Description
Rationale
Ramp lesions are relatively novel as apparent in their low literature volume on databases, with the majority of current research focusing on the diagnosis, imaging techniques, and treatment of ramp lesions. The latest literature indicates that more severe and unstable ramp lesions may not fully heal whilst leading to poorer knee biomechanics if left unrepaired. With increasing trends amongst U45 ESKKA members and many orthopaedic surgeons, it is beneficial that we synthesise a decision-making management guideline based on its presentation.
Objective
We aim to investigate the effectiveness of exploratory probing techniques through the anteromedial portal for assessing and grading ramp lesion instability. We defined 3 grades of instability and assessed the clinical outcome using existing data.
Methods
Following the PRISMA 2020 Guideline, in July 2023 two researchers independently screened 613 titles and abstracts available on Pubmed. We grouped similar surgeon's subjective definitions of ‘stability’ and ‘instability’ through probing as stated by the author in each text, then categorised data from the pools of finalised literature to compare their clinical outcomes between suture repair and conservative treatments.
Results
Suture repair and conservative treatment resulted in statistically significant improvement in all clinical outcomes, including the IKDC, Lysholm score, SSD, and subjective scores.
However, suturing unstable ramps resulted in sturdier knees with lower post-operative SSD scores when compared to conservative treatment stable ramps: at 0.4±1.8mm in the repaired unstable, compared to 1.89±1.3mm of untreated lesion (P<0.001). Suturing a stable ramp provided statistically insignificant improvement to the SSD and the IKDC.
Suturing stable ramps led to greater healing rates when assessed with MRI at a mean follow-up of 28 months. 76% of sutured stable ramps fully healed, with only 1% not healed by MRI evaluation (n =65), as opposed to 67% and 21% of conservatively treated stable ramps (n = 58, P<0.05), respectively.
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). In contrast, 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.
