Total knee arthroplasty has been the standard of treatment of debilitating knee arthritis for over 3 decades. While there have been steady improvements in implant design, the surgical technique has centered on adequate exposure and soft tissue releases to correctly position the components. The minimal incision approach is less invasive, which minimizes soft tissue dissection, but can be converted to a standard approach if necessary. Critical to this minimally invasive approach is patient selection, since all cases may not be performed with limited dissection. The ideal patient should have a fixed angular deformity of <10 degrees of varus or <15 degrees of valgus, <10 degree flexion contracture, and >90 degrees arc of motion. Clinical observations relating to the length of the incision and arthrotomy include the size of the femur, length of the patellar tendon, and body habitus. The wider the femur, as measured by the epicondylar width, the longer the incision. The lower the patellar, as measured by the Insall-Salvati ratio, the longer the incision. Therefore, a short patellar tendon means a longer incision. Realizing that the goal is to obtain adequate exposure, the case can be started with a carefully placed 10- to 14-cm skin incision, which is extended gradually as needed. A limited medial parapatellar arthrotomy can be used and the patella subluxed laterally without eversion for joint exposure. A subvastus approach can also be used as a quadriceps sparing approach. Adequate exposure should be obtained since the surgical technique should not compromise the surgical result.