CT scan analysis of implant mating comparing APA versus TEA in simultaneous bilateral TKA: One technique per knee.

BACKGROUND: The optimal landmark for setting femoral component rotation in primary TKA remains a debate. This study compares the Anterior-Posterior Axis (APA) versus the Transepicondylar Axis (TEA) in patients undergoing simultaneous bilateral TKA, where one reference line was randomized to each knee. Implant mating was assessed via post-operative CT scans. METHOD: The study included 32 patients with osteoarthritis in both knees with similar varus deformities. All patients underwent the same surgical procedure on both knees, aside from the selected femoral rotation axis line: APA randomized to one side and TEA to the contralateral. Post-operative CT scans were performed in extension to assess in-vivo mating. RESULTS: CT scan analysis showed mean rotation of the femoral implant externally rotated relative to the radiographic TEA with no significant difference between the APA and TEA groups (p = 0.28). Tibial implant rotation was also externally rotated to the radiographic TEA with no significant difference (p = 0.59). Femoral-tibial implant mating showed a mean external rotation of the tibia relative to the femur in both groups: 0.86 ± 4.0° external rotation in the APA group and 0.23 ± 3.7° external rotation in the TEA group. There was no significant difference between groups (p = 0.52). The range of mating mismatch was 15° in the APA group and 16.5° in the TEA group. CONCLUSIONS: When using a measured resection, posterior referencing technique, post-operative femoral-tibial implant mating measured by CT scan showed no superiority comparing the APA method versus the TEA method. LEVEL OF EVIDENCE: 2 Randomized prospective study.

Anterior Closing Wedge Osteotomy for Failed Anterior Cruciate Ligament Reconstruction: State of the Art.

The sagittal anatomy of the proximal tibia has a bearing on the forces exerted on the cruciate ligaments. A high posterior tibial slope is now a well-known risk factor causing failure of anterior cruciate ligament (ACL) reconstructions. The posterior slope can be calculated on short or full-length radiographs, MRI scans, or three-dimensional CT scans. Reducing the slope surgically by a sagittal tibial osteotomy is biomechanically protective for the ACL graft. An anterior closing wedge osteotomy may be contemplated when the lateral tibial slope is greater than 12°, in the setting of ACL reconstruction failure(s). Careful surgical planning to calculate the correction, taking into account knee hyperextension and patella height, is critical to avoid complications. It can be done above, at, or below the tibial tuberosity level. A transtuberosity correction can be done with or without a tibial tubercle osteotomy. This complex surgery can be conducted safely by meticulous execution to protect the posterior hinge and neurovascular structures and achieving stable fixation with staples. The limited literature available justifies the usage of anterior closing wedge osteotomy in appropriately selected patients.

ACL repair for athletes?

Background: The current gold standard treatment for an anterior cruciate ligament (ACL) tear in an athlete is an arthroscopic ACL reconstruction with autografts. This restores the knee stability but is associated with unique complications like graft re-tear, kinesiophobia and graft donor site morbidity. ACL suture repair (ACLSR) is an attractive alternative method of surgical management of this injury. Current science of ACLSR: The potential advantages of performing a repair are the preservation of native biology and proprioceptive function of ACL, elimination of a graft and preservation of bone stock. The purported benefits are better stability, reduction of kinesiophobia and faster rehabilitation. ACLSR is now performed only for proximal (femoral-sided) tears in the acute phase, when the tissue quality is good and using high-strength nonabsorbable sutures. There are several techniques for performing ACLSR but broadly speaking are either non-augmented, static augmented with suture tape, dynamic augmented or using bio-scaffolds. Clinical outcome of ACLSR: There is a lot of literature on ACLSRs including case series, cohort studies and randomized controlled trials. The results from these studies are encouraging but mostly pertain to patient reported outcome measures, are in small numbers and in the short-term. The results are also inconsistent across different studies and not specifically performed for the athletic population. Moreover, most of these studies are from the innovator or designer surgeons and groups and have not been independently validated. Conclusion: Currently, there is insufficient evidence to recommend ACLSR as a preferred method of managing even acute proximal tears in athletes. Improved rates of return to sports, lower retear rate and lesser kinesiophobia needs to be proven in athletes.

Comparison of Anterior-Posterior Axis Versus Transepicondylar Axis in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty: One Technique per Knee.

BACKGROUND: In primary total knee arthroplasty (TKA), the preferred reference line for setting femoral component rotation is debatable. This study compared the anterior-posterior axis line (APAL) versus the transepicondylar axis line (TEAL) in patients undergoing simultaneous bilateral TKA using a measured resection technique where one reference line was randomized to each knee. METHODS: This prospective study compared the two reference lines using posterior knee referencing with a cemented posterior stabilized knee. The study included 32 patients with osteoarthritis with both knees having similar varus knee deformities. All patients had the same surgical procedure with the only change being the selected femoral rotation axis line. Patients were followed up for a minimum of two years. RESULTS: There was no significant difference in any of the measured radiographic, operative, and clinical parameters, except for a postoperative radiographic limb alignment (APAL 179.7° vs TEAL 180.1° P = .04). The mean femoral external rotation relative to the posterior condylar axis line (PCAL) was 3.0 degrees (0-7 degrees) using the APAL and 3.3 degrees (2-7 degrees) using the TEAL (P = .46). Two-year knee flexion and revised Oxford Knee Scores showed no difference. Seventy-five percent of patients stated no preference for either knee technique. CONCLUSION: When using a measured resection, a posterior referencing technique, we found no difference in knee function and scores when setting femoral component rotation using the APAL versus TEAL. LEVEL OF EVIDENCE: 2, Randomized prospective study.

Outcomes of Combined Lateral Meniscus Posterior Root Repair and Anterior Cruciate Ligament Reconstruction.

Background: Lateral meniscus posterior root tears (LMPRTs) almost always occur in association with anterior cruciate ligament (ACL) tears. Their repair is advocated to restore the stabilizing and load-sharing functions of the meniscus. Purpose: To study the functional outcomes of combined arthroscopic repair of LMPRTs and ACL reconstruction (ACLR). Study Design: Case series; Level of evidence, 4. Methods: The authors evaluated patients who underwent simultaneous arthroscopic ACLR and LMPRT repair. All patients had chronic injuries, with a mean time since ACL rupture of 7.9 months. Patient characteristics, Lachman and pivot-shift test results, type of LMPRT, associated injuries, and surgery details were documented. Pre- and postoperative functional status was assessed using the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score. An independent single-tunnel transtibial repair using 2 SutureTapes was performed for Forkel type 1 and 3 tear root avulsions, while side-to-side suture repair was performed for type 2 radial/oblique tears. The Wilcoxon signed rank test and minimal clinically important difference (MCID) of the IKDC score were used for statistical analysis. Results: Included were 25 patients with a mean age of 29.6 ± 6.5 years. Of these, 22 patients (88%; 95% CI, 73.1%-100%) had a high-grade (grade 2 or 3) preoperative pivot shift. Diagnosis of the LMPRT on magnetic resonance imaging (MRI) scans was possible only in 5 patients (20%). At final evaluation, performed at 37.4 ± 7.1 months postoperatively, all functional scores had improved significantly from preoperatively: IKDC score, from 47.6 ± 9.5 to 81.8 ± 11.5; KOOS, from 45.5 ± 10.9 to 86.5 ± 10.3, and Lysholm score, from 49.0 ± 11.5 to 88.8 ± 7.6 (P < .001 for all). Twenty-four patients (96%) achieved the MCID for the IKDC score. All knees had a negative pivot shift at final analysis, and no patient underwent revision ACLR or LMPRT repair. Conclusion: LMPRT repair combined with ACLR led to good short-term clinical outcomes in this study. An LMPRT may frequently go undetected on preoperative MRI scans, but a high-grade pivot shift is present in a large majority of these patients.

Anatomic medial knee reconstruction restores stability and function at minimum 2 years follow-up.

PURPOSE: Chronic grade 3 tears of the medial collateral ligament and posterior oblique ligament may result in valgus laxity and anteromedial rotational instability after an isolated or multiligament injury. The purpose of this study was to prospectively analyze the restoration of physiologic medial laxity as assessed on stress radiography and patient reported subjective functional outcomes in patients who undergo an anatomic medial knee reconstruction. METHODS: This was a prospective study which included patients with chronic (> 6 weeks old) posteromedial corner injury with or without other ligament and meniscus lesions. Pre- and post-operative valgus stress radiographs were performed in 20° knee flexion and functional outcome was recorded as per the International Knee Documentation Committee (IKDC) and Lysholm scores. All patients underwent anatomic medial reconstruction with two femoral and two tibial sockets using ipsilateral hamstring tendon autograft. Simultaneous ligament and meniscus surgery was performed as per the associated injury pattern. All patients were followed up for a minimum of 24 months post-surgery. RESULTS: Thirty-four patients (23 males, 11 females) were enrolled in the study and all were available till final follow-up of mean 49.7 ± 14.9 months. The mean age was 30.6 ± 7.9 (18-52 years). Two patients had isolated medial sided lesions and 23 had associated ligament injuries. The mean follow up was 49.7 (24-72) months. The mean IKDC score improved from 58 ± 8.3 to 78.2 ± 9.5 (p < 0.001). Post-operatively there were 15 excellent, 11 good and 8 fair outcomes on Lysholm score. The mean pre-operative valgus side-to-side opening improved from 7.5 ± 2.5 mm to 1.2 ± 0.7 mm on stress radiography (p < 0.001). CONCLUSION: Anatomic reconstruction of the superficial medial collateral and posterior oblique ligaments restore stability in a consistent manner cases of chronic grade 3 instability. The objective functional results, subjective outcomes and measures of static medial stability are satisfactory in the short term. LEVEL OF EVIDENCE: IV.

Revision ACL Reconstruction: Principles and Practice.

INTRODUCTION: The incidence of anterior cruciate ligament reconstruction (ACLR) surgeries is increasing and so is the number of revision surgeries for a failed ACLR. The spectrum of ACL failure includes symptoms of recurrent instability, pain, and/or stiffness. DISCUSSION: Factors contributing to ACL failure may be classified as patient-related, surgeon-related, and biological factors. Of these, tunnel malposition and recurrent trauma are the most common causes. Detailed patient assessment, imaging, and studying details of the index surgery are critical prior to planning revision surgery. Infection has to be ruled out prior to planning any reconstructive surgical procedure. Osseous malalignment in the coronal or sagittal planes would also need correction along with or prior to revision ACL surgery. Revision ACL reconstruction maybe performed as a one-stage or two-stage procedure. Severe tunnel dilatation, infection, or arthrofibrosis necessitates a two-stage approach. Autografts are preferred for revision ACL due their lesser re-tear rates and better outcomes. Associated meniscus tears and cartilage injuries are more common in revision than in primary surgery and need to be managed appropriately. Extra-articular reconstruction for controlling anterolateral instability is frequently required as well. CONCLUSION: Revision ACL reconstruction is a complex undertaking due to limited graft options, compromised anatomy and high frequency of associated injuries. Patient expectations must be tempered because functional outcomes and return to pre-injury sports are inferior to a primary surgery.

Indirect Magnetic Resonance Arthrography May Help Avoid Second Look Arthroscopy for Assessment of Healing After Bucket Handle Medial Meniscus Repairs: A Prospective Clinico-Radiological Observational Study.

OBJECTIVES: The objectives were: (1) to analyze the MRI healing rates of bucket-handle meniscus repair; (2) to compare the accuracy of assessment of meniscus healing for conventional MRI and Indirect Magnetic Resonance Arthrography (IMRA); and (3) to identify patients who may require second-look arthroscopy after meniscus repair. METHODS: This is a prospective observational case series of thirty-seven patients with repaired bucket-handle medial meniscus tear with a minimum one year follow-up. Meniscus healing rates were assessed on direct MRI and IMRA using Henning's criteria. At the same time, patients' symptoms were evaluated according to Barrett's criteria and functional outcomes were recorded using International Knee Documentation Committee (IKDC) score, Knee Osteoarthritis and Outcomes Score (KOOS) and Tegner-Lysholm scores. A further clinical review was performed 18 months after the imaging to assess the evolution of symptoms. RESULTS: At a mean of 22.3 ± 7.8 months after the meniscus repair, 56.7% patients showed complete healing and 40.5% patients demonstrated incomplete repair healing on IMRA. 52% patients with complete healing and 40% patients with incomplete healing demonstrated meniscus symptoms. At the second clinical review, 19% patients with complete healing and 20% patients with incomplete healing had meniscus symptoms. There was no co-relation between symptoms, PROMs and healing on MRI. CONCLUSION: Indirect MR arthrography offers distinct advantages over direct MRI for assessment of meniscus healing, especially in symptomatic patients. Patient-reported outcome measures and symptomatology are not co-related with the healing status of the meniscus and they resolve in the majority on longer follow-up. A more conservative approach guided by IMRA to assess meniscus healing will avoid early re-operations.

Discoid lateral meniscus: current concepts.

The discoid meniscus is a congenital morphological abnormality encountered far more commonly on the lateral than the medial side. The discoid lateral meniscus (DLM) is more prevalent in Asia with an incidence of 10%-13%, than in the Western world with an incidence of 3%-5%. DLM can be bilateral in more than 80% cases. Due to its abnormal shape and size, the discoid meniscus is prone to tearing and has an impact on gait mechanics. The discoid meniscus has deranged collagen arrangement and vascularity which can have implications for healing after a repair. Patients with a DLM may or may not be symptomatic with mechanical complaints of locking, clicking, snapping or pain. Symptoms often arise due to a tear in the body of the meniscus or a peripheral detachment. Asymptomatic patients usually do not require any treatment, while symptomatic patients who do not have locking are managed conservatively. When a peripheral detachment is present, it must be stabilised while preserving the meniscus rim to allow transmission of hoop stresses. Rehabilitation after surgery is highly individualised and return to sports is possible after more than 4 months in those undergoing a repair. The functional outcomes and onset of radiographic arthritis after saucerisation and repairing a discoid meniscus are better in the long term, compared with a subtotal meniscectomy. However, there is no compelling evidence currently favouring a repair as results deteriorate with increasing follow-up. Poor prognosis is reported in patients undergoing a total meniscectomy, a higher age at presentation and valgus malalignment.

Limb position influences component orientation in Oxford mobile bearing unicompartmental knee arthroplasty: an experimental cadaveric study.

AIMS: The mobile bearing Oxford unicompartmental knee arthroplasty (OUKA) is recommended to be performed with the leg in the hanging leg (HL) position, and the thigh placed in a stirrup. This comparative cadaveric study assesses implant positioning and intraoperative kinematics of OUKA implanted either in the HL position or in the supine leg (SL) position. METHODS: A total of 16 fresh-frozen knees in eight human cadavers, without macroscopic anatomical defects, were selected. The knees from each cadaver were randomized to have the OUKA implanted in the HL or SL position. RESULTS: Tibial base plate rotation was significantly more variable in the SL group with 75% of tibiae mal-rotated. Multivariate analysis of navigation data found no difference based on all kinematic parameters across the range of motion (ROM). However, area under the curve analysis showed that knees placed in the HL position had much smaller differences between the pre- and post-surgery conditions for kinematics mean values across the entire ROM. CONCLUSION: The sagittal tibia cut, not dependent on standard instrumentation, determines the tibial component rotation. The HL position improves accuracy of this step compared to the SL position, probably due to better visuospatial orientation of the hip and knee to the surgeon. The HL position is better for replicating native kinematics of the knee as shown by the area under the curve analysis. In the supine knee position, care must be taken during the sagittal tibia cut, while checking flexion balance and when sizing the tibial component.

Does increased femoral component size options reduce anterior femoral notching in total knee replacement?

OBJECTIVE: Total knee arthroplasty (TKA) is currently the best option for management of advanced knee arthritis for patients who have exhausted conservative management. There have been significant implant design improvements and this is a continuing process to help the surgeon replicate patient anatomy and kinematics. Amongst the many variables in implantation to achieve a well-functioning TKA, getting optimal femoral component sizing is one. Every implant system has certain discreet implant sizes and the surgeon has to strive to obtain the best fit possible for the patient and attain a well aligned and stable TKA. The aim of this study was to assess the frequency of various femoral component sizes being implanted with a system which has 2.5 mm antero-posterior increment between sizes, and to assess the incidence of anterior femoral notching when using a posterior referencing system. MATERIALS AND METHODS: A retrospective analysis of 739 TKAs implanted in 532 patients between January 2013 and January 2016 at a single center using a single posterior stabilized implant system was done. Patient demographics and femur component size used was obtained from hospital patient records. Immediate post-operative radiographs were analyzed to look for anterior femoral notching and presence of this was classified according to Tayside classification. A telephonic follow up at minimum 2 tears post-surgery was done to interview for occurrence of supracondylar femur fracture or revision for any other causes. RESULTS: There were 207 bilateral and 325 unilateral TKAs performed in 532 patients during the study period. There were 245 males and 287 females with an average age of 61.3 years (43-81 years, SD = 7.2). The most commonly used femoral component was 60 mm and an intermediate size prosthesis was used in 43.11% patients. The incidence of femoral notching ranged from 0 to 6.3%. No patient had sustained a supracondylar condylar fracture at minimum 2 years follow up. CONCLUSION: The availability of a larger number of femoral components in a TKA system allows the surgeon the modularity to choose and obtain the best fit possible. Restoration of posterior condylar offset, preventing anterior notching, medio-lateral overhang and patellofemoral joint stuffing are greatly dependent on correct femoral component sizing. The findings from our study underscore the need to use an implant system with as many femoral size options as possible with lesser increments in between sizes to minimize anterior femoral notching when using a posterior referencing technique.

Anterior Cruciate Ligament Rupture with Medial Collateral Ligament Tear with Lateral Meniscus Posterior Root Tear with Posterolateral Tibia Osteochondral Fracture: A New Injury Tetrad of the Knee.

INTRODUCTION: Injuries to the knee ligaments, menisci, and cartilage are possible in high-velocity trauma as in road traffic accidents. Similarly, these structures can be disrupted in proximal tibia fractures. We present a series of three cases which had a previously undescribed injury combination. CASE PRESENTATION: The first and second patients presented primarily to us following fall from motorbikes. Both these patients had injuries of the anterior cruciate ligament (ACL), medial collateral ligament (MCL), lateral meniscus body and posterior root tear, and osteochondral fracture of posterolateral tibia. The osteochondral fracture was managed by internal fixation with headless compression screws. The ligaments were either repaired or reconstructed and meniscus root tear was treated by transtibial pull through repair. The third patient also had the same injury but was treated at another center. He presented with early arthritis of the lateral tibiofemoral joint and valgus malalignment. Treatment for him was in the form of lateral distal femur open-wedge osteotomy and MCL reconstruction. All three patients had good outcome at the end of 1year. CONCLUSION: We report a new injury tetrad of ACL tear, MCL tear, lateral meniscus posterior root tear, and posterolateral tibia osteochondral fracture. The mechanism of injury is most likely a violent external rotation and anterior translation of the tibia with a valgus directed force during impact. The treatment of this injury can be performed in single or two stages based on the merits of the case. Anatomic reduction and fixation of the fracture takes precedence to avoid later devastating sequel for the knee.

Comparison of Gap Balancing vs Measured Resection Technique in Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty: One Technique per Knee.

BACKGROUND: Total knee arthroplasty requires careful surgical technique to attain the goal of a well-aligned and symmetrically balanced knee. Soft tissue balance and correct femoral component rotation are paramount in achieving these goals. The two competing techniques to select femoral component rotation and soft tissue balance are the gap balance technique and the measured resection technique. METHODS: We performed a randomized, prospective study to compare the two techniques in patients undergoing simultaneous bilateral total knee arthroplasty, whereby one technique was performed in each knee. Fifty (50) subjects were enrolled into the study. The inclusion criteria were osteoarthritic varus knee deformities with similar deformities in both knees. Subjects were followed up for a minimum of two years. RESULTS: The knees balanced via the gap balance technique had significantly more posterior medial bone removed from the femur than those knees balanced via the measured resection technique (P < .001). Knees in the gap balance group tended to require more medial knee releases in extension and tended to have smaller sized femoral components as a result of cutting more bone from the femur in flexion. The modular tibial polyethylene bearing tended to be thicker in the gap balance group. Despite these differences, average knee flexion and functional revised Oxford Knee Scores at 2-year follow-up were not statistically different. CONCLUSION: At 2-year follow-up, there were no differences between the function and scores using the two techniques. Long-term follow-up will be necessary to evaluate any differences in long-term durability.

Osteochondral Lesion in Diffuse Pigmented Villonodular Synovitis of the Knee.

Pigmented villonodular synovitis (PVNS) is a rare benign condition that is locally aggressive and may destructively invade the surrounding soft tissues and bone causing functional loss of the joint and the limb. The knee is the most affected joint (range, 28% to 70%) but involvement of the bone is not a common feature seen at this site. We present a rare case of diffuse PVNS of the knee associated with subchondral cyst of the lateral femoral condyle. This posed a diagnostic dilemma because of bone invasion. The radiological image of synovitis was pathognomonic of PVNS but etiology of the osteolytic lesion was confirmed only on histopathology. The large osteochondral defect was eventually managed in a staged manner with bone grafting and osteochondral autograft transfer.

Anatomic Posterolateral Corner Reconstruction With Autogenous Peroneus Longus Y Graft Construct.

The posterolateral corner of the knee is composed of the fibular collateral ligament, popliteus tendon, and popliteofibular ligament, which provide varus and rotational stability to the knee. An anatomic technique reconstructs these structures through 2 femoral sockets and 1 tibial and 1 fibular tunnel. This reconstruction can be performed using a peroneus longus autograft that is prepared as a Y construct. The peroneus longus autograft is preferred because it provides adequate length and diameter for the entire reconstruction. Initially, the doubled loop of the Y is passed into the tibial tunnel and fixed with an adjustable cortical button. The shorter limb of the Y is used for reconstruction of the popliteus tendon. The longer limb of the Y is passed from posterior to anterior through the fibular tunnel and is fixed in the tunnel with an interference screw to re-create the popliteofibular ligament. The remaining graft is then shuttled deep to the iliotibial band and superficial to the popliteus tendon, into the femoral socket, to re-create the fibular collateral ligament.

Knotless Medial Meniscus Posterior Root Repair.

Medial meniscus posterior root tears are common injuries, especially in the Asian world. This injury must be repaired where indicated to restore knee biomechanics and prevent arthritis. Suturing the meniscus using suture tapes provides good hold of the tissue. The use of a 70° arthroscope and creation of a transseptal portal improve visualization of the posterior compartment. Creation of a high posteromedial portal achieves the correct trajectory for the suture anchor insertion. A knotless suture anchor can be used to fix the posterior root at its anatomic attachment site. This obliterates the need for transtibial drilling for a suture pull-out repair or for knot tying and suture shuttling as for a conventional suture anchor.

Primary Anterior Cruciate Ligament Repair With Augmentation.

Anterior cruciate ligament (ACL) tears are usually managed by reconstruction with autograft or allograft, but primary repair in carefully selected patients is a reasonable option. Proximal avulsions presenting early with excellent tissue quality are amenable to repair and healing. Restoration of native ACL preserves its proprioceptive and kinematic functions. A repair is less invasive and avoids graft-related problems, and faster rehabilitation is possible. Protection for the repair in the early stages will allow better healing. We present our technique of ACL repair using knotless suture anchors with high-strength sutures and protection using high-strength sutures tapes inserted through the same anchors.

Meniscal Preservation is Important for the Knee Joint.

Native joint preservation has gained importance in recent years. This is mostly to find solutions for limitations of arthroplasty. In the knee joint, the menisci perform critical functions, adding stability during range of motion and efficiently transferring load across the tibiofemoral articulation while protecting the cartilage. The menisci are the most common injury seen by orthopedicians, especially in the younger active patients. Advances in technology and our knowledge on functioning of the knee joint have made meniscus repair an important mode of treatment. This review summarizes the various techniques of meniscus tear repair and also describes biological enhancements of healing.

Localized pigmented villonodular synovitis of posterior compartment of the knee.

Pigmented villonodular synovitis (PVNS) is an uncommon entity involving articular or extra-articular tissues and maybe localized or diffuse in extent. The knee is by far the commonest joint to get involved. Localized PVNS of the knee can occur in any location but its confinement to the posterior compartment is infrequent. We present our experience of managing localized posterior compartment PVNS of the knee. There were 10 patients (7 males and 3 females) with average age of 33 years. These patients had symptoms of pain, locking, or swelling for a mean of 13.9 years before diagnosis. All the patients underwent arthroscopic synovectomy without adjuvant therapy, and PVNS was proven on histopathology. At an average follow-up of 23 months, no patient had recurrence of symptoms. The average International Knee Documentation Committee (IKDC) score at last follow-up was 85.21. Magnetic resonance imaging evaluation at final follow-up did not reveal any residual disease or recurrence in any patient.