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Comparison of the Vastus-Splitting and Median Parapatellar Approaches for Primary Total Knee Arthroplasty: A Prospective, Randomized Study
Matthew J. Kelly, MD1; Mustasim N. Rumi, MD2; Milind Kothari, DO3; Michael A. Parentis, MD4; Katrina J. Bailey, PT3; William M. Parrish, MD3; Vincent D. PellegriniJr., MD5
1 20415 Stable Lane, Waynesville, MO 65583
2 Orthopaedic Associates of Central Texas, 16020 Park Valley Drive, Round Rock, TX 78746
3 Departments of Neurology (M.K.), Physical Therapy (K.J.B.), and Orthopaedics and Rehabilitation (W.M.P.), The Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA 17033
4 The Knee Center of Western New York 100 Corporate Way, Suite 12, Amherst NY 14226
5 Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Suite S 11 B, Baltimore, MD 21201. E-mail address: vpellegrini@umoa.umm.edu
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A video supplement to this article is being developed by the American Academy of Orthopaedic Surgeons and JBJS and will be available at the JBJS web site, www.jbjs.org. To obtain a copy of the video, contact the AAOS at 800-626-6726 or go to their web site, www.aaos.org, and click on Educational Resources Catalog.
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedics and Rehabilitation, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Apr 01;88(4):715-720. doi: 10.2106/JBJS.E.00107
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Background: A vastus-splitting approach for total knee arthroplasty has been advocated to preserve function of the extensor mechanism and to decrease the prevalence of lateral release. Critics have claimed that there is greater blood loss and compromised exposure in large patients who are managed with this approach. The purpose of the present study was to compare vastus-splitting and median parapatellar approaches for primary total knee arthroplasty.

Methods: Forty-two consecutive patients (fifty-one knees) undergoing primary total knee arthroplasty were randomized to treatment with a median parapatellar or vastus-splitting approach. The interval of the vastus muscle split was marked with radiopaque vascular clips. Surgical data, functional parameters, and preoperative and postoperative electromyograms were assessed.

Results: Early (six-month) and intermediate-term (five-year) follow-up showed no differences in functional parameters, tourniquet time, or the frequency of patellar resurfacing. Significantly more lateral releases (p < 0.01) and greater blood loss (p = 0.03) occurred in the median parapatellar group. Nine (43%) of twenty-one knees in the vastus-splitting group had abnormal electromyographic findings at six months postoperatively, whereas all patients in the median parapatellar group had normal findings. Seven knees with abnormal electromyographic findings at six months had normal findings when restudied at five years; in each of these knees, the vastus split had been developed bluntly. The other two knees with abnormal findings at six months had had sharp dissection for the muscle split. Both of these knees had chronic changes, one with changes indicative of reinnervation and the other with ongoing denervation, but neither demonstrated functional compromise.

Conclusions: The vastus-splitting approach offers a viable alternative to the median parapatellar approach for primary total knee arthroplasty that reduces the need for lateral retinacular release without impairment of quadriceps function. Electromyographic abnormalities in the quadriceps muscle have no functional consequence and most likely represent reversible neurapraxic injury that may be avoided by blunt dissection in the vastus medialis muscle.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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