Quadriceps Sparing Versus Standard Total Knee Arthroplasty
Quadriceps Sparing Versus Standard Total Knee Arthroplasty
This study is a randomized clinical trial comparing standard medial para-patellar total knee
 arthroplasty with a quadriceps sparing mid-vastus approach. Patients who are medically well
 and have a good support structure at home will be randomized to a standard or quadriceps
 sparing surgical approach stratified by type of analgesia (adductor canal block or local
 infiltration). We will compare patient satisfaction and costs from the perspective of the
 Ministry of Health, the institution, society and the patient.
Over the past 20 years the length of stay in hospital after total knee replacements has
 decreased from 9 days to 3 days in Canada and in just the last 10 years the mean length of
 stay has decreased by half from 6 to 3 days. In order to discharge patients quicker from
 hospital it's been theorized that less invasive techniques and better, longer lasting
 anaesthesia are required.

 The less invasive quadriceps sparing mid-vastus approach for TKA has been compared to the
 standard medial para-patellar technique in many studies. Meta-analyses that have looked at
 studies comparing these approaches have shown some early advantages for quadriceps sparing
 early post-surgery, but no differences between groups later on and no difference in
 complications. Early advantages of the mid-vastus approach could potentially allow for
 earlier and safer discharge from hospital.

 Adductor canal block (ACB) and local infiltration analgesia (LIA) form the mainstay of opioid
 sparing multimodal analgesia for TKA. The nerves of the adductor canal innervate the
 superficial and deep tissues of the anterior and medial aspects of the knee. ACB has been
 shown to provide equivalent analgesia while maintaining quadriceps power compared to femoral
 nerve block (FNB). LIA involves infiltrating the soft tissues of the posterior, lateral and
 medial aspects of the knee with local anesthetics, ketorolac and morphine. Due to their
 minimal impact on motor function, ACB and LIA are suitable for fast track TKA.

 In combination, quadriceps sparing mid-vastus TKA with ACB may allow patients to be
 discharged from hospital quicker when compared with standard medial para-patellar TKA with
 LIA. With our study we aim to investigate whether a quadriceps sparing TKA can provide cost
 savings without changing complication rates when compared to the current standard of care.
Inclusion Criteria:

 -  patients requiring primary total knee replacement

 -  patients willing and able to comply with follow-up requirements and self-evaluations

 -  patients willing to sign an IRB approved informed consent form

 -  English fluency (printed instructions are provided in English only)

 -  varus arthropathy

 -  osteoarthritis

 -  ASA less than or equal to 3

 -  home/cell phone access

 -  adult to accompany patient home post-operatively and to stay with patient for a
 minimum period of 1-2 days

 Exclusion Criteria:

 -  patients with inflammatory arthritis

 -  patients with a BMI greater than 40 or less than 18

 -  patients who are skeletally immature

 -  patient with an active infection or suspected latent infection in or about the joint

 -  bone stock that is inadequate for support or fixation of the prosthesis

 -  hardware precluding intramedullary instrumentation

 -  prior osteotomies of the femur or tibia

 -  patients living greater than 1.5 hours from the hospital

 -  patients without access to caregivers, or unable to go to their home after surgery

 -  cognitive or neuromotor conditions

 -  patient has significant pain management issues

 -  patient/family history of anaesthesia related complications (e.g. malignant
 hypothermia, pseudocholinesterase deficiency, airway difficulties, obstructive sleep
 apnea)

 -  significant psycho/social issues that would prevent the patient from managing at home
 safely