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Cristiani R, van de Bunt F, Kvist J, Stålman A. High prevalence of associated injuries in anterior cruciate ligament tears: A detailed magnetic resonance imaging analysis of 254 patients. Skeletal Radiol 2024; 53:2417-2427. [PMID: 38532195 PMCID: PMC11410909 DOI: 10.1007/s00256-024-04665-9] [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: 12/26/2023] [Revised: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 03/28/2024]
Abstract
OBJECTIVES To evaluate the type and prevalence of associated injuries by using magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) tears. METHODS Data from the Natural Corollaries and Recovery after ACL injury multicenter longitudinal cohort study were analyzed. Between May 2016 and October 2018, patients aged between 15 and 40 years, who had experienced an ACL tear within the last 6 weeks and sought medical attention at one of seven healthcare clinics in Sweden, were invited to participate. The mean time from injury to MRI was 19.6 ± 15.2 days. An orthopedic knee surgeon and a musculoskeletal radiologist reviewed all the MRI scans. The following structures were assessed: posterior cruciate ligament (PCL), medial collateral ligament (MCL) complex, lateral collateral ligament (LCL), popliteus tendon, medial meniscus (MM), lateral meniscus (LM), and cartilage. In addition, the presence of bone bruising, impaction fractures in the lateral femoral condyle (LFC) or posterolateral tibia (PLT), and Segond fractures were also assessed. RESULTS: A total of 254 patients (48.4% males) with a mean age of 25.4 ± 7.1 years were included. The prevalence of associated injuries was as follows: PCL (0.4%), MCL {41.3% [superficial MCL and deep MCL (dMCL) 16.5%; isolated dMCL 24.8%]}, LCL (2.4%), MM (57.4%), LM (25.2%), cartilage (15.0%), bone bruising (92.9%), impaction fracture in the LFC (45.7%) and PLT (4.7%), and Segond fracture (7.5%). CONCLUSIONS The prevalence of associated injuries in patients with ACL tears was high. The findings reported in this study may serve as a reference tool for orthopedic surgeons and radiologists in the diagnosis of associated injuries using MRI in patients with ACL tears.
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Affiliation(s)
- Riccardo Cristiani
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden.
- Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486, Stockholm, Sweden.
| | | | - Joanna Kvist
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
- Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of Physiotherapy, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anders Stålman
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
- Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486, Stockholm, Sweden
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Wagala NN, Fatora G, Brown C, Lesniak BP. Complications in Anterior Cruciate Ligament Surgery and How to Avoid Them. Clin Sports Med 2024; 43:465-477. [PMID: 38811122 DOI: 10.1016/j.csm.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Complications following anterior cruciate ligament (ACL) reconstruction can be detrimental to a patient's recovery and limit their ability to successfully return to sport. Arthrofibrosis, graft failure, and infection are a few examples of complications that can arise. Therefore, it is important for surgeons to recognize that each step during perioperative surgical decision making can impact patients' risk for such complications. The purpose of this paper is to discuss common complications following ACL reconstruction and how surgeons can avoid or reduce the risk of complications.
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Affiliation(s)
- Nyaluma N Wagala
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gabrielle Fatora
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cortez Brown
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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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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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.
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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
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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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D'Ambrosi R, Di Maria F, Ursino C, Ursino N, Di Feo F, Formica M, Kambhampati SB. Magnetic resonance imaging shows low sensitivity but good specificity in detecting ramp lesions in children and adolescents with ACL injury: A systematic review. J ISAKOS 2024; 9:371-377. [PMID: 38135056 DOI: 10.1016/j.jisako.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/25/2023] [Accepted: 12/18/2023] [Indexed: 12/24/2023]
Abstract
IMPORTANCE The diagnosis of ramp lesions can be problematic, even with arthroscopy, due to their extreme posteromedial position. Consequently, they have been colloquially referred to as the "hidden lesions" of the knee. Undiagnosed and untreated injuries in this knee region may be associated with ongoing dynamic rotational laxity of the knee after anterior cruciate ligament reconstruction and an increased risk of anterior cruciate ligament graft failure. AIM This study aimed to systematically review the literature to assess the sensitivity, specificity and accuracy of magnetic resonance imaging (MRI) for detecting ramp lesions in children and adolescents with anterior cruciate ligament (ACL)-deficient knees. It was hypothesized that MRI has poor sensitivity for identifying ramp lesions in children and adolescents. EVIDENCE REVIEW A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following search terms were used in the title, abstract and keywords fields: "ramp" or "meniscus" AND "children" or "adolescents." The outcome data extracted from the studies were incidence of ramp in concomitant with ACL lesion, MRI sensitivity, specificity, accuracy and positive and negative predictive values (PPV and NPV). FINDINGS Of the 387 patients with ACL injury, 90 were reported to have ramp lesions (23.3%). The mean age at the time of diagnosis was 15.3 ± 0.81 years. The mean time from injury to MRI was 116.1 ± 113.5 days, while the mean time from injury to surgery was 172.6 ± 139.1 days. The MRI taken to detect ramp lesions in the paediatric population showed a pooled sensitivity of 50%, specificity of 75%, accuracy of 70%, PPV of 41% and NPV of 79%. CONCLUSIONS AND RELEVANCE The prevalence of ACL-associated ramp lesions in children and adolescents is similar to that in adult populations. Magnetic resonance imaging has low sensitivity but good specificity for assessing ramp lesions. In the presence of a posteromedial tibial bone bruise or a thin fluid signal separating the posterior horn of the medial meniscus and the posteromedial capsule a ramp lesion should always be suspected. LEVEL OF EVIDENCE Level IV. STUDY REGISTRATION PROSPERO -: CRD42023453895.
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Affiliation(s)
- Riccardo D'Ambrosi
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, 20157, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, 20133, Italy.
| | - Fabrizio Di Maria
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, Surgery, AOU Policlinico-Vittorio Emanuele, University of Catania, Catania, 95124, Italy.
| | - Chiara Ursino
- Orthopaedic Clinic, IRCCS Hospital Policlinico San Martino, Genoa, 16132, Italy; DISC - Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 16132, Italy.
| | - Nicola Ursino
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, 20157, Italy.
| | - Fabrizio Di Feo
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, 20157, Italy.
| | - Matteo Formica
- Orthopaedic Clinic, IRCCS Hospital Policlinico San Martino, Genoa, 16132, Italy; DISC - Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, 16132, Italy.
| | - Srinivas Bs Kambhampati
- Sri Dhaatri Orthopaedic, Maternity and Gynaecology Center, SKDGOC, Vijayawada, Andhra Pradesh, 520011, India.
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Dingel AB, Tompkins M, Yen YM, Karius AK, Cinque M, Vuong BB, Taylor V, Pham NS, Ganley TJ, Wilson P, Ellis HB, Green D, Fabricant PD, Boucher L, Shea KG. A Recess Is Observed Between the Posterior Knee Capsule and the Meniscotibial Ligament Complex in Pediatric Specimens. Arthrosc Sports Med Rehabil 2024; 6:100852. [PMID: 39006787 PMCID: PMC11240032 DOI: 10.1016/j.asmr.2023.100852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 11/19/2023] [Indexed: 07/16/2024] Open
Abstract
Purpose To define the surgical anatomy of the meniscotibial ligament complex of the pediatric medial and lateral menisci and their relation to the proximal tibial physis and posterior joint capsule. Methods Fourteen pediatric cadaveric knee specimens (aged 3 months to 11 years) were dissected to clarify the relation of the posterior knee capsule, the meniscus, and the meniscotibial ligament complex. Metallic markers were placed marking the meniscotibial ligament capsular attachment on the proximal tibia. Specimens underwent computed tomography scanning to evaluate pin placement and relation to the physis. A digital measurement tool was used to measure the distances between the proximal tibial physis and the pins (placed at 5 points on both the lateral and medial menisci). Results In each specimen, clear separation was noted between the posterior joint capsule from the meniscus and meniscotibial ligament complex in the medial and lateral compartments. There was an increase in the distance between the proximal tibial physis and the insertion points of the meniscotibial ligament complex with increasing specimen age. For both the medical and lateral menisci in group 1, the median meniscotibial ligament insertion points were often less than 7 mm (interquartile range, 0.00-7.8 mm) away from the physis. The median meniscotibial ligament insertion points in group 2 tended to be farther from the physis but always less than 20 mm (interquartile range, 2.5-17.5 mm)-and as close as less than 5 mm (lateral posterior root). Conclusions In this anatomic study of pediatric knees, we observed a distinct recess/cul-de-sac space between the posterior knee capsule and meniscal attachments in all specimens. This defines a distinct plane between the posterior knee capsule and the meniscotibial ligament complex, with a distance between the physis and meniscotibial ligament capsular attachments that increases with age. Clinical Relevance The anatomic parameters evaluated in our study should be considered as future meniscal repair and transplantation techniques aim to restore the meniscal anatomy, stability, and mobility provided by the meniscotibial ligament complex and capsule structures.
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Affiliation(s)
- Aleksei B. Dingel
- School of Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Marc Tompkins
- TRIA Orthopaedic Center, Minneapolis, Minnesota, U.S.A
- University of Minnesota, Minneapolis, Minnesota, U.S.A
- Gillette Children’s Specialty Healthcare, St. Paul, Minnesota, U.S.A
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, U.S.A
| | | | - Mark Cinque
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, U.S.A
| | - Brian B. Vuong
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, U.S.A
| | - Vanessa Taylor
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, U.S.A
| | - Nicole S. Pham
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, U.S.A
| | - Theodore J. Ganley
- Department of Orthopaedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | | | | | - Daniel Green
- Pediatric Orthopaedic Surgery Division, Hospital for Special Surgery, New York, New York, U.S.A
| | - Peter D. Fabricant
- Pediatric Orthopaedic Surgery Division, Hospital for Special Surgery, New York, New York, U.S.A
| | - Laura Boucher
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, U.S.A
| | - Kevin G. Shea
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, U.S.A
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10
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Fukushima H, Kato J, Hanaki S, Ota K, Kobayashi M, Kawanishi Y, Yoshida M, Takenaga T, Kuroyanagi G, Murakami H, Nozaki M. Anterior Cruciate Ligament-Injured Knees With Meniscal Ramp Lesions Manifest Greater Anteroposterior and Rotatory Instability Compared With Isolated Anterior Cruciate Ligament-Injured Knees. Arthroscopy 2024:S0749-8063(24)00304-9. [PMID: 38697327 DOI: 10.1016/j.arthro.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 05/04/2024]
Abstract
PURPOSE To investigate the effects of ramp lesion (RL) and its repair on knee instability in patients with anterior cruciate ligament (ACL) injury by quantitatively assessing anteroposterior and rotational knee instability before and after ACL reconstruction. METHODS All primary double-bundle ACL reconstructions using hamstring autografts between 2016 and 2021 were evaluated retrospectively. Patients with RLs without other meniscal injuries were included in group R, whereas those with isolated ACL injuries constituted group C. RL was repaired using all-inside devices in all patients in group R. Knee instability, including the amount of anterior tibial translation (ATT), and the acceleration and external rotational angular velocity of the knee joint (ERAV) during the pivot-shift test were assessed at the time of surgery. The pivot-shift test grade was recorded. RESULTS A total of 73 patients were included in this study. Preoperatively, group R (n = 23) had significantly greater pivot-shift grades (P = .039), ATT (6.0 mm, group R; 4.5 mm, group C, P < .001), acceleration (6.8, 2.8; P = .037), and ERAV (3.9, 2.8; P = .001) than group C (n = 50). Intraoperatively, ATT (-1.0 mm, -1.0 mm; P < .001), acceleration (1.2, 1.1; P < .001), and ERAV (1.4, 1.2; P < .001) were significantly decreased compared with the preoperative values in both groups. No significant differences in these values were observed between groups R and C. CONCLUSIONS ACL-injured knees accompanied by RLs exhibited significantly greater anteroposterior and rotatory instability than knees with isolated ACL injuries; increased knee instability can be effectively addressed by performing RL repair in conjunction with ACL reconstruction. The quantitative assessments employed-specifically measuring ATT, acceleration, and ERAV during the pivot-shift test-have allowed us to delineate these aspects of knee instability with greater precision. LEVEL OF EVIDENCE Level Ⅲ, retrospective comparative study.
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Affiliation(s)
- Hiroaki Fukushima
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Jiro Kato
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shunta Hanaki
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kyohei Ota
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Makoto Kobayashi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yusuke Kawanishi
- Department of Orthopedic Surgery, Ogaki Municipal Hospital, Ogaki, Japan
| | - Masahito Yoshida
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tetsuya Takenaga
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Gen Kuroyanagi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hideki Murakami
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masahiro Nozaki
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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11
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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.
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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
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12
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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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13
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Deichsel A, Miets H, Peez C, Raschke MJ, Klimek M, Glasbrenner J, Herbst E, Kittl C. The Effect of Varying Sizes of Ramp Lesions in the ACL-Deficient and Reconstructed Knee: A Biomechanical Robotic Investigation. Am J Sports Med 2024; 52:928-935. [PMID: 38343294 DOI: 10.1177/03635465231223686] [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: 03/17/2024]
Abstract
BACKGROUND Conflicting evidence has been reported regarding the biomechanical relevance of ramp lesions (RLs) on knee kinematics. Furthermore, the influence of the defect size of the RLs on anterior tibial translation (ATT) and external rotation (ER) is currently unknown. PURPOSE To evaluate the influence of RL defect size on knee kinematics in anterior cruciate ligament (ACL) deficiency and after simulated ACL reconstruction (sACLR). STUDY DESIGN Controlled laboratory study. METHODS Eight cadaveric knee specimens were tested in a 6 degrees of freedom robotic test setup. Force-controlled clinical laxity tests were performed with 200 N of axial compression in 0°, 30°, 60°, and 90° of flexion: 5 N·m internal rotation (IR)/ER torque, 134 N ATT force, and an anteromedial drawer test consisting of 134 N ATT force under 5 N·m ER torque. After determining the native knee kinematics, the ACL was cut at the tibial insertion, followed by a transosseous refixation to simulate a surgical repair or reconstruction (simulated ACL reconstruction; sACLR). An RL was sequentially created with a length of 1, 2, and 3 cm. Each state of the RL was evaluated in the ACL-deficient state and after sACLR. RESULTS In the ACL-deficient state, only an RL of 3 cm length resulted in a significant increase of ATT in 30° of flexion (mean difference 0.73 mm; 95% CI, 0.36-1.1 mm). After sACLR, an RL had no significant effect. When looking at ER, an RL significantly increased ER in full extension in the ACL-deficient state in 2 cm (mean difference 0.9°; 95% CI, 0.08°-1.74°) and 3 cm length (mean difference 1.9°; 95% CI, 0.57-3.25). Furthermore, a 3-cm RL significantly increased IR in 0° of flexion in the ACL-deficient state (mean difference 1.9°; 95% CI, 0.2°-3.6°). No effect of ramp lesions on rotation was found after sACLR. CONCLUSION RLs result in a small increase in ATT, ER, and IR in ACL-deficient knees at early flexion angles, but not after sACLR. CLINICAL RELEVANCE Small RLs did not change time-zero knee kinematics and may, therefore, be left untreated, especially when the ACL is reconstructed.
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Affiliation(s)
- Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Henrike Miets
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Matthias Klimek
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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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.
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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
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15
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Giurazza G, Saithna A, An JS, Lahsika M, Campos JP, Vieira TD, Guier CA, Sonnery-Cottet B. Incidence of and Risk Factors for Medial Meniscal Lesions at the Time of ACL Reconstruction: An Analysis of 4697 Knees From the SANTI Study Group Database. Am J Sports Med 2024; 52:330-337. [PMID: 38205511 DOI: 10.1177/03635465231216364] [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: 01/12/2024]
Abstract
BACKGROUND Medial meniscal (MM) lesions (MMLs) are a common finding at the time of anterior cruciate ligament reconstruction (ACLR). It is recognized that evaluation of the posteromedial compartment reduces the rate of missed MML diagnoses. PURPOSE To determine the incidence of MMLs in patients undergoing ACLR, when using a standardized arthroscopic approach that included posteromedial compartment evaluation, as well as to determine how the incidence of MMLs changed with increasing time intervals between injury and surgery, and to investigate what risk factors were associated with their presence. STUDY DESIGN Case series; Level of evidence, 4. METHODS A retrospective analysis of prospectively collected data was performed. All patients who underwent primary ACLR between January 2013 and March 2023 were considered for study eligibility. The epidemiology was defined by categorizing and reporting the incidence and categorizing the spectrum of MM tear types. Risk factors associated with MMLs were analyzed using a logistic regression model. RESULTS MMLs were identified in 1851 (39.4%) of 4697 consecutive patients undergoing ACLR. The overall incidence of MMLs was 33.1% for the period of 0 to 3 months, 38.7% for the period of 3 to 12 months, and 59.6% for the period of >12 months. The overall incidence of MMLs increased with longer durations of time between injury and surgery, along with significant increases in complex, bucket-handle, ramp, and/or flap lesions. The largest increase in incidence of MMLs was observed for complex MM tear patterns. Risk factors associated with MMLs included time between injury and surgery >3 months (odds ratio [OR], 1.320; 95% CI, 1.155-1.509; P < .0001) and >12 months (OR, 3.052; 95% CI, 2.553-3.649; P < .0001), male sex (OR, 1.501; 95% CI, 1.304-1.729; P < .0001), body mass index (BMI) ≥25 (OR, 1.193; 95% CI, 1.046-1.362; P = .0088), and lateral meniscal lesion (OR, 1.737; 95% CI, 1.519-1.986; P < .0001). CONCLUSION Overall, MMLs were identified in 39.4% of 4697 patients undergoing ACLR when posteromedial compartment evaluation was performed in addition to standard anterior viewing. The incidence of MMLs and the complexity of tear types increased significantly with increasing time intervals between the index injury and ACLR. Secondary risk factors associated with an increased incidence of medial meniscal tears include male sex, increased BMI, and lateral meniscal lesions.
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Affiliation(s)
- Giancarlo Giurazza
- Centre Orthopédique Santy, Lyon, France
- Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Adnan Saithna
- Arizona Brain, Spine & Sports Injuries Center, Scottsdale, Arizona, USA
| | - Jae-Sung An
- Centre Orthopédique Santy, Lyon, France
- Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Mohammed Lahsika
- Centre Orthopédique Santy, Lyon, France
- Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Joao Pedro Campos
- Centre Orthopédique Santy, Lyon, France
- Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Lyon, France
- Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Christian A Guier
- San Francisco Orthopaedics and Sports Medicine, San Francisco, California, USA
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, Lyon, France
- Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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16
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Severyns M, Zot F, Harika-Germaneau G, Germaneau A, Herpe G, Naudin M, Valle V, Danion J, Vendeuvre T. Extrusion and meniscal mobility evaluation in case of ramp lesion injury: a biomechanical feasibility study by 7T magnetic resonance imaging and digital volume correlation. Front Bioeng Biotechnol 2024; 11:1289290. [PMID: 38249805 PMCID: PMC10796713 DOI: 10.3389/fbioe.2023.1289290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction: The existing body of literature on the biomechanical implications of ramp lesions is limited, leaving a significant gap in our understanding of how these lesions impact joint kinematics and loading in the medial compartment. This cadaveric biomechanical study aims to address this gap by employing an innovative Digital Volume Correlation (DVC) method, utilizing 7 Tesla Magnetic Resonance Imaging (MRI) images under various loading conditions. The primary objective is to conduct a comprehensive comparison of medial meniscal mobility between native knees and knees affected by grade 4 ramp lesions. By focusing on the intricate dynamics of meniscal mobility and extrusion, this work seeks to contribute valuable insights into the biomechanical consequences of medial meniscus ramp lesions. Materials and methods: An initial set of 7T MRI imaging sessions was conducted on two intact native knees, applying load values up to 1500N. Subsequently, a second series of images was captured on these identical knees, with the same loads applied, following the creation through arthroscopy of medial meniscus ramp lesions. The application of DVC enabled the precise determination of the three components of displacement and spatial variations in the medial menisci, both with and without ramp lesions. Results: The measured directional displacements between native knees and injured knees indicate that, following the application of axial compression load, menisci exhibit increased extrusion and posterior mobility as observed through DVC. Discussion: Injuries associated with Subtype 4 medial meniscus ramp lesions appear to elevate meniscal extrusion and posterior mobility during axial compression in the anterior cruciate ligament of intact knees. Following these preliminary results, we plan to expand our experimental approach to encompass individuals undergoing weight-bearing MRI. This expansion aims to identify meniscocapsular and/or meniscotibial insufficiency or rupture in patients, enabling us to proactively reduce the risk of osteoarthritic progression.
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Affiliation(s)
- M. Severyns
- Institut Pprime UPR 3346, Centre National de Recherche Scientifique–Université de Poitiers–ISAE-ENSMA, Poitiers, France
- Department of Orthopaedic Surgery and Traumatology, Clinique Porte Océane, Les Sables d’Olonne, France
| | - F. Zot
- Institut Pprime UPR 3346, Centre National de Recherche Scientifique–Université de Poitiers–ISAE-ENSMA, Poitiers, France
| | - G. Harika-Germaneau
- Unité de Recherche Clinique Pierre Deniker, CH Henri Laborit, Centre de Recherches sur la Cognition et l’Apprentissage UMR 7295, Centre National de Recherche Scientifique–Université de Poitiers, Poitiers, France
| | - A. Germaneau
- Institut Pprime UPR 3346, Centre National de Recherche Scientifique–Université de Poitiers–ISAE-ENSMA, Poitiers, France
| | - G. Herpe
- CHU de Poitiers, Department of Radiology, LabCom I3M Centre National de Recherche Scientifique–Siemens Healthineers, LMA, UMRCNRS 7348, Université de Poitiers, Poitiers, France
| | - M. Naudin
- CHU de Poitiers, Department of Radiology, LabCom I3M Centre National de Recherche Scientifique–Siemens Healthineers, LMA, UMRCNRS 7348, Université de Poitiers, Poitiers, France
| | - V. Valle
- Institut Pprime UPR 3346, Centre National de Recherche Scientifique–Université de Poitiers–ISAE-ENSMA, Poitiers, France
| | - J. Danion
- CHU de Poitiers, ABS Lab, Poitiers, France
| | - T. Vendeuvre
- Institut Pprime UPR 3346, Centre National de Recherche Scientifique–Université de Poitiers–ISAE-ENSMA, Poitiers, France
- CHU de Poitiers, Department of Orthopaedic Surgery and Traumatology, Poitiers, France
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D’Ambrosi R, Annibaldi A, Carrozzo A, Vieira TD, An JS, Freychet B, Sonnery-Cottet B. Evaluating the Reliability of YouTube as a Source of Information for Meniscal Ramp Lesions. Orthop J Sports Med 2024; 12:23259671231219815. [PMID: 38188623 PMCID: PMC10768595 DOI: 10.1177/23259671231219815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/31/2023] [Indexed: 01/09/2024] Open
Abstract
Background Videos uploaded to YouTube do not go through a review process, and therefore, videos related to medial meniscal ramp lesions may have little educational value. Purpose To assess the educational quality of YouTube videos regarding ramp lesions of the meniscus. Study Design Cross-sectional study. Methods A standard search was performed on the YouTube website using the following terms: "ramp lesion" and "posterior meniscal detachment" and "ramp" and "meniscocapsular" and "meniscotibial detachment," and the top 100 videos based on the number of views were included for analysis. The video duration, publication data, and number of likes and views were retrieved, and the videos were categorized based on video source (health professionals, orthopaedic company, private user), the type of information (anatomy, biomechanics, clinical examination, overview, radiologic, surgical technique), and video content (education, patient support, patient experience/testimony).The content analysis of the information on the videos was evaluated with the use of the DISCERN instrument (score range, 16-80), the Journal of the American Medical Association (JAMA) benchmark criteria (score range, 0-4), and the Global Quality Score (GQS; score range, 1-5). Results A total of 74 videos were included. Of these videos, 70 (94.6%) were published by health professionals, while the remaining 4 (5.4%) were published by orthopaedic companies. Most of the videos were about surgical technique (n = 36; 48.6%) and all had an educational aim (n = 74; 100%). The mean length of the videos was 10.35 ± 17.65 minutes, and the mean online period was 18.64 ± 13.85 months. The mean DISCERN score, JAMA benchmark score, and GQS were 31.84 ± 17.14 (range, 16-72), 1.65 ± 0.87 (range, 1-4), and 2.04 ± 1.21 (range, 1-5), respectively. Videos that reported an overview about ramp lesions were the best in terms of quality for DISCERN and JAMA benchmark score, while biomechanics videos were the best according to GQS. The worst category of videos was about surgical technique, with all having lower scores. Conclusion The educational content of YouTube regarding medial meniscal ramp lesions showed low quality and validity based on DISCERN score, JAMA benchmark score, and GQS.
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Affiliation(s)
- Riccardo D’Ambrosi
- IRCCS Ospedale Galeazzi-Sant’Ambrogio, Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Annibaldi
- Orthopaedic Unit, Sant’Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Alessandro Carrozzo
- Orthopaedic Unit, Sant’Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hopital Mermoz, Groupe Ramsay, Lyon, France
| | - Jae-Sung An
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hopital Mermoz, Groupe Ramsay, Lyon, France
| | - Benjamin Freychet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hopital Mermoz, Groupe Ramsay, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hopital Mermoz, Groupe Ramsay, Lyon, France
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18
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Dansuk E, Kemah B, Polat G, Erdil ME. The effect of anterior cruciate ligament reconstruction and RAMP lesion repair on psychological status. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2873-2880. [PMID: 36877408 DOI: 10.1007/s00590-023-03510-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/26/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND There are few studies examining anterior cruciate ligament reconstruction (ACLR) and RAMP lesion repair. However, no studies have investigated the level of functional performance and psychological state after ACLR and all-inside RAMP lesion repair. HYPOTHESIS/PURPOSE The aim of this study is to determine the effect of ACLR and RAMP lesion repair on psychological status. ACLR and meniscal RAMP lesion repair were hypothesized to be associated with better psychological outcomes. STUDY DESIGN This is a cohort study. METHODS Patients who underwent ACLR with semitendinosus and gracilis autografts by a single surgeon were determined retrospectively. Fifteen patients who underwent ACLR and all-inside meniscus RAMP lesion repair (ACLR-RR) and 15 patients who underwent isolated ACLR were compared. Patients were evaluated by a physiotherapist at least 9 months after surgery. The primary outcome measure was anterior cruciate ligament-return to sports after injury (ACL-RSI), and the psychological status of the patients was examined. Secondary outcomes were visual analog scale (VAS), Tegner activity score, Lysholm knee score, single hop tests, and limb symmetry index (LSI). While pain intensity at rest and during movement was evaluated with VAS, functional performance level was evaluated with the Tegner activity score, the Lysholm knee score, single hop tests, and limb symmetry index (LSI). RESULTS A significant difference was found in the ACL-RSI values in the ACLR-RR group compared to the isolated ACLR group (p = 0.02). The results of the groups in VAS scores at rest and during movement, Tegner activity levels, and Lysholm knee scores, in the intact and operated leg single hop tests (single leg hop, cross hop, triple hop, and six-meter hop test), and the LSI values in the single leg hop tests showed no significant difference. CONCLUSIONS This study revealed different psychological outcomes and similar functional levels for ACLR and all-inside meniscus RAMP repair compared with isolated ACLR. It was observed that the psychological status of patients with RAMP lesions should also be evaluated.
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Affiliation(s)
- Emre Dansuk
- Department of Physiotherapy and Rehabilitation, Institute of Health Sciences, Istanbul Medipol University, Istanbul, Turkey.
| | - Bahattin Kemah
- Department of Orthopaedics and Traumatology, S.B University Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Gökhan Polat
- Department of Orthopaedics and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Emin Erdil
- Department of Orthopaedics and Traumatology, Acibadem Maslak Hospital, Acibadem University, Istanbul, Turkey
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Miyamoto K, Kurokouchi K, Ishizuka S, Takahashi S, Idota M, Haga T, Imagama S. Arthroscopic All-Suture Anchor Technique for Unstable Ramp Lesions with Medial Meniscal Defects. Arthrosc Tech 2023; 12:e1837-e1842. [PMID: 37942093 PMCID: PMC10628196 DOI: 10.1016/j.eats.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/22/2023] [Indexed: 11/10/2023] Open
Abstract
A ramp lesion is a specific type of tear in the meniscocapsular junction of the posterior horn of the medial meniscus, usually associated with anterior cruciate ligament (ACL) injury. Biomechanical cadaveric studies have shown that ACL injury combined with ramp lesions significantly increases anterior tibial translation and external rotation, which ACL reconstruction alone cannot completely control. Additionally, ramp lesions are sometimes associated with medial meniscal defects, especially in cases of chronic ACL deficiency after repetitive traumatic events, in which the anatomical repair of the meniscocapsular junction is infeasible. This report describes a new arthroscopic repair technique using an all-suture anchor through a posteromedial portal for unstable ramp lesions with medial meniscal defects.
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Affiliation(s)
- Kentaro Miyamoto
- Department of Orthopaedic Surgery and Arthroscopy Center, Juko Memorial Hospital, Nagoya, Japan
| | - Kazutoshi Kurokouchi
- Department of Orthopaedic Surgery and Arthroscopy Center, Juko Memorial Hospital, Nagoya, Japan
| | - Shinya Ishizuka
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigeo Takahashi
- Department of Orthopaedic Surgery and Arthroscopy Center, Juko Memorial Hospital, Nagoya, Japan
| | - Masaru Idota
- Department of Orthopaedic Surgery and Arthroscopy Center, Juko Memorial Hospital, Nagoya, Japan
| | - Takahiro Haga
- Department of Orthopaedic Surgery and Arthroscopy Center, Juko Memorial Hospital, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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20
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Gilat R, Mitchnik IY, Mimouni T, Agar G, Lindner D, Beer Y. The meniscotibial ligament role in meniscal extrusion: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:5777-5786. [PMID: 37266692 DOI: 10.1007/s00402-023-04934-7] [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: 02/20/2023] [Accepted: 05/25/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The meniscotibial ligament (MTL) limits extrusion of the medial meniscus (MM). While meniscal extrusion may be detrimental to knee joint biomechanics, the role of the MTL in meniscal extrusion is debatable. We sought to perform a systematic review and meta-analysis to evaluate the role of the MTL and surgical techniques for MTL repair. MATERIALS AND METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines we searched PubMed, Cochrane Library, and Embase for: (("Meniscotibial") OR ("Coronary") OR ("Ramp")) AND ("Extrusion"). After screening and applying eligibility criteria, data were extracted for MTL pathology types ("traumatic" ruptures or "induced" injuries) and meniscal extrusion. A meta-analysis evaluated the mean difference of extrusion between "intact" MTLs (native or repaired) and "injured" MTLs (induced or traumatic). We further performed a subgroup analysis between traumatic and induced MTL lesions. RESULTS This systematic review included six studies, which all evaluated MM extrusion. There were 74 knees with induced MTL injuries and 19 knees with traumatic MTL ruptures. Study designs were heterogenic and utilized three types of MTL repair procedures. The meta-analysis included 18 human knees and revealed that sectioning the MTL created a 2.92 mm [- 0.18 to 6.03] MM extrusion, while MTL repair decreased MM extrusion by - 2.11 mm [- 3.03 to - 1.21]. CONCLUSIONS MTL injury may result in approximately 3 mm of MM extrusion, while repair of the MTL can decrease extrusion by 2 mm. Several novel surgical techniques exist to repair the MTL. However, studies reporting clinical outcomes of these various procedures are scarce.
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Affiliation(s)
- Ron Gilat
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ilan Y Mitchnik
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
- Department of Military Medicine, Hebrew University, Jerusalem, Israel
| | - Tomer Mimouni
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Agar
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror Lindner
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yiftah Beer
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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21
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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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22
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Joshi A, Nepal S, Regmi S, Pradhan I, Singh N, Basukal B, Bista R, Sharma R. Ramp Tear among Patients Undergoing Arthroscopic Anterior Cruciate Ligament Reconstruction in a Tertiary Care Centre. JNMA J Nepal Med Assoc 2023; 61:633-635. [PMID: 38289817 PMCID: PMC10566604 DOI: 10.31729/jnma.8235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Ramp tear is a specific injury that affects the posterior horn of the medial meniscus and its meniscosynovial or meniscocapsular attachments. The actual prevalence of ramp lesion is unknown due to the high probability of misdiagnosis or underdiagnosis caused by the low sensitivity of imaging modalities and poor visualization during arthroscopy. This study aimed to find out the prevalence of ramp tear among patients undergoing arthroscopic anterior cruciate ligament reconstruction in a tertiary care centre. Methods A descriptive cross-sectional study was conducted among patients undergoing arthroscopic anterior cruciate ligament reconstruction after getting ethical approval from the Institutional Review Committee. Data from 1 March 2019 to 31 December 2022 was collected between 1 May 2023 to 30 May 2023 from medical records. The study included all patients who underwent arthroscopic anterior cruciate ligament reconstruction. Patients with a previous history of medial meniscus injury or repair and undergoing revision anterior cruciate ligament reconstruction were excluded. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results Out of 412 patients who underwent arthroscopic anterior cruciate ligament reconstruction, 53 (12.86%) (9.63-16.09, 95% Confidence Interval) had ramp tears. The mean age of patients with ramp tears was 28.64±7.57 years. Among 53 patients, 42 (79.24%) were male and 11 (20.75%) were female. Conclusions The prevalence of ramp tears in patients undergoing arthroscopic anterior cruciate ligament reconstruction in a tertiary care centre was found to be lower than other studies done in other international studies. Keywords anterior cruciate ligament injuries; anterior cruciate ligament reconstruction; arthroscopy.
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Affiliation(s)
- Amit Joshi
- Department of Orthopedics, B&B Hospital Pvt. Ltd., Gwarko, Lalitpur, Nepal
| | - Santosh Nepal
- Department of Orthopedics, B&B Hospital Pvt. Ltd., Gwarko, Lalitpur, Nepal
| | - Subhash Regmi
- Department of Orthopedics, B&B Hospital Pvt. Ltd., Gwarko, Lalitpur, Nepal
| | - Ishor Pradhan
- Department of Orthopedics, B&B Hospital Pvt. Ltd., Gwarko, Lalitpur, Nepal
| | - Nagmani Singh
- Department of Orthopedics, B&B Hospital Pvt. Ltd., Gwarko, Lalitpur, Nepal
| | - Bibek Basukal
- Department of Orthopedics, B&B Hospital Pvt. Ltd., Gwarko, Lalitpur, Nepal
| | - Rohit Bista
- Department of Orthopedics, B&B Hospital Pvt. Ltd., Gwarko, Lalitpur, Nepal
| | - Rajiv Sharma
- Department of Orthopedics, B&B Hospital Pvt. Ltd., Gwarko, Lalitpur, Nepal
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23
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Marin F, Soto J, Barahona M, Negrin R. Searching for the Best Treatment for Ramp Lesions: A Systematic Review and Network Meta-Analysis. Cureus 2023; 15:e41651. [PMID: 37435014 PMCID: PMC10332486 DOI: 10.7759/cureus.41651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 07/13/2023] Open
Abstract
Ramp lesions are a common occurrence in patients with anterior cruciate ligament (ACL) tears. These lesions can be difficult to diagnose due to their concealed nature, and their treatment is crucial due to the stabilizing function of the medial meniscocapsular region. The optimal treatment option for ramp lesions varies depending on the size and stability of the lesion. The purpose of this study was to evaluate the best treatment option for ramp lesions based on the stability of the lesion, including no treatment, biological treatment, and arthroscopic repair. We hypothesize that stable lesions have a favorable prognosis with techniques that do not require the use of meniscal sutures. In contrast, unstable lesions require appropriate fixation, either through an anterior or posteromedial portal. This study is a systematic review and meta-analysis with a level of evidence IV. The study used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for a systematic review of clinical studies reporting outcomes of ramp lesion treatment. The PubMed/MEDLINE database was searched using Mesh and non-Mesh terms related to ramp lesions, medial meniscus ramp lesions, and meniscocapsular injuries. The inclusion criteria encompassed clinical studies in English or Spanish that reported the treatment of ramp meniscal lesions, with a follow-up of at least six months and inclusion of functional results, clinical stability tests, radiological evaluation, or arthroscopic second look. The analysis included 13 studies with 1614 patients. Five studies distinguished between stable and unstable ramp lesions using different criteria (displacement or size) for assessment. Of the stable lesions, 90 cases received no treatment, 64 cases were treated biologically (debridement, edge-curettage, or trephination), and 728 lesions were repaired. There were 221 repaired unstable lesions. All different methods of repair were registered. In stable lesions, three studies were included in a network meta-analysis. The best-estimated treatment for stable lesions was biological (SUCRA 0.9), followed by repair (SUCRA 0.6), and no treatment (SUCRA 0). In unstable lesions, seven studies using International Knee Documentation Committee Subjective Knee Form (IKDC) and 10 studies using Lysholm for functional outcomes showed significant improvement from preoperative to postoperative scores after repair, with no differences between repairing methods. We recommend simplifying the classification of ramp lesions as stable or unstable to determine treatment. Biological treatment is preferred for stable lesions rather than leaving them in situ. Unstable lesions, on the other hand, require repair, which has been associated with excellent functional outcomes and healing rates.
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Affiliation(s)
- Felipe Marin
- Department of Orthopaedics, Clínica Las Condes, Santiago, CHL
| | - Julio Soto
- Department of Orthopaedics, Clínica Las Condes, Santiago, CHL
| | - Maximiliano Barahona
- Department of Orthopaedics, Clínica Las Condes, Santiago, CHL
- Department of Orthopaedics, Hospital Clínico Universidad de Chile, Santiago, CHL
| | - Roberto Negrin
- Department of Orthopaedics, Clínica Las Condes, Santiago, CHL
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24
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Hollnagel KF, Pennock AT, Bomar JD, Chambers HG, Edmonds EW. Meniscal Ramp Lesions in Adolescent Patients Undergoing Primary Anterior Cruciate Ligament Reconstruction: Significance of Imaging and Arthroscopic Findings. Am J Sports Med 2023; 51:1506-1512. [PMID: 36847270 DOI: 10.1177/03635465231154600] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
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.
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Affiliation(s)
| | | | - James D Bomar
- Rady Children's Hospital, San Diego, California, USA
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25
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Shroff JB, Hanna P, Edgar CM. Surgeon-Directed Arthroscopic Infiltration Between the Popliteal Artery and Capsule of the Knee (IPACK) Block: Technical Description. Arthrosc Tech 2023; 12:e531-e536. [PMID: 37138697 PMCID: PMC10150044 DOI: 10.1016/j.eats.2022.12.005] [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: 08/26/2022] [Revised: 11/21/2022] [Accepted: 12/08/2022] [Indexed: 05/05/2023] Open
Abstract
Advances in regional anesthesia techniques for knee surgery have led to drastic improvements in postoperative pain control and have reduced reliance on perioperative opioid analgesics. The infiltration between the popliteal artery and capsule of the knee (IPACK) block has been a useful tool for providing posterior knee analgesia as an adjuvant to traditional femoral or adductor canal blocks in knee surgery. We present a simple and reproducible technique for the arthroscopic administration of this block.
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Affiliation(s)
| | - Philip Hanna
- University of Connecticut Health, Farmington, Connecticut, U.S.A
| | - Cory M. Edgar
- Department of Orthopedic Surgery, Farmington, Connecticut, U.S.A
- Department of Orthopedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
- Address correspondence to Cory M. Edgar, M.D., Ph.D., Department of Orthopedic Surgery, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030.
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26
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Li S, Qin Y, Wang H, Qin Z, Jiang L, Zhu S, Zeng F, Sun K, Wen J, Yin D. Repair of Ramp Lesions of the Medial Meniscus With ACL Reconstruction Can Better Restore Knee Stability: A Cadaveric Study. Orthop J Sports Med 2023; 11:23259671221140120. [PMID: 37152620 PMCID: PMC10160337 DOI: 10.1177/23259671221140120] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/30/2022] [Indexed: 05/09/2023] Open
Abstract
Background Ramp lesions of the medial meniscus have an impact on joint stability in anterior cruciate ligament (ACL)-deficient knees, but the impact of lesion length and repair is unclear. Purpose/Hypothesis The purpose of this cadaveric study was to evaluate the effect of medial meniscal ramp lesion repair on the biomechanics of ACL-deficient knee joints. It was hypothesized that (1) ramp lesions will increase the anterior tibial translation (ATT), internal rotation (IR), and external rotation (ER) in ACL-deficient knee joints; (2) increasing the length of the ramp lesion will further increase the ATT, IR, and ER; and (3) repairing the ramp lesion will reduce the ATT, IR, and ER after ACL reconstruction. Study Design Controlled laboratory study. Methods Included were 9 fresh-frozen cadaveric specimens (4 left knees, 5 right knees; 6 males and 3 females; mean age, 60 years [range, 40-73 years]). The specimens were tested on a biomechanical rig. Two external loading conditions were applied: a 134-N anterior tibial load and 5-N·m internal/external tibial torque with the knee at full extension and at 15°, 30°, 60°, and 90° of flexion. ATT was tracked via a high-speed video camera. The following knee states were tested: intact; ACL-deficient; ACL-deficient combined with a 5-, 10-, 15-, or 20 mm-long ramp lesion of the medial meniscus; ACL reconstruction; and ACL reconstruction combined with ramp lesion repair. The ATT, IR, and ER at all knee angles were analyzed by 1-way analysis of variance. Results The ATT, IR, and ER were significantly increased after cutting of the ACL (P < .05). The ATT, IR, and ER continued to increase when ACL deficiency was combined with ramp lesions of 5 to 20 mm in length (P < .05). The ATT, IR, and ER significantly decreased after ACL reconstruction and ACL reconstruction combined with ramp lesion repair (P < .05). Conclusion The laxity of knees with ACL deficiency combined with a ramp lesion of the medial meniscus increased more obviously as the ramp lesion increased in length. In a cadaveric model, ACL reconstruction combined with ramp repair improved knee joint stability.
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Affiliation(s)
- Shuzhen Li
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yu Qin
- Department of Orthopedic Surgery, The Affiliated Ruikang Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Hao Wang
- Department of Orthopedic Surgery, The Affiliated Ruikang Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Zhi Qin
- Department of Orthopedic Surgery, The Affiliated Ruikang Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Lianjian Jiang
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Shengwang Zhu
- Department of Orthopedic Surgery, The Affiliated Ruikang Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Feng Zeng
- Department of Orthopedic Surgery, The Affiliated Ruikang Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Ke Sun
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Jieming Wen
- School of Mechanical Engineering, Guangxi University, Nanning, China
| | - Dong Yin
- Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
- Dong Yin, PhD, Department of Joint Surgery and Sports Medicine, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, Guangxi Province, China ()
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Over One-Third of Patients With Multiligament Knee Injuries and an Intact Anterior Cruciate Ligament Demonstrate Medial Meniscal Ramp Lesions on Magnetic Resonance Imaging. Arthroscopy 2023; 39:592-599. [PMID: 36575108 DOI: 10.1016/j.arthro.2022.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/08/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE To determine the incidence of ramp lesions and posteromedial tibial plateau (PMTP) bone bruising on magnetic resonance imaging (MRI) in patients with multiligament knee injuries (MLKIs) and an intact anterior cruciate ligament (ACL). METHODS A retrospective review of consecutive patients surgically treated for MLKIs at 2 level I trauma centers between January 2001 and March 2021 was performed. Only MLKIs with an intact ACL that received MRI scans within 90 days of the injury were included. All MLKIs were diagnosed on MRI and confirmed with operative reports. Two musculoskeletal radiologists retrospectively rereviewed preoperative MRIs for evidence of medial meniscus ramp lesions (MMRLs) and PMTP bone bruises using previously established classification systems. Intraclass correlation coefficients were used to calculate the reliability between the radiologists. The incidence of MMRLs and PMTP bone bruises was quantified using descriptive statistics. RESULTS A total of 221 MLKIs were identified, of which 32 (14.5%) had an intact ACL (87.5% male; mean age of 29.9 ± 8.6 years) and were included. The most common MLKI pattern was combined injury to the posterior cruciate ligament and posterolateral corner (n = 27, 84.4%). PMTP bone bruises were observed in 12 of 32 (37.5%) patients. Similarly, MMRLs were diagnosed in 12 of 32 (37.5%) patients. A total of 8 of 12 (66.7%) patients with MMRLs demonstrated evidence PMTP bone bruising. CONCLUSIONS Over one-third of MLKI patients with an intact ACL were diagnosed with MMRLs on MRI in this series. PMTP bone bruising was observed in 66.7% of patients with MMRLs, suggesting that increased vigilance for identifying MMRLs at the time of ligament reconstruction should be practiced in patients with this bone bruising pattern. LEVEL OF EVIDENCE Level IV, retrospective case series.
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28
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Farinelli L, Abermann E, Meena A, Ueblacker P, Hahne J, Fink C. Return to Play and Pattern of Injury After ACL Rupture in a Consecutive Series of Elite UEFA Soccer Players. Orthop J Sports Med 2023; 11:23259671231153629. [PMID: 36896098 PMCID: PMC9989402 DOI: 10.1177/23259671231153629] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/09/2022] [Indexed: 03/11/2023] Open
Abstract
Background Anterior cruciate ligament rupture represents a career-threatening injury for professional soccer players. Purpose To analyze the pattern of injury, return to play (RTP), and performance of a consecutive series of elite professional soccer players after anterior cruciate ligament reconstruction (ACLR). Study Design Case series; Level of evidence, 4. Methods We evaluated the medical records of 40 consecutive elite soccer players who underwent ACLR by a single surgeon between September 2018 and May 2022. Patient age, height, weight, body mass index, position, injury history, affected side, RTP time, minutes played per season (MPS), and MPS as a percentage of playable minutes before and after ACLR were retrieved from medical records and from publicly available media-based platforms. Results Included were 27 male patients (mean ± SD age at surgery, 23.2 ± 4.3 years; range, 18-34 years). The injury occurred during matches in 24 players (88.9%), with a noncontact mechanism in 22 (91.7%). Meniscal pathology was found in 21 patients (77.8%). Lateral meniscectomy and meniscal repair were performed in 2 (7.4%) and 14 (51.9%) patients, respectively, and medial meniscectomy and meniscal repair were performed in 3 (11.1%) and 13 (48.1%) patients, respectively. A total of 17 players (63.0%) underwent ACLR with bone-patellar tendon-bone autograft and 10 (37.0%) with soft tissue quadriceps tendon. Lateral extra-articular tenodesis was added in 5 patients (18.5%). The overall RTP rate was 92.6% (25 of 27). Two athletes moved to a lower league after surgery. The mean MPS% during the last preinjury season was 56.69% ± 21.71%; this decreased significantly to 29.18% ± 20.6% (P < .001) in the first postoperative season and then increased to 57.76% ± 22.89% and 55.89% ± 25.8% in the second and third postoperative seasons. Two (7.4%) reruptures and 2 (7.4%) failed meniscal repairs were reported. Conclusion ACLR in elite UEFA soccer players was associated with a 92.6% rate of RTP and 7.4% rate of reinjury within 6 months after primary surgery. Moreover, 7.4% of soccer players moved to a lower league during the first season after surgery. Age, graft selection, concomitant treatments, and lateral extra-articular tenodesis were not significantly associated with prolonged RTP.
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Affiliation(s)
- Luca Farinelli
- Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Elisabeth Abermann
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
| | - Amit Meena
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria.,Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | | | - Jochen Hahne
- Football Club FC Bayern München, Munich, Germany
| | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
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Abstract
Acute knee injury ranges among the most common joint injuries in professional and recreational athletes. Radiographs can detect joint effusion, fractures, deformities, and malalignment; however, MR imaging is most accurate for radiographically occult fractures, chondral injury, and soft tissue injuries. Using a structured checklist approach for systematic MR imaging evaluation and reporting, this article reviews the MR imaging appearances of the spectrum of traumatic knee injuries, including osteochondral injuries, cruciate ligament tears, meniscus tears and ramp lesions, anterolateral complex and collateral ligament injuries, patellofemoral translation, extensor mechanism tears, and nerve and vascular injuries.
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Menéndez SE, González PG, Morís ARM, Soto MDV, Fernández AM. Reproducibility of MRI in the diagnosis of meniscal ramp lesions: an inter-observer study. Acta Radiol 2023; 64:1078-1085. [PMID: 35607260 DOI: 10.1177/02841851221101878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Meniscal ramp lesions have gained much prominence in recent years due to a significant increase in their diagnosis and their important biomechanical involvement in the knee. A new proposed classification of these lesions has recently been published. PURPOSE To evaluate the reproducibility of the new classification of meniscal ramp lesions recently published using magnetic resonance imaging (MRI). MATERIAL AND METHODS A total of 249 post-traumatic knee MRI studies were evaluated by three musculoskeletal radiologists independently. Patients with an anterior cruciate ligament (ACL) tear on MRI in addition to a recent history of trauma to the knee for <12 months were included in the study, for a total of 95. We carried out an inter-observer concordance study to analyze whether the new classification is reproducible to detect meniscal ramp lesions and to classify them into their different types. RESULTS Among our study cohort of 95 patients, we found 47 (49.5%) ramp lesions. In the inter-observer study, we obtained a good concordance (k = 0.733) in the detection of these lesions and an excellent one (k = 0.843) when the type of lesion is described. CONCLUSION This study demonstrates that the new classification of meniscal ramp lesions has good reproducibility on MRI.
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Affiliation(s)
| | | | - Ana Rosa Meana Morís
- Department of Radiology, 16475Hospital Universitario de Cabueñes, Gijón, Asturias, Spain
| | - Miguel Del Valle Soto
- Department of Morphology and Cell Biology, 16763University of Oviedo, Oviedo, Asturias, Spain
- Health Research Institute of the Principality of Asturias (ISPA), Oviedo, Asturias, Spain
| | - Antonio Maestro Fernández
- Department of Orthopedic Surgery, Clínica Molinón, Gijón, Asturias, Spain
- Real Sporting de Gijón. Spain
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31
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Moran J, Jimenez AE, Katz LD, Wang A, McLaughlin WM, Gillinov SM, Patel RR, Kunze KN, Hewett TE, Alaia MJ, LaPrade RF, Medvecky MJ. Examining Preoperative MRI for Medial Meniscal Ramp Lesions in Patients Surgically Treated for Acute Grade 3 Combined Posterolateral Corner Knee Injury. Orthop J Sports Med 2023; 11:23259671221144767. [PMID: 36756171 PMCID: PMC9900669 DOI: 10.1177/23259671221144767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/13/2022] [Indexed: 02/05/2023] Open
Abstract
Background While medial meniscocapsular tears (ramp lesions) are commonly associated with isolated anterior cruciate ligament injuries, there are limited descriptions of these meniscal injuries in multiligament knee injuries (MLKIs). Purpose To (1) retrospectively evaluate preoperative magnetic resonance imaging (MRI) scans for the presence of ramp lesions in patients surgically treated for acute grade 3 combined posterolateral corner (PLC) knee injuries and (2) determine if a preoperative posteromedial tibial plateau (PMTP) bone bruise is associated with the presence of preoperative ramp lesions on MRI in these same patients. Study Design Cross-sectional study; Level of evidence, 3. Methods Data on consecutive patients at a level 1 trauma center with MLKIs between 2001 and 2021 were retrospectively reviewed. Only patients with acute grade 3 combined PLC injuries who received an MRI scan within 30 days of injury were assessed. Two musculoskeletal radiologists retrospectively reviewed each patient's preoperative MRI for evidence of ramp lesions and bone bruises. Intraclass correlation coefficients (ICCs) were used to calculate reliability among the reviewers. Multivariate analysis was used to evaluate the relationship between PMTP bruising and the presence of a ramp lesion on MRI. Results A total of 68 patients (79.4% male; mean age, 33.8 ± 13.7 years) with an acute grade 3 combined PLC injury were included in the study. On MRI, the ICCs for detection of ramp lesions and PMTP bone bruising were 0.921 and 0.938, respectively. Medial meniscal ramp lesions were diagnosed in 18 of 68 (26.5%) patients. Eleven of 18 (61.1%) patients with ramp lesions also showed evidence of PMTP bruising, while 13 of 50 (26.0%) patients without ramp lesions had PMTP bruising (P = .008). When controlling for age and sex, PTMP bruising was significantly associated with the presence of a ramp lesion in combined PLC injuries (odds ratio, 4.62; P = .012). Conclusion Preoperative medial meniscal ramp lesions were diagnosed on MRI in 26.5% of patients with acute grade 3 combined PLC injuries. PMTP bone bruising was significantly associated with the presence of a ramp lesion on MRI. These findings reinforce the need to assess for potential ramp lesions at the time of multiligament reconstruction.
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Affiliation(s)
- Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
- Jay Moran, BS, Department of Orthopaedics and Rehabilitation,
Yale School of Medicine, 367 Cedar Street, New Haven, CT 06511, USA (
) (Twitter: @JayMoran25)
| | - Andrew E. Jimenez
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Lee D. Katz
- Department of Musculoskeletal Imaging, Yale School of Medicine, New
Haven, Connecticut, USA
| | - Annie Wang
- Department of Musculoskeletal Imaging, Yale School of Medicine, New
Haven, Connecticut, USA
| | - William M. McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Stephen M. Gillinov
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Rohan R. Patel
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
| | - Kyle N. Kunze
- Hospital for Special Surgery–Weill Cornell Medical School, New York
New York, USA
| | | | - Michael J. Alaia
- Orthopedic Surgery, Division of Sports Medicine, New York University
Langone Health, New York, New York, USA
| | | | - Michael J. Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of
Medicine, New Haven, Connecticut, USA
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Cristiani R, van de Bunt F, Kvist J, Stålman A. High prevalence of meniscal ramp lesions in anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc 2023; 31:316-324. [PMID: 36045182 PMCID: PMC9859899 DOI: 10.1007/s00167-022-07135-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/19/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To evaluate the prevalence of and factors associated with meniscal ramp lesions on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) injuries. METHODS Data from the Natural Corollaries and Recovery after ACL injury multicentre longitudinal cohort study (NACOX) were analysed. Only patients who underwent MRI were included in this study. All MRI scans were reviewed by an orthopaedic knee surgeon and a musculoskeletal radiologist. The patients were divided into two groups, those with and without ramp lesions according to MRI findings. Univariable and stepwise forward multiple logistic regression analyses were used to evaluate patient characteristics (age, gender, body mass index, pre-injury Tegner activity level, activity at injury) and concomitant injuries on MRI (lateral meniscus, medial collateral ligament [MCL], isolated deep MCL, lateral collateral ligament, pivot-shift-type bone bruising, posteromedial tibial [PMT] bone bruising, medial femoral condyle bone bruising, lateral femoral condyle [LFC] impaction and a Segond fracture) associated with the presence of meniscal ramp lesions. RESULTS A total of 253 patients (52.2% males) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of meniscal ramp lesions was 39.5% (100/253). Univariate analyses showed that contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising, LFC impaction and the presence of a Segond fracture increased the odds of having a meniscal ramp lesion. Stepwise forward multiple logistic regression analysis revealed that the presence of a meniscal ramp lesion was associated with contact sports at ACL injury [odds ratio (OR) 2.50; 95% confidence intervals (CI) 1.32-4.72; P = 0.005], pivot-shift-type bone bruising (OR 1.29; 95% CI 1.01-1.67; P = 0.04), PMT bone bruising (OR 4.62; 95% CI 2.61-8.19; P < 0.001) and the presence of a Segond fracture (OR 4.38; 95% CI 1.40-13.68; P = 0.001). CONCLUSION The overall prevalence of meniscal ramp lesions in patients with ACL injuries was high (39.5%). Contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising and the presence of a Segond fracture on MRI were associated with meniscal ramp lesions. Given their high prevalence, meniscal ramp lesions should be systematically searched for on MRI in patients with ACL injuries. Knowledge of the factors associated with meniscal ramp lesions may facilitate their diagnosis, raising surgeons' and radiologists' suspicion of these tears. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Riccardo Cristiani
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden. .,Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486, Stockholm, Sweden.
| | - Fabian van de Bunt
- grid.24381.3c0000 0000 9241 5705Division of Radiology, Department of Clinical Science, Karolinska University Hospital, Stockholm, Sweden
| | - Joanna Kvist
- grid.4714.60000 0004 1937 0626Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden ,grid.5640.70000 0001 2162 9922Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of Physiotherapy, Linköping University, Linköping, Sweden
| | - Anders Stålman
- grid.4714.60000 0004 1937 0626Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden ,grid.416138.90000 0004 0397 3940Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486 Stockholm, Sweden
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Park YB, Kim H, Lee HJ, Baek SH, Kwak IY, Kim SH. The Clinical Application of Machine Learning Models for Risk Analysis of Ramp Lesions in Anterior Cruciate Ligament Injuries. Am J Sports Med 2023; 51:107-118. [PMID: 36412925 DOI: 10.1177/03635465221137875] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Peripheral tears of the posterior horn of the medial meniscus, known as "ramp lesions," are commonly found in anterior cruciate ligament (ACL)-deficient knees but are frequently missed on routine evaluation. PURPOSE To predict the presence of ramp lesions in ACL-deficient knees using machine learning methods with associated risk factors. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS This study included 362 patients who underwent ACL reconstruction between June 2010 and March 2019. The exclusion criteria were combined fractures and multiple ligament injuries, except for medial collateral ligament injuries. Patients were grouped according to the presence of ramp lesions on arthroscopic surgery. Binary logistic regression was used to analyze risk factors including age, sex, body mass index, time from injury to surgery (≥3 or <3 months), mechanism of injury (contact or noncontact), side-to-side laxity, pivot-shift grade, medial and lateral tibial/meniscal slope, location of bone contusion, mechanical axis angle, and lateral femoral condyle (LFC) ratio. The receiver operating characteristic curve and area under the curve were also evaluated. RESULTS Ramp lesions were identified in 112 patients (30.9%). The risk for ramp lesions increased with steeper medial tibial and meniscal slopes, higher knee laxity, and an increased LFC ratio. Comparing the final performance of all models, the random forest model yielded the best performance (area under the curve: 0.944), although there were no significant differences among the models (P > .05). The cut-off values for the presence of ramp lesions on receiver operating characteristic analysis were as follows: medial tibial slope >5.5° (P < .001), medial meniscal slope >5.0° (P < .001), and LFC ratio >71.3% (P = .033). CONCLUSION Steep medial tibial and meniscal slopes, an increased LFC ratio, and higher knee rotatory laxity were observed risk factors for ramp lesions in patients with an ACL injury. The prediction model of this study could be used as a supplementary diagnostic tool for ramp lesions in ACL-injured knees. In general, care should be taken in patients with ramp lesions and its risk factors during ACL reconstruction.
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Affiliation(s)
- Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyojoon Kim
- Department of Computer Science, Princeton University, Princeton, New Jersey, USA
| | - Han-Jun Lee
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Suk-Ho Baek
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Il-Youp Kwak
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Seong Hwan Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
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Meniscal ramp lesions: a lot is known, but a lot is also unknown…. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07292-w. [PMID: 36544052 DOI: 10.1007/s00167-022-07292-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
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Diagnosis of medial meniscal ramp lesion is difficult by pre-operative magnetic resonance imaging evaluation and needs a methodical arthroscopic exploration. J Orthop Sci 2022; 27:1271-1277. [PMID: 34404612 DOI: 10.1016/j.jos.2021.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/29/2021] [Accepted: 07/17/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Meniscal ramp lesion (RL) is the peripheral lesion of the posterior horn of the medial meniscus (PHMM) associated with anterior cruciate ligament (ACL) tear. The purpose of this study was to evaluate the accuracy of pre-operative magnetic resonance imaging (MRI) evaluation in diagnosing RL and to identify whether the difficulty in diagnosis differs depending on the location of RL. METHODS ACL-injured patients undergoing ACL reconstruction from January 2017 to January 2019 were enrolled. A methodical arthroscopic exploration to identify RL was conducted intra-operatively using three steps, namely, the anterior visualization step, the inter-condylar visualization step, and the posteromedial step. The location of the RLs was evaluated and classified into two types as follows: Red-red zone (RR) - a meniscal tear of the red-red zone of the PHMM. Menisco-capsular junction (MCJ) - a lesion at the menisco-capsular junction of the PHMM, which is more peripheral than RR. Furthermore, the accuracy of 1.5-T MRI evaluation to diagnose RL by two testers using sagittal proton-density fat-saturated images was calculated. RESULTS Of the 81 patients enrolled, 11 had RL: 5 cases each were at the MCJ and RR, and 1 case was at both locations. The sensitivity of MRI for detecting RL was 27.3-45.5%, whereas the specificity was 84.3-95.7% in total. The sensitivity of MRI in detecting RL at the RR and MCJ was 40.0-80.0%, 0-20.0%, respectively. The intra-observer reliability of the MRI evaluation was moderate (κ coefficient: 0.40-0.46), while the inter-observer reliability was fair to moderate (κ coefficient: 0.27-0.41). CONCLUSIONS A low sensitivity of the MRI in detecting RL at the MCJ was observed, and the reliability of the MRI evaluation for diagnosis of RL was not high. Therefore, methodical arthroscopic exploration is essential to diagnose RL even when it is not suspected on pre-operative MRI.
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36
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Rauch A. [Knee injuries in winter sports]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:870-881. [PMID: 36239771 PMCID: PMC9663366 DOI: 10.1007/s00132-022-04317-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 11/05/2022]
Abstract
Winter sports represent a relevant entity for knee injuries due to their great popularity. In alpine skiing and snowboarding, knee joint injuries are the most common affected body regions, while in ice hockey they are in third place. Various accident mechanisms lead to different injury types and severities. In addition to medial collateral ligament injuries, anterior cruciate ligament injuries are of particular importance. In professional sports, severe combination injuries are more common. Therapy is exemplified using the anterior cruciate ligament rupture. The gold standard is replacement ligament surgery. The return-to-sport rate of 80% for skiing and snowboarding is comparable to summer sports such as football, basketball or baseball. For ice hockey, it is even better. Prevention is possible by targeted training programs, but also by optimizing the equipment and its adjustment.
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Affiliation(s)
- Alexander Rauch
- ECOM - Praxis für Orthopädie, Sportmedizin & Unfallchirurgie, Arabellastraße 17, 81925, München, Deutschland.
- Sporttraumatologie und Kniechirurgie, ATOS-Klinik München, Effnerstraße 38, 81925, München, Deutschland.
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Tuphé P, Foissey C, Unal P, Vieira TD, Chambat P, Fayard JM, Thaunat M. Long-term Natural History of Unrepaired Stable Ramp Lesions: A Retrospective Analysis of 28 Patients With a Minimum Follow-up of 20 Years. Am J Sports Med 2022; 50:3273-3279. [PMID: 36074027 DOI: 10.1177/03635465221120058] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a lack of consensus about whether stable ramp lesions associated with anterior cruciate ligament (ACL) injuries need to be repaired. PURPOSE/HYPOTHESIS The purpose of this study was to evaluate how many stable ramp lesions left in situ during ACL reconstruction (ACLR) have subsequently failed after >20 years of follow-up. We hypothesized that ACL-reconstructed knees with ramp lesions left in situ without repair have a high risk of meniscal failure over the long term. STUDY DESIGN Case series; Level of evidence, 4. METHODS All patients who underwent arthroscopic ACLR by a single experienced surgeon between January 1998 and December 2000 were evaluated retrospectively. Included were all cases of longitudinal tears in the meniscocapsular junction or the red zone of the posterior horn of the medial meniscus that were left in situ and identified through the anterior portals. Successful anterior probing confirmed a meniscal tear of the posterior segment. A lesion was considered stable if it was ≤2 cm and did not extend beyond the lower pole of the femoral condyle. The following data were collected preoperatively and at the last follow-up: demographics, time to surgery, side-to-side laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner activity scale, and meniscal failure rate. We defined 2 groups based on our findings: medial meniscal failure versus no medial meniscal failure. RESULTS A total of 716 knees underwent primary ACLR during this period. The 39 (5.4%) stable unrepaired ramp lesions identified were included in the case series. Mean ± standard deviation follow-up was 262.1 ± 10.5 months. Eleven patients (28%) were lost to follow-up. Of the remaining patients, 8 (28.6%) had a medial meniscal failure, of which 6 (21.4%) were bucket-handle tears. The average time elapsed before complications was 87.8 ± 52 months (range, 6-156 months). The medial meniscal survival rate was 93% at 5 years, 75% at 10 years, and 71% at 15 and 20 years. The failure event mainly happened between 96 and 120 months (8 and 10 years) after ACLR. No risk factors for failure were found, but some trends appeared, such as older age, higher body mass index, and preoperative rotational instability. All postoperative scores were significantly improved at the last follow-up (P < .0001); 16 patients (57%) returned to their sport of choice. CONCLUSION With nearly one-third of patients developing meniscal complications, including a large share of bucket-handle tears and mostly occurring 8 years after the ACLR, it may not be wise to leave stable ramp lesions unrepaired.
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Affiliation(s)
- Pierre Tuphé
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Constant Foissey
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Pauline Unal
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Thais Dutra Vieira
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Pierre Chambat
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Jean-Marie Fayard
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Mathieu Thaunat
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
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Gousopoulos L, Hopper GP, Saithna A, Grob C, Levy Y, Haidar I, Fayard JM, Thaunat M, Vieira TD, Sonnery-Cottet B. Suture Hook Versus All-Inside Repair for Longitudinal Tears of the Posterior Horn of the Medial Meniscus Concomitant to Anterior Cruciate Ligament Reconstruction: A Matched-Pair Analysis From the SANTI Study Group. Am J Sports Med 2022; 50:2357-2366. [PMID: 35666109 DOI: 10.1177/03635465221100973] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Secondary meniscectomy rates after repair of longitudinal tears of the posterior horn of the medial meniscus (PHMM) performed concomitantly with anterior cruciate ligament reconstruction (ACLR) are reported to be as high as 25% with an all inside repair technique. Posteromedial portal suture hook repair is an emerging technique; however, it is unknown whether it confers a significantly reduced secondary meniscectomy rate compared with the current gold standard. PURPOSE/HYPOTHESIS The primary objective of this study was to compare the secondary meniscectomy rates of suture hook repair and all inside repair for longitudinal tears of the PHMM performed concomitant to ACLR. The secondary outcome was to determine the risk factors associated with the failure of the repair. It was hypothesized that repair with an all inside device would be associated with higher secondary meniscectomy rates when compared with suture hook repair and that concomitant anterolateral ligament reconstruction (ALLR) would confer improved meniscal repair survivorship. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients with longitudinal tears of the PHMM who underwent meniscal repair during primary ACLR between January 2011 and December 2015 at our institution were eligible for the study. Patients undergoing suture hook repair were propensity matched in a 1:1 ratio to patients who underwent all inside repair. At the end of the study period, secondary meniscectomy rates were determined. RESULTS The study population comprised 237 matched pairs. The mean follow up was 97.7 ± 17.3 months. Patients who underwent an all inside repair had a >2-fold higher failure rate compared with patients who underwent suture hook repair through a posteromedial portal (31.2% vs 15.6%; P = .0003). Patients in the suture hook repair group undergoing additional ALLR demonstrated a >3-fold higher meniscal repair survival rate compared with all other subgroups (P = .0014). This association was not seen in the all inside repair group. The only statistically significant risk factor for meniscal repair failure was the suture repair technique (hazard ratio, 2.133 [95% CI, 1.383-3.292]; P = .0008). CONCLUSION Suture hook repair through a posteromedial portal is associated with a significantly lower secondary meniscectomy rate when compared with the all inside meniscal repair of longitudinal tears of the PHMM performed at the time of ACLR. Furthermore, patients in the suture hook repair group who underwent an additional ALLR had a significantly better meniscal repair survivorship compared with all other subgroups.
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Affiliation(s)
- Lampros Gousopoulos
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Graeme P Hopper
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Adnan Saithna
- Arizona Brain, Spine & Sports Injuries Center, Scottsdale, Arizona, USA
| | - Charles Grob
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Yoann Levy
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Ibrahim Haidar
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Jean-Marie Fayard
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Mathieu Thaunat
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, Hopital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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Gracia G, Cavaignac M, Marot V, Mouarbes D, Laumonerie P, Cavaignac E. Epidemiology of Combined Injuries of the Secondary Stabilizers in ACL-Deficient Knees: Medial Meniscal Ramp Lesion, Lateral Meniscus Root Tear, and ALL Tear: A Prospective Case Series of 602 Patients With ACL Tears From the SANTI Study Group. Am J Sports Med 2022; 50:1843-1849. [PMID: 35416066 DOI: 10.1177/03635465221092767] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial meniscal ramp lesion (MMRL), lateral meniscus root tear (LMRT), and anterolateral ligament (ALL) tear are individual injuries that have been described in patients who have an anterior cruciate ligament (ACL) tear. However, the prevalence of these lesions and their combination has not been defined. PURPOSES To define the individual and combined prevalence of MMRL, LMRT, and ALL tears in a case series of patients undergoing ACL reconstruction and to identify the risk factors for combined injuries. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Patients aged >15 years undergoing primary ACL reconstruction between January 2019 and June 2021 were enrolled in the study. A preoperative ultrasound scan was performed to look for an ALL tear. The presence of MMRL and LMRT was determined during a standardized arthroscopy exploration. A multivariate logistic regression model was used to determine the individual effect of patient variables on the risk of associated single, dual, triad, or tetrad injuries (MMRL, LMRT, ALL, ACL), represented by an adjusted odds ratio. RESULTS The case series consisted of 602 patients who underwent primary ACL reconstruction. An isolated ACL injury was present in 147 patients (24%). A dual injury was detected in 34 patients (6%) who had ACL-MMRL, 16 (2.65%) who had ACL-LMRT, and 265 (44%) who had ACL-ALL. A triad injury was detected in 80 patients (13.28%) who had ACL-ALL-MMRL, 36 (6%) who had ACL-ALL-LMRT, and 3 (0.5%) who had ACL-MMRL-LMRT. A tetrad injury pattern was detected in 21 patients (3.5%). Multivariate analysis showed that the occurrence of tetrad injury was significantly lower in older patients (adjusted odds ratio by year, 0.93 [95% CI, 0.88-0.99]; P = .028). Identifying LMRT increased the likelihood of finding MMRL-ALL injuries by 2.11 times (95% CI, 1.09-3.12; P = .031). CONCLUSION Isolated ACL tear is less common than combined injuries, which are quite frequent. Younger age is a risk factor for combined injuries. The search for damaged secondary stabilizers of the knee must be meticulous and systematic, especially when 1 injured structure has already been diagnosed.
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Affiliation(s)
- Gauthier Gracia
- Department of Orthopaedic Surgery, Polyclinique Côte Basque Sud, Saint-Jean-de-Luz, France
| | | | - Vincent Marot
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Dany Mouarbes
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | | | - Etienne Cavaignac
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
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Pioger C, Claes S, Haidar I, Fradin T, Ngbilo C, Rayes J, Hopper GP, Vieira TD, Sonnery-Cottet B. Prevalence and Incidence of Chondral and Meniscal Lesions in Patients Undergoing Primary and Subsequent Revision Anterior Cruciate Ligament Reconstruction: An Analysis of 213 Patients From the SANTI Group. Am J Sports Med 2022; 50:1798-1804. [PMID: 35575386 DOI: 10.1177/03635465221094624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have shown a higher prevalence of meniscal and chondral lesions at the time of revision anterior cruciate ligament reconstruction (R-ACLR) compared with primary ACLR procedures. However, studies that follow the development of meniscal and chondral status through primary and subsequent R-ACLR are scarce. PURPOSE To compare the prevalence of meniscal and chondral injuries in patients undergoing primary ACLR and subsequent R-ACLR. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients who underwent ACLR and subsequently needed R-ACLR between January 2009 and February 2018 in a single center were included. A retrospective analysis of prospectively collected data was conducted. RESULTS A total of 213 patients were included, with a mean follow-up of 59.7 months. The mean age was 22 years at primary ACLR and 26.1 years at the time of revision. The proportion of meniscal tears was higher at the time of R-ACLR compared with the time of primary reconstruction (70.0% vs 44.6%, respectively; P < .001). Similarly, the prevalence of chondral lesions was significantly higher at the time of revision versus the primary reconstruction (15.5% vs 7.0%, respectively; P = .003). CONCLUSION R-ACLR is associated with a higher rate of concomitant meniscal and chondral lesions than primary ACLR.
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Affiliation(s)
- Charles Pioger
- Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Steven Claes
- Department of Orthopedic Surgery, AZ Herentals Hospital, Herentals, Belgium
| | - Ibrahim Haidar
- Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Thomas Fradin
- Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Cedric Ngbilo
- Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Johnny Rayes
- Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Graeme Philip Hopper
- Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
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Ramp lesion repair via dual posteromedial arthroscopic portals: A cadaveric feasibility study. Orthop Traumatol Surg Res 2022; 108:103175. [PMID: 34906726 DOI: 10.1016/j.otsr.2021.103175] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Ramp lesions are found in 16% to 40% of patients undergoing anterior cruciate ligament reconstruction. The repair technique traditionally involves using a suture hook through a posteromedial portal, with the arthroscope positioned in the intercondylar view via an antero-lateral portal. Ramp lesions may be difficult to visualize and repair, even with a 70° arthroscope. The objective of this study was to assess the feasibility of suturing ramp lesions via dual posteromedial portals for the arthroscope and instruments. HYPOTHESIS Dual posteromedial arthroscopic portals allow good visualisation and high-quality suturing of ramp lesions, without inducing specific iatrogenic injuries. MATERIAL AND METHODS We used 11 fresh cadaver knees. Two posteromedial portals were created under visualisation via an arthroscope introduced through an antero-lateral portal: one was the traditional instrumental portal and the other, located more proximally, was the optical portal. A 2-cm long ramp lesion was created. A suture hook was used to place one or two stitches of PDS n°0 suture. A probe was used to test the quality and stability of the suturing. The posteromedial plane was then dissected to evaluate the anatomical relationships of the portals. RESULTS The dual posteromedial approach allowed the visualisation and hook suturing of the ramp lesions in all 11 cases. A single stitch was placed in 4 cases and two stitches in 7 cases. The suture was always of good quality and stable when tested with the probe. The dissection found no injuries to nerves, blood vessels, or tendons. CONCLUSION Ramp lesions can be repaired through a dual posteromedial arthroscopic approach. This surgical technique provides good visibility of these lesions and allows high-quality suturing, with no specific iatrogenic injuries. It is an alternative to ramp lesion repair via a single posteromedial portal, which can be challenging. LEVEL OF EVIDENCE IV, experimental study with no control group.
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Meniscal ramp lesions – Skillful neglect or routine repair? J Orthop 2022; 32:31-35. [DOI: 10.1016/j.jor.2022.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/01/2022] [Indexed: 11/22/2022] Open
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Escoda Menéndez S, García González P, Meana Morís AR, del Valle Soto M, Maestro Fernández A. Meniscal Ramp Lesions: What the Radiologist Needs to Know. Acad Radiol 2022; 29:619-626. [PMID: 33663972 DOI: 10.1016/j.acra.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 01/11/2023]
Abstract
Meniscal ramp lesions are a special type of injury that affects the periphery of the posterior horn of the medial meniscus (PHMM) and/or its meniscocapsular attachments. They are strongly associated with acute and chronic anterior cruciate ligament (ACL) tears. These lesions have gained much prominence in recent years, due to a significant increase in their diagnosis and their important biomechanical involvement in the knee. It is known that their presence in ACL-deficient knees is related to instability and if they are not repaired during ACL reconstruction, they can ultimately cause the failure of the graft. Since this type of injury is often underdiagnosed due to its localization at the "blind" point of arthroscopic vision, it is crucial to make an accurate preoperative diagnosis of them with MRI. The objective of this article is to review the recent literature regarding meniscal ramp lesions and to summarize the anatomical, biomechanical and fundamentally diagnostic aspects, emphasizing the radiological findings described until now.
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Meniscal Ramp Lesions: Anatomy, Epidemiology, Diagnosis, and Treatment. J Am Acad Orthop Surg 2022; 30:255-262. [PMID: 34936583 DOI: 10.5435/jaaos-d-21-00091] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 11/24/2021] [Indexed: 02/01/2023] Open
Abstract
Injuries to the medial meniscus meniscocapsular junction, also known as ramp lesions, are common in the setting of anterior cruciate ligament injuries with a prevalence of 9% to 42%. Anatomically, ramp lesions involve disruption of the posterior meniscocapsular junction and meniscotibial ligaments. Biomechanically, ramp lesions are associated with an increase in anterior tibial translation and internal and external tibial rotation in anterior cruciate ligament-deficient cadaveric knees. Magnetic resonance imaging is useful in evaluating the meniscocapsular junction. Irregularity or increased signal near the posterior meniscocapsular junction and/or signal change indicative of posterior medial tibial plateau edema can suggest these injuries are present before surgical intervention. The current benchmark for diagnosis is arthroscopic visualization of the posterior medial meniscocapsular junction viewed through the intercondylar notch. Once a ramp lesion is identified, stability should be assessed by arthroscopic probing to determine the degree of anterior displacement. Optimal treatment has been debated in the literature, especially for stable ramp lesions, although good outcomes have been shown with and without repair. Repair is warranted for those lesions that are unstable to probing. Unfortunately, only limited literature available to guide clinicians on the optimal rehabilitation for ramp lesions.
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Srimongkolpitak S, Chernchujit B. Current concepts on meniscal repairs. J Clin Orthop Trauma 2022; 27:101810. [PMID: 35282657 PMCID: PMC8904242 DOI: 10.1016/j.jcot.2022.101810] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 02/07/2022] [Accepted: 02/18/2022] [Indexed: 11/30/2022] Open
Abstract
The specific meniscus injury pattern were divided into many patterns. Nowadays, the meniscus root injury, radial tear meniscus, bucket handle tear meniscus and Ramp lesion were particularly focused on many way to manage and still controversial a lot of issues. Meniscus root tears (MRTs) and Ramp lesion are the most ignored, or misdiagnosed causes of chronic knee pain. Most patients delayed seeking treatment, consequently resulting in cartilage loss, and leading to the condition progressing to osteoarthritis knee. This has resulted in the rate of MR and Ramp repair increase significantly. The bucket handle meniscus tear trend to strong saving the anatomical meniscus and avoid to menisectomy. This article, on the other hand, will reveal you how to save and secure a nearly native meniscus fixation. In case of the radial meniscus, the partial meniscectomy is still used to treat this type of injury today, but it does not prevent degenerative changes from occurring, which can lead to unfavorable outcomes. Meniscal repair is a popular procedure for treating radial tears as an alternative to surgery. However, this pattern of meniscus tear can be difficult to repair and has a high failure rate, the arthroscopic meniscus repair techniques are published.
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Affiliation(s)
- Surasak Srimongkolpitak
- Department of Orthopedic, Faculty of Medicine, Queen Savang Vadhana Memorial Hospital, 209 Jermjormpol Road, Si Racha District, Chon Buri Province, 20110, Thailand,Corresponding author.
| | - Bancha Chernchujit
- Department of Orthopedic, Faculty of Medicine, Thammasat University, Thailand
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Rodriguez AN, LaPrade RF, Geeslin AG. Combined Meniscus Repair and Anterior Cruciate Ligament Reconstruction. Arthroscopy 2022; 38:670-672. [PMID: 35248223 DOI: 10.1016/j.arthro.2022.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/04/2022] [Indexed: 02/02/2023]
Abstract
Meniscal tear patterns associated with anterior cruciate ligament (ACL) tears, such as root tears and ramp lesions are common but less easily recognized on magnetic resonance imaging (MRI) compared with a complete radial tear or a locked bucket-handle tear. Timely treatment of these tears improves outcomes in the setting of ACL reconstruction. While physical examination does not enable a definitive diagnosis of meniscal root tears and ramp lesions, high-grade laxity, including a 3+ Lachman and 3+ pivot shift, should raise suspicions for these tear patterns. MRI allows visualization of both root tears and ramp lesions, although the gold standard for diagnosis is probing at the time of arthroscopy due to a high false-negative rate on MRI. Up to 17% of patients with an ACL tear have a lateral meniscal root tear; a contact mechanism and increased posterior slope are both associated with a greater incidence of lateral meniscal root tears and these are repaired with a tunnel technique. Meniscal ramp lesions occur in up to 41% of patients with ACL tears due to a contact mechanism, and we prefer repair with an inside-out technique. More than 60% of complete radial meniscal tears occur in the setting of ACL tears and are preferentially repaired with a hashtag technique for minimally separated tears and a 2-tunnel technique combined with an inside-out repair for more severe tears. Bucket-handle tears are more common in the setting of chronic ACL deficiency; concurrent with ACL reconstruction urgent meniscal repair with an inside-out technique is the gold standard, which allows for precise approximation of the tear with multiple points of fixation for improved biomechanical performance. It is critical to identify and treat these tears during ACL reconstruction because of their role as secondary stabilizers and for long-term chondral protection.
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Affiliation(s)
| | | | - Andrew G Geeslin
- University of Vermont, Larner College of Medicine, Orthopaedics and Rehabilitation, Burlington, Vermont, U.S.A..
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Thaunat M, Foissey C, Ingale P, Haidar I, Bauwens PH, Penet A, Kacem S, Fayard JM. Survival and Risk Factor Analysis of Arthroscopic Ramp Lesion Repair During Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2022; 50:637-644. [PMID: 35099318 DOI: 10.1177/03635465211068524] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a lack of research on the management of ramp lesions associated with anterior cruciate ligament (ACL) injuries. Furthermore, there has been no report of the risk factors for failure of ramp lesion sutures, linked to either the technique used (all-inside suture implant vs suture hook through a posteromedial portal) or the type of lesion (location in the red zone or meniscocapsular junction, longitudinal extension, partial- or full-thickness tear). PURPOSE To evaluate the results of arthroscopic repair of ramp lesions and determine the risk factors associated with ramp lesion repair failure, with special focus on their subtype and the suture technique. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS All patients who underwent arthroscopic ramp lesion repair in association with ACL reconstruction between November 2015 and January 2018 were evaluated retrospectively. The following parameters were studied: demographics; clinical history; clinical findings including International Knee Documentation Committee score, complications, time from injury to surgery, side-to-side laxity, and pivot shift; and surgical findings including subtype, surgical management, and type and number of sutures. Failure of the ramp lesion repair was defined at secondary arthroscopy. RESULTS Among the 248 lesions analyzed, 18 (7.3%) failures were documented. The failures occurred in 21.1% of repairs managed with the all-inside device versus 4.3% of sutures managed with the suture hook (P = .003). Among the 6 factors included in the Cox model, the only one identified as a risk factor for failure was the type of repair (P = .003), with a risk for the all-inside device that was >5-fold higher than that for the suture hook repair (corresponding hazard ratio, 5.1 [95% CI, 1.8-14.5]). No other complications involving the surgical technique or device were registered. CONCLUSION An arthroscopic all-inside technique of meniscal repair of ramp lesions appeared to be safe and effective. It provided excellent healing of the repaired meniscus, with an overall failure rate of 7.3%. The type of suture was associated with failure of the ramp lesion repair, with a significantly higher risk with the all-inside device than with suture hook repair sutures.
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Affiliation(s)
- Mathieu Thaunat
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center, Lyon, France
| | - Constant Foissey
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center, Lyon, France
| | - Pramod Ingale
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center, Lyon, France
| | - Ibrahim Haidar
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center, Lyon, France
| | - Paul Henri Bauwens
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center, Lyon, France
| | - Alexandre Penet
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center, Lyon, France
| | - Samih Kacem
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center, Lyon, France
| | - Jean-Marie Fayard
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center, Lyon, France
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Knee Injuries in the Elite American Football Player: A Descriptive Pictorial Imaging and Mechanism of Injury Review. J Comput Assist Tomogr 2022; 46:197-211. [PMID: 35081603 DOI: 10.1097/rct.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Musculoskeletal injuries are common in American football, with an incidence ranging from approximately 10 to 35 per 1000 playing hours. Injuries occur more commonly in games than in practice. Although several studies have analyzed specific injury types in football, this review aims to describe the most common knee injuries sustained by American football players and to review the existing literature pertaining to the radiologic findings used in the diagnosis of these injuries.
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Abreu FG, Canuto SMDG, Canuto MMDG, Chagas EF, Zutin TLM, Pádua VBCD. Incidência de lesões da rampa meniscal nas reconstruções do ligamento cruzado anterior. Rev Bras Ortop 2022; 57:422-428. [PMID: 35785120 PMCID: PMC9246525 DOI: 10.1055/s-0041-1735942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 06/02/2021] [Indexed: 10/31/2022] Open
Abstract
Resumo
Objetivo Avaliar a incidência e o perfil epidemiológico das lesões da rampa meniscal nos pacientes submetidos a cirurgia de reconstrução do ligamento cruzado anterior (LCA), e determinar os fatores de risco relacionados.
Métodos Foram analisados retrospectivamente 824 pacientes submetidos a cirurgia de reconstrução do LCA. Os pacientes que apresentaram instabilidade meniscal medial foram submetidos a avaliação do compartimento posteromedial do joelho. Em caso de lesão, o reparo cirúrgico foi realizado. Potenciais fatores de risco associados às lesões foram analisados.
Resultados A incidência geral de lesões da rampa na população estudada foi de 10,6% (87 lesões em 824 pacientes). A análise multivariada pelo teste do Qui-quadrado demonstrou que a presença de lesões da rampa meniscal foi significativamente associada aos seguintes fatores de risco: lateralidade direita e lesões crônicas. Sexo, idade e atividade esportiva não foram estatisticamente significantes. O futebol foi a causa mais frequente de lesões da rampa relacionadas ao esporte, com 78,2% dos casos. No entanto, não se mostrou ser um fator de risco. De 2014 a 2019, a incidência anual variou de 4,0% a 20,6%.
Conclusão A incidência das lesões da rampa meniscal foi de 10,6% nas cirurgias de reconstrução do LCA, sendo mais frequente em pacientes com lesões crônicas. A incidência anual foi crescente, e variou de 4,0%, em 2014, a 20,6%, em 2019.
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Isolated Meniscotibial Ligament Rupture: The Medial Meniscus "Belt Lesion". Arthrosc Tech 2022; 11:e133-e138. [PMID: 35155104 PMCID: PMC8821026 DOI: 10.1016/j.eats.2021.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/29/2021] [Indexed: 02/03/2023] Open
Abstract
Ramp lesions play a major role in both anteroposterior and rotational instability following anterior cruciate ligament rupture. The meniscotibial ligament (MTL) is the most important structure to repair and is the primary stabilizer of the posterior horn of the medial meniscus. The posteroinferior insertion of the MTL on the posterior horn of the medial has been described, forming a posterior "belt." Isolated MTL lesion diagnosis can be challenging, as the absence of a meniscocapsular ligament lesion prevents its correct visualization through transnotch vision. This article details a technique to diagnose and repair the "belt lesion" of the medial meniscus.
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