Meniscal ramp lesions - Skillful neglect or routine repair?

Background: Meniscal ramp lesions are injuries of the posterior horn of the medial meniscus at the meniscocapsular junction or the meniscotibial ligament and are frequently associated with concomitant anterior cruciate ligament (ACL) injury. Objective: To review the current literature on meniscal ramp lesion management to better define the indications for and outcomes of repair. Methods: A narrative literature review was performed using PubMed, Embase, and Scopus databases. Studies of all evidence levels (I-V) pertaining to meniscal ramp lesions were reviewed and included. Results: The incidence of ramp lesions has been reported between 16% and 42%. Arthroscopy remains the diagnostic gold standard as magnetic resonance imaging has limited sensitivity. Biomechanically, ramp lesions are known to increase anterior tibial translation and rotational laxity. Clinical investigations regarding optimal management are largely limited to studies of low evidence levels. While case series have demonstrated that repair is safe and efficacious, comparative studies have failed to suggest that repair of stable lesions results in superior outcomes when compared to conservative treatment approaches. However, repair may be warranted in unstable ramp lesion injuries despite the increased risk for revision surgery. Conclusion: While there is evidence to suggest that ramp lesion repair can restore joint kinematics, the current body of clinical literature fails to suggest that outcomes following repair are superior to injuries managed conservatively. The current body of clinical literature is limited, and further robust, long-term study is warranted to better guide injury diagnosis and management protocol.

Ramp lesion repair via dual posteromedial arthroscopic portals: A cadaveric feasibility study.

BACKGROUND: Ramp lesions are found in 16% to 40% of patients undergoing anterior cruciate ligament reconstruction. The repair technique traditionally involves using a suture hook through a posteromedial portal, with the arthroscope positioned in the intercondylar view via an antero-lateral portal. Ramp lesions may be difficult to visualize and repair, even with a 70° arthroscope. The objective of this study was to assess the feasibility of suturing ramp lesions via dual posteromedial portals for the arthroscope and instruments. HYPOTHESIS: Dual posteromedial arthroscopic portals allow good visualisation and high-quality suturing of ramp lesions, without inducing specific iatrogenic injuries. MATERIAL AND METHODS: We used 11 fresh cadaver knees. Two posteromedial portals were created under visualisation via an arthroscope introduced through an antero-lateral portal: one was the traditional instrumental portal and the other, located more proximally, was the optical portal. A 2-cm long ramp lesion was created. A suture hook was used to place one or two stitches of PDS n°0 suture. A probe was used to test the quality and stability of the suturing. The posteromedial plane was then dissected to evaluate the anatomical relationships of the portals. RESULTS: The dual posteromedial approach allowed the visualisation and hook suturing of the ramp lesions in all 11 cases. A single stitch was placed in 4 cases and two stitches in 7 cases. The suture was always of good quality and stable when tested with the probe. The dissection found no injuries to nerves, blood vessels, or tendons. CONCLUSION: Ramp lesions can be repaired through a dual posteromedial arthroscopic approach. This surgical technique provides good visibility of these lesions and allows high-quality suturing, with no specific iatrogenic injuries. It is an alternative to ramp lesion repair via a single posteromedial portal, which can be challenging. LEVEL OF EVIDENCE: IV, experimental study with no control group.

Diagnostic Performance of Magnetic Resonance Imaging for Detecting Meniscal Ramp Lesions in Patients With Anterior Cruciate Ligament Tears: A Systematic Review and Meta-analysis.

BACKGROUND: The clinical importance of meniscal ramp lesions in patients with anterior cruciate ligament (ACL) tear has emerged as a major issue. However, the diagnostic accuracy of magnetic resonance imaging (MRI) for detecting ramp lesions has a wide range. PURPOSE: To perform a systematic review and meta-analysis of the diagnostic performance of MRI for diagnosing ramp lesion in patients with ACL tear. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A literature search of PubMed, EMBASE, and the Cochrane Library was performed based on the revised guidelines for the PRISMA DTA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Accuracy Studies) statement. Diagnostic performance studies using MRI as the index test and arthroscopy as the reference standard for ramp lesion were included. Bivariate and hierarchical summary receiver operating characteristic modeling was used to evaluate the diagnostic performance. Meta-regression analyses were performed to identify potential sources of heterogeneity. RESULTS: The review and meta-analysis included 9 studies from 8 articles (883 patients with ACL tear and reconstruction). The summary sensitivity, summary specificity, and area under the hierarchical summary receiver operating characteristic for ramp lesion were 0.71 (95% CI, 0.59-0.81), 0.94 (95% CI, 0.88-0.97), and 0.90 (95% CI, 0.87-0.92), respectively. Among the potential covariates, magnet strength (P < .01), patient knee position (P = .04), and MRI interpreter (P = .04) were associated with heterogeneity in terms of sensitivity, whereas magnet strength (P = .03) was associated with heterogeneity in terms of specificity. CONCLUSION: MRI demonstrated moderate sensitivity and excellent specificity for diagnosing ramp lesion. Routine arthroscopic assessment is recommended for the presence of ramp lesion, regardless of whether it is suspected on MRI. Further clinicoradiological studies of diagnostic algorithms are needed for identifying ramp lesion, including high-resolution MRI with appropriate knee position.