Page 26 - 2020 ISAKOS Newsletter Volume I

CURRENT CONCEPTS
Is It Necessary to Repair Meniscal Ramp Lesions?
Inside-out repair techniques have been reported to increase the strength of the repair construct through the use of an increased number of sutures. Although inside-out techniques are technically demanding, their advantages include the versatility of suture placement and the anatomical repair of the meniscus to the posterior part of the capsule. The disadvantages of inside-out repair techniques include the need for additional incisions, the risk of neurovascular injuries in association with the surgical approach, and the extended surgical time needed for the meniscus repair. With the relatively high reported failure rate (11%) following all- inside meniscal ramp repair, future clinical studies are necessary to assess patient outcomes following inside-out ramp-repair techniques.
Authors’ Preferred Technique: ACLR with Inside-Out Ramp Repair
An examination is performed with the patient under anesthesia to assess for ACL instability, as Mouton et al. reported that grade-III Lachman and pivot-shift tests are associated with combined ACL tears and meniscal ramp lesions. The ACL femoral tunnel is reamed first, and then attention is directed toward the medial compartment. The posteromedial aspect of the knee is evaluated directly with use of the modified Gillquist view, with the arthroscope passing medial to the posterior cruciate ligament. A 70° arthroscope can be used to improve visualization of the posteromedial part of the capsule. Once the ramp tear is confirmed, a posteromedial incision is made posterior to the medial collateral ligament and a retractor is placed to protect the neurovascular structures. Four to six inside-out meniscal sutures are then placed in a vertical mattress fashion to ensure that both meniscocapsular and meniscotibial attachments are reduced. The sutures are then tied under direct visualization via the modified Gillquist view, and the repair is reassessed to confirm stability (Figure 1). The ACL tibial tunnel is then reamed, and the ACLR graft is passed and fixed in the femur and tibia.
01C Inside-out repair of a ramp lesion under
direct visualization.
01D Vertical mattress repair with stability confirmed
on probing.
01A Meniscal ramp lesion with increased anterior translation on probing.
01B Ramp lesion seen with a modified Gillquist view.
Figs. 1-A through 1-D Arthroscopic images made during inside-out medial meniscus ramp repair. MFC: medial femoral condyle, PMC: posteromedial capsule, MM: medial meniscus.
Summary
There is biomechanical evidence to support the repair of meniscal ramp lesions at the time of ACLR. Both all-inside and inside-out repair techniques have been described, but both methods still lack sufficient clinical validation. Future studies of meniscal ramp lesions should focus on clinical outcomes following combined ACLR and meniscal ramp repair.
References
1. DePhillipo NN, Moatshe G, Brady A, et al. Effect of Meniscocapsular and Meniscotibial Lesions in ACL-Deficient and ACL-Reconstructed Knees: A Biomechanical Study. The American journal of sports medicine 2018:363546518774315. doi: 10.1177/0363546518774315 2. Edgar C, Kumar N, Ware JK, et al. Incidence of Posteromedial Meniscocapsular Separation and the Biomechanical Implications on the Anterior Cruciate Ligament. The Journal of the American Academy of Orthopaedic Surgeons 2018 doi: 10.5435/JAAOS-D-17-00327 3. Stephen JM, Halewood C, Kittl C, et al. Posteromedial Meniscocapsular Lesions Increase Tibiofemoral Joint Laxity With Anterior Cruciate Ligament Deficiency, and Their Repair Reduces Laxity. The American journal of sports medicine 2016;44(2):400-8. doi: 10.1177/036354651561745 4. Ahn JH, Bae TS, Kang KS, et al. Longitudinal tear of the medial meniscus posterior horn in the anterior cruciate ligament-deficient knee significantly influences anterior stability. The American journal of sports medicine 2011;39(10):2187-93. doi: 10.1177/0363546511416597 5. Peltier A, Lording T, Maubisson L, et al. The role of the meniscotibial ligament in posteromedial rotational knee stability. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2015;23(10):2967-73. doi: 10.1007/s00167-015- 3751-0
24 ISAKOS NEWSLETTER 2020: VOLUME I