Technical Note

Arthroscopic Ramp Repair: “No-Implant, Pass, Park,

and Tie Technique” Using Knee Scorpion
Sheetal Gupta, M.S., M.B.B.S., Prayank Hishikar, M.B.B.S., M.S., and
Binayak Ray, M.B.B.S., M.S.

Abstract: Ramp lesions play a significant role in both anteroposterior and rotational knee stability. Ramp lesions are
difficult to diagnose clinically as well as on magnetic resonance imaging. Arthroscopic identification by visualizing the
posterior compartment and probing via the posteromedial portal will confirm the diagnosis of ramp lesion. Failure to
address this lesion properly will lead to poor knee kinematics, residual knee laxity, and increased chances of failure of
reconstructed anterior cruciate ligament. Here, we describe a simple arthroscopic surgical technique to repair ramp lesion,
the pass, park, and tie at the end, via 2 posteromedial portals using a knee scorpion suture passing device.

R amp lesions, first described by Strobel, are

meniscocapsular or meniscosynovial longitudinal
peripheral tears of the posterior horn of the medial
Surgical Technique (With Video Illustration)
Positioning
meniscus. Ramp lesions are considered as hidden le- Under spinal anesthesia, the patient is positioned su-
sions because they are missed not only on preoperative pine on the operating table with the knee in 90 of
magnetic resonance imaging but also on arthroscopic flexion at the edge of the table on the affected side to
examination if done through standard portals.1,2 Ramp allow full range of motion and adequate exposure to
lesion, if left untreated, will lead to rotational instability, back of the knee (Fig 1a). In this position, the neuro-
retear of the reconstructed anterior cruciate ligament vascular bundle falls posteriorly. A thigh support is
(ACL), and altered biomechanics of the knee joint.3,4 placed just proximal to the knee at mid-thigh level. The
Thaunat et al.5 classified ramp lesions and described a tourniquet is placed high on the thigh.
technique for their repair using a single posteromedial The operative site is prepared with an aseptic sterile
(PM) portal. We describe here a simple technique of technique. Draping is done in the standard way to
“pass, park, and tie,” which uses an antegrade suture expose the distal one-third of the thigh and proximal
device with 3 major portals: a high PM portal for one-third of the leg. The lower limb is exsanguinated,
visualization, a low PM portal for instrumentation, and and the tourniquet is inflated. Provisional surface
an anterolateral (AL) portal for parking the sutures. marking is done (Fig 1b). Required instrumentation for
surgery is prepared on back table (Fig 2).

Portal Placement and Arthroscopy

A standard AL portal is created 1 cm above the joint
From Galaxy Hospital, Bhopal, Madhya Pradesh, India. line and just next to the patellar tendon in a palpable
The authors report that they have no conflicts of interest in the authorship soft spot. A second anteromedial portal is made 1 cm
and publication of this article. Full ICMJE author disclosure forms are above the joint line and 1 cm medial to the patellar
available for this article online, as supplementary material. tendon in a palpable soft spot. Diagnostic arthroscopy is
Received November 6, 2022; accepted February 8, 2023.
Address correspondence to Dr. Sheetal Gupta, M.S., M.B.B.S., Galaxy
performed first (Video 1). We look for an ACL tear, any
Hospital, 25 Danish kunj, Kolar road, Bhopal, Madhya Pradesh, 462042, associated meniscal tear, and the meniscal mobility.
India. E-mail: [email protected] For identification of ramp lesion from the anterior
Ó 2023 THE AUTHORS. Published by Elsevier Inc. on behalf of the compartment, a 30 arthroscope (AL portal) is passed
Arthroscopy Association of North America. This is an open access article under through the medial wall of intercondylar notch beneath
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).
the posterior cruciate ligament and with the knee
2212-6287/221465 slightly flexed in valgus (Gillquist maneuver) to enter
https://doi.org/10.1016/j.eats.2023.02.005 the PM compartment.

Arthroscopy Techniques, Vol 12, No 5 (May), 2023: pp e763-e770 e763

e764 S. GUPTA ET AL.

Fig 1. (A) Right knee, positioning

of the limb: the patient is in a
supine position with a tourniquet
over the thigh. The right leg is
hanging down at the edge of table
in 90 flexion with lateral side
support. (B) Surface marling of
right knee showing marking for
MFC, medial femoral condyle,
MTC, medial tibial condyle, red
dot for low posteromedial portal,
and green dot for high poster-
omedial portal.

From the PM aspect of knee just above the joint line, is passed, followed by portal creation over spinal needle
an 18-G spinal needle is passed (outside in) from low trajectory with a no. 11 blade scalpel and a hemostat
PM portal with the help of transillumination (Fig 3 a under direct vision. An 8-mm arthroscopic cannula or
and b). A tear at the meniscocapsular junction, using a PassPort Cannula (Arthrex, Naples, FL) is then placed
needle as a probe, confirms the ramp lesion (Fig 4). for ease of instrumentation through this portal (Fig 5a).
Once the diagnosis of ramp lesion is confirmed, 2 PM The edges of the tear are abraded with the help of a
portals are made. A low PM portal is made just above shaver or meniscal rasp to stimulate the healing
the joint line with the transillumination technique to response. A high PM portal is made in the same manner
avoid neurovascular structures. An 18-G spinal needle 4 cm above the joint line.

Fig 2. Instruments used for this

technique: from leftdswitching
stick, spinal needle, suture
manipulator, 6-mm cannula, knot
pusher, 8-mm cannula, suture
cutter, PassPort Cannula 6-mm,
Scorpion needle, 8-mm PassPort
cannula, Knee Scorpion, arthro-
scopic sleeve with trocar.
 PASS, PARK, AND TIE TECHNIQUE e765

Fig 3. Right knee in 90 flexion:

Portal placement using trans-
illumination technique. (A) Spi-
nal needle is introduced using
transillumination in the poster-
omedial compartment. (B) Post-
eromedial portal is created using a
no. 11 blade.

Posterior Compartment Arthroscopy and Ramp As the ramp is a longitudinal tear, there are 2 portion/
Repair leavesdthe anterior (meniscal side) and the posterior
A switching rod is then passed, and the arthroscope is (capsular side). The ramp repair technique is basically
switched to high PM portal and probing is done (Fig approximating these 2 surfaces. A Knee Scorpion
5b). We use an all-inside antegrade suture technique (Arthrex) is introduced, loaded with one end of no. 2-
for repair of the ramp lesion with passing and parking 0 FiberWire suture (Arthrex), through the low PM
of sequential sutures and tying at the end. portal via a cannula. Using the Scorpion, a first bite is
taken on anterior aspect of the tear (meniscal side) (Fig
6a). The Knee Scorpion is manipulated such that it
holds the substance of meniscus well and its tip pene-
trates the medial meniscus from inferior to superior. In
case of difficulty in passage knee a flexioneextension
maneuver can be performed to ensure a good bite.
This device, the self-retrieving suture device 2-0 Fiber-
Wire, is passed through the meniscus and retrieved via
the PM portal. The 2-0 FiberWire is removed from the
Scorpion. Another end of 2-0 FiberWire is now
mounted onto the Scorpion again.
The Scorpion is introduced through low PM cannula,
and this time a bite is taken on the posterior aspect
(capsular side) of the tear (Fig 6b). Ensure a good tissue
bite from the capsular side also; this step passes the
suture through the capsular side and is retrieved out
through the low PM cannula. Now, both the sutures are
ready and already passed though both meniscus side
and capsular side (Fig 6c). Confirm that there is no
entanglement of sutures. Now, the suture retriever is
passed from AL portal and both suture ends are taken
out through this portal for parking suture here for knot
tying at later stage (Fig 6d). Knot-tying is not done at
Fig 4. Right knee in 90 flexion: Visualization is from the
this stage; otherwise, it will be very difficult to pass the
anterolateral portal, using Gillquist maneuver, entry is made Scorpion device underneath the meniscus and capsule.
into the posteromedial compartment, needle test is performed Now, another FiberWire is taken loaded onto the Knee
using a spinal needle to confirm the ramp lesion. Same spinal Scorpion, and a bite is taken in similar manner as
needle is used as trajectory to make create the posteromedial described previously (Fig 7 a-c). Again, 2 suture ends
portal. (MM, medial meniscus; PMC, posteromedial capsule.) are retrieved from AL portal for parking and knot-tying
e766 S. GUPTA ET AL.

Fig 5. (A) Right knee in 90

flexion: Looking from the ante-
rolateral portal into the poster-
omedial compartment, a low
posteromedial portal is created,
and PassPort Cannula is intro-
duced for instrumentation, a high
posteromedial portal is created
and switching stick is introduced.
(B) Now the arthroscope is shifted
to the high posteromedial portal
using the switching stick and
probing of the ramp lesion is done
through the low posteromedial
portal. (MM, medial meniscus;
PMC, posteromedial capsule.)

at a later stage (Fig 7d). Depending on size of the tear, taken from the meniscus and capsule. Now, we are
more sutures can be “passed and parked” (Fig 8 a-c). In ready for knot-tying; we prefer to use nonsliding mul-
the technique demonstrated here, one more bite is tiple half hitches so a cheese-grating effect on the

Fig 6. Right knee in 90 flexion:

visualization through the high
posteromedial portal and instru-
mentation from the low poster-
omedial portal. (A) The first bite is
taken from the meniscus using an
antegrade suture passing devi-
cedKnee Scorpion loaded with
FiberWire sutures. (B) The second
bite is taken from the posterior
capsule. (C) The first set of sutures
can be seen with some approxi-
mation of the ramp lesion. (D)
The first set of sutures is parked
through the anterolateral portal
without tying the knot to ease the
further suture passing. (fw,
FiberWire; MM, medial meniscus;
PMC, posteromedial capsule.)
 PASS, PARK, AND TIE TECHNIQUE e767

Fig 7. Right knee in 90 flexion:

visualizing from the high poster-
omedial portal and instrumenta-
tion from the low posteromedial
portal. (A) The third bite is taken
again from the meniscus using the
Knee Scorpion loaded with
FiberWire. (B) The fourth bite
through the posterior capsule; the
Scorpion needle is turned away
from the articular cartilage to
avoid damage. (C) The second set
of sutures with further approxi-
mation can be seen. (D) The sec-
ond set of sutures also is parked
through the anterolateral portal
for the later knot-tying process.
(fw, FiberWire; MFC, medial
femoral condyle; MM, medial
meniscus; PMC, posteromedial
capsule.)

Fig 8. Right knee in 90 flexion: looking through the high posteromedial portal and instrumentation from the low posteromedial
portal. (A) The fifth bite is taken from the meniscus using knee scorpion. (B) The sixth bite is taken from the posterior capsule.
(C) All 3 sets of sutures can be seen: the first 2 parked in the anterolateral portal and the third coming from the low poster-
omedial portal approximation of the ramp lesion can be seen. (fw, FiberWire; MFC, medial femoral condyle; MM, medial
meniscus; PMC, posteromedial capsule.)
e768 S. GUPTA ET AL.

Fig 9. Right knee in 90 flexion:

visualization through the high
posteromedial portal and instru-
mentation from the low poster-
omedial portal. (A) Knot-tying
using a knot pusher with multiple
half hitches; the third set (most
medial) is tied first. (B) Knot tied
and cut using a suture cutter;
approximation of the ramp lesion
can be seen. (MM, medial
meniscus; PMC, posteromedial
capsule.)

capsule can be avoided. Knot-tying is started for the last Still the 2 sets of sutures are parked in AL portal, out of
suture passed, using a knot pusher (Fig 9a), and fol- which middle set of sutures is retrieved from low PM
lowed by a suture cutter once tying is done (Fig 9b). portal (Fig 10a) and knot-tying done (Fig 10b),

Fig 10. Right knee in 90 flexion:

looking through the high poster-
omedial portal and instrumenta-
tion from the low posteromedial
portal. (A) second set of sutures
(middle) are retrieved from the
low posteromedial portal using a
suture manipulator. (B) The sec-
ond set knot-tying using a knot
pusher. (C) The first set of sutures
are retrieved from the low post-
eromedial portal and tied. (D) All
3 sets of knots are tied, and
approximation of the ramp lesion
can be seen. (MM, medial
meniscus; PMC, posteromedial
capsule.)
 PASS, PARK, AND TIE TECHNIQUE e769

to fourth week, 0 to 90 of motion with partial weight-

bearing is allowed. After 4 weeks, full weight-bearing
and full range of motion are permitted. Return to
greater activities is guided by associated ligament injury
and varies from 3 to 6 months.

Discussion
Failure to diagnose ramp or inadequate repair may
lead to failure of concomitant ACL reconstruction.6
Systemic arthroscopic exploration is therefore essen-
tial for identifying this hidden lesion.7 Hypermobility of
the meniscal ramp during flexion and extension will
prevent healing of ramp, necessitating the need of very
stable repair.8
Various techniques are described for ramp repair,
which include the inside-out repair,9 all-inside repair
using fast T-fix,10 and fast fix.11 The inside-out tech-
nique involves a long outside incision and possesses risk
to neurovascular structures. The all-inside device tech-
nique is expensive and is done without proper visuali-
zation of both meniscus and capsule simultaneously.
Fig 11. Right knee in 90 flexion: final picture after the repair Different techniques use different portals to visualize
visualization through the high posteromedial portal and probe the ramp properly, which includes the standard ante-
from the low posteromedial portal, the ramp lesion is seen to
rior portal,12 anterior portal with medial collateral lig-
be well approximated and stable.
ament pie crusting,13 PM portal,14 and transseptal
portal.15 The major drawback of visualization only from
ensuring that knot comes on the capsular side not on to the anterior portal is that the true extent of ramp lesion
meniscus side. This is followed by retrieving last set of cannot be assessed. Two PM portals give an added
sutures and knot tying (Fig10 c and d). These sequential advantage not only for visualization of the full extent of
steps of pass, park each suture, and tie once all sutures the ramp but ease of repair from the low PM portal.
are passed ensure good suture management and stable Recently, 2-PM portal was described by Siboni et al.16;
ramp repair. Finally, after the repair visualization we have been using the same 2 PM technique for
through the high PM portal and probed from the low 4 years, but the repair is done using a Scorpion passer
PM portal, the ramp lesion is seen to be well approxi- and all sutures are passed first and then sequential tying
mated and stable (Fig 11). is done at the end.
Two essential steps in ramp surgery are identification
Postoperative Rehabilitation of lesion’s extension and its secure repair. The first step
From the next day, quadriceps isometric, ankle is achieved by 2 PM portals, giving a bird’s eye view of
pumping, and hip rotation exercises are advised. Toe- the ramp, and second step by suture passage and repair
touch weight-bearing and passive range of motion up while looking at both meniscus and capsule. Our
to 45 are permitted in the first 2 weeks. From second technique covers both the steps to achieve fixation,

Table 1. Advantages and Disadvantages of a PM Antegrade Suture Technique Using the Knee Scorpion
Advantages Disadvantages
 Technically simpler and easily reproducible  Risk of cartilage injury in tight medial compartment to the
posterior aspect of femoral condyles.
 All-inside, low-cost, nonimplant surgery  Demands special instruments like the Scorpion Passer
 Multiple sutures can be used  May require medial release
 Less chance of injury to posterior structures  Failure to heal or inappropriate rehabilitation can lead to
changes knee biomechanics.
 Less associated morbidity as compared with the inside-out
technique
 Use of PM portals allows better visualization of the extent
of the tear, hidden lesions, better maneuvering, and repair
 High healing rates
 Strong repair construct
PM, posteromedial.
e770 S. GUPTA ET AL.

Table 2. Pitfalls and Tips for PM Antegrade Suture Technique Using Knee Scorpion
Pitfall Tips
Entering the PM compartment is difficult in a tight knee Use shaver from the transpatellar tendon portal and make space
between ACL and PCL to enter in the PM compartment
Difficulty in making low PM portal Transillumination circle at PM aspect with operation theater’s lights
off makes entry very easy
Finding the right trajectory for instrumentation through the low PM Use of spinal needle before making the portal in such a way that it is
portal at the level of meniscus and not too anterior
Passing of suture through meniscus with the Scorpion may be Use of flexioneextension movements will allow easy entry beneath
difficult the meniscus
Once the first suture is passed, subsequent sutures passage and Pass, park, tie: after passing first suture, park it in anterolateral portal
management is difficult without tying it. This will ensure easy subsequent passage and also
will prevent suture entanglement
ACL, anteroposterior cruciate ligament; PCL, posterior cruciate ligament; PM, posteromedial.

which is stable with knee movements, ensuring good 7. Sonnery-Cottet B, Conteduca J, Thaunat M, Gunepin FX,
healing. Seil R. Hidden lesions of the posterior horn of the medial
Our pass, park, and tie technique offers unique ad- meniscus: A systematic arthroscopic exploration of the
vantages (Table 1) in terms of excellent visualization, concealed portion of the knee. Am J Sports Med 2014;42:
921-926.
easy multiple suture passage, self-retrieving of the su-
8. Ahn JH, Kim SH, Yoo JC, Wang JH. All-inside suture
ture, direct view of knot-tying, and is a secure, stable,
technique using two posteromedial portals in a medial
nonimplant, low-cost fixation. The learning curve for meniscus posterior horn tear. Arthroscopy 2004;20:
this technique can be shortened with the technical tips 101-108.
as given in Table 2. 9. DePhillipo NN, Cinque ME, Kennedy NI, et al. Inside-out
repair of meniscal ramp lesions. Arthrosc Tech 2017;6:
References e1315-e1320.
1. Espejo-Baena A, Espejo-Reina A, Espejo-Reina MJ, Ruiz- 10. Chen Z, Li WP, Yang R, et al. Meniscal ramp lesion repair
Del Pino J. The Finochietto sign as a pathognomonic using the FasT-Fix technique: Evaluating healing and
finding of ramp lesion of the medial meniscus. Arthrosc patient outcomes with second-look arthroscopy. J Knee
Tech 2020;9:e549-e552. Surg 2018;31:710-715.
2. Chahla J, Dean CS, Moatshe G, et al. Meniscal ramp le- 11. Negrín R, Reyes NO, Iñiguez M, Pellegrini JJ, Wainer M,
sions: Anatomy, incidence, diagnosis, and treatment. Duboy J. Meniscal ramp lesion repair using an all-inside
Orthop J Sports Med 2016;4(7). technique. Arthrosc Tech 2018;7:e265-e270.
3. Hatayama K, Terauchi M, Saito K, Takase R, Higuchi H. 12. Mostafa Zaky Abdelrazek BH, Waly MR, Abdel Aziz MA,
Healing status of meniscal ramp lesion affects anterior Abdel Aziz A. Different techniques for the management of
knee stability after ACL reconstruction. Orthop J Sports Med meniscal ramp lesions using standard anterior portals.
2020;8(5). Arthrosc Tech 2019;9:e39-e44.
4. DePhillipo NN, Moatshe G, Brady A, et al. Effect of 13. Choi KY, Koh IJ, Kim MS, In Y. Medial meniscal ramp
meniscocapsular and meniscotibial lesions in ACL- lesion repair through anterior portals using a medial
deficient and ACL-reconstructed knees: A biomechanical collateral ligament pie-crusting technique. Arthrosc Tech
study. Am J Sports Med 2018;46:2422-2431. 2021;10:e1073-e1077.
5. Thaunat M, Jan N, Fayard JM, Kajetanek C, et al. Repair 14. Thaunat M, Fayard J-M, Freychet B, Vieira TD, Sonnery-
of meniscal ramp lesions through a posteromedial portal Cottet B. Rationale and surgical technique of ramp lesion
during anterior cruciate ligament reconstruction: repair through an additional posteromedial portal. Video J
Outcome study with a minimum 2-year follow-up. Sports Med 2021;1.
Arthroscopy 2016;32:2269-2277. 15. Buyukdogan K, Laidlaw MS, Miller MD. Meniscal ramp
6. Stephen JM, Halewood C, Kittl C, Bollen SR, Williams A, lesion repair by a trans-septal portal technique. Arthrosc
Amis AA. Posteromedial meniscocapsular lesions increase Tech 2017;6:e1379-e1386.
tibiofemoral joint laxity with anterior cruciate ligament 16. Siboni R, Pioger C, Jacquet C, et al. Meniscal ramp repair:
deficiency, and their repair reduces laxity. Am J Sports Med A 2-portal posteromedial approach. Arthrosc Tech 2022;11:
2016;44:400-408. e1163-e1169.