Inside-Out Repair of Meniscal Ramp Lesions

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.

Fig 1

A magnetic resonance image (MRI) depicting a ramp lesion (depicted with arrow) with an associated posteromedial bone bruise (also depicted with arrow). MRI does not have a very high sensitivity for depicting ramp lesions, however, it should always be part of a diagnostic work-up, and in some cases, such as image depicted, it can be quite helpful.

Fig 2

(A) Illustration depicting technique to assess for ramp lesion, using a probe to retract the posteromedial capsule away from the posteromedial meniscocapsular attachment on a left knee. A ramp lesion is diagnosed if a tear or separation is present at this junction. (B) Corresponding arthroscopic evaluation of meniscal ramp lesion without the use of an accessory posteromedial portal as viewed from the anteromedial portal and inserting the probe through the anterolateral portal.

Fig 3

The interval is identified between the medial head of the gastrocnemius and the posteromedial capsule on a right knee. This schematic image also depicts the anatomic relationship of the superficial medial collateral ligament and the semimembranosus in relation to the interval.

Fig 4

A bent spoon is used as a retractor inserted between the posteromedial (PM) joint capsule anteriorly and the medial head of the gastrocnemius muscle posteriorly in this right knee. The probe can be inserted through the anteromedial portal and used to visualize the trajectory of suture needle placement prior to beginning meniscal repair.

Fig 5

Suture placement for inside-out meniscus ramp repair in a right knee. (A and B) Images of suture shuttling device with corresponding arthroscopic placement of cannula with vertical suture mattress technique as viewed from the anteromedial portal and with the suture shuttling device from the anterolateral portal (MFC, medial femoral condyle; MM, medial meniscus; MTP, medial tibial plateau).

Fig 6

Surgeon confirming stability of the repair construct using a probe placed through the anteromedial portal following inside-out repair of a meniscal ramp lesion in a right knee. If needed, additional sutures can be placed at this point to ensure adequate fixation. (MFC, medial femoral condyle; MM, medial meniscus; MTP, medial tibial plateau).