It's my pleasure to be a part of this fantastic course and have the opportunity to present meniscal ramp lesion techniques. Remember, this is the lesion when the posterior medial meniscus and capsular tissue is trapped between the femur and tibia during an ACL injury. It occurs in conjunction with an ACL injury in approximately 20% to 30% of our pediatric and adolescent patients. Thano and his colleagues gave us a classification scheme of these peripheral injuries. And on imaging, we want to look for meniscal irregularity, junctional fluid signal, deep MCL injury, or certainly posterior medial tibial bone bruise is sensitive but not highly specific. Young patients, increased instability time, those posterior medial bone contusions, increased slope and varus all can be concomitant features for this injury. You can treat these with inside to out techniques. All inside techniques with devices from the front or all inside with not tying in the back. The literature suggests all of these are reasonable and effective. We probe very extensively and have a view of this either from the notch or from the front, often viewing in both ways and looking for this instability when the bone bruise is present. Use of that modified Gilquist notch view can be very useful. You see here we're probing through the notch or using a 70 degree arthroscope and a needle in the back posterior medially to manipulate the tissues can be very useful to evaluate and manage these lesions. Certainly, percutaneous partial MCL release with 18 gauge needle percutaneous release is very useful for both access to the joint, but as well as allowing less tension on the tissues and less valve is required for repair. So with our inside to out technique, it's our usual approach and our usual not tying with the knee in a flexed position. This can be particularly advantageous to allow those tissues to relax, to allow reduction of these peripheral lesions. If we're going to use an all inside technique from the front, this is one example. Here's our lesion on MRI. Again, you can see secondary changes on the femoral condyle, unstable meniscus in the front probing. Here we're viewing from the notch. We can see with our needle where our lesion is. We've done a partial percutaneous MCL release. We've used a vertical mattress technique. We've pushed that tissue back during the repair to decrease the tension and improve apposition of the tissues. Here we can see our accomplished repair. All inside in a further peripheral lesion, we might want to consider a vertical cerclage technique. So here we've got our unstable lesion, but we can see our capsular injury is further peripheral. So in this case, we've accomplished a vertical cerclage, allowing our device to reach further behind the meniscus into the capsule. And here we can see through the notch our repair. When that bone bruise is present, having that high index of suspicion and using the 70-degree arthroscope, again, we can see some diffuse injury here on our MRI. From the front, we sense some instability. We see the secondary change. We look through the notch, can see something far there. But if we put that 70-degree scope in, it really helps visualize this injury, can help guide our all-inside device, and can help guide our device to the right position. Can help guide our all-inside device. And here you can see our accomplished repair and visualization, again, through the notch. When these are far medial, as you see on that axial scalp view, again, as you see on the right, a 70-degree arthroscope to really look around that femoral condyle and see the lesion can be helpful. When working from the back, we want to use assisted leg abduction. Use of a portal, either a five or seven millimeter portal, or I prefer often a half or three-quarter cannula to shuttle instruments, and that 18-gauge needle to assist us not only with tissue management, but also management of our wire passer and our sutures. Here we can see our lesion by MRI. Here in the back, we can see our lesion. We've accomplished a portal with a three-quarter cannula, and we're just shuttling our instruments in and out. You can see here's our wire passer. We're using our needle to hold the wire while we use a single cannula to manipulate the wire suture and knot tying. Again, here we can see we're using the needle to stabilize the tissues while we pass our suture, shuttle the suture in, and accomplish our knot. Some ramps are indeed stable and don't require repair. Here's a clear secondary sign of injury. But with probing, we see despite the secondary changes, no instability of our meniscus. We've released the MCL partially again to see and better visualize that partial injury. Here you can see petechiae in the back, but no instability. And some of these stable lesions may indeed heal nonoperatively. Here you can see a clear lesion preoperatively. Arthroscopic evaluation. And here we can see our lesion is healed. We see the collagen change across the zone of repair. And by the time this patient had surgery, their ramp had healed. So in summary, maintain a high index of suspicion. Indications for repair of stable lesions are unclear. Have a low threshold to repair any that are unstable to probing. And any of these techniques can be successful. Please use what you're most comfortable with and what's most appropriate for the repair. Dr. Ganley and his colleagues gave us an excellent current concept review. And Thano and his colleagues gave additional video examples of techniques. Thanks again, and happy to discuss these with you when we get a chance.

meniscal ramp lesions

ACL injury

imaging techniques

treatment options

repair techniques