The low-mMV approach advances the principles of minimally invasive surgery by maximizing VMO preservation compared to the standard mMV while retaining the flexibility of exposure advantages over the SV approach. This technique represents an incremental but important step forward in the evolution of MIS approaches, with the potential to improve recovery outcomes and patient satisfaction. Further research will determine its place as a standard technique for primary TKA in the context of a rapidly evolving field.
Kein Boon Poon et al stated one relative contraindication to using our low-mMV incision would be that of revision TKA, as well as morbid (class III) obesity defined as a body mass index of more than 35 owning to the requirement for more extensive exposure to the knee joint in such patients. Factors such as severe varus or valgus deformities, chronic patellar dislocations requiring extensive lateral releases, use of robotic navigation, well-developed quadricep musculature, or preoperative flexion deformities were not strict contraindications to employing our low-mMV approach.
The technique
A straight incision is originating 2 fingerbreadths proximal to the superior pole of the patella, and extending slightly obliquely across the medial border of the patella in the direction of the tibial tuberosity, and ending 2 fingerbreadths distal to the inferior margin of the patella. The length of this skin incision is reliably less than 12 cm.
Superficial dissection continues through the planes of loose connective tissue until the depth of VMO epimysium is reached.
The deep incision is then initiated by incising vertically through the medial parapatellar retinaculum at the level of and distance of 5 mm to the medial patellar facet. This incision is then extended proximally, sectioning an inferomedial cuff of VMO fibers up to a width of 1 cm. The incision is then acutely angled superiorly and medially, splitting the VMO fibers along the direction of travel, and extending no further than 5 cm proximal to the patellar margin.The rest of the procedure is continued in routine fashion.
Following a postoperative assessment by the physiotherapy team, patients are ambulated with full weight-bearing on the operated leg starting from 4 hours after surgery, with aggressive bed exercises in between ambulation sessions.
Further reading:
The Low Mini-Midvastus Approach for Minimally Invasive Total Knee Arthroplasty, Kein Boon Poon et al Arthroplasty Today 33 (2025) 101686
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