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Pioger C, Ayata M, Pettinari F, Ali AA, Alayane A, Campos JP, Vieira TD, Saithna A, Sonnery-Cottet B. Secondary Meniscectomy Rates and Risk Factors for Failed Repair of Ramp Lesions Performed at the Time of Primary ACL Reconstruction: An Analysis of 1037 Patients From the SANTI Study Group. Am J Sports Med 2024; 52:1944-1951. [PMID: 38853744 DOI: 10.1177/03635465241253841] [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: 06/11/2024]
Abstract
BACKGROUND Studies evaluating secondary meniscectomy rates and risk factors for failure of ramp repair are sparse and limited by small numbers and heterogeneity. PURPOSES/HYPOTHESIS The purposes were to determine the secondary meniscectomy rate for failure of ramp repair performed using a posteromedial portal suture hook at the time of anterior cruciate ligament reconstruction (ACLR) and to identify risk factors for secondary meniscectomy. It was hypothesized that patients who underwent ACLR combined with a lateral extra-articular procedure (LEAP) would experience significantly lower rates of secondary meniscectomy compared with those undergoing isolated ACLR. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Patients undergoing primary ACLR and ramp repair between 2013 and 2020 were included in the study. Final follow-up for each patient was defined by his or her last appointment recorded in a prospective database (with a study end date of March 2023). The database and medical records were used to determine whether patients had undergone secondary meniscectomy for failure of ramp repair. Survivorship of ramp repair (using secondary meniscectomy as an endpoint) was determined using the Kaplan-Meier method. Multivariate analysis was used to investigate possible risk factors. RESULTS A total of 1037 patients were included in the study. The secondary meniscectomy rate after ramp repair was 7.7% at a mean final follow-up of 72.4 months. Patients without combined ACLR + LEAP were >2-fold more likely to undergo a secondary medial meniscectomy compared with those with combined ACLR + LEAP (hazard ratio, 2.455; 95% CI, 1.457-4.135; P = .0007). Age, sex, preoperative Tegner score, and time between injury and surgery were not significant risk factors for failure. CONCLUSION The rate of secondary meniscectomy after ramp repair performed through a posteromedial portal at the time of primary ACLR was low. Patients who underwent isolated ACLR (rather than ACLR + LEAP) were >2-fold more likely to undergo a secondary medial meniscectomy for failure of ramp repair. Additional risk factors for failure of ramp repair were not identified.
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Affiliation(s)
- Charles Pioger
- Department of Orthopedic Surgery, Ambroise Paré Hospital, Paris Saclay University, Paris, France
| | - Merwane Ayata
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Francesco Pettinari
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Ahmad Abed Ali
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Ali Alayane
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Joao Pedro Campos
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Adnan Saithna
- AZBSC Orthopedics, Scottsdale, Arizona, USA
- Arizona State University, Tempe, Arizona, USA
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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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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Nicolas Q, Samargandi R, Calloch S, Dubrana F, Gunepin FX, Di Francia R. Biomechanical characteristics of the meniscocapsular junction of the posterior segment of the medial meniscus. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-03987-7. [PMID: 38809423 DOI: 10.1007/s00590-024-03987-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/08/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE Despite extensive literature available on the mechanical properties of knee ligaments and menisci, research on the mechanical properties of the meniscus-capsular junction (MCJ) is lacking. This study aims to investigate the biomechanical behavior of the MCJ of the medial meniscus using a tensile failure test. MATERIALS AND METHODS Seven dissected cadaveric knees were used for biomechanical analysis. Tensile failure tests were performed using an INSTRON ElectroPuls E1000 stress system to measure stress/strain curves, maximum load at failure, elastic limit load, elongation at break, elongation at the elastic limit, and linear stiffness, were collected and analyzed. RESULTS All ruptures occurred at the MCJ. The MCJ displayed similar mechanical properties to knee ligaments. Average values were: maximum load at failure (63.9 ± 3.2 N), yield load (52.9 N ± 2.6 N), elongation at break (2.5 mm ± 0.3 mm), elongation at the elastic limit (1.25 mm ± 0.15 mm), strain at break (47.0% ± 3.5%), strain at yield (23.2% ± 2.3%), and stiffness (56.6 ± 9. N/mm-1). CONCLUSION The meniscus-capsular junction's mechanical properties are similar to other knee ligaments and may play a role in knee stability. The findings provide insights into the the behavior of the meniscus-capsular junction could have clinical implications for diagnosing and surgical treatment of meniscocapsular lesions.
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Affiliation(s)
- Quentin Nicolas
- Orthopedic Surgery Department, Tours Regional University Hospital, University of Tours - CHRU Trousseau Orthopedic Trauma Department, 1C, Avenue de la République, Chambray-les-Tours, 37170, Tours, France.
- Faculty of Medicine, University of Bretagne Occidentale, Brest, France.
| | - Ramy Samargandi
- Orthopedic Surgery Department, Tours Regional University Hospital, University of Tours - CHRU Trousseau Orthopedic Trauma Department, 1C, Avenue de la République, Chambray-les-Tours, 37170, Tours, France
- Orthopedic Surgery Department, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | | | - Frederic Dubrana
- Faculty of Medicine, University of Bretagne Occidentale, Brest, France
- Orthopedic Surgery Department, Brest Regional University Hospital, Brest, France
| | | | - Remi Di Francia
- Faculty of Medicine, University of Bretagne Occidentale, Brest, France
- Orthopedic Surgery Department, Brest Regional University Hospital, Brest, France
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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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Kato J, Fukushima H, Hanaki S, Kawanishi Y, Kobayashi M, Ota K, Yoshida M, Takenaga T, Kawaguchi Y, Kuroyanagi G, Sakai H, Murakami H, Nozaki M. Efficacy of all-inside devices in reducing gap and step-off in knee extension for ramp lesion repair: A cadaveric study. Knee Surg Sports Traumatol Arthrosc 2024; 32:257-264. [PMID: 38226718 DOI: 10.1002/ksa.12034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 12/08/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE The aim of this study is to assess the dynamics of the tear site of meniscal ramp lesions, particularly considering knee flexion angles, and validate anchor fixation using an all-inside device. METHODS Eight Thiel-embalmed paired cadaveric knees with their whole bodies were used in this study. The ramp lesions were created arthroscopically, and ramp lesion dynamics were evaluated by gradually extending the knee from 90° of knee flexion. Changes in the gap and step-off (0: no step-off; 1: cross-sectional overlap exists; and 2: tibial articular surface exposed) were evaluated at 90°, 60°, 30°, and 10° of knee flexion. After dynamic evaluation, all-inside repairs of the ramp lesions using all-inside devices were conducted. Dissection was performed to confirm the position of anchor fixation. RESULTS As the knee was extended, the gap significantly decreased at all knee flexion angles. Similarly, the step-off grade decreased as the knee was extended, and the step-off completely disappeared in all cases when the knee was extended from 30° to 10°. The average knee flexion angle at which the gap and step-off completely disappeared was 22.5°. After suturing the ramp lesion, arthroscopic evaluation showed that the gap had disappeared and the step-off had been repaired in all cases. Anchor fixation locations were not found within the joint but were fixed to the semimembranosus tendon or its surrounding articular capsule. Overall, 31% (5/16) anchors were fixed to the attachment site of the semimembranosus tendon, whereas the remaining were fixed to the articular capsule, located peripherally to the semimembranosus tendon. CONCLUSION Suturing with an all-inside device for ramp lesions is a good option, and the repair in knee extension was found to be reasonable, considering the dynamics of ramp lesions in this study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Jiro Kato
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Hiroaki Fukushima
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Shunta Hanaki
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Yusuke Kawanishi
- Department of Orthopedic Surgery, Ogaki Municipal Hospital, Ogaki City, Gifu, Japan
| | - Makoto Kobayashi
- Department of Orthopedic Surgery, Nagoya City University Midori Municipal Hospital, Nagoya City, Aichi, Japan
| | - Kyohei Ota
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Masato Yoshida
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Tetsuya Takenaga
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Yohei Kawaguchi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Gen Kuroyanagi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Hiroaki Sakai
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Hideki Murakami
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
| | - Masahiro Nozaki
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya City, Aichi, Japan
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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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Simonetta R, Russo A, Palco M, Costa GG, Mariani PP. Meniscus tears treatment: The good, the bad and the ugly-patterns classification and practical guide. World J Orthop 2023; 14:171-185. [PMID: 37155506 PMCID: PMC10122773 DOI: 10.5312/wjo.v14.i4.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/22/2023] [Accepted: 03/31/2023] [Indexed: 04/18/2023] Open
Abstract
Over the years, several studies demonstrated the crucial role of knee menisci in joint biomechanics. As a result, save the meniscus has become the new imperative nowadays, and more and more studies addressed this topic. The huge amount of data on this topic may create confusion in those who want to approach this surgery. The aim of this review is to provide a practical guide for treatment of meniscus tears, including an overview of technical aspects, outcomes in the literature and personal tips. Taking inspiration from a famous movie directed by Sergio Leone in 1966, the authors classified meniscus tears in three categories: The good, the bad and the ugly lesions. The inclusion in each group was determined by the lesion pattern, its biomechanical effects on knee joint, the technical challenge, and prognosis. This classification is not intended to substitute the currently proposed classifications on meniscus tears but aims at offering a reader-friendly narrative review of an otherwise difficult topic. Furthermore, the authors provide a concise premise to deal with some aspects of menisci phylogeny, anatomy and biomechanics.
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Affiliation(s)
- Roberto Simonetta
- Department of Orthopaedic and Traumatology, Villa del Sole Clinic, Catanzaro 88100, Italy
| | - Arcangelo Russo
- Orthopaedic and Traumatology Unit, Umberto I Hospital, Enna 94100, Italy
| | - Michelangelo Palco
- Department of Orthopaedic and Traumatology, Villa del Sole Clinic, Catanzaro 88100, Italy
| | | | - Pier Paolo Mariani
- Department of Orthopaedic and Traumatology, Villa Stuart Sport Clinic-FIFA Medical Centre of Excellence, Roma 00135, Italy
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Kawada K, Furumatsu T, Tamura M, Xue H, Higashihara N, Kintaka K, Yokoyama Y, Ozaki T. Effectivity of the Outside-In Pie-Crusting Technique and an All-Inside Meniscal Repair Device in the Repair of Ramp Lesions. Arthrosc Tech 2023; 12:e273-e278. [PMID: 36879867 PMCID: PMC9984773 DOI: 10.1016/j.eats.2022.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/02/2022] [Indexed: 01/20/2023] Open
Abstract
Ramp lesions are characteristic medial meniscus injuries seen in anterior cruciate ligament-injured knees. Anterior cruciate ligament injuries combined with ramp lesions increase the amount of anterior tibial translation and tibial external rotation. Therefore, the diagnosis and treatment of ramp lesions have received increasing attention. However, ramp lesions can be difficult to diagnose on preoperative magnetic resonance imaging. Additionally, ramp lesions are difficult to observe and treat intraoperatively in the posteromedial compartment. Although good results have been reported with the use of a suture hook through the posteromedial portal in the treatment of ramp lesions, the complexity and difficulty of the technique are further problems. The outside-in pie-crusting technique is a simple procedure that can enlarge the medial compartment and facilitate the observation and repair of ramp lesions. After this technique, ramp lesions can be properly sutured, using an all-inside meniscal repair device, without damaging the surrounding cartilage. A combination of the outside-in pie-crusting technique and an all-inside meniscal repair device (with only anterior portals) is effective in the repair of ramp lesions. This Technical Note aims to report in detail the flow of a series of techniques, including our diagnostic and therapeutic methods.
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Affiliation(s)
- Koki Kawada
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Takayuki Furumatsu
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Masanori Tamura
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Haowei Xue
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Naohiro Higashihara
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Keisuke Kintaka
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Yusuke Yokoyama
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, Okayama, Japan
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Mahmood A, MLV SK, Mittal R, Digge VK, Garika SS, Gamanagatti S. Ramp Lesions in Chronic Anterior Cruciate Ligament Injuries. Cureus 2022; 14:e28450. [PMID: 36176859 PMCID: PMC9512317 DOI: 10.7759/cureus.28450] [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] [Accepted: 08/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Meniscus ramp lesions associated with anterior cruciate ligament (ACL) injuries are being increasingly reported in the literature. This study was carried out to know the incidence of ramp lesions in ACL injured patients and to study the characteristics of these patients in our population. Methods: Seventy-five patients who underwent ACL reconstruction from January 2021 to December 2021 were prospectively studied. Patients with multi-ligament injuries or a history of previous knee surgery were excluded. All patients were examined clinically and all underwent MRI examinations. The findings of arthroscopy during ACL reconstruction were recorded and analyzed. Result: Seventeen patients had ramp lesions with an incidence of 22.67%. Eight were isolated ramp lesions, and nine had other meniscus injuries. Ramp lesions were identified with 41.18% sensitivity using preoperative MRI. Thirteen out of 17 patients with ramp lesions had increased mobility of the posterior horn of the medial meniscus on anterior probing. The duration from injury to surgery was significantly longer in patients with ramp lesions as compared to patients without ramp lesions. Conclusion: A ramp lesion is not an uncommon lesion in ACL injuries and can occur either as an isolated meniscus lesion or in association with other meniscus lesions.Ramp lesions can occur in road traffic accidents as well and are not just sports-related injuries. Ramp lesions are not visible through routine anterior portal diagnostic arthroscopy and their repair adds to the stability of the knee. The absence of ramp lesions on MRI does not rule out their presence; hence, one should always look for ramp lesions in the posteromedial compartment of the knee in all cases undergoing ACL reconstruction.
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Machida T, Fukao M, Watanabe A, Miyazawa S. Video Evidence of Tissue Sliding Improvement by Ultrasound-Guided Hydrorelease on Scars After Arthroscopic Knee Surgery: A Case Report. Cureus 2022; 14:e27975. [PMID: 36120201 PMCID: PMC9467909 DOI: 10.7759/cureus.27975] [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] [Accepted: 08/13/2022] [Indexed: 11/06/2022] Open
Abstract
Postoperative scarring is a complication of arthroscopic knee surgery that causes a lack of terminal extension and tissue sliding defects. We present video evidence of tissue sliding before and after ultrasound-guided hydrorelease in a 53-year-old man. The patient presented with pain in the scarred area following arthroscopic knee surgery. His active and passive extension was -5° with restricted patellar mobility. Dynamic ultrasonography revealed scar tissue sliding defects. For ultrasound-guided hydrorelease, a needle (22G, 60 mm) was aimed at a site within 10 mm depth of the hypoechoic change in the scar area below the patella, and saline solution (10 mL) mixed with 1% lidocaine (10 mL) and 10 mg prednisolone was injected. Immediately after injection, the patient's extension was 0° with no pain or limitation of patellar mobility, and dynamic ultrasonography showed tissue sliding improved. Video evidence from dynamic ultrasonography clarifies the direction of the inadequate slide and the indication for and efficacy of ultrasound-guided hydrorelease. This case highlights the benefits of video evidence from dynamic ultrasonography before and after ultrasound-guided hydrorelease.
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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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Arthroscopic All – Inside Repair of Meniscal Ramp Lesions. J ISAKOS 2022; 7:82-83. [DOI: 10.1016/j.jisako.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/22/2022] [Accepted: 04/12/2022] [Indexed: 11/23/2022]
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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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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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Keyhani S, Vaziri AS, Vosoughi F, Verdonk R, Movahedinia M. Overview of Posterior knee arthroscopy in the medial meniscal repair: technical note. J ISAKOS 2022; 7:33-38. [DOI: 10.1016/j.jisako.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/07/2022] [Accepted: 02/12/2022] [Indexed: 10/19/2022]
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Abstract
The importance of the menisci in providing joint stability and their role in load transmission within the knee are well understood. A growing body of literature has emerged on 2 distinct injury patterns to these crucial anatomic structures, ramp lesions and root tears. Ramp lesions may be characterized as tears at the posterior meniscocapsular junction, while root tears involve bony or soft tissue avulsion of the meniscal insertions at the anterior or posterior intercondylar regions. In this 2-part review, we present an overview of the current available literature on ramp lesions and meniscal root tears, summarizing the unique anatomic considerations, etiology, biomechanics, management decisions, clinical outcomes pertinent to these very distinct injuries.
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Labarre C, Graveleau N, Bouguennec N. Meniscal Ramp Lesions Repair: An Under-Meniscus All-Inside Suture in Cases of Isolated Meniscotibial Ligament Tears. Arthrosc Tech 2021; 10:e1417-e1424. [PMID: 34258185 PMCID: PMC8252850 DOI: 10.1016/j.eats.2021.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/07/2021] [Indexed: 02/03/2023] Open
Abstract
Anterior cruciate ligament ruptures are commonly associated with ramp lesions of the medial meniscus. These posterior longitudinal peripheral tears induce medial meniscus instability and increase the anteroposterior and rotational knee laxity. We divided ramp lesions in 3 types: meniscocapsular ligament tears, meniscotibial ligament tears, and a combination of both lesions. The conventional surgical technique for treating meniscal ramp lesions is to use a suture hook device through a posteromedial approach, which is a complex process requiring a learning curve and extensive surgical time. An anterior approach often is criticized as underestimating the true incidence of ramp lesion and to offer insufficient operating space. The purpose of this technical note is to describe our arthroscopic repair technique in cases of isolated meniscotibial ligament tears. The suture is performed by an under-meniscus anterior approach with a percutaneous medial collateral ligament release to create an additional opening of the medial compartment. This simple procedure allows for accurate diagnoses of the meniscotibial lesions and enables repair of the lesions with an all-inside suture device without the usual drawbacks of a posteromedial approach.
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Affiliation(s)
- Chloé Labarre
- Address correspondence to Chloé Labarre, M.D., Center of Orthopaedic Sports Surgery of Bordeaux-Merignac, 2 Rue Georges Negrevergne, 33700 Mérignac, France.
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Choi KY, Koh IJ, Kim MS, In Y. Medial Meniscal Ramp Lesion Repair Through Anterior Portals Using a Medial Collateral Ligament Pie-Crusting Technique. Arthrosc Tech 2021; 10:e1073-e1077. [PMID: 33981553 PMCID: PMC8085387 DOI: 10.1016/j.eats.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/15/2020] [Indexed: 02/03/2023] Open
Abstract
Ramp injury, that is, injury to the peripheral attachment of the posterior horn of the medial meniscus, often requires additional surgery during anterior cruciate ligament (ACL) reconstruction. Diagnosis and treatment of ramp lesions are important because unrepaired ramp lesions could cause risk to the reconstructed ACL because of anteroposterior and external rotation laxity, whereas acute rupture or chronic deficiency of the ACL could also cause ramp lesions because of instability. Ramp lesions are difficult to diagnose and treat from the anterior compartment during arthroscopy. Typically, this repair requires technically demanding skills and is performed from the posterior portal using a suture hook under visualization with the arthroscope through the intercondylar notch. Inexperienced surgeons often struggle with using the posterior portal and the suture hook. Our all-inside repair technique using the FasT-Fix system (Smith & Nephew, Andover, MA) under direct visualization from the anterior compartment accompanied by a medial collateral ligament pie-crusting technique facilitates repair of ramp lesions without causing medial instability.
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Affiliation(s)
- Keun Young Choi
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Jun Koh
- Department of Orthopedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Man Soo Kim
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong In
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Address correspondence to Yong In, M.D., Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, Republic of Korea.
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Cavaignac E, Sylvie R, Teulières M, Fernandez A, Frosch KH, Gomez-Brouchet A, Sonnery-Cottet B. What Is the Relationship Between the Distal Semimembranosus Tendon and the Medial Meniscus? A Gross and Microscopic Analysis From the SANTI Study Group. Am J Sports Med 2021; 49:459-466. [PMID: 33332976 DOI: 10.1177/0363546520980076] [Citation(s) in RCA: 27] [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 Some authors have suggested that the semimembranosus tendon is involved in the pathophysiology of ramp lesions. This led us to conduct a gross and microscopic analysis of the posterior horn of the medial meniscus and the structures inserted on it. HYPOTHESIS (1) The semimembranosus tendon has a tendinous branch inserting into the posterior horn of the medial meniscus, and (2) the meniscotibial ligament is inserted on the posteroinferior edge of the medial meniscus. STUDY DESIGN Descriptive laboratory study. METHODS In total, 14 fresh cadaveric knees were dissected. From each cadaveric donor, a stable anatomic specimen was harvested en bloc, including the medial femoral condyle, medial tibial plateau, whole medial meniscus, cruciate ligaments, joint capsule, and distal insertion of the semimembranosus tendon. The harvested blocks were cut along the sagittal plane to isolate the distal insertion of the semimembranosus tendon on the posterior joint capsule and the posterior horn of the medial meniscus in a single slice. Histological slides were made from these samples and analyzed under a microscope. RESULTS In all knees, gross examination revealed a direct branch of the semimembranosus and a tendinous capsular branch ending behind the posterior horn of the medial meniscus. This capsular branch protruded over the joint capsule, over the meniscotibial ligament below and the meniscocapsular ligament above, but never ended directly in the meniscal tissue. The capsular branch was 14.3 ± 4.4 mm long (mean ± SD). The direct tendon inserted 11 ± 2.8 mm below the articular surface of the tibial plateau. The meniscotibial ligament inserted on the posteroinferior edge of the medial meniscus, and the meniscocapsular ligament insertion was on its posterosuperior edge. Highly vascularized adipose tissue was found, delimited by the posterior horn of the medial meniscus, meniscotibial ligament, meniscocapsular ligament, and capsular branch of the semimembranosus tendon. CONCLUSION In all knees, our study found a capsular branch of the semimembranosus tendon inserted behind the medial meniscus. The meniscotibial ligament was inserted on the posteroinferior edge of the medial meniscus. Histological analysis of this area revealed that this ligament inserted differently from the insertion previously described in the literature. CLINICAL RELEVANCE This laboratory study provides insight into the pathophysiology of ramp lesions frequently associated with anterior cruciate ligament injury. To restore anatomy, it is mandatory to reestablish meniscotibial ligament continuity in ramp repairs.
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Affiliation(s)
- Etienne Cavaignac
- Department of Orthopedic Surgery and Trauma, Pierre Paul Riquet University Hospital, Toulouse, France.,I2R, Toulouse, France.,SPS Research, Toulouse, France
| | - Rémi Sylvie
- Department of Orthopedic Surgery and Trauma, Pierre Paul Riquet University Hospital, Toulouse, France
| | - Maxime Teulières
- Department of Orthopedic Surgery and Trauma, Pierre Paul Riquet University Hospital, Toulouse, France
| | - Andrea Fernandez
- Department of Orthopedic Surgery and Trauma, CHU Nancy, Nancy, France
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Gomez-Brouchet
- Department of Pathology, IUCT-Oncopole, CHU Toulouse and University of Toulouse, Toulouse, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
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Ramp Lesions of the Posterior Segment of the Medial Meniscus: What Is Repaired? A Qualitative Histological Study of the Meniscocapsular and Meniscotibial Attachments. Clin Orthop Relat Res 2020; 478:2912-2918. [PMID: 33009236 PMCID: PMC7899392 DOI: 10.1097/corr.0000000000001509] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lesions of the posterior segment of the medial meniscus are the most common intraarticular lesions associated with ACL injuries. Ramp lesions are tears in the peripheral attachment of the posterior horn of the medial meniscus. Such injuries are difficult to detect on preoperative MRI. Arthroscopically, the prevalence of these lesions can reach 24%. Anatomical descriptions of the posterior horn of the medial meniscus are becoming clearer, however, histological descriptions are lacking, especially with regard to the presence or absence of capillaries. QUESTIONS/PURPOSES The present qualitative histologic study focused on the posterior segment of the medial meniscus and the meniscocapsular and meniscotibial junctions. Specifically, the objective of this study was to analyze the posterior segment of the medial meniscus and the meniscosynovial junction and to determine whether the meniscus tibial ligament exists. METHODS We dissected 10 unpaired cadaveric knees (five male, five female, age range 55 to 66 years), five left and five right, from the French "Don du corps" body donation program via a posterior approach to the posteromedial capsule. We excluded specimens with intra-articular abnormalities (ACL rupture, meniscal tear, arthrosis) preceding dissection by arthrotomy. We thus accessed the posterior segment of the medial meniscus and the meniscosynovial junction. The proximal capsule, posterior segment of the medial meniscus, entire meniscal capsular-tibial junction, and a fragment of the tibia were removed en bloc. For each knee, three sagittal spaced sections of the posterior segment of the medial meniscus (Zone 4 as defined by Śmigielski) were performed. Two experienced pathologists performed qualitative histological analysis on the 30 samples after Hematoxylin and eosin staining, and Safranin O staining. RESULTS Macroscopically, the meniscotibial attachments were pellucid and homogeneous, as were the meniscocapsular attachments; however, the meniscocapsular attachments appeared to be denser in both the anterior and posterior regions of the capsule. Microscopy of the meniscosynovial junction revealed loose collagen fibers that were partially oriented but not parallel, a cellular network featuring a few fibroblasts and adipocytes, and several capillaries. No between-attachment histologic differences were apparent; both tissues shared a site of attachment to the posterior horn of the medial meniscus. We did not detect the meniscotibial ligament, macroscopically or microscopically. CONCLUSIONS A ramp lesion may not be a ligamentous injury because the meniscotibial ligament was not detected. Rather, it appears that a ramp lesion is a tear in the common attachment point between the posterior horn of the medial meniscus and meniscocapsular and meniscotibial junctions. This structure is vascularized, and contains nonoriented low cellularity collagen of moderate density. CLINICAL RELEVANCE Based on our results, a better rationale for the recommendation of surgical repair of a ramp appears to be needed, given the absence of a meniscotibial ligament, and the presence of capillaries in the meniscocapsular and meniscotibial attachments.
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Balazs GC, Greditzer HG, Wang D, Marom N, Potter HG, Rodeo SA, Marx RG, Williams RJ. Non-treatment of stable ramp lesions does not degrade clinical outcomes in the setting of primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2020; 28:3576-3586. [PMID: 32358631 DOI: 10.1007/s00167-020-06017-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/17/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical outcomes of various methods of treatment of stable and unstable ramp lesions compared to patients with no meniscal pathology at the time of primary ACL reconstruction. METHODS All patients with a preoperative MRI performed at our facility who were enrolled in an institutional ACL registry and 1-year clinical follow-up were identified. A musculoskeletal radiologist reviewed preoperative MRI scans for evidence of a ramp lesion. Ramp lesions were classified as stable if a peripheral tear of the posterior horn of the medial meniscus was identified by MRI, but did not displace into the medial compartment with anteriorly directed probing at the time of surgery. Ramp lesions were classified as unstable if a tear was identified by preoperative MRI at the meniscocapsular junction and the meniscus was displaceable into the medial compartment with probing. Reoperation rates for ACL graft failure or recurrent medial meniscus pathology were collected. Patient-reported outcome scores (IKDC, SF12 PCS, SF12 MCS, and Marx Activity scale) were recorded at baseline and final follow-up. RESULTS A total of 162 patients were included in the analysis with median 2-year (range 1-5 years) clinical follow-up. Patients with a repaired unstable ramp lesion had a significantly higher likelihood of reoperation for recurrent medial meniscus pathology than patients without meniscal pathology at the time of index surgery. Patients with an untreated stable ramp lesion had a similar rate of reoperation when compared to patients without meniscal pathology. At final follow-up, there was no difference between groups in IKDC score, SF12 PCS/MCS, or Marx activity score or change in any score. CONCLUSIONS Patients with untreated stable ramp lesions have similar clinical outcomes at median 2-year (range 1-5 years) follow-up when compared to patients without a ramp lesion. Treatment of stable ramp lesions at the time of ACL reconstruction does not have clinical benefit. LEVEL OF EVIDENCE III.
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Affiliation(s)
- George C Balazs
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.
| | - Harry G Greditzer
- Department of Radiology, Hospital for Special Surgery, New York, USA
| | - Dean Wang
- Department of Orthopaedic Surgery, University of California, Irvine, USA
| | - Niv Marom
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Hollis G Potter
- Department of Radiology, Hospital for Special Surgery, New York, USA
| | - Scott A Rodeo
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Robert G Marx
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Riley J Williams
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
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Examining Techniques for Treatment of Medial Meniscal Ramp Lesions During Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2020; 36:2921-2933. [PMID: 32674943 DOI: 10.1016/j.arthro.2020.05.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to systematically review the clinical outcomes and adverse events among different techniques for treatment of medial meniscal ramp lesions performed in conjunction with anterior cruciate ligament (ACL) reconstruction. METHODS A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane Reviews, Web of Science, and Medline databases were searched for studies examining clinical outcomes after surgical treatment of ramp lesions. Studies were selected if they met the following criteria: (1) evaluation of the outcome of surgical repair of meniscal ramp lesions, (2) injuries associated with ACL tears, (3) minimum 6-month follow up, (4) publication in a peer-reviewed journal, and (5) English language or translation readily available. RESULTS Seven studies met inclusion criteria (485 patients; mean age 27.1 years [range 12 to 59]; mean follow-up 26.9 months [range 8 to 40]). Two all-inside techniques (suture-hook and an all-inside meniscus repair device) in addition to abrasion and trephination alone were analyzed. Each technique demonstrated significant increases in postoperative Lysholm and International Knee Documentation Committee (IKDC) scores, reaching the established minimal clinically important difference (MCID) for each patient reported outcome. Incomplete healing was documented in 12.1% to 12.9% of cases in which the tear was not repaired at the time of ACL reconstruction, 2.3% to 11.7% in cases using the suture-hook for repair, and 10.8% to 15% in the all-inside meniscus repair device group. CONCLUSION This systematic review demonstrated that several approaches used to treat medial meniscal ramp lesions associated with ACL tears lead to positive clinical outcomes. Small, stable tears <2 cm in size may be managed with debridement alone. For larger, more unstable lesions, an all-inside approach has demonstrated positive clinical outcomes. Prospective trials are needed to determine the best management for meniscal ramp lesions. Additionally, further research is needed to better understand how to minimize the risk of technique-related complications (e.g., improper implant deployment). LEVEL OF EVIDENCE Level IV, systematic review of level II, III, and IV studies.
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Moreira J, Almeida M, Lunet N, Gutierres M. Ramp lesions: a systematic review of MRI diagnostic accuracy and treatment efficacy. J Exp Orthop 2020; 7:71. [PMID: 32978704 PMCID: PMC7519018 DOI: 10.1186/s40634-020-00287-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/09/2020] [Indexed: 01/11/2023] Open
Abstract
Purpose We conducted a systematic review of the published literature to assess the accuracy of Magnetic Resonance Imaging (MRI) in establishing the presence of ramp lesions (RLs) in Anterior Cruciate Ligament (ACL) deficient knees and the clinical efficacy of the surgical repair of RLs. Methods A comprehensive search of the MEDLINE, Web of Science and Scopus databases was performed according to PRISMA guidelines. Studies assessing MRI diagnostic accuracy for RLs or the clinical effect of RL repair in participants with ACL injuries were included. Diagnostic accuracy measures were pooled and plotted in forest plots. Preoperative and at last follow-up treatment efficacy outcome measures were extracted and plotted in forest plots, for graphical comprehension. Results Sixteen studies met the criteria and were included. The diagnostic analysis showed a pooled sensitivity, specificity, positive and negative likelihood ratios of 65.1% (95% CI, 59.73 to 70.42), 91.6% (95% CI, 89.14 to 94.05), 2.91 (95% CI, 2.38–3.55) and 0.53 (95% CI, 0.44–0.64), respectively, with high heterogeneity (I2 above 80%) for all measures. Treatment analysis showed improved Lysholm Knee Score, IKDC score and laxity difference between the knees in all studies after meniscal suture repair. A separate analysis showed no differences between repair of smaller, stable, RLs with meniscal sutures and repair with abrasion and trephination only. Conclusion Although the results present considerable heterogeneity, MRI seems to demonstrate moderate accuracy in the diagnosis of RLs in patients with ACL tear and the surgical repair of RLs can be associated with improved overall outcomes.
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Affiliation(s)
- José Moreira
- Faculty of Medicine, University of Porto, Alameda Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Margarida Almeida
- Faculty of Medicine, University of Porto, Alameda Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Nuno Lunet
- EPIUnit-Instituto de Saúde Pública, University of Porto, Porto, Portugal.,Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Manuel Gutierres
- Faculty of Medicine, University of Porto, Alameda Hernâni Monteiro, 4200-319, Porto, Portugal.,Serviço de Ortopedia e Traumatologia, Centro Hospitalar de S. João, Porto, Portugal
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25
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Hatayama K, Terauchi M, Saito K, Takase R, Higuchi H. Healing Status of Meniscal Ramp Lesion Affects Anterior Knee Stability After ACL Reconstruction. Orthop J Sports Med 2020; 8:2325967120917674. [PMID: 32426412 PMCID: PMC7222250 DOI: 10.1177/2325967120917674] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Although the biomechanical importance of the ramp lesion in the anterior cruciate ligament (ACL)-deficient knee has been demonstrated, there is no clear consensus on the appropriate treatment for ramp lesions during ACL reconstruction. Purpose To compare the postoperative outcomes for ramp lesions between patients treated with all-inside repair through the posteromedial portal and those whose ramp lesions were left in situ without repair during ACL reconstruction. We also determined whether ramp lesion healing status affected postoperative knee stability. Study Design Cohort study; Level of evidence, 3. Methods A total of 57 patients who underwent anatomic double-bundle ACL reconstruction between August 2011 and December 2017 had attendant ramp lesions. Of these, 25 ramp lesions that were considered stable were left in situ without repair (Nonrepaired group), and 25 ramp lesions, including 21 stable and 4 unstable lesions, were treated using all-inside repair through the posteromedial portal (Repaired group). We evaluated the side-to-side difference (SSD) in anterior tibial translation on stress radiographs and rotational stability by using the pivot-shift test 2 years after surgery, and healing status of the ramp lesions was evaluated on 3.0-T magnetic resonance imaging (MRI) scans 1 year after surgery. Results The mean SSDs in anterior translation were 2.4 ± 1.6 mm for the Nonrepaired group and 1.9 ± 1.6 mm for the Repaired group, with no significant differences. The positive ratios on the pivot-shift test were not significantly different between groups. Healing rates of ramp lesions on MRI scans showed a significant difference between the Nonrepaired group (60%) and the Repaired group (100%) (P = .001). The mean SSDs for knees in which the ramp lesion had healed as shown on MRI scans and those in which it had not healed were 1.9 ± 1.6 mm and 3.2 ± 1.1 mm, respectively, which was a significant difference (P = .02). Conclusion Healing rates of ramp lesions were significantly better in the Repaired group than in the Nonrepaired group, although postoperative knee stability was not significantly different between groups. Anterior laxity in the knees in which the ramp lesion was unhealed was significantly greater compared with the knees in which the ramp lesion healed. All-inside repair through the posteromedial portal was a reliable surgical procedure to heal ramp lesions.
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Affiliation(s)
- Kazuhisa Hatayama
- Department of Orthopaedic Surgery, Japan Community Health Care Organization Gunma Central Hospital, Maebashi, Japan
| | - Masanori Terauchi
- Department of Orthopaedic Surgery, Japan Community Health Care Organization Gunma Central Hospital, Maebashi, Japan
| | - Kenichi Saito
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Ryota Takase
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hiroshi Higuchi
- Department of Orthopaedic Sports Surgery, Asakura Sports Rehabilitation Clinic, Maebashi, Japan
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26
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Mostafa Zaky Abdelrazek BH, Waly MR, Abdel Aziz MA, Abdel Aziz A. Different Techniques for the Management of Meniscal Ramp Lesions Using Standard Anterior Portals. Arthrosc Tech 2020; 9:e39-e44. [PMID: 32021772 PMCID: PMC6993190 DOI: 10.1016/j.eats.2019.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 08/27/2019] [Indexed: 02/03/2023] Open
Abstract
There is strong association between meniscal lesions and anterior cruciate ligament injuries. Recently, light was shown on a new entity: ramp lesions. The incidence of these lesions and their management is still unclear. Although some believe that some lesions, when stable, can be managed conservatively, most surgeons repair ramp tears. Accessibility of these tears is challenging; they are best accessed through posterior portals, which is time-consuming and poses potential risk to vital structures. Our technique allows access to and management of ramp lesions through safe standard anterior portals. Ramp lesions are searched for as a routine step during anterior cruciate ligament reconstruction by advancing the scope through the intercondylar notch just beside the medial femoral condyle. If a lesion is found, it is repaired; only very stable small tears are treated with needling to refresh the edges and induce a healing response. A simple suture, horizontal mattress suture, or a circumferential stitch is used.
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Affiliation(s)
- Begad Hesham Mostafa Zaky Abdelrazek
- Trauma and Orthopaedics Faculty of Medicine, Cairo University, Cairo, Egypt
- Trauma and Orthopaedics, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | | | - Mahmoud Ahmed Abdel Aziz
- Trauma and Orthopaedics Faculty of Medicine, Cairo University, Cairo, Egypt
- Student Hospital, Cairo University, Cairo, Egypt
| | - Ahmed Abdel Aziz
- Trauma and Orthopaedics Faculty of Medicine, Cairo University, Cairo, Egypt
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27
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Bumberger A, Koller U, Hofbauer M, Tiefenboeck TM, Hajdu S, Windhager R, Waldstein W. Ramp lesions are frequently missed in ACL-deficient knees and should be repaired in case of instability. Knee Surg Sports Traumatol Arthrosc 2020; 28:840-854. [PMID: 31076825 PMCID: PMC7035224 DOI: 10.1007/s00167-019-05521-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/24/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE The aim of the current study was (1) to provide an overview of common definitions and classification systems of ramp lesions (RL) and (2) to systematically review the available literature with regard to the diagnosis and treatment of RLs in anterior cruciate ligament (ACL)-deficient knees. METHODS Following the PRISMA guidelines, MEDLINE and Scopus were searched for articles (1) reporting on acute or chronic ACL injuries, (2) with concomitant medial meniscus injury, (3) located at the posterior meniscocapsular attachment site (and red-red zone). Ex vivo studies, reviews and technical notes were excluded. RESULTS Twenty-seven studies were included based on the criteria mentioned above. RLs are common in ACL-deficient knees with a prevalence ranging from 9 to 24%. RLs should especially be suspected in younger patients, patients with an increased meniscal slope and in patients with prolonged time from injury to surgery. The sensitivity of MRI for the detection of RLs ranges from 48 to 86% at a specificity of 79-99%. For arthroscopy, RLs are easily missed through standard anterior portals (sensitivity 0-38%). RL repair leads to a significant improvement of subjective knee scores, regardless of the specific fixation technique. For stable RLs, the literature suggests equivalent postoperative stability for trephination and abrasion compared to surgical RL repair. CONCLUSION Ramp lesions are frequently missed in ACL-deficient knees on standard arthroscopy with anterior portals only. If a RL is suspected, exploration via an additional posteromedial portal is indicated. In case of instability, RL repair should be performed. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alexander Bumberger
- Department of Orthopaedics and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ulrich Koller
- Department of Orthopaedics and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Marcus Hofbauer
- Department of Orthopaedics and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Manfred Tiefenboeck
- Department of Orthopaedics and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Hajdu
- Department of Orthopaedics and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Wenzel Waldstein
- Department of Orthopaedics and Trauma Surgery, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Naendrup JH, Pfeiffer TR, Chan C, Nagai K, Novaretti JV, Sheean AJ, Shafizadeh ST, Debski RE, Musahl V. Effect of Meniscal Ramp Lesion Repair on Knee Kinematics, Bony Contact Forces, and In Situ Forces in the Anterior Cruciate Ligament. Am J Sports Med 2019; 47:3195-3202. [PMID: 31560563 DOI: 10.1177/0363546519872964] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Meniscal ramp lesions are possible concomitant injuries in cases of anterior cruciate ligament (ACL) deficiency. Although recent studies have investigated the influence of ramp lesions on knee kinematics, the effect on the ACL reconstruction graft remains unknown. PURPOSE/HYPOTHESIS The purpose was to determine the effects of ramp lesion and ramp lesion repair on knee kinematics, the in situ forces in the ACL, and bony contact forces. It was hypothesized that ramp lesions will significantly increase in situ forces in the native ACL and bony contact forces and that ramp lesion repair will restore these conditions comparably with those forces of the intact knee. STUDY DESIGN Controlled laboratory study. METHODS Investigators tested 9 human cadaveric knee specimens using a 6 degrees of freedom robotic testing system. The knee was continuously flexed from full extension to 90° while the following loads were applied: (1) 90-N anterior load, (2) 5 N·m of external-rotation torque, (3) 134-N anterior load + 200-N compression load, (4) 4 N·m of external-rotation torque + 200-N compression load, and (5) 4 N·m of internal-rotation torque + 200-N compression load. Loading conditions were applied to the intact knee, a knee with an arthroscopically induced 25-mm ramp lesion, and a knee with an all-inside repaired ramp lesion. In situ forces in the ACL, bony contact forces in the medial compartment, and bony contact forces in the lateral compartment were quantified. RESULTS In response to all loading conditions, no differences were found with respect to kinematics, in situ forces in the ACL, and bony contact forces between intact knees and knees with a ramp lesion. However, compared with intact knees, knees with a ramp lesion repair had significantly reduced anterior translation at flexion angles from full extension to 40° in response to a 90-N anterior load (P < .05). In addition, a significant decrease in the in situ forces in the ACL after ramp repair was detected only for higher flexion angles when 4 N·m of external-rotation torque combined with a 200-N compression load (P < .05) and 4 N·m of internal-rotation torque combined with a 200-N compression load were applied (P < .05). CONCLUSION In this biomechanical study, ramp lesions did not significantly affect knee biomechanics at the time of surgery. CLINICAL RELEVANCE From a biomechanical time-zero perspective, the indications for ramp lesion repair may be limited.
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Affiliation(s)
- Jan-Hendrik Naendrup
- Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Trauma Surgery, Orthopaedic Surgery and Sports Traumatology, Witten/Herdecke University, Cologne Merheim Medical Centre, Cologne, Germany
| | - Thomas R Pfeiffer
- Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Trauma Surgery, Orthopaedic Surgery and Sports Traumatology, Witten/Herdecke University, Cologne Merheim Medical Centre, Cologne, Germany
| | - Calvin Chan
- Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kanto Nagai
- Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - João V Novaretti
- Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Orthopaedics and Traumatology Sports Center (CETE), Department of Orthopaedics and Traumatology, Paulista School of Medicine (EPM), Federal University of São Paulo, São Paulo, Brazil
| | - Andrew J Sheean
- Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sven T Shafizadeh
- Department of Trauma Surgery, Orthopaedic Surgery and Sports Traumatology, Witten/Herdecke University, Sana Medical Centre Cologne, Cologne, Germany
| | - Richard E Debski
- Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Orthopaedic Robotics Laboratory, Department of Orthopaedic Surgery, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Alessio-Mazzola M, Lovisolo S, Capello AG, Zanirato A, Chiarlone F, Formica M, Felli L. Management of ramp lesions of the knee: a systematic review of the literature. Musculoskelet Surg 2019; 104:125-133. [PMID: 31595426 DOI: 10.1007/s12306-019-00624-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/01/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this systematic review is to evaluate the current literature and to assess the clinical outcomes following meniscal ramp lesion treatment and anterior cruciate ligament (ACL) reconstruction. A consensus of the treatment of this pattern of tears is still lacking. METHODS A systematic review of the literature was performed with a comprehensive search on Medline through PubMed, CINAHL, Cochrane, Embase and Google Scholar databases. The PRISMA 2009 flowchart and checklist were considered to edit the review. The included studies were evaluated based on indications, management, surgical technique and clinical results. RESULTS Seven studies (two level II and five level IV evidence) were identified that met inclusion criteria, including a total of 509 patients. The overall main follow-up was 23.6 months. Treatment failure occurred in 8.3% of patients receiving ACL repair and ramp lesion treatment. The repair of ramp lesion is the most used approach in the literature. CONCLUSION There is a lack of literature focused on the management of ramp lesion and ACL injuries. The repair resulted in the most used approach with good clinical results and low failure rate. However, further high-quality studies evaluating the long-term outcomes of different surgical strategies are needed.
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Affiliation(s)
- M Alessio-Mazzola
- Orthopedic Clinic, Department of Surgical Sciences (DISC), University of Genova, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - S Lovisolo
- Orthopedic Clinic, Department of Surgical Sciences (DISC), University of Genova, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
| | - A G Capello
- Orthopedic Clinic, Department of Surgical Sciences (DISC), University of Genova, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - A Zanirato
- Orthopedic Clinic, Department of Surgical Sciences (DISC), University of Genova, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - F Chiarlone
- Orthopedic Clinic, Department of Surgical Sciences (DISC), University of Genova, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - M Formica
- Orthopedic Clinic, Department of Surgical Sciences (DISC), University of Genova, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - L Felli
- Orthopedic Clinic, Department of Surgical Sciences (DISC), University of Genova, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
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30
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Balazs GC, Greditzer HG, Wang D, Marom N, Potter HG, Marx RG, Rodeo SA, Williams RJ. Ramp Lesions of the Medial Meniscus in Patients Undergoing Primary and Revision ACL Reconstruction: Prevalence and Risk Factors. Orthop J Sports Med 2019; 7:2325967119843509. [PMID: 31205962 PMCID: PMC6537250 DOI: 10.1177/2325967119843509] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Ramp lesions are peripheral tears of the posterior horn of the medial meniscus that involve the meniscocapsular attachments or red-red zone and typically occur in conjunction with anterior cruciate ligament (ACL) ruptures. Purpose: To identify the prevalence of, and risk factors for, ramp lesions in a large cohort of patients undergoing primary and revision ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: We queried our institutional registry of patients who underwent primary or revision surgical treatment for an ACL injury. Those who underwent preoperative magnetic resonance imaging (MRI) at our facility were included in the study. Clinical details were extracted and verified using electronic records. All preoperative MRI scans were reviewed by a musculoskeletal radiologist for the presence of a ramp lesion. Stable ramp lesions were defined as a peripheral posterior horn medial meniscal tear identified on MRI but either not identifiable with viewing and probing from the anterior portals or, if identified, not displaceable with anteriorly directed probing. Unstable ramp lesions were defined as peripheral posterior horn medial meniscal tears at the meniscocapsular junction that were identifiable at the time of surgery and displaced into the medial compartment with probing. The prevalence of stable and unstable ramp lesions was calculated. Demographic, injury, and imaging parameters were determined using univariate statistics. Results: A total of 372 patients were included. The overall prevalence of ramp lesions was 42% (155/372). Unstable ramp lesions were present in 73 (20%) patients, and stable ramp lesions were present in 82 (22%) patients. The presence of any ramp lesion (stable or unstable) was associated with bone marrow edema of the posteromedial tibia on MRI (odds ratio [OR], 3.0; P < .0001), a contact injury mechanism (OR, 1.8; P = .02), and a concurrent lateral meniscal tear (OR, 1.7; P = .02). No demographic, injury, surgical, or radiological variable was associated with a stable versus unstable ramp lesion. Conclusion: The overall prevalence of a ramp lesion in patients treated for ACL ruptures at our institution was 42%. The presence of bone marrow edema of the posteromedial tibia, a contact injury mechanism, or a lateral meniscal tear should alert surgeons to the potential presence of a medial meniscal ramp lesion.
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Affiliation(s)
- George C Balazs
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Harry G Greditzer
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA
| | - Dean Wang
- Department of Orthopaedic Surgery, University of California, Irvine, Irvine, California, USA
| | - Niv Marom
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Hollis G Potter
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York, USA
| | - Robert G Marx
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Scott A Rodeo
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - Riley J Williams
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
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31
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DePhillipo NN, Engebretsen L, LaPrade RF. Current Trends Among US Surgeons in the Identification, Treatment, and Time of Repair for Medial Meniscal Ramp Lesions at the Time of ACL Surgery. Orthop J Sports Med 2019; 7:2325967119827267. [PMID: 30828582 PMCID: PMC6388449 DOI: 10.1177/2325967119827267] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Given the potential hidden nature of medial meniscal ramp lesions and the controversy regarding treatment, it is important to understand the current trends regarding the identification and treatment strategies of meniscal ramp lesions by the leading surgeons and educators in the field of sports medicine. Purpose To better understand the current trends in orthopaedic surgery regarding arthroscopic identification and treatment of medial meniscal ramp lesions at the time of anterior cruciate ligament (ACL) surgery. Study Design Cross-sectional study. Methods An electronic questionnaire was sent in a blinded fashion to 91 directors of orthopaedic sports medicine fellowship training programs in the United States. Participants' email addresses were obtained through the American Orthopaedic Society for Sports Medicine directory of current fellowship program directors. Inclusion criteria were only those surgeons who currently performed ACL reconstruction surgery. Exclusion criteria were those surgeons who did not perform ACL reconstruction or who chose to opt out of the survey. Results Overall, 19 surgeons opted out of the survey; 36 responded from the remaining 72 surveys (50%). The majority (n = 31, 86%) reported routinely checking for a medial meniscal ramp lesion via inspection of the posteromedial meniscocapsular junction during an ACL reconstruction. The most common repair technique cited was all-inside (n = 24, 66.7%), followed by inside-out (n = 8, 22.2%). Three (8%) surgeons indicated that they did not repair meniscal ramp lesions. Regarding surgical treatment (repair vs no treatment), the majority reported using the extent of the tear (89%; partial vs full thickness) and the stability of the tear upon probing (81%) as the main criteria for intraoperative decision making. Nineteen (52.8%) surgeons required a mean time of <15 minutes for meniscal ramp repair; 16 surgeons (44.4%), 15 to 30 minutes; and 1 surgeon (2.8%), 30 to 45 minutes. Conclusion This study provides insight regarding meniscal ramp tear identification, treatment, and repair strategies from the fellowship directors of sports medicine orthopaedic surgery in the United States. Such information may be useful for current orthopaedic surgeons to advance their practice according to the current trends surrounding ACL reconstruction and medial meniscal ramp repair.
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Affiliation(s)
- Nicholas N DePhillipo
- The Steadman Clinic, Vail, Colorado, USA.,Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
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32
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Sonnery-Cottet B, Praz C, Rosenstiel N, Blakeney WG, Ouanezar H, Kandhari V, Vieira TD, Saithna A. Epidemiological Evaluation of Meniscal Ramp Lesions in 3214 Anterior Cruciate Ligament-Injured Knees From the SANTI Study Group Database: A Risk Factor Analysis and Study of Secondary Meniscectomy Rates Following 769 Ramp Repairs. Am J Sports Med 2018; 46:3189-3197. [PMID: 30307740 DOI: 10.1177/0363546518800717] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ramp lesions are characterized by disruption of the peripheral meniscocapsular attachments of the posterior horn of the medial meniscus. Ramp repair performed at the time of anterior cruciate ligament reconstruction (ACLR) has been shown to improve knee biomechanics. PURPOSE The primary objectives of this study were to evaluate the incidence of and risk factors for ramp lesions among a large series of patients undergoing ACLR. Secondary objectives were to determine the reoperation rate for failure of ramp repair, defined by subsequent reoperations for partial medial meniscectomy. STUDY DESIGN Case-control study; Level of evidence, 3. Case series; Level of evidence, 4. METHODS All patients underwent transnotch posteromedial compartment evaluation of the knee during ACLR. Ramp repair was performed if a lesion was detected. Potentially important risk factors were analyzed for their association with ramp lesions. A secondary analysis of all patients who underwent ramp repair and had a minimum follow-up of 2 years was undertaken to determine the secondary partial meniscectomy rate for failed ramp repair. RESULTS The overall incidence of ramp lesions in the study population was 23.9% (769 ramp lesions among 3214 patients). Multivariate analysis demonstrated that the presence of ramp lesions was significantly associated with the following risk factors: male sex, patients aged <30 years, revision ACLR, chronic injuries, preoperative side-to-side laxity >6 mm, and concomitant lateral meniscal tears. The secondary meniscectomy rate was 10.8% at a mean follow-up of 45.6 months (range, 24.2-66.2 months). Patients who underwent ACLR + anterolateral ligament reconstruction had a >2-fold reduction in the risk of reoperation for failure of ramp repair as compared with patients who underwent isolated ACLR (hazard ratio, 0.457; 95% CI, 0.226-0.864; P = .021). CONCLUSION There is a high incidence of ramp lesions among patients undergoing ACLR. The identification of important risk factors for ramp lesions should help raise an appropriate index of suspicion and prompt posteromedial compartment evaluation. The overall secondary partial meniscectomy rate after ramp repair is 10.8%. Anterolateral ligament reconstruction appears to confer a protective effect on the ramp repair performed at the time of ACLR and results in a significant reduction in secondary meniscectomy rates.
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Affiliation(s)
- Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Cesar Praz
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Nikolaus Rosenstiel
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - William G Blakeney
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Herve Ouanezar
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Vikram Kandhari
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Adnan Saithna
- Southport and Ormskirk Hospital, Southport, UK.,School of Science and Technology, Nottingham Trent University, Clifton Campus, Nottingham, UK
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Heilpern G, Stephen J, Ball S, Amis A, Williams A. It is safe and effective to use all inside meniscal repair devices for posteromedial meniscal 'ramp' lesions. Knee Surg Sports Traumatol Arthrosc 2018; 26:2310-2316. [PMID: 29752501 DOI: 10.1007/s00167-018-4976-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/03/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE Recently, it has been recognized that meniscocapsular ('ramp') lesions of the posterior one-third of the medial meniscus frequently occur during injuries causing ACL rupture, and that these lesions are easily missed at arthroscopy. Furthermore, it is clear that these lesions are biomechanically significant, adding to the deficits caused by ACL rupture, and that their repair can reverse this. The efficacy of an all inside repair technique has been questioned by some authors and by those who advocate a suture shuttle technique via an accessory posteromedial portal. The use of Ultra FastFix and FastFix 360 meniscal repair devices to repair posteromedial meniscocapsular separations was investigated in terms of safe deployment and the effectiveness. METHODS Twenty cadaveric fresh frozen knees were used-ten in each of two groups. A ramp lesion was created using a Beaver knife. The lesion was then repaired with either 4 Ultra FastFix (Smith and Nephew) or 4 FastFix 360 (Smith and Nephew) meniscal repair devices. The knees were put through a standardized loading cycle consisting of 10 Lachman's tests and ten maximum loading manual anterior drawer tests at 90° of flexion. Each knee was then flexed and extended fully ten times. The specimens were sectioned just proximal to the menisci and each suture anchor identified and its position recorded and photographed. RESULTS In the Ultra FastFix group, a single anchor was found to be in an intra-articular position-a failure rate of 2.5%. In the FastFix 360 group, 5 anchors failed-a 12.5% failure rate. In all cases, the anchors were attached to their suture and so not truly loose within the joint. CONCLUSIONS This study confirms the safe and effective deployment of an all inside repair device for repair of medial meniscal 'ramp' lesions, and therefore its use is advocated in treating these difficult lesions. Ultra FastFix had the lower failure rate of 2.5%, which the authors believe is acceptable, and makes this device preferable to the FastFix360.
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Affiliation(s)
- Giles Heilpern
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK.
| | - Jo Stephen
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK
| | - Simon Ball
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK
| | | | - Andy Williams
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK
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Diagnostic Accuracy of Sequential Arthroscopic Approach for Ramp Lesions of the Posterior Horn of the Medial Meniscus in Anterior Cruciate Ligament-Deficient Knee. Arthroscopy 2018; 34:1582-1589. [PMID: 29402583 DOI: 10.1016/j.arthro.2017.12.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 12/05/2017] [Accepted: 12/06/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To document the diagnostic accuracy and steps for sequential arthroscopic exploration of ramp lesions-peripheral tear within 4 mm of meniscocapsular junction of medial meniscus-associated with anterior cruciate ligament (ACL) injury. METHODS This was a prospective consecutive study of 195 primary ACL reconstructions with arthroscopic exploration for ramp lesion in 4 steps: (1) standard exploration through the anterolateral portal, (2) through the intercondylar space using a 30° arthroscope, (3) through the intercondylar space using a 70° arthroscope, and (4) after creation of a posteromedial portal. Acute (<3 months) and chronic case (>3 months) groups were compared, and the sensitivity and specificity of magnetic resonance imaging (MRI) were assessed. RESULTS Overall, 50 patients (26.6%) were confirmed as having a ramp lesion. After step 1, only 19 cases (38%) were identified as a ramp lesion. After step 2, 24 cases (48%) were found, and the sensitivity of step 2 was estimated at 48%. After step 3, an additional 26 cases (52%) were identified. No more additional cases of ramp lesion were found after step 4. There were statistically significant differences between steps 2 and 3 (P = .001), but no differences between steps 1 and 2, or steps 3 and 4. Although there were no statistical differences in overall prevalence for acute (28/128, 21.8%) and chronic (22/67, 32.8%) groups (P = .136), the incidence of ramp lesion confirmed through the standard portal approach was found to be significantly correlated with chronic group (odds ratio: 2.95, P = .023). The sensitivity and specificity of preoperative MRI were 84% and 95.17%. CONCLUSIONS Many ramp lesions could not be diagnosed through the standard portal and intercondylar space using a 30° arthroscope. Posteromedial inspection using a 70° arthroscope has improved the diagnostic accuracy for ramp lesion without direct exploration through the posteromedial portal. Care should be taken to identify ramp lesions when ACL reconstruction is performed. LEVEL OF EVIDENCE Level I, diagnostic study of consecutive patients.
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Negrín R, Reyes NO, Iñiguez M, Pellegrini JJ, Wainer M, Duboy J. Meniscal Ramp Lesion Repair Using an All-Inside Technique. Arthrosc Tech 2018; 7:e265-e270. [PMID: 29881699 PMCID: PMC5989817 DOI: 10.1016/j.eats.2017.09.001] [Citation(s) in RCA: 18] [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: 08/09/2017] [Accepted: 09/01/2017] [Indexed: 02/03/2023] Open
Abstract
Posteromedial meniscotibial ligament lesions, known as meniscal ramp lesions, are typically associated with ACL injuries, but frequently underdiagnosed. When correctly diagnosed, repair is mandatory in most cases. Retraction of the soft tissues makes it difficult to repair and leads to suture failure. Previously described techniques include all-inside and inside-out meniscal sutures, but do not ensure correct meniscotibial closure because of the soft tissue retraction. The purpose of this Technical Note is to describe a meniscal ramp lesion arthroscopic repair with an all-inside technique with the Fast-Fix 360 device, detailing the use of the accessory posteromedial portal, and the addition of an arthroscopic grasper that raises the retracted meniscotibial ligament, to allow correct fixation.
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Affiliation(s)
- Roberto Negrín
- Address correspondence to Roberto Negrín, M.D., Lo Fontecilla 441, Santiago 6772610, Chile.
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Arner JW, Herbst E, Burnham JM, Soni A, Naendrup JH, Popchak A, Fu FH, Musahl V. MRI can accurately detect meniscal ramp lesions of the knee. Knee Surg Sports Traumatol Arthrosc 2017; 25:3955-3960. [PMID: 28343325 DOI: 10.1007/s00167-017-4523-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/10/2017] [Indexed: 01/11/2023]
Abstract
PURPOSE Posterior horn meniscal tears are commonly found in conjunction with anterior cruciate ligament (ACL) injury. Some believe tears in the posterior meniscocapsular zone, coined ramp lesions, are important to knee stability. The purpose of this study was to determine whether pre-operative MRI evaluation was able to accurately and reproducibly identify ramp lesions. METHODS Three blinded reviewers assessed MRIs twice for the presence of ramp lesions in patients undergoing ACL reconstruction. Sensitivity, specificity, negative predictive value, and positive predictive value for MRI were calculated based on arthroscopic diagnosis of a ramp lesion. Intra-class correlation coefficient was calculated to assess intra- and interobserver reliability of the MRI assessment between the three examiners. Significance was set at p < 0.05. RESULTS Ninety patients met inclusion criteria (45 males, 45 females, mean age 28.0 years). Thirteen of these patients had arthroscopy-confirmed ramp lesions, while the other 77 had other meniscal pathology. Sensitivity of detecting a ramp lesion on MRI ranged from 53.9 to 84.6%, while specificity was 92.3-98.7%. Negative predictive value was 91.1-97.4%, while positive predictive value was 50.0-90.0%. Inter-rater reliability between three reviewers was moderate at 0.56. The observers had excellent intra-rater reliability ranging from 0.75 to 0.81. CONCLUSIONS This study demonstrates high sensitivity and excellent specificity in detecting meniscal ramp lesions on MRI. Ramp lesions are likely more common and may have greater clinical implications than previously appreciated; the outcomes of untreated lesions must be investigated. Pre-operative identification of ramp lesions may aid clinicians in surgical planning and patient education to improve outcomes by addressing pathology which may have otherwise been missed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Justin W Arner
- UPMC Center for Sports Medicine, 3200 S Water St, Pittsburgh, PA, 15203, USA
| | - Elmar Herbst
- UPMC Center for Sports Medicine, 3200 S Water St, Pittsburgh, PA, 15203, USA
| | - Jeremy M Burnham
- UPMC Center for Sports Medicine, 3200 S Water St, Pittsburgh, PA, 15203, USA
| | - Ashish Soni
- UPMC Center for Sports Medicine, 3200 S Water St, Pittsburgh, PA, 15203, USA
| | | | - Adam Popchak
- UPMC Center for Sports Medicine, 3200 S Water St, Pittsburgh, PA, 15203, USA
| | - Freddie H Fu
- UPMC Center for Sports Medicine, 3200 S Water St, Pittsburgh, PA, 15203, USA
| | - Volker Musahl
- UPMC Center for Sports Medicine, 3200 S Water St, Pittsburgh, PA, 15203, USA.
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Buyukdogan K, Laidlaw MS, Miller MD. Meniscal Ramp Lesion Repair by a Trans-septal Portal Technique. Arthrosc Tech 2017; 6:e1379-e1386. [PMID: 29354444 PMCID: PMC5622595 DOI: 10.1016/j.eats.2017.05.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/21/2017] [Indexed: 02/03/2023] Open
Abstract
The identification of meniscal ramp lesions can be quite difficult or even impossible with conventional anterior arthroscopic viewing and working portals. Although even the use of transnotch viewing maneuvers into the posteromedial compartment increases the likelihood of diagnosis, it is the posteromedial and trans-septal portals that provide the best direct visualization of these many times "hidden lesions." In this surgical technique description, we describe a method to not only adequately visualize the ramp lesion, but also provide subtle variations to existing surgical techniques that can help limit injury to neurovascular structures as well as gain satisfactory vertical suture repair of this posteromedial meniscocapsular injury.
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Affiliation(s)
| | | | - Mark D. Miller
- Address correspondence to Mark D. Miller, M.D., Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Drive, Suite 300, Charlottesville, VA 22903, U.S.A.Department of Orthopaedic SurgeryUniversity of Virginia400 Ray C. Hunt DriveSuite 300CharlottesvilleVA22903U.S.A.
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Abstract
Meniscal ramp lesions have been reported to be present in 9% to 17% of patients undergoing anterior cruciate ligament reconstruction. Detection at the time of arthroscopy can be accomplished based upon clinical suspicion and careful evaluation without the use of an accessory posteromedial portal. Options for surgical treatment include arthroscopic repair using an all-inside or inside-out technique. The purpose of this Technical Note is to detail our arthroscopic inside-out repair technique for meniscal ramp lesions.
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Kumar NS, Edgar C, Spencer T, Ware JK, Reed DN, Cote MP, Arciero RA. Anatomic Repair of Posteromedial Meniscocapsular Separation Using an All-Inside Technique. Arthrosc Tech 2017; 6:e921-e926. [PMID: 29487781 PMCID: PMC5800956 DOI: 10.1016/j.eats.2017.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 03/02/2017] [Indexed: 02/03/2023] Open
Abstract
Separation of the posteromedial meniscocapsular junction (PMC) is a unique injury seen in patients with disruption of the anterior cruciate ligament. PMC tears may go unrecognized despite preoperative magnetic resonance imaging and diagnostic arthroscopy of the medial compartment. Unrepaired lesions may lead to persistent laxity of the knee after anterior cruciate ligament reconstruction. Inside-out repair techniques risk iatrogenic injury to the articular cartilage during needle passage and require dissection of the posteromedial knee for suture retrieval. Previous all-inside techniques have required specialized implants and repaired PMC lesions with direct visualization of the tear. The presented all-inside technique is an easily reproducible, cost-effective means to anatomically repair separation of the PMC. The technique provides the surgeon direct visualization and full arthroscopic access to the lesion, making repair technically easy and efficient.
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Affiliation(s)
- Neil S. Kumar
- Address correspondence to Neil S. Kumar, M.D., University of Connecticut Health Center, MARB Fourth Floor, Farmington, CT 06032, U.S.A.University of Connecticut Health CenterMARB Fourth FloorFarmingtonCT06032U.S.A.
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Tiftikçi U, Serbest S. Does the location of placement of meniscal sutures have a clinical effect in the all-inside repair of meniscocapsular tears? J Orthop Surg Res 2017; 12:87. [PMID: 28599660 PMCID: PMC5466734 DOI: 10.1186/s13018-017-0591-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/31/2017] [Indexed: 11/10/2022] Open
Abstract
Background Meniscocapsular separation (MCS) is a lesion of the area which is attached from the peripheral section of the meniscus to the capsule and is seen less often than other meniscus injuries. The aim of this study was to investigate which of the different side applications of all-inside MCS repair of the meniscus was better in respect of clinical and functional results. Methods In this retrospective study, 53 patients with MCS pattern in their knee joints were treated with arthroscopic meniscus repair made with the all-inside method. The patients were separated into three groups according to the surface from which the fixation was applied: group 1, from the femoral joint surface of the meniscus (n = 17), group 2, from the tibial joint surface of the meniscus (n = 21) and group 3, from the femoral and tibial joint surfaces of the meniscus (n = 15). The participants were assessed using the subjective International Knee Documentation Committee Scoring (IKDC), Lysholm Knee Scale, Tegner Activity Level Scale, Barrett criteria and Kellgren–Lawrence classification after a 45 ± 12.1 months (range, 24–70 months) follow-up. Results Postoperatively, all the groups exhibited significantly increased subjective IKDC score, Lysholm score and Tegner activity score compared with their preoperative results (p < 0.001). At 6 months postoperatively, a statistically significant difference was determined between the groups in respect of the subjective IKDC score, Tegner activity score and Lysholm score with group 2 showing better results than the other groups (p < 0.001). At the final follow-up examination, no statistically significant difference was determined between the groups in respect of the subjective IKDC score, Tegner activity score or Lysholm score. A statistically significantly lower level of pulling and stress sensation was determined in group 2 (p < 0.001). Conclusions MCS repair made with the all-inside method is successful clinically and functionally and in respect of MRI findings. In addition, it was seen that the fixation method applied from the tibial surface of the meniscus does not disturb the anatomic position of the meniscus in MCS repair. The tibial joint surface is the most appropriate area for suturation in all-inside repair of MCS. Level of evidence Level IV.
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Affiliation(s)
- Uğur Tiftikçi
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Kırıkkale University, Kırıkkale, Turkey
| | - Sancar Serbest
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Kırıkkale University, Kırıkkale, Turkey.
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Yang J, Guan K, Wang J. Clinical study on the arthroscopic refreshing treatment of anterior cruciate ligament injury combined with stable medial meniscus ramp injury. JOURNAL OF MUSCULOSKELETAL & NEURONAL INTERACTIONS 2017; 17:108-113. [PMID: 28574418 PMCID: PMC5492326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
This study sought to investigate the clinical efficacy of arthroscopic refreshing treatment of anterior cruciate ligament (ACL) injury combined with stable medial meniscus ramp injury. Sixty-eight patients treated between January 2010 and January 2014 were included, and their clinical data were retrospectively analyzed. All patients, after being treated using ACL reconstruction, were divided into 2 groups according to meniscus injury treatment method. The observation group (31 cases) was treated by arthroscopic refreshing, which removed the tissue on both sides of the tear edge using a cutting knife, while the control group (37 cases) was treated using Fast-fix sutures. All patients were followed up for at least 24 months. Surgical duration, postoperative function recovery time, and hospital stay for patients in the observation group were significantly shorter than for those of the control group (P⟨0.05). Both groups showed significant post-operative improvement for Lysholm scores, IKDC scores, and average knee range of motion at 12 and 24 months post-operation (P⟨0.05), but no significant differences between groups were observed (P⟩0.05). Regarding the difference in movement range between the healthy and injured sides, both groups showed significant decrease post-operation (P⟨0.05). Ultimately, there was no significant difference in the recovery of ramp damage and objective symptoms between the two groups (P⟩0.05). Arthroscopic refreshing treatment of patients with anterior cruciate ligament injury combined with stable ramp lesion can achieve similar clinical curative effects as the Fast-fix suture, thereby providing a simple alternative for patient treatment worth popularizing.
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Affiliation(s)
- J. Yang
- Department of Articular Surgery, Henan Provincial Hospital of Traditional Chinese Medicine
| | - K. Guan
- Department of Orthopedics, The First people’s Hospital of Xianyang City
| | - J.Z. Wang
- Department of Orthopedics, Hospital of Hebei University, Baoding, Hebei province, 071000, China,Corresponding author: Jianzhong Wang, PhD, Department of Orthopedics, Hospital of Hebei University, NO.212, Yuhua Road, Baoding, Hebei province, 071000, China E-mail:
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Kongmalai P, Chernchujit B. Posterior Horn of Medial Meniscal Peripheral Capsular Lesion: The Arthroscopic Repair Technique Working in the Posterior Compartment. Arthrosc Tech 2016; 5:e763-e767. [PMID: 27709034 PMCID: PMC5040096 DOI: 10.1016/j.eats.2016.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/04/2016] [Indexed: 02/03/2023] Open
Abstract
A posterior horn of medial meniscal peripheral capsular is usually associated with the anterior cruciate ligament injury. The conventional repair technique with the camera in the anterolateral portal cannot precisely restore the slope capsular synovium to the original attachment point. We present the arthroscopic technique for improving the accuracy and quality of the repair by working in the posterior compartment. When the posterolateral portal is used as the viewing portal, the accuracy of repair is improved because we can assess the full extent of the lesion and lift the sagging peripheral tissue to the more central part.
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Affiliation(s)
- Pinkawas Kongmalai
- Department of Orthopaedics, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok,Address correspondence to Pinkawas Kongmalai, M.D., Department of Orthopaedics, Faculty of Medicine, Srinakharinwirot University, 62 Moo 7, Nakhon Nayok 26120, Thailand.Department of OrthopaedicsFaculty of MedicineSrinakharinwirot University62 Moo 7Nakhon Nayok26120Thailand
| | - Bancha Chernchujit
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Rangsit, Pathum Thani, Thailand
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Chahla J, Dean CS, Moatshe G, Mitchell JJ, Cram TR, Yacuzzi C, LaPrade RF. Meniscal Ramp Lesions: Anatomy, Incidence, Diagnosis, and Treatment. Orthop J Sports Med 2016; 4:2325967116657815. [PMID: 27504467 PMCID: PMC4963625 DOI: 10.1177/2325967116657815] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Meniscal ramp lesions are more frequently associated with anterior cruciate ligament (ACL) injuries than previously recognized. Some authors suggest that this entity results from disruption of the meniscotibial ligaments of the posterior horn of the medial meniscus, whereas others support the idea that it is created by a tear of the peripheral attachment of the posterior horn of the medial meniscus. Magnetic resonance imaging (MRI) scans have been reported to have a low sensitivity, and consequently, ramp lesions often go undiagnosed. Therefore, to rule out a ramp lesion, an arthroscopic evaluation with probing of the posterior horn of the medial meniscus should be performed. Several treatment options have been reported, including nonsurgical management, inside-out meniscal repair, or all-inside meniscal repair. In cases of isolated ramp lesions, a standard meniscal repair rehabilitation protocol should be followed. However, when a concomitant ACL reconstruction (ACLR) is performed, the rehabilitation should follow the designated ACLR postoperative protocol. The purpose of this article was to review the current literature regarding meniscal ramp lesions and summarize the pertinent anatomy, biomechanics, diagnostic strategies, recommended treatment options, and postoperative protocol.
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Affiliation(s)
- Jorge Chahla
- The Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Chase S. Dean
- The Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Gilbert Moatshe
- The Steadman Philippon Research Institute, Vail, Colorado, USA
- Department of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
- OSRTC, The Norwegian School of Sports Sciences, Oslo, Norway
| | - Justin J. Mitchell
- The Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
| | - Tyler R. Cram
- The Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Carlos Yacuzzi
- The Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Robert F. LaPrade
- The Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
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Tiftikci U, Serbest S. The Optimal Placement of Sutures in All-inside Repair of Meniscocapsular Separation. Open Orthop J 2016; 10:89-93. [PMID: 27347236 PMCID: PMC4897031 DOI: 10.2174/1874325001610010089] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/01/2016] [Accepted: 01/22/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The aim of this study was to show the effects on the meniscus of repair applied from the femoral, the femoral-tibial and the tibial surfaces. METHODS In the treatment of meniscocapsular separation, although the accepted gold standard technique in the past was the inside-out suture technique, the current treatment method is all-inside repair methods. The all-inside techniques include the hook method and applications with a meniscus suture device. The hook method is difficult with a steep learning curve. In meniscus repair applied with the all-inside meniscus devices, the application of the suture can change the anatomic structure and position of the meniscus. RESULTS The suturing method applied from the tibial section of the meniscus does not disrupt the anatomic position of the meniscus in meniscocapsular separation. Thus, the optimum conditions are provided for restoration of the functions of the meniscus. CONCLUSION The optimal repair in meniscocapsular separations can be considered to be that made with sutures from the tibial section of the meniscus. This technique may be helpful in obtaining better clinical results.
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Affiliation(s)
- Uğur Tiftikci
- Department of Orthopaedics and Traumatology, Faculty of Medicine Kırıkkale, Kırıkkale University, Turkey
| | - Sancar Serbest
- Department of Orthopaedics and Traumatology, Faculty of Medicine Kırıkkale, Kırıkkale University, Turkey
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Repairing Posteromedial Meniscocapsular Separation: A Technique Using Inside-Out Meniscal Repair Needles. Arthrosc Tech 2016; 5:e23-5. [PMID: 27073773 PMCID: PMC4809743 DOI: 10.1016/j.eats.2015.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/15/2015] [Indexed: 02/03/2023] Open
Abstract
Posteromedial meniscocapsular separation of the knee has received renewed interest, with many articles describing a high incidence in association with anterior cruciate ligament injury. Various techniques have been described to address these lesions using all-inside meniscal repair sutures or using rotator cuff repair instruments through the posteromedial portal. Most orthopaedic surgeons are accustomed to using the "inside-out" meniscal repair technique with a double-armed suture. This technique is cost-effective and, in our opinion, more efficient in repairing such tears. We present our technique of repairing peripheral meniscocapsular lesions using an inside-out meniscal repair system. We believe that this technique is easily reproducible, is less time-consuming, and ensures a good "bite" of the capsular tissue, producing a robust repair.
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