Analysis of Risk Factors for Ramp Lesions Associated With Anterior Cruciate Ligament Injury

Abstract

Background: The incidence of meniscocapsular junction tears of the medial meniscus posterior horn, known as ramp lesions, is reported to be 9.3% to 23.9%. However, these lesions are not consistently diagnosed with routine arthroscopic exploration and magnetic resonance imaging (MRI). Purpose: To determine risk factors associated with ramp lesions in anterior cruciate ligament–injured knees. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 275 patients undergoing anterior cruciate ligament reconstruction between June 2011 and March 2019 were included in this study. Exclusion criteria were revisions, fracture histories, and multiple-ligament injuries other than medial collateral ligament injury. Patients were divided into 2 groups, those with and without ramp lesions according to arthroscopic diagnosis. Binary logistic regression was used to analyze risk factors: age, sex, body mass index, time from injury to surgery (<3 or ≥3 months), mechanism of injury (contact/noncontact), Segond fracture, side-to-side laxity, location of bone contusion, medial and lateral tibial/meniscal slope, and mechanical axis angle. Receiver operating characteristic curves and area under the curve were evaluated. A prediction model was developed by multivariable regression with generalized estimating equations. Results: Overall, 95 patients (34.5%) were confirmed as having a ramp lesion. The sensitivity of MRI for ramp lesions was 85.3%, and specificity was 78.3%. Significant risk factors for ramp lesion were as follows: posterior medial tibial plateau bone contusion on MRI (odds ratio [OR], 4.201; 95% CI, 2.081-8.482; P < .001), ≥3 months from injury (OR, 4.818; 95% CI, 2.158-10.757; P < .001), varus knee >3° (OR, 2.339; 95% CI, 1.048-5.217; P = .038), steeper medial tibial slope (OR, 1.289; 95% CI, 1.002-1.66; P = .049) and meniscal slope (OR, 1.464; 95% CI, 1.137-1.884; P = .003), and gradual lateral tibial slope (OR, 0.775; 95% CI, 0.657-0.914; P = .002). The area under the curve for the prediction model developed by logistic regression was 0.779 (sensitivity, 75.8%; specificity, 71.7%; P < .001) for ramp lesions. Conclusion: Care should be taken with patients who have significant risk factors for ramp lesions, including bone contusion at the posterior medial tibial plateau, chronic injury, steeper medial tibial and meniscal slope, gradual lateral tibial slope, and varus knee >3°.

Prevalence and Detection of Meniscal Ramp Lesions in Pediatric Anterior Cruciate Ligament–Deficient Knees

“…The time from injury to surgery was relatively long in our series, with an average of 10 months, which has been reported as a risk factor for ramp lesions when exceeding 3 months. 5 In this time frame, some ramp lesions could have occurred while others could have healed. Indeed, in our study, some cases show discordance between MRI and arthroscopic assessment.…”

Editorial Commentary: Ramp Lesion: The Eye Sees Only What the Mind Is Prepared to Comprehend

“…[18][19][20] In clinical practice, the rate of ramp lesions in ACLinjured knees has been reported to vary between 10% and 30% [21][22][23][24] with an increased frequency in chronic ACL injuries and in revision ACL reconstruction. [21][22][23][24][25] These findings contribute to the hypothesis that ramp lesions do not heal spontaneously and also raises questions about whether it is the failed graft that leads to a new ramp lesion or vice versa. Thus, I would again like to press upon the readers the importance of systematic exploration of the posteromedial compartment of the knee during arthroscopic ACL reconstruction (Fig 1), even if the initial probing from anterior of the posterior horn of the medial meniscus is normal.…”

Ramp lesion of the medial meniscus

“…Contact knee injury (p = 0.03) and lateral meniscal tear (p = 0.02) were also found to be associated with MRL. 21 , 22 …”