Limited use of tourniquet in total knee arthroplasty using the midvastus approach facilitates recovery: a retrospective study

Limited use of tourniquet in total knee arthroplasty using the midvastus approach facilitates recovery: a retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Limited use of tourniquet in total knee arthroplasty using the midvastus approach facilitates recovery: a retrospective study Lei Liu, Zhicheng Pan, Wangxin Liu, Huihui Sun, Huajie Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6565543/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Total knee arthroplasty(TKA) is regarded as one of the most successful orthopedic surgeries. However, there is still a lack of consensus on the use of tourniquets and the choice of surgical approach. This research aimed to compare recovery outcomes in patients undergoing TKA with limited use of tourniquet through the midvastus(MV) approach and the medial parapatellar(MP) approach. Methods: Patients receiving TKA treatment (MV or MP) were retrospectively recruited in this study between June 2019 and June 2024. The demographic, perioperative, and patient satisfaction data were collected and compared between the MV and MP groups. Results: There was no statistical difference in the general data between the two groups of patients, and they were comparable. Compared with MP approach, patients in MV group had shorter incision length, less postoperative drainage volume, smaller hemoglobin difference before and after surgery, shorter postoperative hospital stay, lower VAS score at firstweek after operation, and higher HSS score at first week and firstmonth after operation. In contrast, patients in the MP approach group had a short operative time. Conclusions: The MV approach and the MP approach are both effective options for TKA and can improve the patients’ knee function. The MV approach was beneficial for the patients’ early postoperative recovery, but there was no significant difference in knee function after three months, complications, or satisfaction between the two groups. Clinical trial number : Not applicable. Figures Figure 1 Figure 2 INTRODUCTION For end-stage knee osteoarthritis, total knee arthroplasty(TKA) is a common and effective treatment,which can quickly relieve the pain symptoms of patients, restore knee function and improve the quality of life[ 3 ]. Nonetheless, more than 10% of patients who had received total knee arthroplasty were not satisfied with postoperative functional recovery, and another study suggested a higher incidence of dissatisfaction[ 4 , 5 ]. Fortunately, postoperative knee function outcome and pain relief are the decisive factors for patient satisfaction, and these factors can be improved by intervention [ 6 ]. The medial parapatellar (MP) approach is a successful surgical approach, but it requires the sacrifice of the peripatellar blood supply, the quadriceps femoral tendon, and the medial quadriceps muscle to provide the surgical visual field[ 7 , 8 ]. The interference to the quadriceps femoris will reduce the strength of the quadriceps femoris, which may be difficult to fully recover[ 9 ]. The midvastus(MV) approach can reduce damage to blood vessels and muscles, and it neither interferes with the knee extensor mechanism extension device nor affects the surgical field[ 1 , 10 ]. Maintaining the integrity of the knee extension device is beneficial to reduce early pain, promote knee function recovery, and reduce the length of hospital stay[ 11 – 15 ]. A meta-analysis by Migliorini et al. [ 15 ]found that the MV approach was beneficial for reducing blood loss and restoring knee function, and surgeons who have mastered minimally invasive approaches should be encouraged to use minimally invasive approaches for knee replacement, but the differences will decrease as time passes. However, some scholars have shown the opposite results. A retrospective study conducted by Lechner et al.[ 16 ] showed that the minimally invasive MV approach did not have different effects on early joint mobility, long-term knee function and prosthesis survival rate. This is consistent with the results reported in a recent prospective study by Zora et al.[ 17 ]. Although scholars have different opinions on the impact of the MV approach on early rehabilitation, most scholars believe that it will not affect the final outcome of patients[ 11 – 14 , 16 – 19 ]. The use of a tourniquet in orthopedic surgery is common practice, which reduces blood loss, maintains a clear surgical view, and subsequently reduces surgical time [ 20 ]. This is not to imply that tourniquet use is beneficial and harmless, after all, it might cause long-term direct limb compression and circulation disorders.And recent studies have linked tourniquet use to an increased risk of postoperative infection, early pain, blood loss and deep vein thrombosis[ 21 – 23 ]. Nevertheless, for TKA, more than 90% of European and American orthopedic surgeons use a tourniquet, since the use of a tourniquet seems to be unavoidable, how to use it reasonably has become the focus of research[ 20 ]. A study by by Cao and colleagues[ 24 ] on full-versus and second half-course use showed that second half-course use had advantages in early pain, postoperative drainage, time to discharge, and reduced blood transfusion, and did not increase the incidence of complications. In conclusion, TKA can quickly relieve pain in patients with end-stage knee osteoarthritis, improve knee function, and enhance self-care ability, which is regarded as one of the most successful orthopedic surgeries[ 25 ]. However, there is still a lack of consensus on the use of tourniquets and the choice of surgical approach[ 1 , 2 ]. In order to further assess whether the tourniquet and surgical approach sufficient would have an impact on the early recovery of TKA, we conducted this retrospective study. MATERIALS AND METHODS The study screened 121 patients who underwent TKA in our hospital from June 2019 to June 2024 and excluded nine patients who met the exclusion criteria (including rheumatoid arthritis, traumatic arthritis, combined ipsilateral femoral head necrosis, and incomplete medical records). A total of 112 patients were included, all of whom had primary knee osteoarthritis with a unilateral primary TKA. Two groups were divided into the MV approach (59 cases) and the MP approach (53 cases). Figure 1 shows the details for screening patients. All the operations were performed by experienced surgeons. The tourniquet was not used until the osteotomy began. The tourniquet was inflated before osteotomy until the incision was closed. Closed suction flow is commonly used to reduce the occurrence of incision complications. Surgical technique: In the MV group, a standard longitudinal midline skin incision is done as previously described. The parapatellar retinacula incision is extended proximally along the length of the quadriceps tendon, leaving about a 4 mm cuff of the tendon on the vastus medialis for later closure. The incision is continued around the medial side of the patella, extending 3–4 cm onto the anteromedial surface of the tibia along the medial border of the patellar tendon. The medial side of the knee is exposed by subperiosteally elevating the anteromedial capsule and deep medial collateral ligament of the tibia to the posteromedial corner of the knee. Extend the knee and evert the patella to allow an optional release of lateral patellofemoral plicae.Then TKA was performed with traditional surgical instruments. In the MP group, the anterior median skin incision of the knee was taken, which was about 10–15 cm long, extending from the tubercle of the tibia to the 4–7 cm proximal to the superior end of the patella. Then, arthrotomy was conducted proximally from the quadriceps tendon incision along the junction between the vastus medialis obliquus and the quadriceps tendon. Then, the capsule was incised downward along the medial patella and the medial patellar tendon. The patella eversion was performed to obtain sufficient surgical exposure and TKA was performed with traditional surgical instruments. After the operation, cefuroxime ester was given for prevention of infection, mannitol swelling, glucose or balanced fluid rehydration, and low molecular weight heparin for prevention of deep vein thrombosis while the same postoperative rehabilitation exercise method was given. The study obtained ethical approval from the local ethical committee. After a detailed explanation of the benefits, hazards and possible complications of the surgery, each patient signed an informed consent form. Inclusion criteria: 1. Primary end-stage knee osteoarthritis; 2. Patients treated with primary TKA. Exclusion criteria: 1. Patients with ipsilateral limb diseases that affect the judgment of patients’ limb function; 2. Incomplete case and follow-up data. We collected data from two groups of patients, including general data, intraoperative data, postoperative data, blood transfusion status, postoperative complications, and patient satisfaction with treatment at the last follow-up. General data included age, gender, height, weight, BMI, literacy, preoperative VAS score, and HSS score. Intraoperative data included the incision length, operation time, and intraoperative bleeding volume. Postoperative data included postoperative drainage volume, hemoglobin difference before and after surgery, time of first postoperative ambulation, postoperative hospital stay (defined as the period from the day of surgery to discharge). VAS score, HSS score postoperatively at the first week, the first month, the third month and the sixth month were also collected. Complications mainly included pulmonary infection, urinary tract infection, incision infection, pressure ulcers, and deep vein thrombosis. The satisfaction survey mainly used a homemade scale, including 4 items: very satisfied, satisfied, dissatisfied, and very dissatisfied[ 26 ]. At the last follow-up visit, the patients were all interviewed personally by phone or WeChat and we kept records at the same time. STATISTICAL ANALYSIS SPSS 25.0 software (IBM Company, Armonk, NY, USA) was used for data processing and analysis. Descriptive data were expressed using standard deviations of the mean, and the Shapiro-Wilk test was used to determine whether measurement data conformed to a normal distribution. Normally distributed measurement data were expressed using the t-test; otherwise, the Mann-Whitney U test was used instead, and measurement data were expressed using the chi-square test. Differences were considered statistically significant at P 0.05) (Table 1 ). The comparison of intraoperative data between the two groups showed that the length of the incision in the MV approach group was shorter, and the difference was statistically significant(P < 0.05). The MP approach group had a shorter surgical time and the difference was statistically significant(P 0.05) (Table 2 ). In terms of postoperative data comparison, patients in the MV approach were better than those in the MP approach in postoperative drainage volume, hemoglobin difference, time of first postoperative ambulation, hospital stay, first-week VAS score, first-week and first-month HSS score (P 0.05)(Fig. 2 ). Similarly, there was no significant difference in HSS scores between the two groups at the third and sixth postoperative months (P > 0.05) (Table 3 ). We observed that most of the longer hospital stay cases in the MV group were concentrated in the early cases of the surgeon, suggesting that there may be a learning curve in the MV approach. There were no statistical differences in the number of postoperative blood transfusions, complications (There was 1 case of pulmonary infection,1 case of urinary tract infection in the MV approach group and 2 cases of pulmonary infection and 1 case of delayed wound healing in the MP approach group) and satisfaction with the last follow-up(P > 0.05) (Table 4 ). Table 1 Comparison of preoperative data between the two groups (values expressed in mean standard deviation) MV group (n = 59) MP group (n = 53) P value Mean age-yr 65.85±6.71 64.3±5.05 0.178 a male sex-no. (%) 26(44.1) 21(39.6) 0.634 b Height-m 1.70±0.06 1.69±0.06 0.116 a Weight-kg 77.53±10.24 74.66±11.13 0.163 a BMI† 26.71±3.46 26.20±3.37 0.436 a Educational level-no. (%) 0.963 c Primary 35(59.3) 31(58.5) Junior 15(25.4) 14(26.4) Senior 6(10.2) 6(11.3) University 3(5.1) 2(3.8) Preoperative VAS score‡ 5.88±1.05 5.77±1.03 0.585 a Preoperative HSS score§ 54.51±10.06 53.38±11.24 0.575 a a:Independent Samples t-test;b:Chi-square test༛c:Mann Whitney test †The body-mass index is the weight in kilograms divided by the square of the height in meters. ‡Scores for the VAS score range from 0 to 10, with higher scores indicating more severe symptoms. §Scores on the HSS score range from 0 to 100, with lower scores indicating worse disability. The HSS score includes functional and pain scores. Table 2 Intraoperative data comparison (values expressed in mean standard deviation) MV group (n = 59) MP group (n = 53) P value Incision length-cm 12.46±1.41 13.18±1.45 0.010 a* Operation time-min 82.12±5.98 74.96±5.85 0.000 a* Intraoperative bleeding volum -ml 128.31±17.69 122.08±16.24 0.058 a a:Independent Samples t-test; *:significant at P <0.05 Table 3 Comparison of postoperative data between the two groups (values expressed in mean standard deviation) MV group (n = 59) MP group (n = 53) P value Postoperative drainage volume-ml 135.20±17.69 122.08±16.24 0.024 a* Hemoglobin difference before and after surgery 24.76±6.07 32.53±6.05 0.000 a* Time of first postoperative ambulation-h 19.34±3.40 25.08±3.31 0.000 a* Postoperative hospital stay-d 8.25±1.13 10.08±1.34 0.000 a* Postoperative VAS scores‡ 1 week 2.71±0.91 4.02±1.01 0.000 a* 1 month 1.12±0.67 1.17±0.67 0.676 a 3 month 0.37±0.52 0.42±0.53 0.663 a 6 month 0.20±0.41 0.23±0.42 0.768 a Postoperative HSS scores§ 1 week 70.08±8.28 63.96±8.73 0.000 a* 1 month 81.41±4.42 79.62±4.63 0.039 a* 3 month 90.75±2.17 90.36±2.19 0.350 a 6 month 92.51±1.65 92.32±1.44 0.525 a a:Independent Samples t-test; *:significant at P <0.05 ‡Scores for the VAS score range from 0 to 10, with higher scores indicating more severe symptoms. §Scores on the HSS score range from 0 to 100, with lower scores indicating worse disability. The HSS score includes functional and pain scores. Table 4 Comparison of the number of postoperative transfusions, complications and patient satisfaction at last follow-up in the two groups MV group (n = 59) MP group (n = 53) P value Transfusion-no. (%) 2(3.4) 3(5.7) 0.902 b Complications-no. (%) 2(3.4) 2(3.4) 0.902 b Satisfaction -no. (%) 0.921 c Very satisfied 42(71.2) 39(73.6) Mostly satisfied 14(23.7) 11(20.8) Dissatisfied 2(3.4) 2(3.8) Very dissatisfied 1(1.7) 1(1.9) b:Chi-square test;c:Mann Whitney test DISCUSSION Our study indicates that TKA with limited use of a tourniquet through the MV approach benefits early functional recovery with a small incision, less blood loss, faster recovery of early joint function and a shorter hospital stay. TKA can quickly relieve the pain of patients with end-stage knee osteoarthritis, improve knee function, and improve self-care ability. It is one of the most successful orthopedic surgeries[ 25 ]. In our study, the MV approach showed better joint function within one month after surgery, but this advantage gradually disappeared three months after surgery. The study of Mohammed et al.[ 11 ] also showed similar results, and they followed up for up to two years. Three months after the operation, the MV approach and the MP approach showed the same knee function. However, some studies suggest that the functional advantages of this approach may last longer. Lin et al[ 13 ] found that the functional recovery advantage of the MV approach continued until six months after surgery. Steven et al.’s study[ 18 ] suggests that it can continue up to one year after surgery. In contrast, one of the main reasons why the MV approach enables patients to achieve faster functional recovery and higher satisfaction may be that the extensor mechanism is preserved as much as possible[ 27 , 28 ]. The increase in operation time was positively correlated with postoperative infection, reoperation, blood transfusion and cardiovascular adverse events. For clinicians, reducing the operation time is beneficial to reduce bleeding and postoperative complications. In surgery, longer surgical incisions increase the incidence of adverse events such as infection, bleeding, and immune reactions[ 29 , 30 ]. In contrast, smaller incisions reduce postoperative incisional pain and also aid in early postoperative recovery. In our study, the incision length of the MV approach group was small, and the average operation time was 82.12 minutes, which was approximately eight minutes longer than that of the MP approach. This difference was statistically significant. The studies of Hakan[ 17 ] et al. and Lin et al.[ 13 ] also showed similar results. The average surgical incision of the MV approach was shorter, but the operation time was longer. A meta-analysis included 19 randomized controlled trials showing that the average operative time between the MV approach and the MP approach was prolonged by 18 minutes[ 31 ]. It is undeniable that a smaller incision requires a longer operation time to compensate for the difficulty of exposure caused by a small incision, which may be the reason for the longer operation time of the MV approach. Hospitalization time is an important indicator for the evaluation of the concept of rapid rehabilitation. Reducing hospitalization time can reduce hospitalization costs and postoperative complications. Patients undergoing surgery using the MV approach show less pain in the early stage. Effective pain control is a prerequisite for early functional exercise. Early functional exercise after surgery can reduce hospital stays and reduce costs, and will not increase adverse events[ 32 ]. This also explains why the MV approach group had better knee function recovery and shorter postoperative hospital stays. In addition, early effective pain control can improve patients’ satisfaction and the mental health of patients[ 33 , 34 ]. These factors will affect the patient’s recovery and hospitalization time. Early discharge of patients’ can not only directly reduce the cost and economic burden of patients’ and save medical resources, but also facilitate the diet and nursing of patients at home as well as reduce the burden of family care. The use of tourniquets in TKA requires more careful consideration. The use of a tourniquet in knee arthroplasty reduces bleeding and provides a distinct view of the operative area, which is beneficial in terms of shorter operative time and fewer blood transfusions[ 35 ]. Nevertheless, systematic reviews and meta-analyses have suggested that tourniquets inflated at high pressure cause limb swelling and rhabdomyolysis, which adversely affects the quadriceps muscle group. It also increases the incidence of deep vein thrombosis and postoperative pain in patients, which collectively affect the early postoperative recovery[ 36 , 37 ]. Therefore, in this study, tourniquets were used limitingly throughout the procedure, and ultimately no complications such as deep vein thrombosis were observed. However, since our study did not specifically examine the use of tourniquets at different times, further controlled trials may be meaningful. This study has some limitations. First, retrospective studies have prevented us from studying patient randomization. However, the preoperative data were comparable between the two groups, which reduces the impact on the results to some extent. Second, the cases included in this study were from a single center with a small sample size and the results of the study may be biased, which needs to be further confirmed by further multicenter studies with large sample sizes. Finally, the short follow-up period caused us to fail to assess patient survival, and we were not able to assess differences in prosthetic infection, fractures, survival, etc. After all, the purpose of our study was only to determine whether there was an early advantage in the MV approach. CONCLUSION TKA with limited use of a tourniquet through the MV approach is beneficial in reducing the length of the surgical incision, blood loss, and length of hospital stay, reducing early pain, and improving early knee function. However, after three months, there was no significant difference in knee function between the two groups compared with the MP approach. We recommend that surgeons who are familiar with the MV approach can use this approach to reduce early pain and facilitate early recovery. However, orthopedic surgeons should still choose the approach they are familiar with, because there is no significant difference in patients’ final recovery outcomes between the two approaches, and there is no impact on the satisfaction rate either. Abbreviations TKA Total knee arthroplasty MV Midvastus MP Medial parapatellar VAS Visual analogue scale HSS Hospital for Special Surgery BMI The body-mass index Declarations Acknowledgements we would like to express our deepest appreciation to Chuzhou Chinese and Western Medicine Hospital for allowing us to conduct this research. This work has not been submitted for publication in any other journal, and all the references are acknowledged. Funding None received. Authors and Affiliations Chuzhou Chinese and Western Medicine Hospital, Lei Liu and Huejie Li. The Second Affiliated Hospital of Tianjin University of TCM, Zhicheng Pan and Wangxin Liu. Lanxi People’s Hospital, Huihui Sun. Contributions L.L. and Z.C.P are the lead authors who coordinated data collection, analyzed the data and wrote the manuscript. W.X.L. and H.H.S. supervised and reviewed the manuscript. H.J.L. edited and reviewed the manuscript. Corresponding author Correspondence to Wangxin Liu and Huihui Sun. Ethical approval statement The study was approved by the Clinical Research Ethics Committee of Chuzhou Chinese and Western Medicine Hospital (approval number: 2024-95). All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from each patient after explaining the benefits, harms, and possible morbidities of surgery in detail. Consent for publication Written informed consent for publication was not required from participants included in the study, but patient confidenciality is strictly maintained. Competing interests The authors declare no competing interests. References Husted H. Fast-track hip and knee arthroplasty: clinical and organizational aspects. Acta Orthop Suppl. 2012;83(346):1–39. McCarthy Deering E, Hu SY, Abdulkarim A. Does Tourniquet Use in TKA Increase Postoperative Pain? A Systematic Review and Meta-analysis. Clin Orthop Relat Res. 2019;477(3):547–58. Yang C, Shang L, Yao S, Ma J, Xu C. Cost, time savings and effectiveness of wearable devices for remote monitoring of patient rehabilitation after total knee arthroplasty: study protocol for a randomized controlled trial. J Orthop Surg Res. 2023;18(1):461. DeFrance M, Scuderi G. Are 20% of Patients Actually Dissatisfied Following Total Knee Arthroplasty? A Systematic Review of the Literature. J Arthroplasty 2022. Migliorini F, Maffulli N, Schäfer L, Schneider J, Nobili AM, Kämmer D, Michalak M, Bell A. Robotic-assisted total knee arthroplasty in clinical practice: protocol for a randomised controlled trial. J Orthop Surg Res. 2023;18(1):623. Kahlenberg CA, Nwachukwu BU, McLawhorn AS, Cross MB, Cornell CN, Padgett DE. Patient Satisfaction After Total Knee Replacement: A Systematic Review. HSS journal: Musculoskelet J Hosp Special Surg. 2018;14(2):192–201. Zhang L, Li X, Rüwald JM, Welle K, Schildberg FA, Kabir K. Comparison of minimally invasive approaches and standard median parapatellar approach for total knee arthroplasty: A systematic review and network meta-analysis of randomized controlled trials. Technol health care: official J Eur Soc Eng Med. 2021;29(3):557–74. Geng L, Fu J, Xu C, Ren P, Wang YM, Ji QB, Xin P, Zheng QY, Ni M, Zhang GQ. The Comparison between Mini-Subvastus Approach and Medial Parapatellar Approach in TKA: A Prospective Double-Blinded Randomized Controlled Trial. Orthop Surg. 2022;14(11):2878–87. Kolisek FR, Bonutti PM, Hozack WJ, Purtill J, Sharkey PF, Zelicof SB, Ragland PS, Kester M, Mont MA, Rothman RH. Clinical experience using a minimally invasive surgical approach for total knee arthroplasty: early results of a prospective randomized study compared to a standard approach. J Arthroplasty. 2007;22(1):8–13. Schroer WC, Diesfeld PJ, Reedy ME, LeMarr AR. Evaluation of complications associated with six hundred mini-subvastus total knee arthroplasties. J bone joint Surg Am. volume 2007;89(Suppl 3):76–81. Aslam MA, Sabir AB, Tiwari V, Abbas S, Tiwari A, Singh P. Approach to Total Knee Replacement: A Randomized Double Blind Study between Medial Parapatellar and Midvastus Approach in the Early Postoperative Period in Asian Population. J Knee Surg. 2017;30(8):793–7. Layher F, Zipfel M, Sander K, Matziolis G, Roth A. [Functional Comparison of the Outcome after Midvastus and Medial Parapatellar Surgical Approach in Total Knee Arthroplasty]. Z fur Orthopadie und Unfallchirurgie. 2016;154(1):50–7. Lin W, Niu J, Dai Y, Yang G, Li M, Wang F. Mini-midvastus versus medial parapatellar approach in total knee arthroplasty: difference in patient-reported outcomes measured with the Forgotten Joint Score. J Orthop Surg Res. 2020;15(1):336. Shukla R, Mahajan P, Singh M, Jain RK, Kumar R. Outcome of Total Knee Replacement via Two Approaches in Indian Scenario. J Knee Surg. 2017;30(2):174–8. Migliorini F, Aretini P, Driessen A, El Mansy Y, Quack V, Tingart M, Eschweiler J. Better outcomes after mini-subvastus approach for primary total knee arthroplasty: a Bayesian network meta-analysis. Eur J Orthop Surg traumatology: orthopedie traumatologie. 2020;30(6):979–92. Lechner R, Lazzeri M, Oberaigner W, Nardelli P, Roth T, Köglberger P, Krismer M, Liebensteiner MC. Does the type of surgical approach affect the clinical outcome of total knee arthroplasty? Der Orthopade. 2021;50(8):674–80. Zora H, Güngör HR, Bayrak G, Şavkın R, Büker N. Does mini-midvastus approach have an advantageous effect on rapid recovery protocols over medial parapatellar approach in total knee arthroplasty? Joint Dis Relat Surg. 2020;31(3):571–81. Haas SB, Manitta MA, Burdick P. Minimally invasive total knee arthroplasty: the mini midvastus approach. Clin Orthop Relat Res. 2006;452:112–6. Pietsch M, Djahani O, Hofmann S. [Minimally invasive mini-midvastus approach as standard in total knee arthroplasty]. Der Orthopade. 2007;36(12):1120–8. Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res. 2014;9(1):13. Ahmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson C, Warwick J, Seers K, Parsons H, Wall PD. Tourniquet use for knee replacement surgery. Cochrane Database Syst Rev. 2020;12(12):Cd012874. Ahmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson CE, Warwick J, Seers K, Parsons H, Wall PDH. Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery. bone joint J 2021, 103–b(5):830–839. Magan AA, Dunseath O, Armonis P, Fontalis A, Kayani B, Haddad FS. Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials. J experimental Orthop. 2022;9(1):62. Cao Q, He Z, Fan Y, Meng J, Yuan T, Zhao J, Bao N. Effects of tourniquet application on enhanced recovery after surgery (ERAS) and ischemia-reperfusion post-total knee arthroplasty: Full- versus second half-course application. J Orthop Surg. 2020;28(1):2309499019896026. Benchekroun S, Lahsika M, Abid H, Idrissi ME, Ibrahimi AE, Mrini AE. [Total knee replacement without patellar resurfacing: about 60 cases]. Pan Afr Med J. 2020;36:132. Liu W, Liu L, Pan Z, Gu E. Percutaneous endoscopic interlaminar discectomy with patients' participation: better postoperative rehabilitation and satisfaction. J Orthop Surg Res. 2024;19(1):547. Karachalios T, Giotikas D, Roidis N, Poultsides L, Bargiotas K, Malizos KN. Total knee replacement performed with either a mini-midvastus or a standard approach: a prospective randomised clinical and radiological trial. J bone joint Surg Br volume. 2008;90(5):584–91. Thienpont E, Zorman D. Higher forgotten joint score for fixed-bearing than for mobile-bearing total knee arthroplasty. Knee Surg sports Traumatol arthroscopy: official J ESSKA. 2016;24(8):2641–5. Ioannidis A, Arvanitidis K, Filidou E, Valatas V, Stavrou G, Michalopoulos A, Kolios G, Kotzampassi K. The Length of Surgical Skin Incision in Postoperative Inflammatory Reaction. JSLS: J Soc Laparoendoscopic Surg 2018, 22(4). De Vivo A, Mancuso A, Giacobbe A, Priolo AM, De Dominici R, Maggio Savasta L. Wound length and corticosteroid administration as risk factors for surgical-site complications following cesarean section. Acta Obstet Gynecol Scand. 2010;89(3):355–9. Peng X, Zhang X, Cheng T, Cheng M, Wang J. Comparison of the quadriceps-sparing and subvastus approaches versus the standard parapatellar approach in total knee arthroplasty: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2015;16:327. Masaracchio M, Hanney WJ, Liu X, Kolber M, Kirker K. Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: A systematic review with meta-analysis. PLoS ONE. 2017;12(6):e0178295. Nguyen UDT, Perneger T, Franklin PD, Barea C, Hoffmeyer P, Lübbeke A. Improvement in mental health following total hip arthroplasty: the role of pain and function. BMC Musculoskelet Disord. 2019;20(1):307. McAuliffe M, Pillay T, Jaber K, Sterling M, O'Leary S. Pre-operative pain pressure threshold association with patient satisfaction following Total Knee Arthroplasty. J Orthop. 2024;52:21–7. Migliorini F, Maffulli N, Aretini P, Trivellas A, Tingart M, Eschweiler J, Baroncini A. Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes. Arch Orthop Trauma Surg. 2021;141(6):1007–23. Morelli I, Maffulli N, Brambilla L, Agnoletto M, Peretti GM, Mangiavini L. Quadriceps muscle group function and after total knee arthroplasty-asystematic narrative update. Br Med Bull. 2021;137(1):51–69. Migliorini F, Maffulli N, Eschweiler J, Knobe M, Tingart M, Betsch M. Tourniquet use during knee arthroplasty: A Bayesian network meta-analysis on pain, function, and thromboembolism. surgeon: J Royal Colleges Surg Edinb Irel. 2022;20(4):241–51. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 15 Jun, 2025 Reviewers agreed at journal 15 Jun, 2025 Reviewers invited by journal 30 May, 2025 Editor invited by journal 07 May, 2025 Editor assigned by journal 05 May, 2025 Submission checks completed at journal 05 May, 2025 First submitted to journal 30 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6565543","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464299866,"identity":"5a685534-f1f1-445c-879e-cc60f7093588","order_by":0,"name":"Lei Liu","email":"","orcid":"","institution":"Chuzhou Chinese and Western Medicine Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Liu","suffix":""},{"id":464299867,"identity":"e29a498b-3f0a-4def-88ae-ea79a8f80980","order_by":1,"name":"Zhicheng Pan","email":"","orcid":"","institution":"The Second Affiliated Hospital of Tianjin University of TCM","correspondingAuthor":false,"prefix":"","firstName":"Zhicheng","middleName":"","lastName":"Pan","suffix":""},{"id":464299868,"identity":"42a4bbff-18a2-4b4f-b862-490665f90ed6","order_by":2,"name":"Wangxin Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYHACxgMMDDY8/OwNJOgBakmTkew5QJqWwzYGNxyIVM7ff8bgMG/beR6GGwyMHz7mEKFF4gBQC8+Z2zyMsxuYJWduI8aagz0Gh3MqbvMwyxxgY+YlRov8YR6gFoNzPGwSCURqMTgG0lJxgIeHaC2GZ9gKDv85k8wjwXOwmTi/yJ0/vPHhzDY7e/vjzQc/fCTK+wwcBlAGYwNR6oGA/QGxKkfBKBgFo2CkAgCxrzcEM2yXwQAAAABJRU5ErkJggg==","orcid":"","institution":"The Second Affiliated Hospital of Tianjin University of TCM","correspondingAuthor":true,"prefix":"","firstName":"Wangxin","middleName":"","lastName":"Liu","suffix":""},{"id":464299869,"identity":"03db07b3-ba9e-48f4-aa7b-75c6ae241e08","order_by":3,"name":"Huihui Sun","email":"","orcid":"","institution":"Lanxi People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Huihui","middleName":"","lastName":"Sun","suffix":""},{"id":464299870,"identity":"b53de1d5-78b4-4ae9-a47b-faf76b551391","order_by":4,"name":"Huajie Li","email":"","orcid":"","institution":"Chuzhou Chinese and Western Medicine Hospital","correspondingAuthor":false,"prefix":"","firstName":"Huajie","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2025-04-30 13:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6565543/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6565543/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83893641,"identity":"91f80434-85b5-4789-9cce-fc22295b35e6","added_by":"auto","created_at":"2025-06-04 08:28:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":106034,"visible":true,"origin":"","legend":"\u003cp\u003eScreening patient flow diagram\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6565543/v1/9862ebedde7c3fc77f9735dc.jpg"},{"id":83894065,"identity":"634662a0-dcfd-4ab7-bd66-c528c83933ac","added_by":"auto","created_at":"2025-06-04 08:36:26","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45377,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in VAS and HSS scores in the two groups. VAS: Visual analogue scale; HSS: Hospital for Special Surgery. MP=medial parapatellar. MV=midvastus\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6565543/v1/b0aebfce85ef4cdd528d4786.png"},{"id":83894098,"identity":"227adbd4-2604-41b6-b90e-45ad4e296043","added_by":"auto","created_at":"2025-06-04 08:36:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":742453,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6565543/v1/c73b4303-393e-400b-8474-04c95ed6ff23.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Limited use of tourniquet in total knee arthroplasty using the midvastus approach facilitates recovery: a retrospective study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eFor end-stage knee osteoarthritis, total knee arthroplasty(TKA) is a common and effective treatment,which can quickly relieve the pain symptoms of patients, restore knee function and improve the quality of life[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Nonetheless, more than 10% of patients who had received total knee arthroplasty were not satisfied with postoperative functional recovery, and another study suggested a higher incidence of dissatisfaction[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Fortunately, postoperative knee function outcome and pain relief are the decisive factors for patient satisfaction, and these factors can be improved by intervention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe medial parapatellar (MP) approach is a successful surgical approach, but it requires the sacrifice of the peripatellar blood supply, the quadriceps femoral tendon, and the medial quadriceps muscle to provide the surgical visual field[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The interference to the quadriceps femoris will reduce the strength of the quadriceps femoris, which may be difficult to fully recover[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The midvastus(MV) approach can reduce damage to blood vessels and muscles, and it neither interferes with the knee extensor mechanism extension device nor affects the surgical field[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Maintaining the integrity of the knee extension device is beneficial to reduce early pain, promote knee function recovery, and reduce the length of hospital stay[\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A meta-analysis by Migliorini et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]found that the MV approach was beneficial for reducing blood loss and restoring knee function, and surgeons who have mastered minimally invasive approaches should be encouraged to use minimally invasive approaches for knee replacement, but the differences will decrease as time passes. However, some scholars have shown the opposite results. A retrospective study conducted by Lechner et al.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] showed that the minimally invasive MV approach did not have different effects on early joint mobility, long-term knee function and prosthesis survival rate. This is consistent with the results reported in a recent prospective study by Zora et al.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Although scholars have different opinions on the impact of the MV approach on early rehabilitation, most scholars believe that it will not affect the final outcome of patients[\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe use of a tourniquet in orthopedic surgery is common practice, which reduces blood loss, maintains a clear surgical view, and subsequently reduces surgical time [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This is not to imply that tourniquet use is beneficial and harmless, after all, it might cause long-term direct limb compression and circulation disorders.And recent studies have linked tourniquet use to an increased risk of postoperative infection, early pain, blood loss and deep vein thrombosis[\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Nevertheless, for TKA, more than 90% of European and American orthopedic surgeons use a tourniquet, since the use of a tourniquet seems to be unavoidable, how to use it reasonably has become the focus of research[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A study by by Cao and colleagues[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] on full-versus and second half-course use showed that second half-course use had advantages in early pain, postoperative drainage, time to discharge, and reduced blood transfusion, and did not increase the incidence of complications.\u003c/p\u003e \u003cp\u003eIn conclusion, TKA can quickly relieve pain in patients with end-stage knee osteoarthritis, improve knee function, and enhance self-care ability, which is regarded as one of the most successful orthopedic surgeries[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, there is still a lack of consensus on the use of tourniquets and the choice of surgical approach[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In order to further assess whether the tourniquet and surgical approach sufficient would have an impact on the early recovery of TKA, we conducted this retrospective study.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThe study screened 121 patients who underwent TKA in our hospital from June 2019 to June 2024 and excluded nine patients who met the exclusion criteria (including rheumatoid arthritis, traumatic arthritis, combined ipsilateral femoral head necrosis, and incomplete medical records). A total of 112 patients were included, all of whom had primary knee osteoarthritis with a unilateral primary TKA. Two groups were divided into the MV approach (59 cases) and the MP approach (53 cases). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the details for screening patients. All the operations were performed by experienced surgeons. The tourniquet was not used until the osteotomy began. The tourniquet was inflated before osteotomy until the incision was closed. Closed suction flow is commonly used to reduce the occurrence of incision complications.\u003c/p\u003e \u003cp\u003eSurgical technique:\u003c/p\u003e \u003cp\u003eIn the MV group, a standard longitudinal midline skin incision is done as previously described. The parapatellar retinacula incision is extended proximally along the length of the quadriceps tendon, leaving about a 4 mm cuff of the tendon on the vastus medialis for later closure. The incision is continued around the medial side of the patella, extending 3\u0026ndash;4 cm onto the anteromedial surface of the tibia along the medial border of the patellar tendon. The medial side of the knee is exposed by subperiosteally elevating the anteromedial capsule and deep medial collateral ligament of the tibia to the posteromedial corner of the knee. Extend the knee and evert the patella to allow an optional release of lateral patellofemoral plicae.Then TKA was performed with traditional surgical instruments.\u003c/p\u003e \u003cp\u003eIn the MP group, the anterior median skin incision of the knee was taken, which was about 10\u0026ndash;15 cm long, extending from the tubercle of the tibia to the 4\u0026ndash;7 cm proximal to the superior end of the patella. Then, arthrotomy was conducted proximally from the quadriceps tendon incision along the junction between the vastus medialis obliquus and the quadriceps tendon. Then, the capsule was incised downward along the medial patella and the medial patellar tendon. The patella eversion was performed to obtain sufficient surgical exposure and TKA was performed with traditional surgical instruments.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter the operation, cefuroxime ester was given for prevention of infection, mannitol swelling, glucose or balanced fluid rehydration, and low molecular weight heparin for prevention of deep vein thrombosis while the same postoperative rehabilitation exercise method was given. The study obtained ethical approval from the local ethical committee. After a detailed explanation of the benefits, hazards and possible complications of the surgery, each patient signed an informed consent form.\u003c/p\u003e \u003cp\u003eInclusion criteria: 1. Primary end-stage knee osteoarthritis; 2. Patients treated with primary TKA. Exclusion criteria: 1. Patients with ipsilateral limb diseases that affect the judgment of patients\u0026rsquo; limb function; 2. Incomplete case and follow-up data.\u003c/p\u003e \u003cp\u003eWe collected data from two groups of patients, including general data, intraoperative data, postoperative data, blood transfusion status, postoperative complications, and patient satisfaction with treatment at the last follow-up. General data included age, gender, height, weight, BMI, literacy, preoperative VAS score, and HSS score. Intraoperative data included the incision length, operation time, and intraoperative bleeding volume. Postoperative data included postoperative drainage volume, hemoglobin difference before and after surgery, time of first postoperative ambulation, postoperative hospital stay (defined as the period from the day of surgery to discharge). VAS score, HSS score postoperatively at the first week, the first month, the third month and the sixth month were also collected. Complications mainly included pulmonary infection, urinary tract infection, incision infection, pressure ulcers, and deep vein thrombosis. The satisfaction survey mainly used a homemade scale, including 4 items: very satisfied, satisfied, dissatisfied, and very dissatisfied[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. At the last follow-up visit, the patients were all interviewed personally by phone or WeChat and we kept records at the same time.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSTATISTICAL ANALYSIS\u003c/h2\u003e \u003cp\u003eSPSS 25.0 software (IBM Company, Armonk, NY, USA) was used for data processing and analysis. Descriptive data were expressed using standard deviations of the mean, and the Shapiro-Wilk test was used to determine whether measurement data conformed to a normal distribution. Normally distributed measurement data were expressed using the t-test; otherwise, the Mann-Whitney U test was used instead, and measurement data were expressed using the chi-square test. Differences were considered statistically significant at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThere were no significant differences in the preoperative demographic parameters, VAS score, or knee HSS scores between the two groups(P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The comparison of intraoperative data between the two groups showed that the length of the incision in the MV approach group was shorter, and the difference was statistically significant(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The MP approach group had a shorter surgical time and the difference was statistically significant(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no significant difference in intraoperative bleeding between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In terms of postoperative data comparison, patients in the MV approach were better than those in the MP approach in postoperative drainage volume, hemoglobin difference, time of first postoperative ambulation, hospital stay, first-week VAS score, first-week and first-month HSS score (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Compared with the MP group, however, the MV group did not have an advantage in VAS scores at the first, third and sixth postoperative months (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05)(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Similarly, there was no significant difference in HSS scores between the two groups at the third and sixth postoperative months (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). We observed that most of the longer hospital stay cases in the MV group were concentrated in the early cases of the surgeon, suggesting that there may be a learning curve in the MV approach. There were no statistical differences in the number of postoperative blood transfusions, complications (There was 1 case of pulmonary infection,1 case of urinary tract infection in the MV approach group and 2 cases of pulmonary infection and 1 case of delayed wound healing in the MP approach group) and satisfaction with the last follow-up(P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of preoperative data between the two groups (values expressed in mean standard deviation)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMV group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMP group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age-yr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.85\u0026plusmn;6.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.3\u0026plusmn;5.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.178 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale sex-no. (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26(44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(39.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.634 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight-m\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.70\u0026plusmn;0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.69\u0026plusmn;0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.116 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight-kg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.53\u0026plusmn;10.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.66\u0026plusmn;11.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.163 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.71\u0026plusmn;3.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.20\u0026plusmn;3.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.436 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational level-no. (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.963\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35(59.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31(58.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative VAS score\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.88\u0026plusmn;1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.77\u0026plusmn;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.585 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative HSS score\u0026sect;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.51\u0026plusmn;10.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.38\u0026plusmn;11.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.575 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ea:Independent Samples t-test;b:Chi-square test༛c:Mann Whitney test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026dagger;The body-mass index is the weight in kilograms divided by the square of the height in meters.\u003c/p\u003e \u003cp\u003e\u0026Dagger;Scores for the VAS score range from 0 to 10, with higher scores indicating more severe symptoms.\u003c/p\u003e \u003cp\u003e\u0026sect;Scores on the HSS score range from 0 to 100, with lower scores indicating worse disability. The HSS score includes functional and pain scores.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative data comparison (values expressed in mean standard deviation)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMV group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMP group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncision length-cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e12.46\u0026plusmn;1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.18\u0026plusmn;1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.010\u003csup\u003ea*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time-min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e82.12\u0026plusmn;5.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e74.96\u0026plusmn;5.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003csup\u003ea*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative bleeding volum -ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e128.31\u0026plusmn;17.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e122.08\u0026plusmn;16.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.058\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ea:Independent Samples t-test; *:significant at \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of postoperative data between the two groups (values expressed in mean standard deviation)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMV group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMP group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative drainage volume-ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e135.20\u0026plusmn;17.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e122.08\u0026plusmn;16.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.024\u003csup\u003ea*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin difference before and after surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e24.76\u0026plusmn;6.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e32.53\u0026plusmn;6.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003csup\u003ea*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime of first postoperative ambulation-h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e19.34\u0026plusmn;3.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e25.08\u0026plusmn;3.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003csup\u003ea*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospital stay-d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.25\u0026plusmn;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.08\u0026plusmn;1.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003csup\u003ea*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative VAS scores\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.71\u0026plusmn;0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.02\u0026plusmn;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003csup\u003ea*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.12\u0026plusmn;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.17\u0026plusmn;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.676\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.37\u0026plusmn;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.42\u0026plusmn;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.663\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.20\u0026plusmn;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.23\u0026plusmn;0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.768\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative HSS scores\u0026sect;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e70.08\u0026plusmn;8.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e63.96\u0026plusmn;8.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003csup\u003ea*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e81.41\u0026plusmn;4.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e79.62\u0026plusmn;4.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.039\u003csup\u003ea*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e90.75\u0026plusmn;2.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e90.36\u0026plusmn;2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.350\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e92.51\u0026plusmn;1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e92.32\u0026plusmn;1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.525\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ea:Independent Samples t-test; *:significant at \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026Dagger;Scores for the VAS score range from 0 to 10, with higher scores indicating more severe symptoms.\u003c/p\u003e \u003cp\u003e\u0026sect;Scores on the HSS score range from 0 to 100, with lower scores indicating worse disability. The HSS score includes functional and pain scores.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the number of postoperative transfusions, complications and patient satisfaction at last follow-up in the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMV group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMP group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfusion-no. (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2(3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3(5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.902\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications-no. (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2(3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.902\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction -no. (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.921\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery satisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42(71.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39(73.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMostly satisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14(23.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11(20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDissatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2(3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery dissatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1(1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eb:Chi-square test;c:Mann Whitney test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur study indicates that TKA with limited use of a tourniquet through the MV approach benefits early functional recovery with a small incision, less blood loss, faster recovery of early joint function and a shorter hospital stay.\u003c/p\u003e \u003cp\u003eTKA can quickly relieve the pain of patients with end-stage knee osteoarthritis, improve knee function, and improve self-care ability. It is one of the most successful orthopedic surgeries[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In our study, the MV approach showed better joint function within one month after surgery, but this advantage gradually disappeared three months after surgery. The study of Mohammed et al.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] also showed similar results, and they followed up for up to two years. Three months after the operation, the MV approach and the MP approach showed the same knee function. However, some studies suggest that the functional advantages of this approach may last longer. Lin et al[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] found that the functional recovery advantage of the MV approach continued until six months after surgery. Steven et al.\u0026rsquo;s study[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] suggests that it can continue up to one year after surgery. In contrast, one of the main reasons why the MV approach enables patients to achieve faster functional recovery and higher satisfaction may be that the extensor mechanism is preserved as much as possible[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe increase in operation time was positively correlated with postoperative infection, reoperation, blood transfusion and cardiovascular adverse events. For clinicians, reducing the operation time is beneficial to reduce bleeding and postoperative complications. In surgery, longer surgical incisions increase the incidence of adverse events such as infection, bleeding, and immune reactions[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In contrast, smaller incisions reduce postoperative incisional pain and also aid in early postoperative recovery. In our study, the incision length of the MV approach group was small, and the average operation time was 82.12 minutes, which was approximately eight minutes longer than that of the MP approach. This difference was statistically significant. The studies of Hakan[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] et al. and Lin et al.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] also showed similar results. The average surgical incision of the MV approach was shorter, but the operation time was longer. A meta-analysis included 19 randomized controlled trials showing that the average operative time between the MV approach and the MP approach was prolonged by 18 minutes[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. It is undeniable that a smaller incision requires a longer operation time to compensate for the difficulty of exposure caused by a small incision, which may be the reason for the longer operation time of the MV approach.\u003c/p\u003e \u003cp\u003eHospitalization time is an important indicator for the evaluation of the concept of rapid rehabilitation. Reducing hospitalization time can reduce hospitalization costs and postoperative complications. Patients undergoing surgery using the MV approach show less pain in the early stage. Effective pain control is a prerequisite for early functional exercise. Early functional exercise after surgery can reduce hospital stays and reduce costs, and will not increase adverse events[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This also explains why the MV approach group had better knee function recovery and shorter postoperative hospital stays. In addition, early effective pain control can improve patients\u0026rsquo; satisfaction and the mental health of patients[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. These factors will affect the patient\u0026rsquo;s recovery and hospitalization time. Early discharge of patients\u0026rsquo; can not only directly reduce the cost and economic burden of patients\u0026rsquo; and save medical resources, but also facilitate the diet and nursing of patients at home as well as reduce the burden of family care.\u003c/p\u003e \u003cp\u003eThe use of tourniquets in TKA requires more careful consideration. The use of a tourniquet in knee arthroplasty reduces bleeding and provides a distinct view of the operative area, which is beneficial in terms of shorter operative time and fewer blood transfusions[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Nevertheless, systematic reviews and meta-analyses have suggested that tourniquets inflated at high pressure cause limb swelling and rhabdomyolysis, which adversely affects the quadriceps muscle group. It also increases the incidence of deep vein thrombosis and postoperative pain in patients, which collectively affect the early postoperative recovery[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Therefore, in this study, tourniquets were used limitingly throughout the procedure, and ultimately no complications such as deep vein thrombosis were observed. However, since our study did not specifically examine the use of tourniquets at different times, further controlled trials may be meaningful.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, retrospective studies have prevented us from studying patient randomization. However, the preoperative data were comparable between the two groups, which reduces the impact on the results to some extent. Second, the cases included in this study were from a single center with a small sample size and the results of the study may be biased, which needs to be further confirmed by further multicenter studies with large sample sizes. Finally, the short follow-up period caused us to fail to assess patient survival, and we were not able to assess differences in prosthetic infection, fractures, survival, etc. After all, the purpose of our study was only to determine whether there was an early advantage in the MV approach.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eTKA with limited use of a tourniquet through the MV approach is beneficial in reducing the length of the surgical incision, blood loss, and length of hospital stay, reducing early pain, and improving early knee function. However, after three months, there was no significant difference in knee function between the two groups compared with the MP approach. We recommend that surgeons who are familiar with the MV approach can use this approach to reduce early pain and facilitate early recovery. However, orthopedic surgeons should still choose the approach they are familiar with, because there is no significant difference in patients\u0026rsquo; final recovery outcomes between the two approaches, and there is no impact on the satisfaction rate either.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTKA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTotal knee arthroplasty\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMidvastus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedial parapatellar\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVisual analogue scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHospital for Special Surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe body-mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ewe would like to express our deepest appreciation to\u0026nbsp;Chuzhou Chinese and Western Medicine Hospital\u0026nbsp;for allowing us to conduct this research. This work has not been submitted for publication in any other journal, and all the references are acknowledged.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChuzhou Chinese and Western Medicine Hospital, Lei Liu and Huejie Li.\u003c/p\u003e\n\u003cp\u003eThe Second Affiliated Hospital of Tianjin University of TCM, Zhicheng Pan and Wangxin Liu.\u003c/p\u003e\n\u003cp\u003eLanxi People’s Hospital, Huihui Sun.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eL.L. and Z.C.P are the lead authors who coordinated data collection, analyzed the data and wrote the manuscript. W.X.L. and H.H.S. supervised and reviewed the manuscript. H.J.L. edited and reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Wangxin Liu and Huihui Sun.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval statement\u003c/strong\u003e The study was approved by the Clinical Research Ethics Committee of Chuzhou Chinese and Western Medicine Hospital (approval number: 2024-95). All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from each patient after explaining the benefits, harms, and possible morbidities of surgery in detail.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was not required from participants included in the study, but patient confidenciality is strictly maintained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHusted H. Fast-track hip and knee arthroplasty: clinical and organizational aspects. Acta Orthop Suppl. 2012;83(346):1\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCarthy Deering E, Hu SY, Abdulkarim A. Does Tourniquet Use in TKA Increase Postoperative Pain? A Systematic Review and Meta-analysis. Clin Orthop Relat Res. 2019;477(3):547\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang C, Shang L, Yao S, Ma J, Xu C. Cost, time savings and effectiveness of wearable devices for remote monitoring of patient rehabilitation after total knee arthroplasty: study protocol for a randomized controlled trial. J Orthop Surg Res. 2023;18(1):461.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeFrance M, Scuderi G. Are 20% of Patients Actually Dissatisfied Following Total Knee Arthroplasty? A Systematic Review of the Literature. J Arthroplasty 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMigliorini F, Maffulli N, Sch\u0026auml;fer L, Schneider J, Nobili AM, K\u0026auml;mmer D, Michalak M, Bell A. Robotic-assisted total knee arthroplasty in clinical practice: protocol for a randomised controlled trial. J Orthop Surg Res. 2023;18(1):623.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKahlenberg CA, Nwachukwu BU, McLawhorn AS, Cross MB, Cornell CN, Padgett DE. Patient Satisfaction After Total Knee Replacement: A Systematic Review. HSS journal: Musculoskelet J Hosp Special Surg. 2018;14(2):192\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang L, Li X, R\u0026uuml;wald JM, Welle K, Schildberg FA, Kabir K. Comparison of minimally invasive approaches and standard median parapatellar approach for total knee arthroplasty: A systematic review and network meta-analysis of randomized controlled trials. Technol health care: official J Eur Soc Eng Med. 2021;29(3):557\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeng L, Fu J, Xu C, Ren P, Wang YM, Ji QB, Xin P, Zheng QY, Ni M, Zhang GQ. The Comparison between Mini-Subvastus Approach and Medial Parapatellar Approach in TKA: A Prospective Double-Blinded Randomized Controlled Trial. Orthop Surg. 2022;14(11):2878\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolisek FR, Bonutti PM, Hozack WJ, Purtill J, Sharkey PF, Zelicof SB, Ragland PS, Kester M, Mont MA, Rothman RH. Clinical experience using a minimally invasive surgical approach for total knee arthroplasty: early results of a prospective randomized study compared to a standard approach. J Arthroplasty. 2007;22(1):8\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchroer WC, Diesfeld PJ, Reedy ME, LeMarr AR. Evaluation of complications associated with six hundred mini-subvastus total knee arthroplasties. J bone joint Surg Am. volume 2007;89(Suppl 3):76\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAslam MA, Sabir AB, Tiwari V, Abbas S, Tiwari A, Singh P. Approach to Total Knee Replacement: A Randomized Double Blind Study between Medial Parapatellar and Midvastus Approach in the Early Postoperative Period in Asian Population. J Knee Surg. 2017;30(8):793\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLayher F, Zipfel M, Sander K, Matziolis G, Roth A. [Functional Comparison of the Outcome after Midvastus and Medial Parapatellar Surgical Approach in Total Knee Arthroplasty]. Z fur Orthopadie und Unfallchirurgie. 2016;154(1):50\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin W, Niu J, Dai Y, Yang G, Li M, Wang F. Mini-midvastus versus medial parapatellar approach in total knee arthroplasty: difference in patient-reported outcomes measured with the Forgotten Joint Score. J Orthop Surg Res. 2020;15(1):336.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShukla R, Mahajan P, Singh M, Jain RK, Kumar R. Outcome of Total Knee Replacement via Two Approaches in Indian Scenario. J Knee Surg. 2017;30(2):174\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMigliorini F, Aretini P, Driessen A, El Mansy Y, Quack V, Tingart M, Eschweiler J. Better outcomes after mini-subvastus approach for primary total knee arthroplasty: a Bayesian network meta-analysis. Eur J Orthop Surg traumatology: orthopedie traumatologie. 2020;30(6):979\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLechner R, Lazzeri M, Oberaigner W, Nardelli P, Roth T, K\u0026ouml;glberger P, Krismer M, Liebensteiner MC. Does the type of surgical approach affect the clinical outcome of total knee arthroplasty? Der Orthopade. 2021;50(8):674\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZora H, G\u0026uuml;ng\u0026ouml;r HR, Bayrak G, Şavkın R, B\u0026uuml;ker N. Does mini-midvastus approach have an advantageous effect on rapid recovery protocols over medial parapatellar approach in total knee arthroplasty? Joint Dis Relat Surg. 2020;31(3):571\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaas SB, Manitta MA, Burdick P. Minimally invasive total knee arthroplasty: the mini midvastus approach. Clin Orthop Relat Res. 2006;452:112\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePietsch M, Djahani O, Hofmann S. [Minimally invasive mini-midvastus approach as standard in total knee arthroplasty]. Der Orthopade. 2007;36(12):1120\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop Surg Res. 2014;9(1):13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson C, Warwick J, Seers K, Parsons H, Wall PD. Tourniquet use for knee replacement surgery. Cochrane Database Syst Rev. 2020;12(12):Cd012874.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson CE, Warwick J, Seers K, Parsons H, Wall PDH. Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery. bone joint J 2021, 103\u0026ndash;b(5):830\u0026ndash;839.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMagan AA, Dunseath O, Armonis P, Fontalis A, Kayani B, Haddad FS. Tourniquet use in total knee arthroplasty and the risk of infection: a meta-analysis of randomised controlled trials. J experimental Orthop. 2022;9(1):62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao Q, He Z, Fan Y, Meng J, Yuan T, Zhao J, Bao N. Effects of tourniquet application on enhanced recovery after surgery (ERAS) and ischemia-reperfusion post-total knee arthroplasty: Full- versus second half-course application. J Orthop Surg. 2020;28(1):2309499019896026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenchekroun S, Lahsika M, Abid H, Idrissi ME, Ibrahimi AE, Mrini AE. [Total knee replacement without patellar resurfacing: about 60 cases]. Pan Afr Med J. 2020;36:132.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu W, Liu L, Pan Z, Gu E. Percutaneous endoscopic interlaminar discectomy with patients' participation: better postoperative rehabilitation and satisfaction. J Orthop Surg Res. 2024;19(1):547.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarachalios T, Giotikas D, Roidis N, Poultsides L, Bargiotas K, Malizos KN. Total knee replacement performed with either a mini-midvastus or a standard approach: a prospective randomised clinical and radiological trial. J bone joint Surg Br volume. 2008;90(5):584\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThienpont E, Zorman D. Higher forgotten joint score for fixed-bearing than for mobile-bearing total knee arthroplasty. Knee Surg sports Traumatol arthroscopy: official J ESSKA. 2016;24(8):2641\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIoannidis A, Arvanitidis K, Filidou E, Valatas V, Stavrou G, Michalopoulos A, Kolios G, Kotzampassi K. The Length of Surgical Skin Incision in Postoperative Inflammatory Reaction. JSLS: J Soc Laparoendoscopic Surg 2018, 22(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Vivo A, Mancuso A, Giacobbe A, Priolo AM, De Dominici R, Maggio Savasta L. Wound length and corticosteroid administration as risk factors for surgical-site complications following cesarean section. Acta Obstet Gynecol Scand. 2010;89(3):355\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeng X, Zhang X, Cheng T, Cheng M, Wang J. Comparison of the quadriceps-sparing and subvastus approaches versus the standard parapatellar approach in total knee arthroplasty: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2015;16:327.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasaracchio M, Hanney WJ, Liu X, Kolber M, Kirker K. Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: A systematic review with meta-analysis. PLoS ONE. 2017;12(6):e0178295.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen UDT, Perneger T, Franklin PD, Barea C, Hoffmeyer P, L\u0026uuml;bbeke A. Improvement in mental health following total hip arthroplasty: the role of pain and function. BMC Musculoskelet Disord. 2019;20(1):307.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcAuliffe M, Pillay T, Jaber K, Sterling M, O'Leary S. Pre-operative pain pressure threshold association with patient satisfaction following Total Knee Arthroplasty. J Orthop. 2024;52:21\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMigliorini F, Maffulli N, Aretini P, Trivellas A, Tingart M, Eschweiler J, Baroncini A. Impact of tourniquet during knee arthroplasty: a bayesian network meta-analysis of peri-operative outcomes. Arch Orthop Trauma Surg. 2021;141(6):1007\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorelli I, Maffulli N, Brambilla L, Agnoletto M, Peretti GM, Mangiavini L. Quadriceps muscle group function and after total knee arthroplasty-asystematic narrative update. Br Med Bull. 2021;137(1):51\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMigliorini F, Maffulli N, Eschweiler J, Knobe M, Tingart M, Betsch M. Tourniquet use during knee arthroplasty: A Bayesian network meta-analysis on pain, function, and thromboembolism. surgeon: J Royal Colleges Surg Edinb Irel. 2022;20(4):241\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6565543/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6565543/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Total knee arthroplasty(TKA) is regarded as one of the most successful orthopedic surgeries. However, there is still a lack of consensus on the use of tourniquets and the choice of surgical approach. This research aimed to compare recovery outcomes in patients undergoing TKA with limited use of tourniquet through the midvastus(MV) approach and the medial parapatellar(MP) approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Patients receiving TKA treatment (MV or MP) were retrospectively recruited in this study between June 2019 and June 2024. The demographic, perioperative, and patient satisfaction data were collected and compared between the MV and MP groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThere was no statistical difference in the general data between the two groups of patients, and they were comparable. Compared with MP approach, patients in MV group had shorter incision length, less postoperative drainage volume, smaller hemoglobin difference before and after surgery, shorter postoperative hospital stay, lower VAS score at firstweek after operation, and higher HSS score at first week and firstmonth after operation. In contrast, patients in the MP approach group had a short operative time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The MV approach and the MP approach are both effective options for TKA and can improve the patients’ knee function. The MV approach was beneficial for the patients’ early postoperative recovery, but there was no significant difference in knee function after three months, complications, or satisfaction between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable.\u003c/p\u003e","manuscriptTitle":"Limited use of tourniquet in total knee arthroplasty using the midvastus approach facilitates recovery: a retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-04 08:28:21","doi":"10.21203/rs.3.rs-6565543/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-06-15T12:02:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214494088757025375245367027953301515884","date":"2025-06-15T11:51:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-30T14:37:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-07T12:46:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-05T07:37:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-05T07:33:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-04-30T13:41:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1c9205d6-c781-4365-8855-3faa108cec52","owner":[],"postedDate":"June 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-04T08:28:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-04 08:28:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6565543","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6565543","identity":"rs-6565543","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}