Roysam and Oakley should be commended for conducting a randomized,
controlled trial comparing the subvastus and parapatellar surgical
approaches for total knee arthroplasty. Their study showed that
some short-term postoperative outcomes were significantly better
after the subvastus approach. However, the significant parameters
identified in this study have few or no long-term clinical consequences.
It has been previously suggested that the subvastus approach should
be avoided in certain clinical circumstances because of the difficulties
with exposure1,2. Hofmann et al.
described several exclusion criteria, including (1) a severely arthritic
knee, (2) a prior major arthrotomy, (3) a prior high tibial osteotomy,
and (4) patient weight exceeding 200 lbs (91 kg)1.
Matsueda and Gustilo2 agreed and
added several contraindications, including (1) a severe flexion
contracture and (2) heavily muscled thighs. The authors of the present
study did not use any of these exclusion criteria in the preoperative patient
selection, and the clinical outcomes in these patient subgroups
were not analyzed. Many of these variables could have had a substantial
effect on the outcomes measured in this study.
In summary, before accepting the authors’ recommendation
that the subvastus approach be more widely used in total knee arthroplasty,
one must take into consideration the appropriate patient population.
Unless the contraindications for this surgical exposure are carefully
defined, one should use caution and understand that there are pitfalls
when selecting this surgical approach for all patients undergoing
primary total knee arthroplasty.