damage and promote faster recovery compared to the classic medial parapatellar (MPP) approach. This study aimed to compare clinical and radiological outcomes, including perioperative blood loss and hospital discharge timing, between the MMV and MPP approaches.

A total of 99 patients with advanced osteoarthritis who underwent primary TKA between 2013 and 2019 were prospectively analyzed. Patients were divided into MMV (n = 50) and MPP (n = 49) groups. All surgeries were performed by the same experienced surgeon using the same prosthetic system and perioperative protocols. Clinical outcomes included hemoglobin (Hb), hematocrit (Hct), discharge timing, range of motion (ROM), Visual Analog Scale (VAS), and Oxford Knee Score (OKS). Radiological outcomes included alignment and component positioning. Statistical analysis was conducted with significance set at p < 0.05.

There were no significant differences between groups in demographic characteristics, surgical duration, alignment parameters (mechanical medial proximal tibial angle, mechanical lateral distal femoral angle, component tibial angle, component femoral angle), VAS, OKS, or final ROM. Postoperative (day 0 and day 3) Hb and Hct values did not differ significantly, and no blood transfusions were required in either group. However, same-day discharge was significantly more common in the MMV group (p = 0.02). One wound complication occurred in the MPP group; one patient from each group required postoperative manipulation under anesthesia.

While both surgical approaches provided comparable clinical and radiological outcomes with no differences in blood loss, the MMV approach was associated with a higher rate of same-day discharge, suggesting an advantage in early recovery and reduced hospital stay.

Keywords

total knee arthroplasty - midvastus approach - medial parapatellar approach - blood loss - hospital stay - arthroplasty


Publication History

Received: 01 July 2025

Accepted: 24 January 2026

Article published online:
27 February 2026

© 2026. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am 2005; 87 (07) 1487-1497
    Search in Google Scholar
  • 2 Culliford DJ, Maskell J, Beard DJ, Murray DW, Price AJ, Arden NK. Temporal trends in hip and knee replacement in the United Kingdom: 1991 to 2006. J Bone Joint Surg Br 2010; 92 (01) 130-135
    Search in Google Scholar
  • 3 Patel A, Pavlou G, Mújica-Mota RE, Toms AD. The epidemiology of revision total knee and hip arthroplasty in England and Wales: A comparative analysis with projections for the United States. A study using the National Joint Registry dataset. Bone Joint J 2015; 97-B (08) 1076-1081
    Search in Google Scholar
  • 4 Hooper G, Lee AJJ, Rothwell A, Frampton C. Current trends and projections in the utilisation rates of hip and knee replacement in New Zealand from 2001 to 2026. N Z Med J 2014; 127 (1401) 82-93
    Search in Google Scholar
  • 5 Soffin EM, YaDeau JT. Enhanced recovery after surgery for primary hip and knee arthroplasty: A review of the evidence. Br J Anaesth 2016; 117 (Suppl. 03) iii62-iii72
    Search in Google Scholar
  • 6 Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: A systematic review. Clin Rehabil 2015; 29 (09) 844-854
    Search in Google Scholar
  • 7 Crawford DA, Adams JB, Berend KR, Lombardi Jr AV. Low complication rates in outpatient total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28 (05) 1458-1464
    Search in Google Scholar
  • 8 Berend ME, Berend KR, Lombardi Jr AV. Advances in pain management: game changers in knee arthroplasty. Bone Joint J 2014; 96-B (11 Supple A): 7-9
    Search in Google Scholar
  • 9 Laskin RS, Beksac B, Phongjunakorn A. et al. Minimally invasive total knee replacement through a mini-midvastus incision: An outcome study. Clin Orthop Relat Res 2004; (428) 74-81
    Search in Google Scholar
  • 10 Tsuji S, Tomita T, Fujii M, Laskin RS, Yoshikawa H, Sugamoto K. Is minimally invasive surgery-total knee arthroplasty truly less invasive than standard total knee arthroplasty? A quantitative evaluation. J Arthroplasty 2010; 25 (06) 970-976
    Search in Google Scholar
  • 11 Bridgman SA, Walley G, MacKenzie G, Clement D, Griffiths D, Maffulli N. Sub-vastus approach is more effective than a medial parapatellar approach in primary total knee arthroplasty: A randomized controlled trial. Knee 2009; 16 (03) 216-222
    Search in Google Scholar
  • 12 Avci CC, Gülabi D, Erdem M, Kurnaz R, Güneş T, Bostan B. Minimal invasive midvastus versus standard parapatellar approach in total knee arthroplasty. Acta Orthop Traumatol Turc 2013; 47 (01) 1-7
    Search in Google Scholar
  • 13 Kolisek FR, Bonutti PM, Hozack WJ. et al. 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 2007; 22 (01) 8-13
    Search in Google Scholar
  • 14 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 2009; 24 (05) 681-688
    Search in Google Scholar
  • 15 Verburg H, Mathijssen NMC, Niesten D-D, Verhaar JAN, Pilot P. Comparison of mini-midvastus and conventional total knee arthroplasty with clinical and radiographic evaluation: a prospective randomized clinical trial with 5-year follow-up. J Bone Joint Surg Am 2016; 98 (12) 1014-1022
    Search in Google Scholar
  • 16 Engh GA, Parks NL, Ammeen DJ. Influence of surgical approach on lateral retinacular releases in total knee arthroplasty. Clin Orthop Relat Res 1996; (331) 56-63
    Search in Google Scholar
  • 17 Heekin RD, Fokin AA. Mini-midvastus versus mini-medial parapatellar approach for minimally invasive total knee arthroplasty: outcomes pendulum is at equilibrium. J Arthroplasty 2014; 29 (02) 339-342
    Search in Google Scholar
  • 18 Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 1989; (248) 9-12
    Search in Google Scholar
  • 19 Shah RR, Cipparrone NE, Gordon AC, Raab DJ, Bresch JR, Shah NA. Is it safe? Outpatient total joint arthroplasty with discharge to home at a freestanding ambulatory surgical center. Arthroplast Today 2018; 4 (04) 484-487
    Search in Google Scholar
  • 20 Berger RA, Sanders S, Gerlinger T, Della Valle C, Jacobs JJ, Rosenberg AG. Outpatient total knee arthroplasty with a minimally invasive technique. J Arthroplasty 2005; 20 (7 Suppl 3): 33-38
    Search in Google Scholar
  • 21 Darrith B, Frisch NB, Tetreault MW, Fice MP, Culvern CN, Della Valle CJ. Inpatient versus outpatient arthroplasty: A single-surgeon, matched cohort analysis of 90-day complications. J Arthroplasty 2019; 34 (02) 221-227
    Search in Google Scholar
  • 22 Courtney PM, Boniello AJ, Berger RA. Complications following outpatient total joint arthroplasty: An analysis of a national database. J Arthroplasty 2017; 32 (05) 1426-1430
    Search in Google Scholar
  • 23 Bonutti PM, Zywiel MG, Ulrich SD, Stroh DA, Seyler TM, Mont MA. A comparison of subvastus and midvastus approaches in minimally invasive total knee arthroplasty. J Bone Joint Surg Am 2010; 92 (03) 575-582
    Search in Google Scholar
  • 24 Dalury DF, Jiranek WA. A comparison of the midvastus and paramedian approaches for total knee arthroplasty. J Arthroplasty 1999; 14 (01) 33-37
    Search in Google Scholar
  • 25 Haas SB, Macdessi SJ, Manitta MA. Mini-midvastus total knee arthroplasty. Minim invasive Surg Orthop 2010; 293-300
    Search in Google Scholar
  • 26 Engh GA, Holt BT, Parks NL. A midvastus muscle-splitting approach for total knee arthroplasty. J Arthroplasty 1997; 12 (03) 322-331
    Search in Google Scholar
  • 27 Nestor BJ, Toulson CE, Backus SI, Lyman SL, Foote KL, Windsor RE. Mini-midvastus vs standard medial parapatellar approach: A prospective, randomized, double-blinded study in patients undergoing bilateral total knee arthroplasty. J Arthroplasty 2010; 25 (6 Suppl): 5-11 , 11.e1
    Search in Google Scholar
  • 28 Yang X, Cheng QH, Yang YZ, Zhang AR, Fan H, Guo HZ. Minimally invasive medial femoral approach to total knee arthroplasty improves short-term outcomes compared to the standard medial parapatellar approach: A systematic review and meta-analysis. J Orthop Surg Res 2023; 18 (01) 657
    Search in Google Scholar
  • 29 Cho K-Y, Kim K-I, Umrani S, Kim S-H. Better quadriceps recovery after minimally invasive total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2014; 22 (08) 1759-1764
    Search in Google Scholar
  • 30 Cuckler JM. The ugly underbelly of the MIS movement: In the affirmative. J Arthroplasty 2007; 22 (4 Suppl 1): 99-101
    Search in Google Scholar
  • 31 Dalury DF, Dennis DA. Mini-incision total knee arthroplasty can increase risk of component malalignment. Clin Orthop Relat Res 2005; 440 (440) 77-81
    Search in Google Scholar
  • 32 Juosponis R, Tarasevicius S, Smailys A, Kalesinskas RJ. Functional and radiological outcome after total knee replacement performed with mini-midvastus or conventional arthrotomy: Controlled randomised trial. Int Orthop 2009; 33 (05) 1233-1237
    Search in Google Scholar
  • 33 Chin PL, Foo LSS, 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 2007; 22 (06) 800-806
    Search in Google Scholar
  • 34 Silva RRD, Matos MA, Badaró DA, Prata PB, Ariel de Lima D. A comparative study of the medial parapatellar and midvastus surgical approaches for total knee arthroplasty. Rev Bras Ortop 2025; 60 (01) s00441800945
    Search in Google Scholar
  • 35 Varela-Egocheaga JR, Suárez-Suárez MA, Fernández-Villán M, González-Sastre V, Varela-Gómez JR, Rodríguez-Merchán C. Minimally invasive subvastus approach: Improving the results of total knee arthroplasty: A prospective, randomized trial. Clin Orthop Relat Res 2010; 468 (05) 1200-1208
    Search in Google Scholar
  • 36 Levine M, Ensom MHH. Post hoc power analysis: An idea whose time has passed?. Pharmacotherapy 2001; 21 (04) 405-409
    Search in Google Scholar