Minimally Invasive Total Knee Replacement with the Quadriceps-Sparing Subvastus Approach

Abstract

The subvastus approach to the knee offers several distinct advantages when applied to minimally invasive total knee replacement. With minor modifications to the technique as described by Hoffman, the subvastus approach becomes an exposure that is optimized for minimally invasive surgery (MIS).1–3 The MIS-optimized subvastus approach provides excellent exposure through a small incision, preserves all four attachments of the quadriceps to the patella, does not require patella eversion, minimizes disruption of the suprapatellar pouch, and facilitates rapid and reliable closure of the knee joint at the conclusion of the procedure. With the MIS-optimized subvastus approach, the patella and distal portion of the extensor mechanism are retracted into the lateral gutter of the knee where they remain out of the way to allow visualization of the distal femur during surgery. Additionally, the broad, triangular tendinous attachment of the vastus medialis to the patella is preserved with this approach and provides an ideal region to place retractors without damaging the quadriceps muscle itself. Those advantages have made the MIS-optimized subvastus approach the exposure of choice for both small incision (4 in. to 5 in.) and very small incision (2.5 in. to 3.5 in.) total knee replacement for the two authors.