Epidemiological Evaluation of Meniscal Ramp Lesions in 3214 Anterior Cruciate Ligament–Injured Knees From the SANTI Study Group Database: A Risk Factor Analysis and Study of Secondary Meniscectomy Rates Following 769 Ramp Repairs

Abstract

Background: Ramp lesions are characterized by disruption of the peripheral meniscocapsular attachments of the posterior horn of the medial meniscus. Ramp repair performed at the time of ACL reconstruction has been shown to improve knee biomechanics. Hypothesis/Purpose: Primary objectives of this study were to evaluate the incidence and risk factors for ramp lesions in a large series of patients undergoing ACL reconstruction, Secondary objectives were to determine the re-operation rate for failure of ramp repair, defined by subsequent re-operations for partial medial meniscectomy Study Design: Case series Methods: All patients underwent trans-notch posteromedial compartment evaluation of the knee during ACL reconstruction. Ramp repair was performed if a lesion was detected. Potentially important risk factors were analyzed for their association with ramp lesions. A secondary analysis of all patients who underwent ramp repair and had a minimum follow-up of two years was undertaken in order to determine the secondary partial meniscectomy rate for failed ramp repair. Results: The overall incidence of ramp lesions in the study population was 23.9% (769 ramp lesions in 3214 patients). Multivariate analysis demonstrated that the presence of ramp lesions was significantly associated with the following risk factors: male gender, patients aged under 30 years, revision ACLR, chronic injuries, pre-operative side-to-side laxity >6 mm and the presence of concomitant lateral meniscus tears. The secondary meniscectomy rate was 10.8% at a mean follow up of 45.6 months (24.2-66.2). Patients who underwent ACLR + ALLR had a greater than 2-fold reduction in the risk of reoperation for failure of ramp repair as compared with patients who underwent isolated ACLR (hazard ratio, 0.457; 95%CI, 0.226-0.864; P = .021) 3 Conclusion: There is a high incidence of ramp lesions in patients undergoing ACLR. The identification of important risk factors for ramp lesions in this study in an individual patient should help raise an appropriate index of suspicion and prompt posteromedial compartment evaluation. The overall secondary partial meniscectomy rate after ramp repair is 10.8%. Anterolateral ligament reconstruction appears to confer a protective effect on the ramp repair performed at the time of ACLR and results in a significant reduction in secondary meniscectomy rates.

Clinical Characteristics and Outcomes After Primary ACL Reconstruction and Meniscus Ramp Repair

“…Because of the potential for stable ramp lesions to heal without repair, these authors recommended conservative treatment for stable ramp lesions at the time of ACLR. 14 Recently, Sonnery-Cottet et al 22 reported an 11% rate of meniscectomy at a mean 45.6 months after all-inside meniscus ramp repair. In the current study, the rate of meniscectomy was 2% at a mean 33.6 months after insideout ramp repair.…”

“…Additionally, the rate of meniscus ramp repair failure after inside-out meniscal repair was 2%, which is lower than previous reports of 11% after all-inside ramp repair. 22 Therefore, we recommend inside-out ramp repair at the time of ACLR because of the potential increased knee kinematics associated with ramp tears in ACLreconstructed knees and equivalence compared with isolated ACLR. 6,9 There were some inherent limitations of this study.…”

“…The median [first quartile, third quartile] outcome scores significantly improved from preoperative to postoperative assessments for 46] to 57 [51, 59]), WOMAC Pain (5 [3,10] to 0 [0, 1]), WOMAC Stiffness (4 [2, 4] to 1 [0, 2]), WOMAC total (28 [17,52] to 0 [0, 8]), Lysholm (53 [31, 69] to 86 [80, 95]), Tegner (2 [1, 3] to 8 [6,9]), and IKDC (66 [62, 72] to 78 [72, 80]) after combined ACLR with meniscus ramp repair (P < .001 for all). Similarly, in isolated ACLR, the median outcome scores significantly improved from preoperative to postoperative assessments for SF-12 PCS (38 [31, 44] to 57 [54, 58]), WOMAC Pain (5 [4,9] to 0 [0, 2]), WOMAC Stiffness (3 [2,5] to 0 [0, 2]), WOMAC total (32 [22,50] to 2 [0, 7]), Lysholm (53 [37, 66] to 85 [80, 94]), Tegner (2 [1, 3] to 7 [6,8]), and IKDC (65 [55, 69] to 77 [72, 84]) (P < .001 for all). At final follow-up, no significant differences in postoperative subjective outcomes were seen between patients who underwent combined ACLR with meniscus ramp repair and those who underwent isolated ACLR (P > .05 for all) ( Table 2).…”

“…6,7,23,24 The collective awareness of such injuries has led to improved diagnostic strategies, 3,21 knowledge of tear incidence at the time of ACL reconstruction (ACLR), 1,13 and reported risk factors for increased risk of meniscus ramp tear. 18,22 Despite this improved awareness, there is a paucity of literature reporting on the results of surgical treatment. Similar results have been reported between surgical repair and nonoperative treatment after stable meniscus ramp tears left in situ at the time of ACLR.…”

Editorial Commentary: Magnetic Resonance Imaging of the Knee Anterolateral Ligament: Does It Really Matter?

“…31,32 5. More recent studies have shown a reduction in graft failure 33 and improved meniscal repair rates 34 with the addition of an ALL reconstruction, another method of addressing ALC deficiency. 6.…”