MRI appearance of the different meniscal ramp lesion types, with clinical and arthroscopic correlation

Greif, Dylan N.; Baraga, Michael G.; Rizzo, Michael G.; Mohile, Neil; Silva, Flávio Duarte; Fox, Terry; Jose, Jean

doi:10.1007/s00256-020-03381-4

Cited by 76 publications

(117 citation statements)

References 45 publications

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“…Their microscopic study showed that the meniscocapsular and meniscotibial insertions had the same characteristics as those of a ligament (linear fibers composed of type I collagen) and that these 2 tissues were not qualitatively histologically different in terms of the collagen matrix composition. It should be noted that in most of the proposed diagrams (particularly those by DePhillipo et al 8 and Greif et al 9 ), the MTL is shown as inserting on the posterior surface of the meniscus (Figure 6), leaving the posteroinferior edge of the medial meniscus free, while we found it clearly inserted on the posteroinferior edge. Moreover, DePhillipo et al 8 described a common attachment of the MCL and MTL on the posterior horn of the medial meniscus (Figure 6A), while we found 2 separate attachments on the posteroinferior edge (for the MTL) and the posterosuperior edge (for the MCL) (Figure 5).…”

Section: Discussionsupporting

confidence: 50%

“…Diagrams of a sagittal cut from the posteromedial corner of the knee proposed by (A) DePhillipo et al 8 and (B) Greif et al 9 show a purely posterior common insertion of the meniscotibial ligament (MTL) and meniscocapsular ligament, leaving the posteroinferior and posterosuperior edges of the medial meniscus free. PHMM, posterior horn of the medial meniscus.…”

Section: Discussionmentioning

confidence: 99%

“…DePhillipo et al 8 and Greif et al 9 described a common insertion of the MTL and MCL on the posterior surface of the meniscus. Our daily clinical observations from using a posteromedial approach and doing routine repair of ramp lesions support the MTL being located on the posteroinferior edge of the medial meniscus.…”

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What Is the Relationship Between the Distal Semimembranosus Tendon and the Medial Meniscus? A Gross and Microscopic Analysis From the SANTI Study Group

et al. 2020

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Background: Some authors have suggested that the semimembranosus tendon is involved in the pathophysiology of ramp lesions. This led us to conduct a gross and microscopic analysis of the posterior horn of the medial meniscus and the structures inserted on it. Hypothesis: (1) The semimembranosus tendon has a tendinous branch inserting into the posterior horn of the medial meniscus, and (2) the meniscotibial ligament is inserted on the posteroinferior edge of the medial meniscus. Study Design: Descriptive laboratory study. Methods: In total, 14 fresh cadaveric knees were dissected. From each cadaveric donor, a stable anatomic specimen was harvested en bloc, including the medial femoral condyle, medial tibial plateau, whole medial meniscus, cruciate ligaments, joint capsule, and distal insertion of the semimembranosus tendon. The harvested blocks were cut along the sagittal plane to isolate the distal insertion of the semimembranosus tendon on the posterior joint capsule and the posterior horn of the medial meniscus in a single slice. Histological slides were made from these samples and analyzed under a microscope. Results: In all knees, gross examination revealed a direct branch of the semimembranosus and a tendinous capsular branch ending behind the posterior horn of the medial meniscus. This capsular branch protruded over the joint capsule, over the meniscotibial ligament below and the meniscocapsular ligament above, but never ended directly in the meniscal tissue. The capsular branch was 14.3 ± 4.4 mm long (mean ± SD). The direct tendon inserted 11 ± 2.8 mm below the articular surface of the tibial plateau. The meniscotibial ligament inserted on the posteroinferior edge of the medial meniscus, and the meniscocapsular ligament insertion was on its posterosuperior edge. Highly vascularized adipose tissue was found, delimited by the posterior horn of the medial meniscus, meniscotibial ligament, meniscocapsular ligament, and capsular branch of the semimembranosus tendon. Conclusion: In all knees, our study found a capsular branch of the semimembranosus tendon inserted behind the medial meniscus. The meniscotibial ligament was inserted on the posteroinferior edge of the medial meniscus. Histological analysis of this area revealed that this ligament inserted differently from the insertion previously described in the literature. Clinical Relevance: This laboratory study provides insight into the pathophysiology of ramp lesions frequently associated with anterior cruciate ligament injury. To restore anatomy, it is mandatory to reestablish meniscotibial ligament continuity in ramp repairs.

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Section: Discussionsupporting

confidence: 50%

Section: Discussionmentioning

confidence: 99%

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What Is the Relationship Between the Distal Semimembranosus Tendon and the Medial Meniscus? A Gross and Microscopic Analysis From the SANTI Study Group

et al. 2020

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“…In 2016, Thaunat et al 30 described a novel classification system that divided ramp lesions into 5 subtypes: meniscocapsular lesion, partial superior lesion, partial inferior lesion or hidden type, complete tear, and double tear. 14,15 We conducted this retrospective study on prospectively collected data to further our knowledge about ramp lesions and to describe the subtype features of ramp lesions. The objectives of this study were (1) to determine the prevalence of ramp lesion subtypes in a large series of patients undergoing arthroscopic ACL reconstruction (ACLR) and (2) to describe the characteristics of ramp lesion subtypes based on imaging and diagnostic arthroscopy.…”

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confidence: 99%

Ramp Lesion Subtypes: Prevalence, Imaging, and Arthroscopic Findings in 2156 Anterior Cruciate Ligament Reconstructions

et al. 2021

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Background: Ramp lesions are defined as a particular type of injury within the posterior horn of the medial meniscus and its meniscocapsular attachments. Five subtypes have been described: type 1, meniscocapsular lesion; type 2, partial superior lesion; type 3, partial inferior lesion or hidden type; type 4, complete tear in the red zone; and type 5, complete double tear. Purpose: (1) To determine the prevalence of different subtypes of ramp lesions in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR). (2) To describe the characteristics of ramp lesions based on imaging and diagnostic arthroscopy. Study Design: Cross-sectional study; Level of evidence, 3. Methods: All patients who underwent arthroscopic ACLRs between November 2015 and November 2018 by 2 senior surgeons at 1 institution were evaluated retrospectively (1) to describe the subtypes of ramp lesions diagnosed intraoperatively using transnotch arthroscopic exploration of the posteromedial compartment and (2) to look for any factors significantly associated with these subtypes. The following parameters were studied: demographics; history and clinical findings including time between injury and surgery, side-to-side laxity, and pivot shift; lesions missed on magnetic resonance imaging (MRI) scans and medial proximal tibial bone contusion visible on MRI scans; and arthroscopic confirmation of ramp lesion (ie, prevalence), associated lateral meniscal tear, or medial chondral tear. Results: Out of 2156 primary or revision arthroscopic reconstructions, 334 ramp lesions were confirmed, giving a prevalence of 15.5%. The subtype distribution was as follows: type 1, 47.9%; type 2, 4.8%; type 3, 11.4%; type 4, 28.7%; type 5, 7.2%. Multivariate analysis showed that gross pivot shift was significantly associated with complete ramp tears (odds ratio, 4.8; 95% CI, 1.7-17.2). Hidden lesions (type 3, inferior partial tear in the red zone) were the most likely to be missed on preoperative MRI (45.9%). Conclusion: In a population undergoing ACLR, the prevalence of ramp lesions was 15.5%. Among the subtypes of ramp lesion, the most common was a meniscocapsular junction tear (type 1). Partial inferior tears (type 3) were the most likely to be missed on preoperative MRI scans. Gross pivot shift was significantly associated with complete ramp tears (types 1, 4, and 5).

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“…Sonnery-Cottet et al [8] and Thaunat et al [13] classified the medial meniscocapsular tears into the following five in their MRI review study proposed the Thaunat classification [18]. In a recent study the arthroscopy classification for meniscal ramp lesions stability adapted for MRI has shown good reproducibility when applied by trained musculoskeletal radiologists [19].…”

Section: Discussionmentioning

confidence: 99%

Meniscal ramp lesions: diagnostic performance of MRI with arthroscopy as reference standard

et al. 2021

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Background The posteromedial meniscal region is gaining interest among orthopedic surgeons, as lesions of this area has been reported to be significantly associated with anterior cruciate ligament tears. The current imaging literature is unclear. Purpose To evaluate the diagnostic performance of MR in the detection of meniscal ramp lesions having arthroscopy as reference standard. Materials and methods We retrospectively included 56 patients (mean age of 25 ± 7 years; 14 females) from January to November 2017 with a arthroscopically proved ACL tear and posterior meniscocapsular separation. On preoperative MRI, two radiologists with 13 and 2 years’ experience in musculoskeletal imaging assessed the presence/absence of ramp lesion, meniscotibial ligament lesion, peripheral meniscal lesion, or their combination, bone bruise. Having arthroscopy as reference standard, diagnostic performance of MRI in the evaluation of ramp area lesions was calculated. Cohen’s kappa (k) and Fisher's Exact Test statistics were used. Results Agreement between radiologists ranged from κ = 0.784 (meniscotibial ligament lesions) to κ = 0.918 red–red meniscal lesion. Sensitivities were 97.4% for ramp lesions, 95.8% for meniscotibial ligament lesion, 94.4% for peripheral meniscal lesions; specificities were 88.9%, 81.3%, and 97.4%, respectively; accuracies were 94.6%, 87.5%, and 96.4%, respectively. Agreement between MR and arthroscopy was almost perfect in identification of ramp lesions (κ = 0.871) and red–red zone meniscal lesions (κ = 0.908). The agreement between the two methods was substantial (κ = 0.751) for meniscotibial lesion. No significant association between tibial plateau bone bruise and the different type of lesions was found (κ ≥ 0.004 and p ≥ 0.08). Conclusion MR has high diagnostic performance in meniscal ramp area lesion assessment, with substantial to almost perfect inter-reader agreement.

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MRI appearance of the different meniscal ramp lesion types, with clinical and arthroscopic correlation

Cited by 76 publications

References 45 publications

What Is the Relationship Between the Distal Semimembranosus Tendon and the Medial Meniscus? A Gross and Microscopic Analysis From the SANTI Study Group

What Is the Relationship Between the Distal Semimembranosus Tendon and the Medial Meniscus? A Gross and Microscopic Analysis From the SANTI Study Group

Ramp Lesion Subtypes: Prevalence, Imaging, and Arthroscopic Findings in 2156 Anterior Cruciate Ligament Reconstructions

Meniscal ramp lesions: diagnostic performance of MRI with arthroscopy as reference standard

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