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

Abstract

Background: Satisfactory outcomes have been reported after all-inside meniscus ramp repair with combined anterior cruciate ligament reconstruction (ACLR). However, clinical outcomes after ACLR with inside-out meniscus ramp repair are limited.Purpose/Hypothesis: The purpose of this study was to evaluate patient-reported outcomes for patients who underwent ACLR and medial meniscus ramp repair compared with those who underwent isolated ACLR; patients in the 2 groups were matched for age, sex, and sport/activity. The null hypothesis was that there would be no significant differences in clinical outcomes between groups at a minimum of 2 years postoperatively.Study Design: Cohort study; Level of evidence 3. Methods:Patients who underwent primary ACLR with bone-patellar tendon-bone (BPTB) autograft by a single surgeon were retrospectively identified. A subgroup of patients with combined ACLR and meniscus ramp repair with a minimum 2-year postoperative follow-up were matched to a cohort who underwent isolated ACLR. Subjective patient-reported questionnaires, knee stability, and return to level of activity/sport were collected.Results: There were 851 patients who underwent primary ACLR; of these, 158 (18.6%) had medial meniscus ramp lesions confirmed at arthroscopy. The most common clinical characteristics in patients with ramp lesions were chronic injuries (68.4%), contact mechanism (88%), concomitant lateral meniscus tears (63.2%), and concomitant lateral meniscus posterior root tears (22.2%). Further, 50 patients who underwent combined ACLR and meniscus ramp repair with minimum 2-year follow-up were matched to patients who underwent isolated ACLR. Both groups reported significant improvements in subjective outcomes from preoperative to postoperative assessments (P < .001). No significant differences were found in postoperative outcomes for combined ACLR with ramp repair versus isolated ACLR (P > .05). Patients with meniscus ramp repair had increased preoperative knee laxity demonstrated by grade 3 Lachman (44% vs 6%) and pivot-shift (38% vs 12%) test results compared with patients who underwent isolated ACLR (P .005 for both). Conclusion:This study demonstrates similar clinical outcomes, knee stability on postoperative physical examination, and returnto-sport rates for patients who underwent combined ACLR with BPTB autograft and inside-out meniscus ramp repair versus a matched cohort who underwent isolated ACLR. Clinicians should have a high index of suspicion for the presence of ramp lesions in patients with ACL tears who have a contact mechanism of injury, grade 3 Lachman test result, and concomitant lateral meniscal abnormality.

Incidence and Risk Factors of Subsequent Meniscal Surgery After Successful Anterior Cruciate Ligament Reconstruction: A Retrospective Study With a Minimum 2-Year Follow-up

“…They noted that these extended lesions had a high failure rate (11.7%) of secondary meniscal surgery. DePhillipo et al 7 documented a 2% rate of secondary meniscectomy at a mean 33.6 months after inside-out ramp repair, and they recommended inside-out repair of all unstable ramp lesions at the time of ACL reconstruction. In the current study, the failure rate of the posterior portion was 7.1% (8/113) and that of posterior to midportion was 8.0% (7/ 87), and no significant difference was detected.…”

Ramp lesion of the medial meniscus

“…MRL repair failure after ACLR is remarkably lower in inside-out sutures (2%) than in all-inside (11%), which was recorded by another research group. 48 However, an earlier comparative study with a higher level of evidence showed that there is no statistical difference in healing status between these two techniques following ACLR. 49 Some studies claim that small and stable MRL does not have to be sutured.…”

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

“…They also found that anterior laxity was significantly greater in the knees with unhealed ramp lesions compared with the knees in which the ramp lesions had healed. 30 DePhillipo et al 24 have shown that patients with combined ACL tear and ramp lesions have increased preoperative knee anteroposterior and rotational knee laxity, as demonstrated by grade 3 Lachman (44% vs 6%) and pivotshift (38% vs 12%) tests when compared with ACL tear group without ramp lesion (P .005 for both). Thus, it makes more sense to repair the ramp lesion to restore the physiological knee stability and kinematics.…”

“…[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.…”

“…This excluded important studies without ACL scores, which evaluated meniscal repair failure rate and secondary meniscectomy after repair of ramp lesions. 23,24,28 Moreover, the incidence of secondary meniscectomy after ramp repair was only evaluated up to 2 years postoperatively; we feel this is insufficient time for follow-up, as we have shown that the failure of repaired meniscus continues up to 4 years. 3,23,28 The systematic review showed incomplete healing of ramp lesions in 12.1% to 12.9% of cases in which the tear was not repaired at the time of ACL reconstruction, 2.3% to 11.7% in cases using the suture-hook for repair, and 10.8% to 15% in the all-inside meniscus repair device group.…”