Background <p>The purpose of this study was to evaluate the efficacy of conventional and minimally invasive approaches to total knee arthroplasty (TKA) by comparing the pain score, range of motion (ROM), and adverse effects. It was hypothesized that minimally invasive approaches would lead to superior outcomes.</p> Methods <p>Randomized control trials comparing various approaches to TKA were identified in various literature databases from conception through December 31, 2022. A network meta-analysis (NMA) of relevant literature was performed to investigate which approaches showed better outcomes. In total, 42 studies were included in this study.</p> Results <p>The main finding of this NMA was that the minimally invasive midvastus (MMV) approach led to better outcomes in terms of pain score (with a surface under the cumulative ranking curve [SUCRA] value of 80.0 and a mean rank of 2.2). Also, the minimally invasive quadriceps-sparing (MQS) approach led to better outcomes in terms of ROM (with a SUCRA value of 90.0 and a mean rank of 1.6). However, the subvastus (SV) and quadriceps-splitting (Qsplitt) approaches led to better outcomes in terms of reduction in adverse effects (SV: SUCRA value of 80.0 and a mean rank of 2.4; Qsplitt: SUCRA value of 70.0 and a mean rank of 3.1).</p> Conclusion <p>According to this NMA, minimally invasive approaches of TKA led to better outcomes in terms of pain score and ROM, while conventional approaches of TKA led to better outcomes in terms of safety. Therefore, orthopedic surgeons should consider various factors when choosing the TKA approach.</p> Trial registration <p>PROSPERO: CRD42024548966</p>