2025 ISAKOS Congress in Munich, Germany

2025 ISAKOS Biennial Congress Paper


Classifying Ramp Lesion Instability: A Systematic Review of Postoperative Outcomes Through Varying Probing Instability

Krittapas Mathurunyanont, Medical Student, Bangkok THAILAND
Kanyakorn Riewruja, MD, Bangkok THAILAND
Danaithep Limskul, MD, Bangkok THAILAND
Thun Itthipanichpong, MD, Bangkok THAILAND
Napatpong Thamrongskulsiri, MD, Bangkok THAILAND
Thanathep Tanpowpong, MD, Bangkok, กทม THAILAND
Somsak Kuptniratsaikul, MD, Pathumwan, Bangkok THAILAND

Faculty of Medicine, Chulalongkorn University, Bangkok, THAILAND

FDA Status Not Applicable

Summary

All ramp lesions benefit from suture repair regardless of instability status upon probing, however, with higher incidences of postoperative complications in repairing stable ramp lesions, those that are not displaced upon anteromedial probing could be approached conservatively without significant compromisation to clinical outcome.

Abstract

Objective

Despite a prevalence rate of 15-40% of ramp lesions among the ACL deficient population in clinical and biomechanical settings, ramp lesion is proportionately under-investigated to other meniscus pathology concomitant to ACL injuries. Current literature mostly explores the diagnostic and treatment outcome, but a consensus on the management algorithms based on different presentation and severity has yet to be introduced. There is an increasing trend to check and suture repair ramp lesions during an arthroscopic ACL reconstruction amongst U45 ESKKA members and US orthopaedic surgeons, therefore, we must establish an evidence-based direction to approach different ramp lesions presentation for future orthopaedic surgeons.

Method

Following the 2020 PRISMA guidelines, two researchers independently reviewed 613 titles and abstracts from a single search command on Pubmed against the predetermined inclusion criteria. Any disagreements are discussed and resolved by consensus. A subjective definition of ‘stable’ and ‘unstable’ was agreed upon through a collation of similar individual definitions stated by the authors in the remaining 6 texts. All comparable and standardised data was compared between suture repair and conservative treatments of both stable and unstable ramp lesions (primarily focusing on clinical outcome).

Results

We defined ‘instability’ as any displacement upon anteromedial portal probing into the medial compartment, under the femoral condyle, or intercondylar notch . In contrast, ‘stable’ ramp lesions lack any displacement when probed through the same angle. Both conservative treatment and suture repairing, both techniques statistically benefited all ramp lesions post-operative Lysholm score, International Knee Documentation Committee (IKDC) score, and mean anterior laxity side-to-side difference (SSD).
However, conservative treatment of stable lesions led to poorer healing rate compared to suture repair of stable ramp lesions, assessed through an MRI scan at a mean follow-up of 28 months. The pooled data showed that sutured stable ramp lesions fully healed in 76% of patients, 23% partially healed, and only 1% not healed by MRI evaluation (n = 65). A statistically significant (p<0.05) slower healing rate in the conservative treatment where 67% fully healed, 11% partially healed, and 21% not healed (n = 58). Notably, both treatments led to improvements in SF-12 PCS, with the conservative group achieving a larger improvement from baseline with 2.5 more points achieved,(P < 0.05)
Suturing unstable ramps resulted in sturdier knees with lower postoperative SSD scores when compared to conservative treatment stable ramps. A postoperative SSD of 0.4±1.8mm in the repaired unstable lesion, compared to 1.89±1.3mm of the untreated lesion (P<0.001). However, repairing unstable ramps elicits higher percentages of postoperative symptoms (20% vs 8%), revision surgery incidences (9.5% vs 4%), and contralateral ACL injury (5% vs 0.2%) when compared to conservative methods.

Conclusion

All ramp lesions benefit from suture repair regardless of instability status upon probing, however, with higher incidences of postoperative complications in repairing stable ramp lesions, those that are not displaced upon anteromedial probing could be approached conservatively without significant compromisation to clinical outcome.