Examining Techniques for Treatment of Medial Meniscal Ramp Lesions During Anterior Cruciate Ligament Reconstruction: A Systematic Review



      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.


      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.


      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.


      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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        • Keene G.C.
        • Bickerstaff D.
        • Rae P.J.
        • Paterson R.S.
        The natural history of meniscal tears in anterior cruciate ligament insufficiency.
        Am J Sports Med. 1993; 21: 672-679
        • Cipolla M.
        • Scala A.
        • Gianni E.
        • Puddu G.
        Different patterns of meniscal tears in acute anterior cruciate ligament (ACL) ruptures and in chronic ACL-deficient knees. Classification, staging and timing of treatment.
        Knee Surg Sports Traumatol Arthrosc. 1995; 3: 130-134
        • Nikolic D.K.
        Lateral meniscal tears and their evolution in acute injuries of the anterior cruciate ligament of the knee. Arthroscopic analysis.
        Knee Surg Sports Traumatol Arthrosc. 1998; 6: 26-30
        • Strobel M.
        Manual of Arthroscopic Surgery.
        Springer, New York, NY1988: 171-178
        • Liu X.
        • Feng H.
        • Zhang H.
        • Hong L.
        • Wang X.S.
        • Zhang J.
        Arthroscopic prevalence of ramp lesion in 868 patients with anterior cruciate ligament injury.
        Am J Sports Med. 2011; 39: 832-837
        • Bollen S.R.
        Posteromedial meniscocapsular injury associated with rupture of the anterior cruciate ligament: a previously unrecognised association.
        J Bone Joint Surg Br. 2010; 92: 222-223
        • Mariani P.P.
        Posterior horn instability of the medial meniscus: A sign of posterior meniscotibial ligament insufficiency.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1148-1153
        • Ahn J.H.
        • Wang J.H.
        • Yoo J.C.
        Arthroscopic all-inside suture repair of medial meniscus lesion in anterior cruciate ligament–deficient knees: Results of second-look arthroscopies in 39 cases.
        Arthroscopy. 2004; 20: 936-945
        • Kumar N.S.
        • Spencer T.
        • Cote M.P.
        • Arciero R.A.
        • Edgar C.
        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. 2018; 6 (2325967118780089)
        • Hash 2nd, T.W.
        Magnetic resonance imaging of the knee.
        Sports Health. 2013; 5: 78-107
        • Noyes F.R.
        • Jetter A.W.
        • Grood E.S.
        • Harms S.P.
        • Gardner E.J.
        • Levy M.S.
        Anterior cruciate ligament function in providing rotational stability assessed by medial and lateral tibiofemoral compartment translations and subluxations.
        Am J Sports Med. 2015; 43: 683-692
        • Shelbourne K.D.
        • Rask B.P.
        The sequelae of salvaged nondegenerative peripheral vertical medial meniscus tears with anterior cruciate ligament reconstruction.
        Arthroscopy. 2001; 17: 270-274
        • Sonnery-Cottet B.
        • Conteduca J.
        • Thaunat M.
        • Gunepin F.X.
        • Seil R.
        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. 2014; 42: 921-926
        • Li W.P.
        • Chen Z.
        • Song B.
        • Yang R.
        • Tan W.
        The FasT-Fix repair technique for ramp lesion of the medial meniscus.
        Knee Surg Relat Res. 2015; 27: 56-60
      1. Borenstein M, Hedges L, Higgins J, Rothstein H. Comprehensive meta-analysis, version 3.

        • Briggs K.K.
        • Kocher M.S.
        • Rodkey W.G.
        • Steadman J.R.
        Reliability, validity, and responsiveness of the Lysholm knee score and Tegner activity scale for patients with meniscal injury of the knee.
        J Bone Joint Surg Am. 2006; 88: 698-705
        • Greco N.J.
        • Anderson A.F.
        • Mann B.J.
        • et al.
        Responsiveness of the International Knee Documentation Committee subjective knee form in comparison to the Western Ontario and McMaster Universities Osteoarthritis Index, modified Cincinnati Knee Rating System, and Short Form 36 in patients with focal articular cartilage defects.
        Am J Sports Med. 2010; 38: 891-902
        • Slim K.
        • Nini E.
        • Forestier D.
        • Kwiatkowski F.
        • Panis Y.
        • Chipponi J.
        Methodological index for non-randomized studies (minors): Development and validation of a new instrument.
        ANZ J Surg. 2003; 73: 712-716
        • Liu X.
        • Zhang H.
        • Feng H.
        • Hong L.
        • Wang X.S.
        • Song G.Y.
        Is it necessary to repair stable ramp lesions of the medial meniscus during anterior cruciate ligament reconstruction? A prospective randomized controlled trial.
        Am J Sports Med. 2017; 45: 1004-1011
        • Yang J.
        • Guan K.
        • Wang J.Z.
        Clinical study on the arthroscopic refreshing treatment of anterior cruciate ligament injury combined with stable medial meniscus ramp injury.
        J Musculoskelet Neuronal Interact. 2017; 17: 108-113
        • Gulenc B.
        • Kemah B.
        • Yalcin S.
        • Sayar S.
        • Korkmaz O.
        • Erdil M.
        Surgical treatment of meniscal ramp lesion.
        J Knee Surg. 2020; 33: 255-259
        • Keyhani S.
        • Ahn J.H.
        • Verdonk R.
        • Soleymanha M.
        • Abbasian M.
        Arthroscopic all-inside ramp lesion repair using the posterolateral transseptal portal view.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 454-458
        • Thaunat M.
        • Jan N.
        • Fayard J.M.
        • et al.
        Repair of meniscal ramp lesions through a posteromedial portal during anterior cruciate ligament reconstruction: Outcome study with a minimum 2-year follow-up.
        Arthroscopy. 2016; 32: 2269-2277
        • Chen Z.
        • Li W.P.
        • Yang R.
        • et al.
        Meniscal ramp lesion repair using the FasT-Fix technique: Evaluating healing and patient outcomes with second-look arthroscopy.
        J Knee Surg. 2018; 31: 710-715
        • Duchman K.R.
        • Westermann R.W.
        • Spindler K.P.
        • et al.
        The fate of meniscus tears left in situ at the time of anterior cruciate ligament reconstruction: A 6-year follow-up study from the MOON cohort.
        Am J Sports Med. 2015; 43: 2688-2695
        • Pujol N.
        • Beaufils P.
        Healing results of meniscal tears left in situ during anterior cruciate ligament reconstruction: A review of clinical studies.
        Knee Surg Sports Traumatol Arthrosc. 2009; 17: 396-401
        • DePhillipo N.N.
        • Engebretsen L.
        • LaPrade R.F.
        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)
        • Rimmer M.G.
        • Nawana N.S.
        • Keene G.C.
        • Pearcy M.J.
        Failure strengths of different meniscal suturing techniques.
        Arthroscopy. 1995; 11: 146-150
        • Barber F.A.
        • Herbert M.A.
        • Bava E.D.
        • Drew O.R.
        Biomechanical testing of suture-based meniscal repair devices containing ultrahigh-molecular-weight polyethylene suture: Update 2011.
        Arthroscopy. 2012; 28: 827-834
        • Barrett G.R.
        • Richardson K.
        • Ruff C.G.
        • Jones A.
        The effect of suture type on meniscus repair. A clinical analysis.
        Am J Knee Surg. 1997; 10: 2-9
        • Ahn J.H.
        • Kim C.H.
        • Lee S.H.
        Repair of the posterior third of the meniscus during meniscus allograft transplantation: Conventional inside-out repair versus FasT-Fix all-inside repair.
        Arthroscopy. 2016; 32: 295-305
        • Albrecht-Olsen P.
        • Kristensen G.
        • Burgaard P.
        • Joergensen U.
        • Toerholm C.
        The arrow versus horizontal suture in arthroscopic meniscus repair. A prospective randomized study with arthroscopic evaluation.
        Knee Surg Sports Traumatol Arthrosc. 1999; 7: 268-273
        • Hantes M.E.
        • Zachos V.C.
        • Varitimidis S.E.
        • Dailiana Z.H.
        • Karachalios T.
        • Malizos K.N.
        Arthroscopic meniscal repair: A comparative study between three different surgical techniques.
        Knee Surg Sports Traumatol Arthrosc. 2006; 14: 1232-1237
        • Chahla J.
        • Dean C.S.
        • Moatshe G.
        • et al.
        Meniscal ramp lesions: Anatomy, incidence, diagnosis, and treatment.
        Orthop J Sports Med. 2016; 4 (2325967116657815)
        • Rosso C.
        • Kovtun K.
        • Dow W.
        • et al.
        Comparison of all-inside meniscal repair devices with matched inside-out suture repair.
        Am J Sports Med. 2011; 39: 2634-2639
        • Rodeo S.A.
        Arthroscopic meniscal repair with use of the outside-in technique.
        Instr Course Lect. 2000; 49: 195-206
        • Choi N.H.
        • Kim B.Y.
        • Hwang Bo B.H.
        • Victoroff B.N.
        Suture versus FasT-Fix all-inside meniscus repair at time of anterior cruciate ligament reconstruction.
        Arthroscopy. 2014; 30: 1280-1286
        • Kalliakmanis A.
        • Zourntos S.
        • Bousgas D.
        • Nikolaou P.
        Comparison of arthroscopic meniscal repair results using 3 different meniscal repair devices in anterior cruciate ligament reconstruction patients.
        Arthroscopy. 2008; 24: 810-816
        • Barber F.A.
        • Schroeder F.A.
        • Oro F.B.
        • Beavis R.C.
        FasT-Fix meniscal repair: Mid-term results.
        Arthroscopy. 2008; 24: 1342-1348
        • Kotsovolos E.S.
        • Hantes M.E.
        • Mastrokalos D.S.
        • Lorbach O.
        • Paessler H.H.
        Results of all-inside meniscal repair with the FasT-Fix meniscal repair system.
        Arthroscopy. 2006; 22: 3-9
        • Hoffelner T.
        • Resch H.
        • Forstner R.
        • Michael M.
        • Minnich B.
        • Tauber M.
        Arthroscopic all-inside meniscal repair—Does the meniscus heal? A clinical and radiological follow-up examination to verify meniscal healing using a 3-T MRI.
        Skeletal Radiol. 2011; 40: 181-187
        • Tucciarone A.
        • Godente L.
        • Fabbrini R.
        • Garro L.
        • Salate Santone F.
        • Chillemi C.
        Meniscal tear repaired with Fast-Fix sutures: Clinical results in stable versus ACL-deficient knees.
        Arch Orthop Trauma Surg. 2012; 132: 349-356
        • Haas A.L.
        • Schepsis A.A.
        • Hornstein J.
        • Edgar C.M.
        Meniscal repair using the FasT-Fix all-inside meniscal repair device.
        Arthroscopy. 2005; 21: 167-175
        • Chiang C.W.
        • Chang C.H.
        • Cheng C.Y.
        • et al.
        Clinical results of all-inside meniscal repair using the FasT-Fix meniscal repair system.
        Chang Gung Med J. 2011; 34: 298-305
        • Tachibana Y.
        • Sakaguchi K.
        • Goto T.
        • Oda H.
        • Yamazaki K.
        • Iida S.
        Repair integrity evaluated by second-look arthroscopy after arthroscopic meniscal repair with the FasT-Fix during anterior cruciate ligament reconstruction.
        Am J Sports Med. 2010; 38: 965-971