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Boonrod A, Jaruwanneechai K, Saengpetch N, Sumanont S, Prachaney P. Biomechanical impact of meniscal ramp lesions on knee joint contact characteristics in ACL deficient knees: a cadaveric analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2735-2742. [PMID: 38761201 DOI: 10.1007/s00590-024-03995-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 05/08/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE To evaluate the changes in contact characteristics of the tibiofemoral joint resulting from a meniscal ramp lesion in the medial meniscus. METHODS Twelve cadaveric knees (six matched pairs) were subjected to a 600 N axial load using a custom testing jig, which allowed for knee positioning at 0°, 45°, and 90° of flexion without other constraints. The knees were randomly assigned to either a ramp lesion group (n = 6) or a posterior root lesion group (n = 6). Four testing conditions were examined: (1) intact, (2) isolated ramp lesion, (3) isolated posterior root tear of the medial meniscus, and (4) combined ramp lesion and posterior root tear of the medial meniscus. Contact characteristics were evaluated using a flexible pressure sensor, the I-Scan System. RESULTS Peak contact pressure in isolated ramp lesions (4.15 ± 0.98 MPa, P = 0.206) showed non-significant increases compared to the intact condition (3.86 ± 1.32 MPa). Peak contact pressure in isolated posterior root tears (4.58 ± 1.70 MPa, P = 0.040) and, combined ramp and posterior root lesions (4.67 ± 1.47 MPa, P = 0.003) were significantly higher than that in the intact condition. The knee flexion position significantly affected the medial tibiofemoral joint's contact area, contact pressure, and peak contact pressure (P < 0.001 for all). CONCLUSION Isolated ramp lesions did not significantly impact force transmission, contact area, or contact pressure. In contrast, isolated root lesions and combined ramp and posterior root tears of the medial meniscus significantly intensified the changes in contact characteristics in the medial tibiofemoral joint compared to the intact condition. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Artit Boonrod
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, 123 Mittraphap Road, Muang District, Khon Kaen, 40002, Thailand.
| | - Khananut Jaruwanneechai
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, 123 Mittraphap Road, Muang District, Khon Kaen, 40002, Thailand
| | - Nadhaporn Saengpetch
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Sermsak Sumanont
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, 123 Mittraphap Road, Muang District, Khon Kaen, 40002, Thailand
| | - Parichat Prachaney
- Department of Anatomy, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
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Allende F, Berreta RS, Allahabadi S, Mowers C, Russo R, Palco M, Simonetta R, Familiari F, Chahla J. Meniscal ramp lesion classification systems: A systematic review. Knee Surg Sports Traumatol Arthrosc 2024; 32:1710-1724. [PMID: 38666656 DOI: 10.1002/ksa.12188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 03/25/2024] [Accepted: 04/02/2024] [Indexed: 07/21/2024]
Abstract
PURPOSE To describe the proposed classification systems for meniscal ramp lesions (RLs) in the literature and evaluate their accuracy and reliability. METHODS A systematic search was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines utilising PubMed, Embase and Cochrane Library databases. Level I-IV studies referencing RLs along with either an arthroscopic- or magnetic resonance imaging (MRI)-based classification system used to describe RL subtypes were included. RESULTS In total, 21 clinical studies were included. Twenty-seven (79%) of the included studies were published in 2020 or later. There were four main classification systems proposed within the literature (two arthroscopic-, two MRI-based), describing tear patterns, mediolateral extent, associated ligament disruption and stability of the lesion. The first classification was proposed in 2015 by Thaunat et al. and is referenced in 22 (64.7%) of the included studies. The application of the Thaunat et al. criteria to MRI showed variable sensitivity (31.70%-93.8%) and interobserver agreement (k = 0.55-0.80). The Greif et al. modification to the Thaunat et al. system was referenced in 32.4% of the included studies and had a substantial interobserver agreement (k = 0.8). Stability to probing and specific tear location were each used to classify RLs in 28.6% and 23.8% of the included clinical studies, respectively. CONCLUSION Although there has been a recent increase in the recognition and treatment of meniscal RLs, there is limited consistency in descriptive classifications used for this pathology. Current RL classification systems based on preoperative MRI have variable reliability, and arthroscopic examination remains the gold standard for diagnosis and classification. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Felicitas Allende
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, USA
| | - Rodrigo Saad Berreta
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, USA
| | - Sachin Allahabadi
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, USA
| | - Colton Mowers
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, USA
| | - Raffaella Russo
- Department of Orthopedics, Magna Graecia University of Catanza, Catanzaro, Italy
| | - Michelangelo Palco
- Department of Orthopedics, Magna Graecia University of Catanza, Catanzaro, Italy
| | - Roberto Simonetta
- Department of Orthopedics, Magna Graecia University of Catanza, Catanzaro, Italy
| | - Filippo Familiari
- Department of Orthopedics, Magna Graecia University of Catanza, Catanzaro, Italy
| | - Jorge Chahla
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, USA
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Moteshakereh SM, Zarei H, Nosratpour M, Zaker Moshfegh M, Shirvani P, Mirahmadi A, Mahdavi M, Minaei Noshahr R, Farrokhi M, Kazemi SM. Evaluating the Diagnostic Performance of MRI for Identification of Meniscal Ramp Lesions in ACL-Deficient Knees: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2024; 106:1117-1127. [PMID: 38595146 DOI: 10.2106/jbjs.23.00501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND Despite vigorous efforts to delineate the efficacy of magnetic resonance imaging (MRI) for the diagnosis of meniscal ramp lesions, there is still a great deal of uncertainty regarding its diagnostic performance. Therefore, we conducted a systematic review and meta-analysis to investigate the diagnostic performance of MRI for detecting ramp lesions in anterior cruciate ligament (ACL)-deficient knees. METHODS We performed a systematic search of MEDLINE via PubMed, Scopus, Web of Science, and Embase and included all articles, published before October 20, 2022, comparing the accuracy of MRI with that of arthroscopy as the gold standard for diagnosis of ramp lesions. We performed statistical analysis using Stata and Meta-DiSc software. Quality assessment of the included studies was performed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool. RESULTS This meta-analysis evaluated 21 diagnostic performance comparisons from 19 original research articles (2,149 patients). The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the summary receiver operating characteristic (SROC) curve for diagnosing a ramp lesion were 0.70 (95% confidence interval [Cl], 0.66 to 0.73), 0.88 (95% Cl, 0.86 to 0.89), 6.49 (95% Cl, 4.12 to 10.24), 0.36 (95% Cl, 0.28 to 0.46), 24.33 (95% Cl, 12.81 to 46.19), and 0.88, respectively. Meta-regression using different variables yielded the same results. CONCLUSIONS MRI exhibited a DOR of 24.33 and moderate sensitivity, specificity, and accuracy for diagnosing ramp lesions in ACL-deficient knees. However, arthroscopy using a standard anterolateral portal with intercondylar viewing is recommended to confirm a diagnosis of a ramp lesion. LEVEL OF EVIDENCE Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Seyed Mohammadmisagh Moteshakereh
- Bone, Joint and Related Tissue Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hooshmand Zarei
- Bone, Joint and Related Tissue Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Miad Nosratpour
- Bone, Joint and Related Tissue Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mana Zaker Moshfegh
- Bone, Joint and Related Tissue Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Proushat Shirvani
- School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Alireza Mirahmadi
- Bone, Joint and Related Tissue Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahyar Mahdavi
- Bone, Joint and Related Tissue Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Minaei Noshahr
- Bone, Joint and Related Tissue Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Farrokhi
- Student Research Committee, Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyyed Morteza Kazemi
- Bone, Joint and Related Tissue Research Center, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Tang Z, Luo Y, Liu D, Zhou S, Xu Z, Zhu T, Yang H. Investigation of the anatomic risk factors in acute anterior cruciate ligament ruptures to develop ramp lesions of the medial meniscus by quantitative MRI. Insights Imaging 2024; 15:133. [PMID: 38825662 PMCID: PMC11144682 DOI: 10.1186/s13244-024-01685-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 04/02/2024] [Indexed: 06/04/2024] Open
Abstract
OBJECTIVE To investigate the anatomic risk factors of knee in patients with acute non-contact anterior cruciate ligament (aACL) ruptures to develop ramp lesions. METHODS A total of 202 subjects were retrospectively divided into three groups: (1) aACL ruptures combined with ramp lesions group (n = 76); (2) isolated ACL ruptures group (n = 56) and (3) normal controls group (n = 70). Quantitative morphological parameters on MRI were measured including: diameter of medial femoral condyle (MFC), anterior-posterior length and depth of medial tibial plateau (MTP AP length and depth), lateral posterior tibial slope (LPTS) and medial posterior tibial slope (MTPS), asymmetry of LPTS and MPTS (LMPTS), lateral meniscal slope (LMS), and medial meniscal slope (MMS). RESULTS The MTP AP length, MTP AP length/MFC diameter ratio, MTP depth, LPTS and the asymmetry of LMPTS showed significant differences among the three groups (p < 0.001). The risk factors associated with the ramp lesions including a longer MTP AP length (OR 1.17, 95% CI 1.00-1.44, p = 0.044), increased MTP depth (OR 1.91, 95% CI 1.22-3.00, p = 0.005) and lager ratio (OR 1.11, 95% CI 1.01-1.22, p = 0.036). The highest AUC was the MTP AP length/MFC diameter ratio (0.74; 95% CI, 0.66-0.82). The combination model increased higher accuracy (0.80; 95% CI, 0.72-0.88). CONCLUSION Several bony anatomic characteristics of the knee, especially the morphology of medial tibia plateau, are additional risk factors for aACL ruptures to develop ramp lesions. CRITICAL RELEVANCE STATEMENT Predictive anatomic risk factors of the knee for patients with acute non-contact anterior cruciate ligament (aACL) ruptures to develop ramp lesions, especially the morphology of medial tibia plateau, are detectable by MRI. KEY POINTS Ramp lesion development can complicate aACL ruptures and requires specific treatment. Longer AP length and increased MTP depth are risk factors for concurrent ramp lesions. Identification of ramp lesions allows for the most appropriate treatment.
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Affiliation(s)
- Ziyi Tang
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yuxi Luo
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Dan Liu
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Suying Zhou
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zhangyan Xu
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Tongxin Zhu
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - HaiTao Yang
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Boksh K, Martins A, Elbashir M, Boutefnouchet T, Aujla R. Modified Mason-Allen vs Two Simple Stitch Fixation for Medial Meniscus Posterior Root Tears: A Systematic Review and Meta-analysis. Am J Sports Med 2024; 52:1877-1887. [PMID: 38258492 DOI: 10.1177/03635465231190650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Various suture configurations are available for medial meniscus posterior root tear (MMPRT) repair. The modified Mason-Allen (MMA) technique has been proposed as a refixation technique for MMPRT instead of the conventional 2 simple stitches (TSS). This is in view of its superior biomechanical characteristics. PURPOSE To perform a systematic review and meta-analysis to compare MMA and TSS configuration techniques for MMPRT repair and identify any differences between the 2 techniques in terms of clinical outcomes, medial meniscal extrusion (MME), and postoperative healing. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase databases were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("meniscus" OR "meniscal injuries") AND ("Mason-Allen" OR "simple stitch" OR "suture techniques"). Data pertaining to all patient-reported outcome measures, postoperative complications, MME, postoperative healing, cartilage degeneration, and progression of knee osteoarthritis were extracted from each study. The pooled outcome data were analyzed using random- and fixed-effects models. RESULTS After abstract and full-text screening, 6 clinical studies were included. In total, there were 291 patients; 160 underwent MMA fixation, and 131 underwent the TSS technique. The majority of studies had similar surgical techniques regarding repair technique, suture material, tibial fixation, and number and position of tibial tunnels. There were no differences between the groups in terms of patient-reported outcome measures at 14.2 months. Both techniques were also similar in the degree of postoperative MME and meniscal healing. CONCLUSION Both suture configurations were equivalent in terms of clinical outcomes, the extent of meniscal extrusion, and postoperative healing. The TSS technique may offer advantages in terms of faster learning curve and shorter operative time. However, randomized controlled trials with large sample sizes, longer follow-up and assessment of chondral degeneration, and presence of knee osteoarthritis are required to assess whether a true difference exists, as the majority of included studies were limited by their retrospective design.
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Affiliation(s)
- Khalis Boksh
- Leicester Knee Unit, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Andre Martins
- Leicester Knee Unit, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Mohamed Elbashir
- Leicester Knee Unit, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Tarek Boutefnouchet
- Department of Mechanical Engineering, University of Birmingham, Birmingham, United Kingdom
| | - Randeep Aujla
- Leicester Knee Unit, Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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Nonaka S, Hatayama K, Kakiage H, Terauchi M, Hashimoto S, Chikuda H. Posterior Displacement of Meniscal Ramp Lesion Is Observed on Flexed Knee Magnetic Resonance Imaging of Anterior Cruciate Ligament-Deficient Knees. Arthroscopy 2024; 40:879-886. [PMID: 37543148 DOI: 10.1016/j.arthro.2023.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/03/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE To confirm whether posterior displacement of the detached meniscocapsular structure in ramp lesions could be observed on magnetic resonance imaging (MRI) in the flexed knee position and to clarify whether this displacement on MRI is related to greater anterior knee laxity. METHODS This retrospective comparative trial study included 50 patients with anterior cruciate ligament injuries in whom attendant ramp lesions were observed on preoperative MRI. All patients underwent 3-T MRI at 120° of knee flexion preoperatively. The gap distance of the ramp lesion on sagittal slices was measured, and a distance greater than 1 mm was classified as gap positive. Additionally, joint effusion in the posteromedial recess was quantitatively evaluated by measuring the surface area of joint fluid. Prior to surgery, the side-to-side difference in anterior tibial translation (ATT) on stress radiographs at 20° of knee flexion was measured to evaluate anterior knee laxity. During anterior cruciate ligament reconstruction, the length of the ramp lesion was measured by a scale from the posteromedial portal. RESULTS Of the 50 knees, 29 had ramp lesion gaps greater than 1 mm on MRI at knee flexion. The gap-positive group had a significantly greater side-to-side difference in ATT (9.6 ± 3.6 mm vs 5.0 ± 2.7 mm, P < .001) and significantly larger ramp lesion length (15.7 ± 4.9 mm vs 11.7 ± 3.9 mm, P = .002) than the gap-negative group. The gap-positive group also had a significantly greater amount of joint effusion than the gap-negative group (P < .001). CONCLUSIONS Posterior displacement of the detached meniscocapsular structure in ramp lesions can be observed on MRI at knee flexion and is related to greater anterior knee laxity, lesion size, and joint effusion. LEVEL OF EVIDENCE Level III, retrospective comparative trial.
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Affiliation(s)
- Satoshi Nonaka
- Department of Orthopedic Surgery, Japan Community Healthcare Organization Gunma Central Hospital, Maebashi, Japan.
| | - Kazuhisa Hatayama
- Department of Orthopedic Surgery, Japan Community Healthcare Organization Gunma Central Hospital, Maebashi, Japan
| | - Hibiki Kakiage
- Department of Orthopedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masanori Terauchi
- Department of Orthopedic Surgery, Japan Community Healthcare Organization Gunma Central Hospital, Maebashi, Japan
| | - Shogo Hashimoto
- Department of Orthopedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hirotaka Chikuda
- Department of Orthopedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Japan
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Kato J, Fukushima H, Hanaki S, Kawanishi Y, Kobayashi M, Ota K, Yoshida M, Takenaga T, Kawaguchi Y, Kuroyanagi G, Sakai H, Murakami H, Nozaki M. Efficacy of all-inside devices in reducing gap and step-off in knee extension for ramp lesion repair: A cadaveric study. Knee Surg Sports Traumatol Arthrosc 2024; 32:257-264. [PMID: 38226718 DOI: 10.1002/ksa.12034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 12/08/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE The aim of this study is to assess the dynamics of the tear site of meniscal ramp lesions, particularly considering knee flexion angles, and validate anchor fixation using an all-inside device. METHODS Eight Thiel-embalmed paired cadaveric knees with their whole bodies were used in this study. The ramp lesions were created arthroscopically, and ramp lesion dynamics were evaluated by gradually extending the knee from 90° of knee flexion. Changes in the gap and step-off (0: no step-off; 1: cross-sectional overlap exists; and 2: tibial articular surface exposed) were evaluated at 90°, 60°, 30°, and 10° of knee flexion. After dynamic evaluation, all-inside repairs of the ramp lesions using all-inside devices were conducted. Dissection was performed to confirm the position of anchor fixation. RESULTS As the knee was extended, the gap significantly decreased at all knee flexion angles. Similarly, the step-off grade decreased as the knee was extended, and the step-off completely disappeared in all cases when the knee was extended from 30° to 10°. The average knee flexion angle at which the gap and step-off completely disappeared was 22.5°. After suturing the ramp lesion, arthroscopic evaluation showed that the gap had disappeared and the step-off had been repaired in all cases. Anchor fixation locations were not found within the joint but were fixed to the semimembranosus tendon or its surrounding articular capsule. Overall, 31% (5/16) anchors were fixed to the attachment site of the semimembranosus tendon, whereas the remaining were fixed to the articular capsule, located peripherally to the semimembranosus tendon. CONCLUSION Suturing with an all-inside device for ramp lesions is a good option, and the repair in knee extension was found to be reasonable, considering the dynamics of ramp lesions in this study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jiro Kato
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Hiroaki Fukushima
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Shunta Hanaki
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Yusuke Kawanishi
- Department of Orthopedic Surgery, Ogaki Municipal Hospital, Ogaki City, Gifu, Japan
| | - Makoto Kobayashi
- Department of Orthopedic Surgery, Nagoya City University Midori Municipal Hospital, Nagoya City, Aichi, Japan
| | - Kyohei Ota
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Masato Yoshida
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Tetsuya Takenaga
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Yohei Kawaguchi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Gen Kuroyanagi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Hiroaki Sakai
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Hideki Murakami
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Masahiro Nozaki
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
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Bae BS, Yoo S, Lee SH. Ramp lesion in anterior cruciate ligament injury: a review of the anatomy, biomechanics, epidemiology, and diagnosis. Knee Surg Relat Res 2023; 35:23. [PMID: 37626385 PMCID: PMC10464050 DOI: 10.1186/s43019-023-00197-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
Ramp lesions, commonly observed in patients with anterior cruciate ligament (ACL) injuries, have been previously defined as longitudinal tears around the meniscocapsular junction. However, the definitions and interpretations of ramp lesions have varied, emphasizing the need to confirm their presence before surgery and the importance of direct visualization using arthroscopy. Recent histological studies have reported new findings on ramp lesions, shedding light on their attachment mechanisms. The anatomical structures around the ramp lesion, such as the posterior horn of medial meniscus (PHMM), semimembranosus (SM), posteromedial (PM) capsule, and meniscotibial ligament (MTL), were assessed regarding how these structures could be attached to each other. The studies of ramp lesions have also contributed to the progression of biomechanical studies explaining the cause and effects of ramp lesions. Ramp lesion has been proven to stabilize the anteroposterior (AP) instability of ACL. In addition, various laboratory studies have demonstrated the relationship between rotational instability of the knee joint and ramp lesions. The analysis of risk factors of ramp lesion helped to understand the injury mechanism of the lesion. Many authors have evaluated the prevalence of ramp lesions in patients with ACL injuries. The development of arthroscopy techniques has influenced the outcomes of ACL reconstruction with the easy detection of ramp lesions. This review article aims to analyze the past findings and recent advancements in anatomical, biomechanical, and epidemiological studies of ramp lesions in patients who underwent ACL reconstruction, and provide various perspectives ramp lesions in patients with ACL reconstruction.
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Affiliation(s)
- Bo Seung Bae
- Department of Orthopedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sunin Yoo
- Department of Orthopedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, 134-727, Seoul, Republic of Korea
| | - Sang Hak Lee
- Department of Orthopedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, 134-727, Seoul, Republic of Korea.
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Kintaka K, Furumatsu T, Okazaki Y, Masuda S, Hiranaka T, Kodama Y, Kamatsuki Y, Ozaki T. Comparison of two simple stitches and modified Mason-Allen suture for medial meniscus posterior root tear based on the progression of meniscal posterior extrusion: A retrospective cohort study. J Orthop Surg (Hong Kong) 2022; 29:23094990211049569. [PMID: 34775855 DOI: 10.1177/23094990211049569] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: Medial meniscus (MM) posterior root (PR) tear leads to severe MM posterior extrusion (PE), resulting in rapid knee cartilage degeneration. MMPR repairs are recommended to reduce MMPE, especially during knee flexion. However, the difference in MMPE between different repair techniques remains unknown. This study aimed to investigate preoperative and postoperative MMPE following several pullout repair techniques. We hypothesized that a technique using two simple stitches (TSS) would be more useful than FasT-Fix-dependent modified Mason-Allen suture (F-MMA) to prevent the progression of MMPE in knee extension. Methods: This retrospective study included 35 patients who underwent MMPR repair. To compare MMPE, patients were divided into two groups according to the use of F-MMA while grasping the posterior capsule and TSS without grasping it. Open magnetic resonance imaging was performed at 10° and 90° knee flexion preoperatively, and at 3 and 12 months postoperatively, and the MMPE of both groups was evaluated. Results: A significant difference was observed between preoperative and 3-month postoperative MMPE at 90° knee flexion in both groups (p < .01). A significant difference was observed in 3- and 12-month postoperative MMPE at 10° knee flexion between both groups (p = .04/.02), whereas no significant difference in the preoperative MMPE at 10° knee flexion was observed between them (p = .45). Conclusions: Both repairs were found to be useful to reduce MMPE in knee flexion. Further, F-MMA repair increased MMPE in knee extension, unlike TSS repair. These findings suggest that TSS might have more advantages for load distribution when standing or walking.
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Affiliation(s)
- Keisuke Kintaka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 92057Okayama University, Okayama, Japan
| | - Takayuki Furumatsu
- Department of Orthopaedic Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 92057Okayama University, Okayama, Japan
| | - Yuki Okazaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 92057Okayama University, Okayama, Japan
| | - Shin Masuda
- Department of Orthopaedic Surgery, 38335Chikamori Hospital, Kochi, Japan
| | - Takaaki Hiranaka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 92057Okayama University, Okayama, Japan
| | - Yuya Kodama
- Department of Orthopaedic Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yusuke Kamatsuki
- Department of Orthopaedic Surgery, Kochi Health Science Center, Kochi, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 92057Okayama University, Okayama, Japan
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10
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Laurens M, Cavaignac E, Fayolle H, Sylvie R, Lapègue F, Sans N, Faruch M. The accuracy of MRI for the diagnosis of ramp lesions. Skeletal Radiol 2022; 51:525-533. [PMID: 34216246 DOI: 10.1007/s00256-021-03858-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the diagnostic accuracy of MRI in diagnosing ramp lesions in patients with an acute lesion of the anterior cruciate ligament (ACL). MATERIALS AND METHODS All consecutive patients over 15 years of age who underwent surgical repair of the ACL at a single hospital between January and May 2019, with MRI data available, were included in this retrospective study, except patients who had previous knee surgery. The gold standard was arthroscopic evaluation. Two trained radiologists with 5 and 14 years of experience did a blinded review of the MRIs. The following pathological signs were studied: complete fluid filling between the capsule and the posterior horn of the medial meniscus, irregular appearance of the posterior wall of the medial meniscus, oedema of the capsule, fluid hyperintensity in contact with the medial meniscus and anterior subluxation of the medial meniscus. Logistic regressions in univariate then multivariate analysis were carried out and measures of diagnostic accuracy and interobserver agreement were calculated with R software (version 3.6). RESULTS Fifty-seven patients were included. Twelve had a ramp lesion diagnosed by arthroscopy (21%). Only complete fluid hyperintensity between the posterior horn of the medial meniscus and the capsule was significantly associated with ramp lesions (P value < 0.01). The diagnostic accuracy of this specific sign was moderate, with a specificity of 84%, sensitivity of 75%, PPV of 56%, NPV of 93% and a good level of inter-observer agreement (k = 0.79). CONCLUSION The complete fluid filling is the only significant pathological MRI sign for ramp lesions, with moderate accuracy.
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Affiliation(s)
- M Laurens
- Service de Radiologie, CHU Toulouse-Purpan, Place du Docteur Baylac, 31059, Toulouse Cedex 9, France.
| | - E Cavaignac
- Service d'Orthopédie, CHU Toulouse-Purpan, Place du Docteur Baylac, 31059, Toulouse Cedex 9, France.,I2R, Institut de Recherche Riquet, Toulouse, France
| | - H Fayolle
- Service de Médecine Nucléaire, CHU Toulouse-Purpan, Place du Docteur Baylac, 31059, Toulouse Cedex 9, France
| | - R Sylvie
- Service d'Orthopédie, CHU Toulouse-Purpan, Place du Docteur Baylac, 31059, Toulouse Cedex 9, France
| | - F Lapègue
- Service de Radiologie, CHU Toulouse-Purpan, Place du Docteur Baylac, 31059, Toulouse Cedex 9, France
| | - N Sans
- Service de Radiologie, CHU Toulouse-Purpan, Place du Docteur Baylac, 31059, Toulouse Cedex 9, France
| | - M Faruch
- Service de Radiologie, CHU Toulouse-Purpan, Place du Docteur Baylac, 31059, Toulouse Cedex 9, France.
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11
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Taneja AK, Miranda FC, Rosemberg LA, Santos DCB. Meniscal ramp lesions: an illustrated review. Insights Imaging 2021; 12:134. [PMID: 34564751 PMCID: PMC8464645 DOI: 10.1186/s13244-021-01080-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/14/2021] [Indexed: 12/02/2022] Open
Abstract
The purpose of this review is to describe the anatomy and lesions affecting the peripheral portion of posterior horn of medial menisci (ramp lesions), along with illustrations and MRI cases. We will correlate imaging features with arthroscopic classification of ramp lesions. Also, postoperative and chronic changes related to meniscocapsular tears will be presented, as well as biomechanical consequences and treatment approach.
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Affiliation(s)
- Atul K Taneja
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil. .,Departamento de Imagem - Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, Morumbi, São Paulo, SP, CEP 05652-900, Brazil.
| | - Frederico C Miranda
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Laercio A Rosemberg
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Durval C B Santos
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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12
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Nakase J, Asai K, Yoshimizu R, Kimura M, Tsuchiya H. How to Detect Meniscal Ramp Lesions Using Ultrasound. Arthrosc Tech 2021; 10:e1539-e1542. [PMID: 34258202 PMCID: PMC8252820 DOI: 10.1016/j.eats.2021.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/13/2021] [Indexed: 02/03/2023] Open
Abstract
The clinical importance of meniscal ramp lesions in patients with anterior cruciate ligament tears has emerged. However, the diagnostic accuracy of magnetic resonance imaging for detecting meniscal ramp lesions is low. The advantage of ultrasonography is that it can be performed in any position and is a real-time imaging modality. The goal of this Technical Note is to describe in detail the ultrasound technique that we use to detect meniscal ramp lesions in patients with anterior cruciate ligament tears. The semimembranosus muscle is a reliable landmark for this technique. The examination position is prone, with the knee joint flexed to 70°. The most important part of this technique is to instruct the patient to perform isometric contractions in knee flexion with the support of an assistant. The presence or absence of a meniscal ramp lesion can be diagnosed preoperatively by setting the probe above the semimembranosus tendon.
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Affiliation(s)
- Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Kazuki Asai
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Rikuto Yoshimizu
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Mitsuhiro Kimura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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13
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Abstract
Ramp lesion of the medial meniscus used to be completely disregarded in the past. Ramp lesion has been now put under the spotlight by orthopaedic and sport medicine surgeons and requires attention. It is closely associated with anterior cruciate ligament injury. Major risk factors include chronic laxity, lateral meniscal lesion, anterior cruciate ligament reconstruction revision, anterolateral ligament tear concomitant with anterior cruciate ligament injury, time from injury, pre-operative side-to-side laxity > 6 mm, age < 30 years old, male sex, etc. Radiologists attempt to create diagnostic criteria for ramp lesion using magnetic resonance imaging. However, the only definite method to diagnose ramp lesion is still arthroscopy. Various techniques exist, among which posteromedial approach is the most highly recommended. Various treatment options are available. The success rate of ramp repair is very high. Major complications are uncommon.
Cite this article: EFORT Open Rev 2021;6:372-379. DOI: 10.1302/2058-5241.6.200126
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Affiliation(s)
- Yusuf Omar Qalib
- Department of Orthopaedics, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China.,These authors contributed equally to this work
| | - Yicun Tang
- Department of Orthopaedics, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China.,These authors contributed equally to this work
| | - Dawei Wang
- Department of Orthopaedics, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Baizhou Xing
- Department of Orthopaedics, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Xingming Xu
- Department of Orthopaedics, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Huading Lu
- Department of Orthopaedics, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, Guangdong, China
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14
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Okazaki Y, Furumatsu T, Hiranaka T, Kintaka K, Kodama Y, Kamatsuki Y, Ozaki T. Steep posterior slope of the medial tibial plateau is associated with ramp lesions of the medial meniscus and a concomitant anterior cruciate ligament injury. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2021; 24:23-28. [PMID: 33680859 PMCID: PMC7896126 DOI: 10.1016/j.asmart.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/13/2021] [Accepted: 01/27/2021] [Indexed: 11/28/2022]
Abstract
Background Medial meniscus (MM) tears are associated with both acute and chronic anterior cruciate ligament (ACL) insufficiency and can lead to degenerative changes in the knee. ACL reconstruction (ACLR) combined with the meniscal repair was reported to result in decreased anterior knee joint laxity with evidence of improved patient-reported outcomes in the long term. However, a subtle tear of the MM posterior segment, also known as a ramp lesion, is difficult to detect on conventional magnetic resonance imaging (MRI) and is frequently missed in ACL-deficient knees. However, there are few studies about the associations between bone geometry and ramp lesion of the MM. This study aimed to compare sagittal medial tibial slope (MTS), medial tibial plateau depth (MTPD), and coronal tibial slope (CTS) between ACL-injured knees with and without ramp lesion of the MM. We hypothesised that patients with ramp lesion of the MM and a concomitant ACL injury have a steeper MTS and shallower MTPD than those without ramp lesion of the MM. Methods Twenty-seven patients who underwent ACLR (group A), and 15 patients with combined MM repair (group AM) were included in the study. Anterior tibial translation (ATT) was measured under general anaesthesia just before surgery using a knee arthrometer. MRI was performed in the 10°-knee-flexed position. The MTS and MTPD were measured on sagittal view, and the CTS was measured on coronal view. These parameters were compared between the groups. Differences in MRI measurements or patient demographics between the groups were evaluated using the Mann-Whitney U test. Results No significant difference was observed in demographic data and post-operative side-to-side difference in ATT between both groups. Pre-operative ATT was significantly higher in group AM than in group A (P < 0.05), whereas post-operative ATT was similar in both groups. Further, Pre-operative ATT was significantly higher in patients with MTS ≥5.0° than in those with MTS <5.0° (P < 0.05). In groups A and AM, the MTS were 3.6° ± 1.8° and 6.2° ± 2.9°, the MTPD were 2.0 ± 0.5 mm and 2.1 ± 0.6 mm, and the CTS were 2.5° ± 1.8° and 2.4° ± 1.6°, respectively. Patients in group AM had a significantly steeper MTS compared to those in group A (P < 0.01), whereas MTPD and CTS were nearly the same in both groups. When the MTS cut-off value was set at 5.0°, the sensitivity and specificity for ACL injury with concomitant ramp lesion of the MM were 0.73 and 0.76, respectively. Conclusion A steep posterior slope of the medial tibial plateau is a risk factor for ramp lesion of the MM associated with an ACL injury. Especially in patients with MTS ≥5.0°, an occult MM ramp lesion should be strongly suspected, and surgeons should prepare for MM repair in combination with ACLR.
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Affiliation(s)
- Yuki Okazaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan.,Department of Orthopaedic Surgery, Kosei Hospital, 3-8-35 Kosei-cho, Kita-ku, Okayama, 700-0985, Japan
| | - Takayuki Furumatsu
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
| | - Takaaki Hiranaka
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
| | - Keisuke Kintaka
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
| | - Yuya Kodama
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan.,Department of Orthopaedic Surgery, University of Pittsburgh, 4200 Fifth Avenue, Pittsburgh, PA, 15260, USA
| | - Yusuke Kamatsuki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kitaku, Okayama, 700-8558, Japan
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