Comparative analysis of the efficacy of quadriceps‑sparing approaches in total knee arthroplasty

Introduction Total knee arthroplasty (TKA) is the gold-standard surgical intervention for end-stage knee osteoarthritis. With the widespread adoption of Enhanced Recovery After Surgery (ERAS) protocols, the selection of an optimal surgical approach has become increasingly relevant to achieving rapid functional recovery.

The aim of this study was to evaluate the efficacy of the subvastus (SV) and midvastus (MV) approaches compared to the medial parapatellar approach (MP) in terms of the rate and ultimate outcomes of functional recovery following TKA.

Materials and Methods This systematic review was conducted in accordance with the PRISMA 2020 guidelines. A literature search was performed across PubMed, Science Direct, Google Scholar, and eLibrary for the period 2020–2025. Eligible studies included original clinical investigations of primary TKA in patients with knee osteoarthritis. Of 607 initially identified publications, 12 studies were included in the final analysis.

Results SV and MV were associated with significantly earlier achievement of active straight leg raise (by 1.3–1.8 days), reduced pain intensity on the VAS during the first 1–3 postoperative days, and greater ROM during the first 3–6 weeks compared with the MP approach (p < 0.05). The rate of intraoperative lateral release was significantly lower in the SV and MV groups. Use of the SV approach was associated with longer operative time by 10–13 minutes. By 3–6 months of follow-up, intergroup differences in KSS, WOMAC, and OKS scores were no longer significant, and at 10–15 years the groups demonstrated full functional equivalence.

Discussion These findings are consistent with the conclusions of major meta-analyses confirming the transient nature of the functional advantages associated with quadriceps-sparing approaches. Heterogeneity in outcomes related to blood loss and length of hospital stay is largely attributable to variability in rehabilitation protocols and discharge criteria across institutions.

Conclusion The choice of surgical approach determines the rate, but not the ultimate outcome, of functional recovery. The SV approach is preferable within ERAS frameworks; however, an individualised strategy accounting for patient-specific anatomy, surgical expertise, and institutional rehabilitation capacity remains the most evidence-based strategy.

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