Mini Invasive Subvastus Total Knee Replacement (MISTKR )

Total Knee replacement is a reliable operation to relieve pain and suffering due to disabling arthritis of the knee. However, many patients have reservations due to its prolonged recovery and need for physiotherapy. Inability to squat and kneel after the operation, which is particularly important to Indian patients also acts as deterrent. Techniques that have been employed by my team, for the first time in MP, have drastically cut the recovery rates down. Many patients after my MIS TKR have been able to walk without even holding a walking stick on the second day post surgery. The need for physiotherapy also has become much less. With the superior quality of joints available, activities such as kneeling and squatting are possible in selected patients. These benefits are enjoyed due to advanced surgical techniques that involve a minimal incision on the front of the knee. This cut is typically less than 4 inches. Former incision lengths were around 9 to 12 inches.

Surgical approach

In subvastus MITKR no cut is made on the underlying thigh muscle called the quadriceps. Instead the joint is approached below the muscle.

This has huge advantages such as not weakening the thigh muscles at all and this is the reason that the patients are able to walk even without holding on to any walking aids almost immediately after the operation. The earlier approach involved cutting the quadriceps. If the quadriceps is cut, the patients typically need walking aids for 3 to 6 weeks to allow this cut to heal. Moreover, cutting the quadriceps causes more pain and delays the recovery from the operation.

Mini Incision
The instruments to implant the joint and the surgical techniques have been suitably modified so that the new knee joint can be implanted accurately through an incision less than 4 inches. This has advantages, as the lesser the cut on the skin, lesser is the pain and earlier the recovery.

Reduced pain during recovery
The mini TKR through the subvastus approach coupled with advanced postoperative analgesia reduces the pain associated with recovery after the operation. This allows the patients to bend the knee and walk freely very early in the post-operative period.

Full bending of the knee
The ability to achieve full bending of the knee requires the joint to be implanted perfectly.
Care is taken intra-operatively to ensure that the joint is bending fully on the operation table. This allows mobilisation of the knee to begin immediately after the operation and to eventually achieve full flexion. The high flex and mobile joints that are available help in achieving this aim.

New Knees that allow Kneeling

Knee Replacement Surgery is getting more popular as it is very effective. However, some people are not yet considering it because of the length of its recovery and the belief that they would not be able to sit down, squat or kneel after the operation. This is even more relevant in Indian setting due to our cultural need for sitting on the floor for praying etc. Many people want to even squat and use Indian toilet after the operation. Recent technological breakthrough has allowed the recovery to be almost miraculous and function to be virtually normal, allowing the person with a replaced knee to squat and kneel, as was found happily by Mr. Madanlal Yadav.

This 60 year old man, hailing from Khargone M.P., was severely troubled by Knee Osteoarthritis. His left knee was getting more and more painful and he was finding it extremely difficult to carry on his daily routine activities. He had extreme difficulty in getting out of the house and had stopped going out for even simple shopping. He had tried various doctors and medicines without any relief.

His neighbour had been operated for a similar problem by Dr. Divyanshu Goyal, a Consultant Joint Replacement Surgeon at Global SNG Hospital with a Total Knee Replacement. Encouraged by the success of this patient he decided to consult Dr. Divyanshu Goyal. Dr. Goyal explained the operation in detail to Mr. Yadav and his family. Dr. Goyal further explained that new techniques (Minimally Invasive subvastus TKR) would be employed in Mr. Yadav’s operation that would not only allow him to recover very quickly but also give him a virtually normal knee. He would be able to sit down, squat etc. More so the operation would involve only a 3 to 4 inch cut in front of the knee and none of the underlying muscles would be cut. This cut would be less than half in size of the cut that others would make for a similar operation. Smaller incision size would mean less blood loss, less pain and an earlier recovery. All this sounded music to his ears and Mr. Yadav readily agreed for surgery as the charges were also reasonable.

Surgery as well as the postoperative recovery was extremely smooth. Mr. Yadav started lifting his leg and bending the knee from the very first day and started walking from the first day onwards. After a brief Hospital stay, he did his own exercises at home. He recovered fully within 6 weeks and he is able to walk as far as he wants without pain. He is able to climb and descend stairs as normal and best of all he can sit down on the floor crosslegged or kneel in the namaaz position or even squat like a normal person. This is very important to him as he wants to use the Indian toilet.

Let us see what is this new technique that has given miraculous results




Subvastus approach

Traditionally knee replacement surgery would involve around a 9 to 10 inch cut in front of the knee. The muscle of the thigh (Quadriceps) would be cut and then the knee joint would be reached. Recovery would take longer and be painful as the muscle needed time to heal. In the subvastus approach, no muscle is cut. The knee is entered below and beneath this muscle (see the diagram above). Hence the recovery is very quick. Moreover, due to better instrumentation, the operation can be carried out through a much smaller incision almost half of the previous length of the incision. This is called Minimally Invasive TKR or MIS – TKR through a subvastus approach. Dr. Divyanshu Goyal is the pioneer surgeon in Central India who is employing these methods for his patients.






New Joints
New knee joints that are available would allow full function and mobility when implanted properly. This is the reason that Dr. Goyal has been getting these kind of results routinely in numerous patients that are treated by this method. This is especially relevant to us in the Indian setting due to our habits and customs.

Patient quotes after Mini invasive subvastus TKR

“ From the first day after the operation I was able to walk without using any sticks and use my leg as I wanted. The pain of rheumatoid arthritis that had troubled me for 20 years was gone.”

– Mrs. Sichoi Wangmo

“ I was amazed at my recovery. People had told me that I would need walker/walking stick to walk after the operation but I was able to walk without anything from the first day onwards. I started using the bathroom from the second day.”

– Mrs. Rai

“ I should have had the operation earlier. I started walking from the first day as if no operation was done on my leg. The pain that had troubled me for years was magically gone. I went to my pilgrimage place where I had to climb 1500 steps which seemed impossible to me without any problem. I thank Dr Goyal”

– Mrs. Baheti

“I have had one knee replaced by the older method and the second one recently by MITKR. I waited for 1 year before getting my second knee done as it took me that long to recover fully from my first operation. I could not believe the speed with which I recovered from the second knee. I recommend a subvastus MIS TKR to all who are getting a Knee Replacement done as I have personal experience of both methods.

-Mrs. Shrivastava

“I was suffering from disabling knee arthritis since 3 years. I tried all sorts of medicines and many different doctors but nothing was helping. I had a Subvastus Mini TKR performed by Dr. Divyanshu Goyal and I have become normal. I am able to sit down, sit cross-legged, squat and even kneel. I wish I had the operation earlier.

-Mr. Yadav