We're grateful to be here. Like with anything, you know, it's all about the team. I worked with a lot of great co-authors on this, especially some of my mentors that are here today. No disclosures. So a little bit about me, PGY5 at Yale and future WashU Sports Fellow. So I'll be here at these meetings coming up and super excited, looking forward to it. So a little bit of background. We heard a little bit about ramp lesions, but some of the literature has shown they're commonly associated with ACL tears. Recent studies show that they can be even as prevalent as 42% in patients that undergo ACL reconstruction. There's increasing recognition that ramp lesions lead to significant biomechanical changes in the knee. So the purpose of this study was to investigate whether patients with type four ramp lesions at the time of initial ACL reconstruction have higher rates of re-operation, specifically revision ACL, compared to those undergoing ACL reconstruction without a ramp lesion. So the methods, it was a retrospective cohort study. It was done at our academic center from 2015 to 2019. MRI criteria was put forth by Zappa et al and was used to define the presence of a ramp lesion. A type four ramp lesion were retrospectively diagnosed on preoperative MRIs by two MSK trained radiologists blinded to clinical information. And we had an ACL database in which we got majority of our information from. Inclusion, if they had an acute ACL tear with MRI less than 30 days from injury and at least two years of follow-up. They were excluded with any prior knee surgery, multiligament knee injury, or prior revision ACL. So the MRI evaluation. So based off a found out classification, there's different types. We wanted to focus on the type four. So type one is just the meniscal capsule lesion. Type two is a superior posterior horn lesion. Type three is that undersurface or meniscal tibial lesion. Type four, which is shown here, is the complete. So you can see on the sagittal, high intensity T2 signal that extends from the femoral articular surface all the way down to the tibial surface. And then it's also associated with posterior medial bruising. So intra-op, ramp lesions were viewed from a standard anterior lateral portal and probed anteriorly through an anterior medial portal. Tears were determined to be stable by lack of displacement and translation with probing into the medial compartment. This point's important and that we'll come back to. Unstable tears were those that were found to displace into the medial compartment with anterior directed probing from anterior medial portal. And then treatment for unstable ramp lesions were done by either all-inside or inside-out technique. So the results. There was 313 patients that were initially included. 255 patients were subsequently, after inclusion-exclusion criteria applied, were remained. There was 170 patients that had an ACL reconstruction without a ramp lesion. And there was 85 patients that had an ACL reconstruction with a type 4 lesion. Of these, 48 patients had an ACL reconstruction with an untreated or stable ramp lesion. And 37 patients had an ACL with a treated type 4 ramp lesion. So just basic demographics. Most of the groups in the no-ramp and the ramp group were similar. The only really thing that stood out was in the ramp group, they were predominantly male at 68%. Majority of them happened in non-contact athletes. Follow-up was, you know, average two years. And then timing to surgery was within 13 weeks to 15 weeks. The reliability of diagnosing a type 4 ramp lesion on an MRI was excellent with an ICC of .934. Associated injuries. We found that ramp lesions were more commonly associated with lateral meniscal tears, classically known posterior medial tibial plateau bruising, and then as well as medial femoral condyle bruising. So knee re-operation. So when we looked at revision ACL reconstruction, we found that the ramp group, there was nine of them for 10.6%. For meniscus surgery, there was 12 at 14.1%. And others included lysis of adhesion, removal of hardware infection, or IF. When we broke down the untreated or stable ramp lesion versus the treated, we found that the revision group had eight for 18.8%. Interestingly, we also found that at the time of the untreated ramp group at their second surgery, eight of these turned into medial bucket handle tears. So last regression analysis, I want you to focus on the green. So this is the untreated ramp group, the type 4. And you can see significantly within the first two years, most of them require ACL revision for hazard ratio of 10.46. If you treat the ramp lesion, it has the same following as an ACL reconstruction without a ramp. Meniscus surgery was similar in both groups. Limitations. During the study period, we didn't technically use the term ramp lesion. It was before that. It was mostly classified as peripheral medial meniscus tear or meniscal capsule or junction tear. And then during the study period, we did not perform a modified Gilquist or use an accessory viewing portal to accurately assess for ramp lesions. So in conclusion, most significantly, untreated ramp lesions with concomitant ACL reconstruction were associated with increased risk of ACL reconstruction revision surgery. If you treat the initial ramp lesion along with the ACL, the revision ACL rate is similar to the no ramp population. There was 17% of the untreated ramp lesions that progressed into medial bucket handle meniscus tears at reoperation surgery. And part of the conclusion we found was standard portals are not significant in diagnosing and assessing stability of ramp lesions intraoperatively. Thank you.

type four ramp lesions

ACL reconstruction

re-operation

retrospective cohort study

MRI evaluation