1
|
Pizza N, Urda LL, Sanchez FS, Ibañez M, Zaffagnini S, Perelli S, Monllau JC. How to repair medial meniscal ramp lesions: A systematic review of surgical techniques. J Exp Orthop 2024; 11:e12037. [PMID: 38887657 PMCID: PMC11180972 DOI: 10.1002/jeo2.12037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 06/20/2024] Open
Abstract
Purpose to provide a comprehensive overview of all the surgical techniques published in the literature for repairing meniscal ramp lesions focusing on the technical aspects and the pros and cons of every procedure. Such lesions can be managed using various approaches, each of this with its specific advantages and disadvantages. Methods Pubmed Central, Scopus, and EMBASE databases were systematically reviewed according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines for studies on surgical techniques for repairing meniscal ramp lesions through May 2023. Overall, 32 articles matched the selection criteria and were included in the study. Results Debridement alone may be sufficient for small stable meniscal ramp lesions but, for tears in the menisco-capsular junction that affect the stability of the medial meniscus, it seems reasonable to repair it, even though the clinical results available in literature are contrasting. All-inside sutures through anterior portals seems to be an effective solution for meniscal ramp lesions with MTL tears. All-inside sutures through posteromedial portals are particularly useful for large meniscal ramp lesions, in which an inside-out suture can also be performed. Conclusion Meniscal ramp lesions can be managed using various approaches, each of this with its specific advantages and disadvantages. Further research is required to determine the optimal technique that can be considered as the gold standard and can provide the better results. Level of Evidence Level III, systematic review.
Collapse
Affiliation(s)
- Nicola Pizza
- Knee and Arthroscopy Unit, ICATME, Hospital Universitari DexeusUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Luis L. Urda
- Knee and Arthroscopy Unit, ICATME, Hospital Universitari DexeusUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Francisco S. Sanchez
- Knee and Arthroscopy Unit, ICATME, Hospital Universitari DexeusUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Maximiliano Ibañez
- Knee and Arthroscopy Unit, ICATME, Hospital Universitari DexeusUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica IIIRCCS Istituto Ortopedico RizzoliBolognaItaly
| | - Simone Perelli
- Knee and Arthroscopy Unit, ICATME, Hospital Universitari DexeusUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Juan C. Monllau
- Knee and Arthroscopy Unit, ICATME, Hospital Universitari DexeusUniversitat Autònoma de BarcelonaBarcelonaSpain
| |
Collapse
|
2
|
Saint-Etienne A, Benhenneda R, Vieira TD, Fayard JM, Thaunat M. Clinical Outcomes of Different Management Techniques for Medial Meniscal Type 3 Ramp Lesions in Anterior Cruciate Ligament Reconstruction: A Comparative Analysis Between All-inside Repair, Suture Hook Repair, and Lesions Left In Situ. Am J Sports Med 2024; 52:1250-1257. [PMID: 38523481 DOI: 10.1177/03635465241232088] [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: 03/26/2024]
Abstract
BACKGROUND There is ongoing debate about the best way to manage ramp lesions at the time of anterior cruciate ligament (ACL) reconstruction (ACLR). Type 3 lesions are not visible by the transnotch approach without superior debridement, making the management debate even more problematic. PURPOSE/HYPOTHESIS The purpose of this study was to evaluate the rate of secondary surgical interventions according to the management method of a type 3 ramp lesion concomitant with primary ACLR. The hypothesis was that the rate of secondary ACL or meniscal interventions would be higher in patients who underwent all-inside repair. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective analysis of all patients who underwent primary ACLR with a type 3 ramp lesion between January 2012 and May 2020, regardless of the treatment method, was performed. The main criterion analyzed in this cohort was a secondary surgical intervention, defined as revision ACLR or a reintervention of the repaired meniscus. A survivorship analysis was performed to evaluate secondary surgical interventions in 3 groups: all-inside repair, suture hook repair, and left in situ. The following data were collected preoperatively and at the last follow-up: patient characteristics, time to surgery, side-to-side difference in laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner score, and meniscal repair failure rate. RESULTS A total of 113 patients who underwent type 3 ramp lesion repair concomitant with ACLR were included: 52 (46.0%) in the all-inside repair group, 23 (20.4%) in the suture hook repair group, and 38 (33.6%) in the lesion left in situ group. There were 17 patients (15.0%) who underwent a secondary intervention because of ACL graft failure (n = 6) or meniscal repair failure (n = 15 [4 of whom underwent a concomitant ACL reintervention]). Overall, 62 patients (54.9%) underwent combined ACLR and anterolateral ligament reconstruction, while 51 patients (45.1%) underwent isolated ACLR. In the adjusted Cox model, the type of meniscal repair was not statistically significantly associated with secondary surgical interventions. The only risk factor for secondary surgical interventions in this cohort was isolated ACLR (hazard ratio, 8.077; P = .007). CONCLUSION The rates of secondary surgical interventions after medial meniscal type 3 ramp lesion repair concomitant with ACLR were similar regardless of the management method of the meniscal lesion. Despite not being associated with meniscal treatment, this rate was 8 times higher for patients who underwent isolated ACLR in this cohort; this is probably because of the protection that lateral extra-articular procedures provide to the ACL graft.
Collapse
Affiliation(s)
- Adrien Saint-Etienne
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Rayane Benhenneda
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Jean-Marie Fayard
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Mathieu Thaunat
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| |
Collapse
|
3
|
Gómez Cáceres A, Mariño IT, Martínez Malo FJ, Riestra IV, Idiart RP. Meniscal Ramp Lesion Repair Without the Need for a Posteromedial Portal. Arthrosc Tech 2024; 13:102902. [PMID: 38690339 PMCID: PMC11056648 DOI: 10.1016/j.eats.2023.102902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/01/2023] [Indexed: 05/02/2024] Open
Abstract
Medial meniscal ramp injury has gained the attention of orthopaedic surgeons in recent years. It consists of a tear of the peripheral insertion of the posterior horn of the medial meniscus. Its prevalence in anterior cruciate ligament reconstruction varies between 9% and 40% according to different studies. Ramp lesions cannot always be diagnosed using magnetic resonance imaging scans. To identify ramp lesions, the arthroscope should be introduced into the posteromedial compartment of the knee during the routine examination of the knee (Gillquist maneuver). Not all authors advocate systematically repairing ramp injuries of the medial meniscus, especially when these injuries are small and stable. They have historically been repaired using an outside-in technique using a hook-type suture passed through a posteromedial portal. In this study, we present our all-inside suture technique without the use of a posteromedial portal.
Collapse
Affiliation(s)
- Abel Gómez Cáceres
- Departamento de Cirugía Ortopédica y Traumatología, Hospital HM Málaga (Malaga Institute of Sports Traumatology [IMATDE] Málaga), Málaga, Spain
- Novem Clinic, Málaga, Spain
| | - Iskandar Tamimi Mariño
- Departamento de Cirugía Ortopédica y Traumatología, Hospital HM Málaga (Malaga Institute of Sports Traumatology [IMATDE] Málaga), Málaga, Spain
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Francisco Javier Martínez Malo
- Departamento de Cirugía Ortopédica y Traumatología, Hospital HM Málaga (Malaga Institute of Sports Traumatology [IMATDE] Málaga), Málaga, Spain
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | |
Collapse
|
4
|
Allende F, García JR, Chahla J. Editorial Commentary: A Gap-Based Subclassification of Ramp Lesions Has the Potential to Enhance Treatment Precision and Patient Outcomes in Anterior Cruciate Ligament-Deficient Knees Subtitle: Customizing Solutions for Anterior Cruciate Ligament-Deficient Knees. Arthroscopy 2024; 40:887-889. [PMID: 38219103 DOI: 10.1016/j.arthro.2023.10.007] [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] [Received: 09/20/2023] [Revised: 10/02/2023] [Accepted: 10/07/2023] [Indexed: 01/15/2024]
Abstract
Our evolving understanding of ramp lesions has significantly affected the field of anterior cruciate ligament injury and meniscal repair. Although these lesions have been linked consistently to increased anterior and rotational instability in anterior cruciate ligament-deficient knees, there remains a contentious debate regarding their optimal treatment. The current literature is divided, as some advocate for surgical repair of only arthroscopically unstable lesions. Others point to a substantial risk of complications, noting a 28.6% incidence in untreated stable lesions, and thus advocate for surgical repair of all lesions. Through the use of magnetic resonance imaging scans of flexed knees, a novel subclassification of ramp lesions based on gap distance at the tear site shows a correlation with posterior capsular displacement, anterior laxity, lesion size, and joint effusion. This nuanced classification offers new insights and promises to refine treatment decisions, potentially minimizing unnecessary surgeries and improving patient outcomes.
Collapse
Affiliation(s)
- Felicitas Allende
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.; Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - José Rafael García
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.; Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.; Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| |
Collapse
|
5
|
Neto JBDA, Cavalcante MLC, Messias da Rocha PH, Helito CP, Lima LLD, Ariel de Lima D. Study of the nerve endings and mechanoreceptors of the medial meniscotibial ligament of the knee: A structural and distribution analysis. Knee 2023. [PMID: 36863118 DOI: 10.1016/j.knee.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND The aim of the present study is to describe the morphology and distribution of the nerve endings of the meniscotibial ligament (MTL) of the knee, in order to understand the interaction between the proprioceptive system and knee mechanics. METHODS Twenty medial MTLs were obtained from deceased organ donors. The ligaments were measured, weighed and cut. Sections (10 mm) were prepared on hematoxylin and eosin-stained slides for analysis of tissue integrity, and 50 mm sections were submitted to immunofluorescence with the protein gene product (PGP) 9.5 as primary antibody and Alexa Fluor 488 as secondary antibody, followed by microscopic analysis. RESULTS The medial MTL was identified in 100% of the dissections, with average length, width, thickness and weight of 7.07 ± 1.34 mm, 32.25 ± 3.09 mm, 3.53 ± 0.27 mm and 0.67 ± 0.13 g, respectively. The hematoxylin and eosin-stained histological sections exhibited typical ligament structure, with dense well-organized collagen fibers and vascular tissue. All the specimens analyzed contained type I (Ruffini) mechanoreceptors and free (type IV) nerve endings, varying from parallel to intertwined fibers. Nerve endings not classified with different irregular shapes were also found. Most type I mechanoreceptors were found close to the MTL insertions on the tibial plateau, while the free nerve endings were found adjacent to the capsule. CONCLUSION The medial MTL showed a peripheral nerve structure, primarily type I and IV mechanoreceptors. These findings suggest that the medial MTL is important for proprioception and medial knee stabilization.
Collapse
|
6
|
Li W, Huang S, Xie Y, Chen G, Yuan J, Yang Y. Model-Based Computational Analysis on the Effectiveness of Enhanced Recovery after Surgery in the Operating Room with Nursing. Front Surg 2022; 9:922684. [PMID: 35662829 PMCID: PMC9159805 DOI: 10.3389/fsurg.2022.922684] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveIn order to better understand the relative surgical process, this work used a model-based computational analysis on the effectiveness of enhanced recovery after surgery (ERAS) in the operating room with nursing.MethodsA total of 360 surgical patients in the First Affiliated Hospital, Sun Yat-sen University, from the period June 2020 to March 2021, were randomly divided into two groups, namely, observation group and control group, with 180 cases in each group. Routine nursing was used in the control group, while ERAS was implemented in the observation group from the point of view of four aspects, namely, preoperative visit, intraoperative cooperation, postoperative return visit, and psychological intervention.ResultsPostoperative complications, average hospital stay, nursing satisfaction, and postoperative quality of life in the observation group were significantly better than those in the control group (all p < 0.05).ConclusionThe application of ERAS for surgical patients can enhance team awareness, optimize the process of cooperation, reduce surgical complications and improve nursing quality, and prognosis, and it is worth popularizing in the operating room.
Collapse
Affiliation(s)
- Wenji Li
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shu Huang
- Department of Orthopedics, Hunan Provincial People’s Hospital (The First-Affiliated Hospital of Hunan Normal University), Changsha, China
| | - Yong Xie
- Department of Orthopedics, Hunan Provincial People’s Hospital (The First-Affiliated Hospital of Hunan Normal University), Changsha, China
| | - Guanyu Chen
- Department of Orthopedics, Hunan Provincial People’s Hospital (The First-Affiliated Hospital of Hunan Normal University), Changsha, China
| | - Jun Yuan
- Department of Orthopedics, Hunan Provincial People’s Hospital (The First-Affiliated Hospital of Hunan Normal University), Changsha, China
| | - Yun Yang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Correspondence: Yun Yang
| |
Collapse
|