artoplastias por osteoartritis

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clinical therapeutics

T h e n e w e n g l a n d j o u r n a l o f medicine

n engl j med 360;17 nejm.org april 23, 2009 1749

ThisJournalfeature begins with a case vignette that includes a therapeutic recommendation. A discussionof the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies,

the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines,if they exist, are presented. The article ends with the authors clinical recommendations.

Minimally Invasive Total Knee Arthroplasty

for OsteoarthritisSeth S. Leopold, M.D.

From the Department of Orthopedicsand Sports Medicine, University of Wash-ington School of Medicine, Seattle. Ad-dress reprint requests to Dr. Leopold at theDepartment of Orthopedics and Sports

Medicine, University of Washington Schoolof Medicine, Box 356500, Seattle, WA98195, or at [email protected].

N Engl J Med 2009;360:1749-58.

Copyright 2009 Massachusetts Medical Society.

A 65-year-old woman with osteoarthritis of her right knee is referred by her primary

care physician for orthopedic consultation. She is healthy except for some well-con-

trolled hypertension. She is 5 ft 5 in. tall (165 cm) and weighs 160 lb (73 kg), so her

body-mass index (the weight in kilograms divided by the square of the height in meters)

is 26.6. Her arthritis is not limited to one part of her knee but is diffuse and severe. She

has minimal joint deformity and good bone quality. For several years, she was able to

control the pain in her right knee with indomethacin, but recently this has been insuf-

ficient. An intraarticular corticosteroid injection was performed several months ago,

with limited effect. The surgeon recommends total knee arthroplasty. The patient has

a friend who has told her that his surgeon used a minimally invasive approach for

his total knee replacement, and it went well. The patient has investigated this approach

on the Internet, and she isnt sure what to do. She asks her primary care physician

whether he recommends that she consider minimally invasive surgery.

The Clinical Problem

Osteoarthritis affects more people than any other joint disease1and is the most com-mon cause of long-term disability in most populations over the age of 65 years.2,3Primary osteoarthritis is rare before the age of 40 years but becomes increasinglycommon each decade thereafter.1A report from the Third National Health andNutrition Examination Survey estimated that 37.4% of adults in the United Stateswho are 60 years of age or older have radiographic evidence of the condition.4Al-though osteoarthritis is not a life-threatening disease, the morbidity associated withthis condition is considerable; 80% of patients with osteoarthritis have limitationof movement, and 25% have difficulty performing major activities of daily living.5The economic burden of osteoarthritis may exceed $60 billion per year in the UnitedStates.1

Pathophysiology and the Effect of Therapy

The pathophysiology of osteoarthritis is complex and incompletely understood, al-though the hallmark of the disease is the loss of articular cartilage, with concomi-tant changes in the underlying bone.6,7Many factors appear to be associated withthe development of this condition, including injury, genetics, changes in tissue struc-ture, and chondrocyte aging.7-9Major trauma, such as an intraarticular fracture,

The New England Journal of Medicine

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n engl j med 360;17 nejm.org april 23, 20091750

clearly increases the risk of subsequent (post-traumatic) arthritis. Research is being done totry to characterize the degree to which minortraumatic events can precipitate cartilage break-down and degenerative joint disease,10particu-larly when the injury is compounded by obesity,joint malalignment, or other predisposing fac-

tors.11

The anatomic features of osteoarthritis includeloss of articular cartilage, eburnation (or sclero-sis) of the subchondral bone, formation of osteo-phytes (or bone spurs), and the presence ofdegenerative subchondral cysts (Fig. 1). In somepatients, there is clinically significant inflamma-tion, including effusions, warmth, and synovitisthat is visible during surgery. When osteoarthri-tis of the knee becomes severe, joint deformities most commonly, varus (bowlegs) or valgus(knock-knees) can occur.

Total knee arthroplasty is an operation thatconsists of removal of the damaged cartilage, cor-rection of joint deformities, and replacement ofthe worn cartilaginous bearing surfaces (on thefemur, tibia, and patella) with an artif icial bear-ing (Fig. 2). Arthroplasty is not a disease-modify-ing procedure but rather is a mechanical solutionto a biologic problem.

For some patients with severe joint damage,arthroplasty may be the only option that offersthe possibility of restored mobility and freedomfrom pain. However, arthroplasty is a major op-eration, and recovery is difficult. Patients typical-ly have substantial postoperative pain, which mustbe tolerated while they undergo the aggressivephysical therapy that is required for a good out-come. They often use assistive devices for ambu-lation for 6 weeks or longer and require frequentphysical therapy and narcotic analgesics for sev-eral months.12

For these reasons, there is interest among sur-geons and patients alike in methods that wouldmake total knee arthroplasty less invasive.13,14A

variety of different procedures and techniques,all intended to reduce the amount of tissue injuryoccurring during surgery, have been lumped to-gether under the label minimally invasive sur-gery (Table 1). This general term is used toidentify all such procedures in this review.

The purported advantages of minimally inva-sive approaches include less postoperative pain,a shorter hospital stay, an earlier return of con-

l

A

B

Figure 1.Radiograph of the Left Knee of a Patientwith Osteoarthritis.

Panel A shows an anteroposterior view with visibleeburnation of the subchondral bone (sclerosis)

(arrow) and loss of articular surface cartilage (or joint-

space narrowing) (arrowhead). Panel B shows a lateralview, in which patellar osteophytes are also readily seen.





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Clinical Therapeutics


trol for quadriceps muscles (leading to a shorterperiod of dependence on external devices for am-bulation), and a briefer convalescence.12-19Al-though there is limited evidence suggesting thatminimally invasive total knee arthroplasty resultsin longer-term benefits in function than doesthe traditional approach,15,20most surgeons think

that any benefits that may accrue are confinedto the recuperative period.

Clinical Evidence

The clinical studies evaluating the potential bene-fit of minimally invasive total knee arthroplastyhave a number of limitations. Of the studies thathave been conducted, very few are randomized,most are quite small, and some evaluate differentmethods or aspects of the minimally invasive ap-proach, making a comparison among studies dif-

ficult. Most of these studies do not take into ac-count the skill development or learning curveof the surgeons who are performing the proce-dures. In addition, all the studies have been per-formed in the context of the evolution of surgicalpractice. In large measure because of these issues,there remains real conflict in the orthopedic litera-ture about the benefit of this surgical approach.

In one of the few randomized trials, Koliseket al.21compared a minimally invasive approachwith the traditional approach in 80 patients. Theinvestigators found no significant differences inclinical or radiographic results at 3 months offollow-up. However, the authors defined mini-mally invasive surgery entirely as a function ofincision length, since no specialized instrumentswere used in the group undergoing minimallyinvasive procedures, and the surgeons evertedthe patella (i.e., rotated it 180 on its tendon) aspart of the operation. The use of incision lengthalone, as in the study by Kolisek et al., is notconsidered an appropriate or sufficient determi-nant to classify the procedure as minimally in-

vasive (Table 1).One of the largest nonrandomized studies22involved 200 consecutive total knee arthroplastyoperations (100 using the traditional approachand 100 using the minimally invasive approach),which were performed by experienced joint sur-geons. The investigators, McAllister and Stepa-

l

A

B

Figure 2. Radiograph of the Right Knee of a Patient

after Total Knee Arthroplasty.

Shown are an anteroposterior view (Panel A) and a

lateral view (Panel B) of the tibial components (arrows)and the femoral components (arrowheads).





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nian, defined minimally invasive surgery as totalknee arthroplasty performed without dissectioninto the quadriceps tendon, eversion of the pa-tella, or dislocation of the tibiofemoral joint;these operations also involved the use of instru-mentation designed specifically for minimallyinvasive surgery. Patients who underwent theminimally invasive procedure had less postopera-tive pain and an improved early range of motion.They also had a significantly decreased risk ofrequiring manipulation under anesthesia (14%vs. 2%, P


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considering surgery is the patients ability andwillingness to participate in an aggressive regi-men of postoperative physical therapy. Vigorousphysical rehabilitation, including exercises spe-cifically intended to require early and repetitivemotion of the affected knee despite substantialpain, is necessary for a good result. Failures of

rehabilitation, which often stem from problemsin managing postoperative pain early on, canpermanently prejudice the outcome.25-27

Once the decision has been made to proceedwith surgery, the discussion can turn to whethera traditional or minimally invasive approach ismore appropriate. An essential factor to considerin this decision is the experience of the surgeon.In our study, we specifically evaluated the effectof experience and showed that a surgeon musttypically perform 25 to 50 procedures usingminimally invasive techniques before benefits of

this approach can be expected.12 A fairly highpractice volume is also important in maintain-ing the skills necessary for minimally invasivesurgery, a principle that obviously applies to con-ventional surgery as well.28,29Given the exclusioncriteria of the major clinical studies, other rela-tive contraindications to the minimally invasiveapproach may include previous open knee sur-gery,15,16,19,30,31severe osteoporosis or rheuma-toid arthritis,14,30,31 obesity or increased limbgirth,12,14,15and severe joint deformity.12,14

Anesthesia can be performed with the use ofany of a variety of approaches. Either generalanesthesia or regional (spinal or epidural) anes-thesia, with or without adjunctive peripheral-nerve block, is appropriate.

During the operation, the patients knee istypically positioned in some flexion, and tourni-quet control is used to reduce bleeding. The tra-ditional approach uses an anterior longitudinalincision of 6 to 9 in. in length, whereas theminimally invasive approach often uses a some-what shorter anteromedial incision along the

medial border of the patella, extending distallyto the level of the tibial tubercle. The traditionalapproach may then involve a longitudinal inci-sion through the quadriceps tendon; the mini-mally invasive approach opens the medial cap-sule and extends proximally and obliquely intoeither the midvastus plane or subvastus plane bya small amount (typically 1 to 3 cm) and avoids

the quadriceps tendon (Fig. 3). In the traditionalapproach, the patella is then everted, whereas inthe minimally invasive approach, the patella isretracted laterally but not everted. In the tradi-tional approach, the tibiofemoral joint is thendislocated and the knee hyperflexed. In the mini-mally invasive approach, that joint is left in situ

without dislocation.In both techniques, cutting jigs and anatomic

landmarks are used to determine the depth andorientation of tibial and femoral bone resections.In the minimally invasive procedure, the cuttingguides are reduced in size, rounded, and designedto optimize accuracy through the smaller antero-medial window. Regardless of approach, carefulattention to ligament balancing and protectingneurovascular structures must be maintained.Trial implants then are placed over the resectedbone surfaces; joint stability, ligament balance,

and range of motion then are assessed. If satis-factory, final components are inserted (Fig. 4).Final hemostasis is then obtained, and the jointis irrigated and closed.

The period of convalescence varies. As noted,in our study,12we found that the mean hospitalstay for patients undergoing minimally invasivetotal knee arthroplasty was 2.8 days, about 1 dayshorter than the mean duration for the tradi-tional approach. Physical therapy is initiated theday of surgery, with an emphasis on range of mo-tion, gait training, safety, and transfers. A machinethat provides continuous passive motion may beused to enhance the exercises performed with aphysical therapist.32Adequate analgesia duringphysical therapy is essential; pain is the mostcommon threat to adequate progression of mo-bility. In general, patients who have undergoneminimally invasive total knee arthroplasty requirethe use of a walker for about a week and the useof a cane for a week to 10 days, at which pointunassisted ambulation is the norm. Physical ther-apy usually concludes by about 6 weeks with the

minimally invasive approach; with the traditionalapproach, an additional month of therapy is usu-ally required.

Appropriate thromboprophylaxis should beused after either traditional or minimally invasivesurgery. A variety of agents, including aspirin, war-farin, unfractionated heparin, and low-molecular-weight heparin, are used for this purpose. In-





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termittent pneumatic-compression devices thatprevent venous stasis and that may enhance fibrin-olysis are also commonly used. There is currentlysubstantial disagreement between the recommen-dations of the American Academy of OrthopedicSurgeons and those of the American College of

Chest Physicians regarding the appropriate inten-sity of anticoagulation.33,34

According to one study, the estimated meancost of primary total knee arthroplasty was $29,290on the basis of data collected from October 2005through June 2006 at four high-volume centers.35

A B

C

Patella

Patella

Patella(everted)

Traditional

Minimally Invasive

il ll

Figure 3.Elements of Minimally Invasive Total Knee Arthroplasty.

Panel A shows the anatomical relations of the deep-tissue surgical incision for total knee arthroplasty. The traditional

incision typically extends into the quadriceps tendon. The minimally invasive incision spares the quadriceps tendonand extends into or beneath the vastus medialis muscle. Joint-space exposure is shown for traditional total knee

arthroplasty (Panel B) and for the minimally invasive procedure (Panel C). In the traditional procedure, a larger incisionis made, and retractors are placed in a fixed position for maximal exposure. The tibiofemoral joint is dislocated, and

the patella is everted (rotated laterally 180 on its tendon). In the minimally invasive procedure, a relatively smallincision is made, and retractors are shifted during surgery to create a mobile window for the minimum necessary

exposure. The tibiofemoral joint is not dislocated, and the patella is retracted laterally without being everted.





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The study did not distinguish between the costof minimally invasive procedures and that oftraditional operations. One expert has observedthat although the cost of minimally invasive to-tal knee arthroplasty could be less than that ofthe conventional procedure (as a result of ashorter hospital stay), current reimbursement

policies may create incentives to keep the patientin the hospital longer.36

Adverse Effects

Many of the complications of total knee arthro-plasty are similar whether a minimally invasiveor traditional procedure is performed. The mostfeared complication, infection of the joint, oc-curs in less than 1% of patients.37By contrast,thromboembolic disease is common even withappropriate thromboprophylaxis. Venographic

studies indicate that 15% of patients may havedeep venous thrombosis, but symptomatic throm-boembolic events occur in only 2 to 3% of pa-tients.38Nerve injuries, especially peroneal nervepalsy, occur in 1 to 2% of patients,39 whereasarterial vascular injury is much rarer. As notedabove, persistent pain or stiffness occurs in 8 to23% of patients.23Prosthesis failure, typically re-quiring surgical revision, occurs in approximate-ly 2% of patients at 5 years.40

In some studies, specific problems associatedwith the minimally invasive approach include in-ferior mean alignment41or an increased frequen-cy of outliers in terms of alignment,41-43concernabout wound healing,21a longer surgical dura-tion,43and an inability to validate claims regard-ing improvements in early recovery or the timeto independent ambulation.21,42However, most ofthese reports come from studies that enrolledpatients early in the surgeons learning curve orthat describe an approach as minimally invasivesolely on the basis of the incision length. Forthese reasons, the experience of the surgeon is an

essential consideration in choosing minimallyinvasive total knee arthroplasty.

Area s of Uncertainty

As noted above, the designation minimally inva-sive total knee arthroplasty encompasses severaldifferent modifications in surgical technique. It

has not been established which of these changesare essential to improving outcomes for the pa-tient. Increasingly, all elements of the minimally

invasive approach are being used together (Table1). It therefore seems unlikely that any trial willbe conducted to distinguish, for example, the ben-efit of sparing the quadriceps tendon from that ofavoiding or minimizing tibiofemoral-joint dislo-cation.

Since the minimally invasive approach has beenin common use for less than 5 years, it has not

Femur Femoralcomponent

Tibialcomponent

Tibia

Patellarcomponent

Patella

il ll

Figure 4.Components of Total Knee Arthroplasty.

Precise resections are made in the distal end of the femur, the proximal

end of the tibia, and the posterior surface of the patella to fit the corre-sponding surfaces of the three arthroplasty components. The femoral com-

ponent is typically made of metal (most commonly, a cobaltchromiumalloy). The patellar component is typically made of ultra-high-molecular-

weight polyethylene (a plastic resin). The tibial implant is usually made ofmetal (either a titanium or a cobaltchromium alloy). There is an exchange-

able polyethylene bearing on the tibia, which makes it possible to replacethe plastic articular surface without replacing the metal component if wear

of the bearing surface occurs.





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yet been established that long-term outcomes willbe as good (even in the hands of experiencedsurgeons) as those of patients undergoing tradi-tional total knee arthroplasty. Although the char-acteristics of the procedure itself do not suggestobvious grounds for concern in this regard, ad-ditional studies will be required to provide a de-

finitive answer to this question.A variety of further modifications of surgical

technique have been described in the past fewyears. These include computer-assisted naviga-tion to aid in the precision of bone excision andprosthesis alignment, as well as recurrent inter-est in unicompartmental (partial) knee arthro-plasty, meniscus replacement, and other similarelaborations, some of which are sometimes de-scribed as minimally invasive techniques. Thepotential advantages of such approaches as com-pared with the operation outlined in this review

are not known.

Guidelines

There are no formal guidelines on the subject ofminimally invasive total knee arthroplasty. TheAmerican Academy of Orthopedic Surgeons of-fers only a brief comment on the guidelines pageof its Web site and does not draw a distinctionbetween minimally invasive total knee arthro-plasty and minimally invasive total hip arthro-plasty. The hip procedure has provoked substan-tial controversy because of a high frequency ofmajor complications.44,45The groups guidelinesstate that minimally invasive surgery for totaljoint replacement is a promising, but evolvingsurgical technique that requires additional scien-tific evidence to validate its short- and long-termsafety and effectiveness, in comparison to con-ventional joint replacement methods.46

In 2004, the American Association of Hip andKnee Surgeons released an advisory statementabout minimally invasive hip and knee arthro-plasty that cites both potential advantages anddisadvantages of the two approaches.47Unfortu-nately, since most of the literature on minimallyinvasive total knee arthroplasty has been published

since 2004, that statement is now out of date.

Recommendations

The patient who is described in the vignette maybe a suitable candidate for minimally invasivetotal knee arthroplasty, but some further consid-eration of her specific circumstances is appropri-ate. I would begin by discussing the major ther-apeutic options with the patient; in particular, Iwould try to ascertain whether she feels stronglythat her quality of life with medical therapy alone

has become unacceptable. If her answer is yes,I would describe the advantages and disadvan-tages of both the traditional and the minimallyinvasive approaches for total knee arthroplasty.I would emphasize that the minimally invasiveapproach should be performed only by a surgeonwith considerable expertise and experience. Iwould describe the operation itself briefly butwould place more emphasis on what she shouldexpect in the perioperative and immediate post-operative period. The patient should be informedthat she would have substantial postoperativepain and that she would need to participate ac-tively in an aggressive regimen of physical ther-apy in order to have a successful outcome: reliefof symptoms and improvement in mobility.

Dr. Leopold reports receiving grant support from the Ortho-pedic Research and Education Foundation, which receives fund-ing from several medical and surgical pharmaceutical and equip-ment manufacturers. No other potential conflict of interestrelevant to this article was reported.

References

Buckwalter JA, Saltzman C, Brown T.1.The impact of osteoarthritis: implicationsfor research. Clin Orthop Relat Res 2004;Suppl 427:S6-S15.

Felson D. The epidemiology of osteo-2.arthritis: prevalence and risk factors. In:Kuettner KE, Goldberg VM, eds. Osteo-arthritic disorders. Rosemont, IL: TheAmerican Academy of Orthopaedic Sur-geons, 1995:13-24.

Praemer A, Furner S, Rice DP. Muscu-3.loskeletal conditions in the United States.Rosemont, IL: American Academy of Or-thopaedic Surgeons, 1999.

Dillon CF, Rasch EK, Gu Q, Hirsch R.4.Prevalence of knee osteoarthritis in theUnited States: arthritis data from the ThirdNational Health and Nutrition Examina-tion Surgery 1991-94. J Rheumatol 2006;33:2271-9.

WHO, Bone and Joint Decade. The5.global economic and healthcare burdenof musculoskeletal disease. Geneva: WorldHealth Organization, 2001. (Available athttp://www.boneandjointdecade.org/.)

Felson DT, Lawrence RC, Dieppe PA,6.et al. Osteoarthritis: new insights. Part 1:the disease and its risk factors. Ann InternMed 2000;133:635-46.

Goldring MB, Goldring SR. Osteo-7.





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arthritis. J Cell Physiol 2007;213:626-34.

Goldring SR, Goldring MB. The role8.of cytokines in cartilage matrix degenera-tion in osteoarthritis. Clin Orthop RelatRes 2004;427:Suppl:S27-S36.

Fukui N, Purple CR, Sandell LJ. Cell9.biology of osteoarthritis: the chondrocytesresponse to injury. Curr Rheumatol Rep

2001;3:496-505.Lohmander LS, Atley LM, Pietka TA,10.Eyre DR. The release of crosslinked pep-tides from type II collagen into humansynovial f luid is increased soon after jointinjury and in osteoarthritis. ArthritisRheum 2003;48:3130-9.

Felson DT. Risk factors for osteoarthri-11.tis: understanding joint vulnerability. ClinOrthop Relat Res 2004;427:Suppl:S16-S21.

King J, Stamper DL, Schaad DC, Leo-12.pold SS. Minimally invasive total kneearthroplasty compared with traditionaltotal knee arthroplasty: assessment of thelearning curve and the postoperative recu-

perative period. J Bone Joint Surg Am2007;89:1497-503.

Bonutti PM, Mont MA, McMahon M,13.Ragland PS, Kester M. Minimally invasivetotal knee arthroplasty. J Bone Joint SurgAm 2004;86:Suppl 2:S26-S32.

Tria AJ Jr, Coon TM. Minimal incision14.total knee arthroplasty: early experience.Clin Orthop Relat Res 2003;416:185-90.

Haas SB, Cook S, Beksac B. Minimally15.invasive total knee replacement through amini midvastus approach: a comparativestudy. Clin Orthop Relat Res 2004;428:68-73.

Laskin RS, Beksac B, Phongjunakorn16.A, et al. Minimally invasive total knee re-

placement through a mini-midvastus inci-sion: an outcome study. Clin Orthop RelatRes 2004;428:74-81.

Seon JK, Song EK. Navigation-assisted17.less invasive total knee arthroplasty com-pared with conventional total knee arthro-plasty: a randomized prospective trial.J Arthroplasty 2006;21:777-82.

Seon JK, Song EK, Yoon TR, Park SJ,18.Bae BH, Cho SG. Comparison of func-tional results with navigation-assistedminimally invasive and conventional tech-niques in bilateral tota l knee arthroplasty.Comput Aided Surg 2007;12:189-93.

Song EK, Seon JK, Yoon TR, Park SJ,19.Bae BH, Cho SG. Functional results ofnavigated minimally invasive and conven-tional total knee arthroplasty: a compari-son in bilateral cases. Orthopedics 2006;29:Suppl 10:S145-S147. [Erratum, Ortho-pedics 2007;30:327.]

Flren M, Davis J, Peterson MG,20.Laskin RS. A mini-midvastus capsular ap-proach with patellar displacement decreas-

es the prevalence of patella baja. J Arthro-plasty 2007;22:Suppl 2:S51-S57.

Kolisek FR, Bonutti PM, Hozack WJ,21.et al. Clinical experience using a mini-mally invasive surgical approach for totalknee arthroplasty: early results of a pro-spective randomized study compared to astandard approach. J Arthroplasty 2007;22:8-13.

McAllister CM, Stepanian JD. The im-22.pact of minimally invasive surgical tech-niques on early range of motion after pri-mary total knee arthroplasty. J Arthroplasty2008;23:10-8.

Lingard EA, Sledge CB, Learmonth ID.23.Patient expectations regarding total kneearthroplasty: differences among the UnitedStates, United Kingdom, and Australia.J Bone Joint Surg Am 2006;88:1201-7.

The Cochrane Collaboration home24.page. (Accessed March 30, 2009, at http://www.cochrane.org.)

Anderson JG, Wixson RL, Tsai D, Stul-25.berg SD, Chang RW. Functional outcomeand patient satisfaction in total knee pa-

tients over the age of 75. J Arthroplasty1996;11:831-40.

Maloney WJ. The stiff total knee ar-26.throplasty: evaluation and management.J Arthroplasty 2002;17:Suppl 1:S71-S73.

Walton NP, Jahromi I, Dobson PJ, An-27.gel KR, Lewis PL, Campbell DG. Arthrofi-brosis following total knee replacement:does therapeutic warfarin make a differ-ence? Knee 2005;12:103-6.

Hervey SL, Purves HR, Guller U, Toth28.AP, Vail TP, Pietrobon R. Provider volumeof total knee arthroplasties and patientoutcomes in the HCUP-Nationwide Inpa-tient Sample. J Bone Joint Surg Am 2003;85:1775-83.

Katz JN, Barrett J, Mahomed NN,29.Baron JA, Wright RJ, Losina E. Associationbetween hospital and surgeon procedurevolume and the outcomes of total knee re-placement. J Bone Joint Surg Am 2004;86:1909-16.

Tashiro Y, Miura H, Matsuda S, Oka-30.zaki K, Iwamoto Y. Minimally invasive ver-sus standard approach in total knee arthro-plasty. Clin Orthop Relat Res 2007;463:144-50.

Lombardi AV Jr, Viacava AJ, Berend31.KR. Rapid recovery protocols and minimal-ly invasive surgery help achieve high kneeflexion. Clin Orthop Relat Res 2006;452:117-22.

Milne S, Brosseau L, Robinson V, et32.al. Continuous passive motion followingtotal knee arthroplasty. Cochrane Data-base Syst Rev 2003;2:CD004260.

American Academy of Orthopaedic33.Surgeons. Clinical guideline on preven-tion of pulmonary embolism in patientsundergoing total hip or knee arthroplasty.

(Accessed March 30, 2009, at http://www.aaos.org/research/guidelines/PE_guideline.pdf.)

Geerts WH, Bergqvist D, Pineo GF, et34.al. Prevention of venous thromboembo-lism: American College of Chest PhysiciansEvidence-Based Clinical Practice Guide-lines (8th edition). Chest 2008;133:6 Suppl:381S-453S.

Bozic KJ, Rubash HE, Sculco TP, Berry35.DJ. An analysis of medicare payment policyfor total joint arthroplasty. J Arthroplasty2008;23:Suppl 1:S133-S138.

Bozic KJ, Hansen E. The economics of36.minimally invasive total knee arthroplasty.J Knee Surg 2006;19:149-52.

Jmsen E, Huhtala H, Puolakka T,37.Moilanen T. Risk factors for infectionafter knee arthroplasty: a register-basedanalysis of 43,149 cases. J Bone Joint SurgAm 2009;91:38-47.

Douketis JD, Eikelboom JW, Quinlan38.DJ, Willan AR, Crowther MA. Short-dura-tion prophylaxis against venous thrombo-embolism after total hip or knee replace-

ment: a meta-analysis of prospective studiesinvestigating symptomatic outcomes. ArchIntern Med 2002;162:1465-71.

Schinsky MF, Macaulay W, Parks ML,39.Kiernan H, Nercessian OA. Nerve injuryafter primary total knee arthroplasty.J Arthroplasty 2001;16:1048-54.

Vessely MB, Whaley AL, Harmsen WS,40.Schleck CD, Berry DJ. The Chitranjan Rana-wat Award: long-term survivorship andfailure modes of 1000 cemented condylartotal knee arthroplasties. Clin OrthopRelat Res 2006;452:28-34.

Chin PL, Foo LS, Yang KY, Yeo SJ, Lo41.NN. Randomized controlled trial compar-ing the radiologic outcomes of conven-

tional and minimally invasive techniquesfor total knee arthroplasty. J Arthroplasty2007;22:800-6.

Dalury DF, Dennis DA. Mini-incision42.total knee arthroplasty can increase riskof component malalignment. Clin OrthopRelat Res 2005;440:77-81.

Huang HT, Su JY, Chang JK, Chen CH,43.Wang GJ. The early clinical outcome ofminimally invasive quadriceps-sparing totalknee arthroplasty: report of a 2-year fol-low-up. J Arthroplasty 2007;22:1007-12.

Bal BS, Haltom D, Aleto T, Barrett M.44.Early complications of primary total hipreplacement performed with a two-incisionminimally invasive technique. J Bone JointSurg Am 2005;87:2432-8.

Pagnano MW, Leone J, Lewallen DG,45.Hanssen AD. Two-incision THA had mod-est outcomes and some substantial compli-cations. Clin Orthop Relat Res 2005;441:86-90.

American Academy of Orthopaedic Sur-46.geons. Clinical practice guidelines: advisory





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statement. (Accessed March 30, 2009, athttp://www.aaos.org/Research/guidelines/guide.asp.)

American Association of Hip and Knee47.

Surgeons. Physician advisory statement:minimally invasive and small incision jointreplacement surgery: what surgeons shouldconsider. (Accessed March 30, 2009, at

http://www.aahks.org/member/resources/MIS_Surgeons.pdf.)

Copyright 2009 Massachusetts Medical Society.

Mallard Drake Paul Rodenhauser, M.D.



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