Skip to main content
SpringerLink
Log in

Meniscal ramp lesions should be considered in anterior cruciate ligament-injured knees, especially with larger instability or longer delay before surgery

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To determine the incidence of meniscal ramp lesions in an anterior cruciate ligament (ACL) injured knees and to clarify whether ramp lesions are related to chronic ACL deficiency and increased knee instability.

Methods

Consecutive ACL injured patients were evaluated arthroscopically for a ramp lesion via a trans-notch view and evidence of menisco-capsular injury was recorded. Other concomitant injuries to the knee were also noted. Incidence of meniscal ramp lesions, delay before surgery, and anterior–posterior stability was analyzed. All patients underwent bilateral KT-2000 evaluation.

Results

One hundred and three consecutive ACL injured patients with a mean age of 24 years were included in this study. In total, a ramp lesion was found in 10 knees (9.7%) via a trans-notch view. None of these lesions could be identified by the standard view from the anterolateral portal. Other medial meniscal lesions were found in 26 knees (25.2%) by standard arthroscopic viewing. The ramp lesion group had significantly longer delay before surgery with a median of 191 days (p < 0.01) as well as a larger side-to-side difference of KT-2000 measurement (7.3 ± 1.8 mm; p < 0.01), compared with the intact medial meniscus group (53 days and 5.5 ± 1.5 mm, respectively).

Conclusion

Ramp lesions that were identified using a trans-notch view were not visualized with standard arthroscopic views. Increased anterior tibial translation and longer delay before surgery were seen in knees with ramp lesions. Careful inspection of the posteromedial menisco-capsular region is required as hidden menisco-capsular lesions may occur which may result in residual knee instability.

Level of evidence

Level II.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

ACL:

Anterior cruciate ligament

MCL:

Medial collateral ligament

PHMM:

Posterior horn of the medial meniscus

MRI:

Magnetic resonance imaging

PCL:

Posterior cruciate ligament

References

  1. Ahn JH, Bae TS, Kang KS, Kang SY, Lee SH (2011) Longitudinal tear of the medial meniscus posterior horn in the anterior cruciate ligamentdeficient knee significantly influences anterior stability. Am J Sports Med 39:2187–2193

    Google Scholar 

  2. Allen CR, Wong EK, Livesay GA, Sakane M, Fu FH, Woo SLY (2000) Importance of the medial meniscus in the anterior cruciate ligament deficient knee. J Orthop Res 18:109–115

    CAS  Google Scholar 

  3. Arner JW, Herbst E, Burnham JM, Soni A, Naendrup JH, Popchak A, Fu FH, Musahl V (2017) MRI can accurately detect meniscal ramp lesions of the knee. Knee Surg Sports Traumatol Arthrosc 25:3955–3960

    Google Scholar 

  4. Balazs GC, Greditzer HG IV, Wang D, Marom N, Potter HG, Marx RG, Rodeo SA, Williams RJ III (2019) Ramp lesions of the medial meniscus in patients undergoing primary and revision ACL reconstruction: prevalence and risk factors. Orthop J Sports Med 15 7(5):2325967119843509

    Google Scholar 

  5. Bollen SR (2010) Posteromedial meniscocapsular injury associated with rupture of the anterior cruciate ligament: a previously unrecognised association. J Bone Jt Surg 92:222–223

    CAS  Google Scholar 

  6. Bumberger A, Koller U, Hofbauer M, Tiefenboeck TM, Hajdu S, Windhager R, Waldstein W (2020) Ramp lesions are frequently missed in ACL-deficient knees and should be repaired in case of instability. Knee Surg Sports Traumatol Arthrosc 28:840–854

    Google Scholar 

  7. Church S, Keating JF (2005) Reconstruction of the anterior cruciate ligament: timing of surgery and the incidence of meniscal tears and degenerative change. J Bone Jt Surg Br 87:1639–1642

    CAS  Google Scholar 

  8. DePhillipo NN, Cinque ME, Chahla J, Geeslin AG, Engebretsen L, LaPrade RF (2017) Incidence and detection of meniscal ramp lesions on magnetic resonance imaging in patients with anterior cruciate ligament reconstruction. Am J Sports Med 45:2233–2237

    Google Scholar 

  9. Di Vico G, Di Donato SL, Balato G, Correra G, D’Addona A, Maffulli N, Rosa D (2018) Correlation between time from injury to surgery and the prevalence of ramp and hidden lesions during anterior cruciate ligament reconstruction: a new diagnostic algorithm. Muscles Ligaments Tendons J 7:491–497

    Google Scholar 

  10. Gillquist J, Hagberg G, Oretorp N (1979) Arthroscopic examination of the posteromedial compartment of the knee joint. Int Orthop 3:13–18

    CAS  Google Scholar 

  11. Greif DN, Baraga MG, Rizzo MG, Mohile NV, Silva FD, Fox T, Jose J (2020) MRI appearance of the different meniscal ramp lesion types, with clinical and arthroscopic correlation. Skelet Radiol 49:677–689

    Google Scholar 

  12. Hagino T, Ochiai S, Senga S, Yamashita T, Wako M, Ando T, Haro H (2015) Meniscal tears associated with anterior cruciate ligament injury. Arch Orthop Trauma Surg 135:1701–1706

    Google Scholar 

  13. Hash T (2013) Magnetic resonance imaging of the knee. Sports Health 5:78–107

    Google Scholar 

  14. Hatayama K, Terauchi M, Saito K, Aoki J, Nonaka S, Higuchi H (2018) Magnetic resonance imaging diagnosis of medial meniscal ramp lesions in patients with anterior cruciate ligament injuries. Arthroscopy 34:1631–1637

    Google Scholar 

  15. Hatayama K, Terauchi M, Saito K, Takase R, Higuchi H (2020) Healing status of meniscal ramp lesion affects anterior knee stability after ACL reconstruction. Orthop J Sports Med 8:2325967120917674

    Google Scholar 

  16. Ihara H, Miwa M, Takayanagi K, Nakayama A (1994) Acute torn meniscus combined with acute cruciate ligament injury: second look arthroscopy after 3-month conservative treatment. Clin Orthop Relat Res 307:146–154

    Google Scholar 

  17. Kumar NS, Spencer T, Cote MP, Arciero RA, Edgar C (2018) Is edema at the posterior medial tibial plateau indicative of a ramp lesion? An examination of 307 patients with anterior cruciate ligament reconstruction and medial meniscal tears. Orthop J Sports Med 6:2325967118780089

    Google Scholar 

  18. Lee JY, Chia ZY, Jiang L, Ang B, Chang P (2020) A review of the Gillquist Maneuver: modifications for a safer and easily reproducible approach for knee transintercondylar notch posterior compartment arthroscopy. Arthrosc Tech 9:e435–e438

    Google Scholar 

  19. Liu X, Feng H, Zhang H, Hong L, Wang XS, Zhang J (2011) Arthroscopic prevalence of ramp lesion in 868 patients with anterior cruciate ligament injury. Am J Sports Med 39:832–837

    Google Scholar 

  20. Mariani PP (2011) Posterior horn instability of the medial meniscus a sign of posterior meniscotibial ligament insufficiency. Knee Surg Sports Traumatol Arthrosc 19:1148–1153

    CAS  Google Scholar 

  21. Mouton C, Magosch A, Pape D, Hoffmann A, Nuhrenborger C, Seil R (2019) Ramp lesions of the medial meniscus are associated with a higher grade of dynamic rotatory laxity in ACL-injured patients in comparison to patients with an isolated injury. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-019-05579-z

    Article  Google Scholar 

  22. Ogilvie-Harris DJ, Weisleder L (1995) Arthroscopic synovectomy of the knee: is it helpful? J Arthrosc Relat Surg 11:91–95

    CAS  Google Scholar 

  23. Papageorgiou CD, Gil JE, Kanamori A, Fenwick JA, Woo SL, Fu FH (2001) The biomechanical interdependence between the anterior cruciate ligament replacement graft and the medial meniscus. Am J Sports Med 29:226–231

    CAS  Google Scholar 

  24. Papastergiou SG, Koukoulias NE, Mikalef P, Ziogas E, Voulgaropoulos H (2007) Meniscal tears in the ACL-deficient knee: correlation between meniscal tears and the timing of ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 15:1438–1444

    Google Scholar 

  25. Pierre A, Hulet C, Locker B, Schiltz D, Delbarre JC, Vielpeau C (2001) Outcome of 95 stable meniscal tears left in place after reconstruction of the anterior cruciate ligament. Rev Chir Orthop Reparatrice Appar Mot 87:661–668

    CAS  Google Scholar 

  26. Peltier A, Lording T, Maubisson L, Ballis R, Neyret P, Lustig S (2015) The role of the meniscotibial ligament in posteromedial rotational knee stability. Knee Surg Sports Traumatol Arthrosc 23:2967–2973

    CAS  Google Scholar 

  27. Reider B (2017) Ramped up. Am J Sports Med 45:1001–1003

    Google Scholar 

  28. Robb C, Kempshall P, Getgood A, Standell H, Sprowson A, Thompson P, Spalding T (2015) Meniscal integrity predicts laxity of anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 23:3683–3690

    Google Scholar 

  29. Robinson JR, Bull AM, Thomas RR, Amis AA (2006) The role of the medial collateral ligament and posteromedial capsule in controlling knee laxity. Am J Sports Med 34:1815–1823

    Google Scholar 

  30. Robinson JR, Sanchez-Ballester J, Bull AMJ, de Thomas RW, Amis AA (2004) The posteromedial corner revisited: an anatomical description of the passive restraining structures of the medial aspect of the human knee. J Bone Jt Surg Br 86:674–681

    CAS  Google Scholar 

  31. Seil R, Mouton C, Coquay J, Hoffmann A, Nührenbörger C, Pape D, Theisen D (2018) Ramp lesions associated with ACL injuries are more likely to be present in contact injuries and complete ACL tears. Knee Surg Sports Traumatol Arthrosc 26:1080–1085

    Google Scholar 

  32. Sonnery-Cottet B, Conteduca J, Thaunat M, Gunepin FX, Seil R (2014) Hidden lesions of the posterior horn of the medial meniscus: a systematic arthroscopic exploration of the concealed portion of the knee. Am J Sports Med 42:921–926

    Google Scholar 

  33. Sonnery-Cottet B, Praz C, Rosenstiel N, Blakeney WG, Ouanezar H, Kandhari V, Vieira TD, Saithna A (2018) 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 46:3189–3197

    Google Scholar 

  34. Stephen JM, Halewood C, Kittl C, Bollen SR, Williams A, Amis AA (2016) Posteromedial meniscocapsular lesions increase tibiofemoral joint laxity with anterior cruciate ligament deficiency, and their repair reduces laxity. Am J Sports Med 44:400–408

    Google Scholar 

  35. Tashiro Y, Okazaki K, Miura H, Matsuda S, Yasunaga T, Hashizume M, Nakanishi Y, Iwamoto Y (2009) Quantitative assessment of rotatory instability after anterior cruciate ligament reconstruction. Am J Sports Med 37:909–916

    Google Scholar 

  36. Thaunat M, Fayard JM, Guimaraes TM, Jan N, Murphy CG, Sonnery-Cottet B (2016) Classification and surgical repair of ramp lesions of the medial meniscus. Arthrosc Tech 5:e871–e875

    Google Scholar 

  37. Thaunat M, Jan N, Fayard JM, Kajetanek C, Murphy CG, Pupim B, Gardon R, Sonnery-Cottet B (2016) Repair of meniscal ramp lesions through a posteromedial portal during anterior cruciate ligament reconstruction: outcome study with a minimum 2-year follow-up. Arthroscopy 32:2269–2277

    Google Scholar 

  38. Walker PS, Erkman MJ (1975) The role of the menisci in force transmission across the knee. Clin Orthop 109:184–192

    Google Scholar 

  39. Warren LF, Marshall JL (1979) The supporting structures and layers on the medial side of the knee: an anatomical analysis. J Bone Jt Surg Am 61:56–62

    CAS  Google Scholar 

  40. Woods GW, Chapman DR (1984) Repairable posterior menisco-capsular disruption in anterior cruciate ligament injuries. Am J Sports Med 12:381–385

    CAS  Google Scholar 

  41. Yagishita K, Muneta T, Ogiuchi T, Sekiya I, Shinomiya K (2004) Healing potential of meniscal tears without repair in knees with anterior cruciate ligament reconstruction. Am J Sports Med 32:1953–1961

    Google Scholar 

  42. Yeo Y, Ahn JM, Kim H, Kang Y, Lee E, Lee JW, Kang HS (2018) MR evaluation of the meniscal ramp lesion in patients with anterior cruciate ligament tear. Skelet Radiol 47:1683–1689

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Kyushu Rosai Hospital, 1-1 Sonekita-machi, Kokura-minami-ku, Kitakyushu, 800-0296, Japan

    Yasutaka Tashiro, Tatsuya Mori, Tsutomu Kawano, Toshihiro Oniduka & Yukihide Iwamoto

  2. Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA

    Justin W. Arner & Freddie H. Fu

Authors
  1. Yasutaka Tashiro
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tatsuya Mori
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tsutomu Kawano
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Toshihiro Oniduka
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Justin W. Arner
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Freddie H. Fu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yukihide Iwamoto
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

YT designed the study, performed surgery, data collection and analysis. He drafted the manuscript. TM also performed surgery, assisted data collection and evaluation. TK assisted designing the study, evaluated the data and co-supervised the clinical aspect of the study. TO assisted data collection, analysis and evaluation. JA advised in a study designed, manuscript preparation, and editing as a native English speaker. FF advised the study design and directed all clinical aspects. He examined the validity of data analysis and supervised the entire research. YI assisted in designing the study and co-supervised the entire research.

Corresponding author

Correspondence to Freddie H. Fu.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

There is no funding source.

Ethical approval

This study was approved by our IRB in Kyushu Rosai Hospital (IRB No. 19–17) and all subjects provided informed consent before they were enrolled.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tashiro, Y., Mori, T., Kawano, T. et al. Meniscal ramp lesions should be considered in anterior cruciate ligament-injured knees, especially with larger instability or longer delay before surgery. Knee Surg Sports Traumatol Arthrosc 28, 3569–3575 (2020). https://doi.org/10.1007/s00167-020-06161-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-020-06161-8

Keywords

Search

Navigation