Summary

All inside suture technique through the posteromedial portal is a more reliable repair procedure for ramp lesions than left without repair.

Abstract

Introduction

Longitudinal tears of the medial meniscus posterior horn around the meniscocapsular junction are frequently associated with anterior cruciate ligament (ACL) injuries, termed as “ramp lesions”. The biomechanical importance of the posterior meniscocapsular junction was recently demonstrated. Ramp lesions must therefore be appropriately treated during ACL reconstruction to avoid causing increased forces in the ACL graft. However, there is no clear consensus on the appropriate treatment for meniscal ramp lesions. The purpose of our study was to compare the postoperative outcomes for ramp lesions between left without repair and all-inside suture through the posteromedial portal.

Methods

Forty patients with ACL injuries and concomitant ramp lesions were included in this study. All knees underwent anatomic ACL reconstruction using a semitendinosus tendon. During surgery, ramp lesions in 23 patients from August 2011 through March 2015 were left without repair (L group), and 17 patients from April 2015 through March 2017 underwent all-inside suture using ACCU-PASS Suture Shuttle 45º® (Smith & Nephew, Andover) through the posteromedial portal (R group). One year after surgery, we evaluated the side-to-side difference (SSD) in anterior tibial translation measured on stress radiographs and rotational stability by the pivot-shift test. 3-T magnetic resonance imaging was also used to evaluate the healing status of the ramp lesions. The Student’s t-test was used to compare the SSD in anterior translation, and the chi-squared test was used to compare pivot-shift test results and the healing status of the ramp lesions. A P-value of < 0.05 was considered significant.
Result: The mean SSDs in anterior translation were 2.3 ± 1.6 mm for the L group and 2.1 ± 1.2 mm for the R group, with no significant difference. The positive ratios on the pivot-shift test in the L and R groups were 17.4% (4 of 23 knees) and 17.6% (3 of 17 knees), with no significant difference. On postoperative MRI, 10 knees (43.5%) in the L group were completely healed, 6 (26.1%) were partially healed, and 7 (30.4%) were unhealed. In the R group, 15 (88.2%) were completely healed and 2 (11.8%) partially healed. No knees were unhealed. The mean SSDs for 7 knees judged it unhealed and 33 knees judged it healed on MRI were 3.4 ± 0.6 mm and 1.9 ± 1.4, respectively, which is significant difference (P=0.009). Two knees in the L group required medial meniscectomy for a subsequent bucket-handle tear after ACL reconstruction.

Conclusion

Our study showed that the healing rate of ramp lesions left without repair was insufficient, and two knees required subsequent medial meniscectomy. In contrast, the healing rate after all-inside suture through the posteromedial portal was 100%. And anterior translation of the knees that ramp lesion was unhealed was significant larger than the knee that it was healed. This suturing technique is a more reliable repair procedure to heal ramp lesions.