Meniscal Ramp Lesions in Adolescent Patients Undergoing Primary Anterior Cruciate Ligament Reconstruction: Significance of Imaging and Arthroscopic Findings

Abstract

Background: Meniscal ramp lesions are associated with anterior cruciate ligament (ACL) injuries and may affect knee stability when left untreated. The diagnostic accuracy of magnetic resonance imaging (MRI) to identify this meniscocapsular injury of the posterior horn of the medial meniscus remains poor, and the arthroscopic findings require vigilance. Purpose: To determine the concordance of arthroscopic and MRI findings to better identify the presence of a ramp lesion in children and adolescent patients undergoing primary ACL reconstruction. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Patients aged <19 years who underwent primary ACL reconstruction at a single institution between 2020 and 2021 were included. Two cohorts were developed by the presence of a ramp lesion arthroscopically. Basic patient descriptive data, preoperative imaging (radiologist assessment and independent reviewer assessment), and concomitant arthroscopic findings at the time of ACL reconstruction were recorded. Results: An overall 201 adolescents met criteria with a mean age of 15.7 years (range, 6.9-18.2) at the time of injury. A ramp lesion was identified in 14% of patients (28 children). No differences were detected between cohorts with regard to age, sex, body mass index, weeks from injury to MRI, or weeks from injury to surgery ( P > .15). The primary predictor of an intraoperative ramp lesion was the presence of medial femoral condylar striations, with an adjusted odds ratio of 722.2 (95% CI, 59.5-8768.2; P < .001); the presence of a ramp lesion on MRI had an adjusted odds ratio of 11.1 (95% CI, 2.2-54.8; P = .003). Patients with neither a ramp lesion on MRI nor medial femoral condylar striations had a 2% rate (2/131) of ramp lesion; those with either of the significant risk factors had a 24% rate (14/54). All patients with both risk factors (100%; n = 12) had a ramp lesion noted on intraoperative examination. Conclusion: The concordance of medial femoral condylar chondromalacia, particularly striations, noted during arthroscopy and posteromedial tibial marrow edema on MRI with or without direct evidence of posterior meniscocapsular pathology should increase suspicion for the presence of a ramp lesion in adolescents undergoing ACL reconstruction.

Meniscal Ramp Lesions in Adolescent Patients Undergoing Primary Anterior Cruciate Ligament Reconstruction: Response

“…2,3 It was not our intent to omit your work, merely our negligence in identifying that the crevice sign appears to be the same as our striations in the cartilage related to medial meniscal ramp lesions. 1 However, it is interesting to note that your 2 articles on the subject focus on meniscal instability, which is slightly in contrast (per your definition using anterior displacement) with our findings and ramp lesions. We did not have anterior displacement of the meniscus as a requisite finding of stability.…”

Meniscal Ramp Lesions in Adolescent Patients Undergoing Primary Anterior Cruciate Ligament Reconstruction: Letter to the Editor

“…2,3 It was not our intent to omit your work, merely our negligence in identifying that the crevice sign appears to be the same as our striations in the cartilage related to medial meniscal ramp lesions. 1 However, it is interesting to note that your 2 articles on the subject focus on meniscal instability, which is slightly in contrast (per your definition using anterior displacement) with our findings and ramp lesions. We did not have anterior displacement of the meniscus as a requisite finding of stability.…”

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We are writing in regard to the recently published study by Hollnagel et al 1 The authors propose that a cartilage striation on the femoral condyle correlates with a ramp lesion of the posterior horn of the medial meniscus in adolescent anterior cruciate ligament (ACL)-deficient knees. They recommend using this as a sign to aid arthroscopic identification.

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What’s New in Pediatric Orthopaedics

“…Identifying meniscal ramp lesions before arthroscopy can be challenging because of low magnetic resonance imaging (MRI) sensitivity, but Hollnagel et al found that medial femoral condylar chondromalacia (striations) noted during arthroscopy had an OR of 722.2 (95% confidence interval [CI], 59.5 to 8,768.2; p < 0.001) in predicting that specific tear pattern 39 .…”