Inside-Out Repair of Meniscal Ramp Lesions

Nicholas N. DePhillipo, M.S., A.T.C., O.T.C., Mark E. Cinque, M.S.,

Nicholas I. Kennedy, M.D., Jorge Chahla, M.D., Ph.D., Andrew G. Geeslin, M.D.,
Gilbert Moatshe, M.D., Lars Engebretsen, M.D., Ph.D., and Robert F. LaPrade, M.D., Ph.D.

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 arthro-
scopic 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.

A “ramp lesion” is a specific medial meniscal tear

that is less well-known, although it is reported to
be present in 9% to 17% of acute anterior cruciate
was reported that a posteromedial tibial bone bruise
was a secondary finding associated with ramp lesions.6
It is believed that repair of meniscal ramp lesions will
ligament (ACL) injuries.1-3 This injury pattern was first lead to improved healing and joint stability, although
reported in 1988 by Strobel4 and described as a medial further anatomical and biomechanical studies need to
meniscal injury involving the peripheral attachment of be undertaken to better describe these lesions and their
the posterior horn. Although less common, lateral biomechanical importance. The purpose of this article is
meniscal ramp lesions may also occur. to demonstrate a systematic evaluation for identifica-
Currently, there are conflicting ideas regarding the tion of ramp lesions and also describe an inside-out
precise anatomic location of ramp lesions; some in- repair arthroscopy-assisted repair technique.
vestigators use the traditional definition of a menisco-
capsular disruption,2 whereas others describe the Surgical Technique
meniscotibial ligament of the posterior horn as the site
of injury.3 This also stems from difficulty diagnosing Prevalence, Clinical Evaluation, and Operative
ramp lesions via both magnetic resonance imaging Indications
(MRI)1 and arthroscopy.3,5 In order to further evaluate Meniscal ramp lesions occur concomitantly with 9%
the ability of MRI to enable diagnosis of these injuries, a to 19% of all ACL tears.1,2 Due to the limited diagnostic
large study was performed by DePhillipo et al., and it sensitivity for both physical exam and MRI (Fig 1) (due
to the closure of the gap between the meniscus and the
From the Steadman Clinic (N.N.D., R.F.L.); Steadman Philippon Research capsule during extension), careful arthroscopic evalu-
Institute (M.E.C., N.I.K., J.C., A.G.G., G.M., R.F.L.), Vail, Colorado, U.S.A.;
ation of the meniscocapsular junction is vital. Patients
and Ulleval Hospital and University of Oslo (L.E.), Oslo, Norway.
The authors report the following potential conflicts of interest or sources of with evidence of acute disruption of the meniscocap-
funding: L.E. receives support from Arthrex, Ossur, Siemans, Smith and sular junction with associated increased meniscal
Nephew, Health East, and a National Institutes of Health grant R-13 for translation are indicated for repair of the ramp lesion,
biologics. R.F.L. receives support from Arthrex, Ossur, Siemans, Smith and especially in the setting of an ACL tear.
Nephew, Health East, and a National Institutes of Health grant R-13 for
biologics. Full ICMJE author disclosure forms are available for this article
Patient Positioning and Anesthesia
online, as supplementary material.
Received March 17, 2017; accepted May 11, 2017. The patient is placed in the supine position on the
Address correspondence to Robert F. LaPrade, M.D., Ph.D., Chief Medical operating table. After the induction of general anes-
Officer, Steadman Philippon Research Institute, The Steadman Clinic, 181 thesia, a bilateral knee examination is performed to
West Meadow Drive, Suite 400, Vail, Colorado 81657, U.S.A. E-mail: assess knee range of motion and evaluate for concur-
[email protected]
rent ligamentous laxity. A well-padded thigh tourni-
Ó 2017 by the Arthroscopy Association of North America. Open access
under CC BY-NC-ND license.
quet is placed on the operative extremity, which is then
2212-6287/17350 secured in a leg holder (Mizuho OSI, Union City, CA)
http://dx.doi.org/10.1016/j.eats.2017.05.011 while the contralateral knee is padded and placed into

Arthroscopy Techniques, Vol 6, No 4 (August), 2017: pp e1315-e1320 e1315

e1316 N. N. DEPHILLIPO ET AL.

meniscal ramp lesions. In patients undergoing a con-

current ACL reconstruction, we prefer to debride the
ACL remnant and ream the femoral tunnel prior to
evaluation of the menisci.
Viewing from the anterolateral portal, the arthro-
scope is advanced through the intercondylar notch with
the knee in 30 of flexion for inspection of the posterior
horn of the medial meniscus. A probe is directed over
the superior aspect of the posterior horn of the medial
meniscus to allow for inspection of the junction be-
tween the meniscus and capsule to identify whether a
ramp lesion is present. The probe is used to displace the
posteromedial capsule from the posteromedial menis-
cocapsular attachment. A ramp lesion is diagnosed if a
tear or separation is present at this junction (Fig 2A).
Additionally, a probe can be inserted under the infe-
rior aspect of the posterior horn of the medial meniscus
and placed in the meniscocapsular junction to assess the
integrity of the tibial attachment (Fig 2B). If a ramp
lesion is present, the meniscus will sublux anteriorly.
An accessory posteromedial portal can be used but is
rarely required to completely visualize the posterior
Fig 1. A magnetic resonance image (MRI) depicting a ramp
meniscocapsular attachment.
lesion (depicted with arrow) with an associated posteromedial
bone bruise (also depicted with arrow). MRI does not have a
Medial Approach
very high sensitivity for depicting ramp lesions, however, it
should always be part of a diagnostic work-up, and in some
After inspection and confirmation of the presence of a
cases, such as image depicted, it can be quite helpful. ramp lesion, a posteromedial approach is planned. The
incision placement may be facilitated by trans-
illumination of the medial compartment and by
an abduction stirrup (Birkova Product, Gothenburg, palpation of an intra-articular probe placed along the
NE). The leg holder should be placed proximal enough medial joint line. Transillumination of the skin with the
to allow a medial or lateral approach for an inside-out arthroscope allows visualization of the saphenous vein.
meniscal repair. The foot of the operating table is then An incision approximately 4 cm in length is made
lowered, allowing the surgeon to freely manipulate the posterior to the medial collateral ligament. Because the
knee. suture needles often angle downward as they exit the
joint capsule, it is helpful to have two-thirds of the
Arthroscopic Evaluation incision distal to the joint line with one-third proximal.
This surgical technique is shown in detail in Video 1. The approach is made with the knee in flexion. The
Additionally, pearls and pitfalls of this technique and a oblique pes fascia should be identified during dissection
step-by-step approach are described in Tables 1 and 2, deep to the subcutaneous tissue. The anterior sartorius
respectively. fascia is identified and subsequently dissected from
An initial diagnostic arthroscopy is performed with proximal to distal. The pes tendons should be retracted
standard anterolateral and anteromedial portals directly to protect the saphenous nerve, which lies poster-
adjacent to the patellar tendon. No additional portals omedial to the tendons. Upon deeper dissection, the
are usually required to assess for the presence of interval between the medial head of the gastrocnemius

Table 1. Pearls and Pitfalls

Pearls Pitfalls
Good visualization of the posterior part of the meniscus to diagnose Nerve injuries
ramp lesions
High level of suspicion Vascular injuries in the posterior knee
A posteromedial portal can help to visualize the posterior part of the Failure to identify the ramp lesions
medial meniscus.
Inside-out meniscal repair with vertical mattress sutures for a strong Failure to protect the repair with appropriate rehabilitation
repair construct protocol
Create a posteromedial approach (Chahla et al.)4
 INSIDE-OUT REPAIR OF MENISCAL RAMP LESIONS e1317

Table 2. Advantages and Disadvantages

Advantages Disadvantages
A high level of suspicion and a comprehensive review of the imaging is Do not attribute bone marrow changes only to the anterior cruciate
vital to detect these lesions: look for posteromedial tibial marrow ligament (ACL) injury. Actively look for associated lesions.
edema and a slight separation of the posteromedial capsule from the
meniscus.
A systematic approach to verify for the absence of this lesion can yield Failing to address a meniscal ramp lesion can result in changed knee
better ACL reconstruction outcomes with lower failure rates. biomechanics and increased failure rates.
Inside-out sutures allow for more versatility when repairing the Technically demanding, need for an additional approach.
meniscus.
Excellent results have been reported for these repairs due to the Although extended surgical time can be expected because of the
favorable zone of the tear and also because they are usually repair, a careful look into the posteromedial capsule should be
associated with ACL reconstructions, which further improves the routinely performed with the creation of accessory portals if
biological profile of these lesions. necessary.

and the posteromedial joint capsule is identified (Fig 3). exits the capsule. With application of a valgus force, the
The gastrocnemius is then dissected off the capsule cannula is directed toward the tear under arthroscopic
using Metzenbaum scissors, followed by using a blunt visualization (Fig 5A). Slight advancement of the
Cobb elevator. Blunt digital dissection may also be needle allows visualization of the precise entry location
useful to aid in the separation of the muscle from the (Fig 5B).
capsule. Working from distal to proximal facilitates the For tears at the meniscocapsular junction, the first
dissection of the gastrocnemius off of the posterior needle is usually passed through the meniscus and the
capsule. A Cobb elevator is temporarily placed posteri- second through the adjacent capsule to create a ver-
orly within this interval followed by a bent spoon tical or oblique pattern. The knee is placed in 10 to
placed anterior to the Cobb to protect the neurovascular 20 of flexion during needle advancement through
structures (Fig 4). The spoon retractor should be held so the meniscus and capsule; after passage, knee flexion
that the needles piercing the posterior capsule are of 70 to 90 may assist in needle retrieval. The can-
deflected medially toward the assistant. Keeping the nula is redirected to deliver the second needle and
knee in 70 to 90 of flexion relaxes the hamstring and place the suture adjacent to the first. It is important to
gastrocnemius, which improves visualization retrieval keep slight tension on the suture to avoid inadvertent
of the needles as they exit the posterior capsule. damage to the suture during advancement of the
second needle.
Meniscal Repair An assistant should be prepared to retrieve the suture
A commercially available device (SharpShooter, needles using a heavy needle driver. Optimal lighting
Stryker, Kalamazoo, MI) is used to place sutures (no. 2 and retraction allow visualization of the needles as they
FiberWire) into the meniscus. For medial meniscus are delivered through the capsule. Sutures are typically
ramp lesions, entry from the anterolateral portal placed sequentially from posterior to anterior; however,
decreases the risk of damaging the neurovascular if there is difficulty visualizing the first needle, an
structures and optimizes the direction of the needle as it anterior suture may be placed because it is typically

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.
e1318 N. N. DEPHILLIPO ET AL.

easier to locate and can help to guide the expected

delivery location of subsequent posterior sutures.
In a similar fashion, multiple sutures are placed be-
tween 3 and 5 mm apart (Fig 4). Sutures may be placed
above the meniscus (i.e. femoral-sided) and below the
meniscus (i.e. tibial sided). Typically, femoral-sided
sutures are placed first. Sometimes, this will create a
“puckering” of the meniscus superiorly and resultant
gapping of the tear on the tibial side. This should be
reduced with tibial-sided sutures placed in a similar
fashion. Compared to all-inside meniscal repair, the
inside-out repair technique results in smaller holes in
the meniscus during suture passage, allowing for the
passage of a greater number of sutures and fixation
points without creating as much iatrogenic meniscal
damage.
As the assistant retrieves the needles, the needles are
promptly cut from the suture and the paired sutures are
tagged with a hemostat. Use of an Allis clamp to grasp
the hemostats through the hemostat finger holes allows
organization of the sequentially passed sutures. How-
ever, rather than delaying knot tying until completion
of suture passage, sutures can also be tied immediately
Fig 3. The interval is identified between the medial head of
after passage. Care to avoid overtightening of the su-
the gastrocnemius and the posteromedial capsule on a right tures is important, and the meniscus can be directly
knee. This schematic image also depicts the anatomic rela- visualized arthroscopically during knot tying. The
tionship of the superficial medial collateral ligament and the meniscocapsular junction is probed to ensure stability
semimembranosus in relation to the interval. following completion of the repair (Fig 6).

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.
 INSIDE-OUT REPAIR OF MENISCAL RAMP LESIONS e1319

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).

Completion of concurrent procedures, such as ACL biomechanics and thereby minimize the risk of injury to
reconstruction, is then performed. At the completion of associated intra-articular structures.
the procedure, the medial incision is thoroughly irri- Both the inside-out7 and all-inside8 techniques to
gated and closed in a standard layered fashion. repair ramp lesions have yielded good results in the
literature. While the inside-out technique is more
Postoperative Rehabilitation technically demanding, this approach affords greater
A full review of rehabilitation is beyond the scope of versatility in suture placement and allows the surgeon to
this article and is strongly influenced by concomitant pass a greater number of sutures, thereby creating a
procedures. However, a brief overview of the rehabili- stronger repair.7,9 Given the posteromedial location of
tation protocol for repair of ramp lesions with a con- the ramp lesions, the saphenous neurovascular bundle
current ACL reconstruction is provided. is at an increased risk during the performance of the
The patient is allowed weight bearing as tolerated with inside-out technique of meniscus repair.10 We recom-
the aid of crutches for approximately 2 weeks. Physical mend directly visualizing the posterior capsule to avoid
therapy is initiated on postoperative day one with a focus iatrogenic injury to these structures. The all-inside
on edema control, unrestricted knee range of motion, and technique has also demonstrated good results and has
gait training with crutches. During the first 6 weeks, the some advantages: it is less technically demanding, in-
patient’s primary exercises are patellar mobilizations, both volves a lower risk of neurovascular injury, requires no
active knee range of motion and wall slides, and quadri- additional incisions, and is a good option for surgeons
ceps activation exercises. Crutches are discontinued once with an inexperienced surgical team. Li et al. specifically
the patient is able to ambulate without a limp and perform reported on 23 ramp lesions treated with an all-inside
a straight leg raise without knee extension sag, and typi- device with a mean follow-up of 14 months.11 The
cally occurs approximately 2 weeks after surgery. Closed- mean Lysholm score improved from 64.4  4.5 preop-
chain strengthening exercises are initiated after 6 weeks eratively to 91.2  4.6 postoperatively.11 However, the
with training periodization focused on first developing all-inside technique does have the risks of anchor
muscular endurance, followed by strength and power.
Patients may begin straight-ahead running exercises at
5 months, with restrictions on pivoting and twisting. In our
practice, gradual return to play progression is initiated after
6 months following the successful completion of a func-
tional sports test. Return to sports or activity is allowed
when the patient achieves normal strength, stability, and
knee range of motion comparable to the contralateral side;
this typically occurs at 7 to 9 months postoperatively.

Discussion
This Technical Note describes our preferred surgical
technique for treatment of meniscal ramp lesions, Fig 6. Surgeon confirming stability of the repair construct
which are defined as a tear of the peripheral attachment using a probe placed through the anteromedial portal
of the posterior horn of the medial meniscus at the following inside-out repair of a meniscal ramp lesion in a right
meniscocapsular junction.1 Treatment of these injuries knee. If needed, additional sutures can be placed at this point
in the acute setting is recommended in order to maxi- to ensure adequate fixation. (MFC, medial femoral condyle;
mize healing potential as well as to restore native MM, medial meniscus; MTP, medial tibial plateau).
e1320 N. N. DEPHILLIPO ET AL.

irritation, meniscal body tears from larger holes created 2. Liu X, Feng H, Zhang H, Hong L, Wang XS, Zhang J.
by device insertion, and implant failure.12 Arthroscopic prevalence of ramp lesion in 868 patients
The improved outcomes observed in studies when the with anterior cruciate ligament injury. Am J Sports Med
repair is performed concurrently with an ACL recon- 2011;39:832-837.
3. Sonnery-Cottet B, Conteduca J, Thaunat M, Gunepin FX,
struction have been hypothesized to be related to the
Seil R. Hidden lesions of the posterior horn of the medial
biological augmentation of the repair from factors in the
meniscus: A systematic arthroscopic exploration of the
bone marrow released within the joint.9 A recent study concealed portion of the knee. Am J Sports Med 2014;42:
reported that the concentrations of vascular endothelial 921-926.
growth factor (VEGF) and its angiogenetic receptor VEGF 4. Strobel M. Manual of Arthroscopic Surgery. New York, NY:
receptor 2 (VEGFR2) were significantly greater after ACL Springer, 1988.
reconstruction than after partial meniscectomy.13 These 5. Chahla J, Dean CS, Moatshe G, et al. Meniscal ramp le-
results indicate a more favorable healing environment sions: Anatomy, incidence, diagnosis, and treatment.
when meniscal repairs are performed concurrently with Orthopaed J Sports Med 2016;4:2325967116657815.
an ACL reconstruction. The authors recommend consid- 6. DePhillipo NN, Cinque ME, Chahla J, Geeslin A,
eration should be given to biologic augmentation due to LaPrade RF. Incidence and detection of meniscal ramp
lesions on magnetic resonance imaging in anterior cruci-
the potential positive effects, especially if this procedure is
ate ligament reconstruction patients. Am J Sports Med 2017
being performed in the absence of other intra-articular
(in press).
reconstructive procedures. A bone marrow stimulation 7. Nelson CG, Bonner KF. Inside-out meniscus repair.
technique known as a marrow venting procedure may be Arthrosc Tech 2013;2:e453-e460.
performed by using a microfracture awl to create holes in 8. Haas AL, Schepsis AA, Hornstein J, Edgar CM. Meniscal
the notch.14 Additionally, platelet-rich plasma may be repair using the FasT-Fix all-inside meniscal repair device.
injected into the intra-articular space following repair Arthroscopy 2005;21:167-175.
completion and incision closure. 9. Hutchinson ID, Moran CJ, Potter HG, Warren RF,
In conclusion, we recommend repair of meniscal Rodeo SA. Restoration of the meniscus: Form and func-
ramp lesions, especially in the setting of ACL tears, via tion. Am J Sports Med 2014;42:987-998.
the reproducible inside-out technique described in this 10. Rodeo S. Arthroscopic meniscal repair with use of
the outside-in technique. Instr Course Lect 2000;49:
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11. Li WP, Chen Z, Song B, Yang R, Tan W. The FasT-Fix
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location. It is believed that concurrent repair of ramp Knee Surg Relat Res 2015;27:56-60.
lesions at the time of ACL reconstruction protects the 12. Grant JA, Wilde J, Miller BS, Bedi A. Comparison of
graft from increased forces that may be experienced in inside-out and all-inside techniques for the repair of iso-
the setting of meniscal deficiency. Further, despite early lated meniscal tears: A systematic review. Am J Sports Med
promising results of meniscal ramp lesion repair, 2012;40:459-468.
longer-term studies with increased sample sizes are 13. Galliera E, De Girolamo L, Randelli P, et al. High
necessary to evaluate the efficacy and outcomes of articular levels of the angiogenetic factors VEGF and
meniscal ramp lesion repairs. VEGF-receptor 2 as tissue healing biomarkers after
single bundle anterior cruciate ligament reconstruc-
tion. J Biol Regul Homeost Agents 2011;25:85-91.
14. Dean CS, Chahla J, Matheny LM, Mitchell JJ, LaPrade RF.
References Outcomes after biologically augmented isolated meniscal
1. Bollen SR. Posteromedial meniscocapsular injury associ- repair with marrow venting are comparable with those
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