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

Abstract

Background: Anterior cruciate ligament (ACL) tears represent 13% of knee injuries in children. Medial meniscal tears are commonly associated with ACL ruptures. Ramp lesions correspond to posterior meniscocapsular tears of the medial meniscus. Depending on the study, the prevalence of ramp lesions is inconsistent. Purpose: To describe the prevalence of ramp lesions in children and adolescents and to investigate the sensitivity of magnetic resonance imaging (MRI) for diagnosing such lesions. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: We analyzed videos from arthroscopic ACL reconstruction (ACLR) in children. During these procedures, we systematically looked for potential ramp lesions. To do so, an arthroscope was passed through the intercondylar notch to visualize the posteromedial compartment. A needle was introduced at the site of a posteromedial portal to unfold the meniscocapsular junction to reveal any hidden meniscal tear. Surgical procedures were performed by 2 senior surgeons. Videos were blindly analyzed by a third surgeon. Preoperative MRIs were screened by 2 blinded, independent senior radiologists to look specifically for ramp lesions. Results: Videos of 50 consecutive arthroscopic ACLRs concerning 32 boys and 18 girls were analyzed. Mean age at surgery was 14.2 years (range, 8.5-17.6 years). A total of 14 ramp lesions (28%) in 8 boys and 6 girls were identified. In addition, there were 22 tears of the meniscal body in 20 patients (40%). Arthroscopic and MRI findings did not correlate. Among 14 arthroscopically diagnosed ramp lesions, only 8 were detected on the MRI. Conversely, 12 patients had a ramp lesion detected on the MRI, which could not be confirmed intraoperatively. The sensitivity of MRI was 57% and the positive predictive value was 40%. Conclusion: A meniscal ramp lesion was present in 14 of 50 children (28%) undergoing ACLR. MRI has a low sensitivity for diagnosis of ramp lesions in children. Careful exploration of the posteromedial compartment is strongly recommended. Overlooking such lesions during ACLR may contribute to ongoing instability and higher re-rupture rates in these young patients.

Combining Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Procedures in Skeletally Immature Patients Is Safe and Associated With a Low Failure Rate

“…This result was verified more recently by Sonnery-Cottet et al. 70 and Bernardini et al., 71 who found respectively a prevalence of 23.9% and 28% of those lesions, very similar to our series (20%). This outcome finally echoes the overall prevalence in the adult population that was evaluated at 23.9% in the largest series evaluating incidence of ramp lesions 72 and 21.9% in a systematic review.…”

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

“…15 To date, there have been 2 additional studies to our knowledge that have evaluated the ability of MRI to detect a ramp lesion in the adolescent patient population. Bernardini et al 3 performed a prospective consecutive case series of 50 patients undergoing primary ACL reconstruction. A ramp lesion was detected in 28% of patients at the time of surgery, and MRI had a sensitivity of 57%.…”

Utility of axial magnetic resonance images for detecting meniscal ramp lesions associated with anterior cruciate ligament injuries

“… 2 However, it is difficult to detect RLs before surgery using conventional sagittal magnetic resonance imaging (MRI) and arthroscopy from the anteromedial and lateral portals, used during ACL reconstruction. 3 The sagittal images of a longitudinal tear around the medial posterior horn are tangent due to the curvature of the meniscus, and the diagnostic rate is reportedly low. However, with axial imaging, the tear is sliced vertically.…”