Translate this page into:
All-inside ramp lesion repair via anterior portals and pie-crusting: Excellent outcomes and survivorship at one-year follow-up
, Francesco Boscof,g,, Francesco Sacciaa,b
⁎Corresponding author: Francesco Bosco. francesco.bosco03@unipa.it
-
Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Ramp lesions, located in the posterior horn of the medial meniscus, are commonly associated with anterior cruciate ligament (ACL) injuries and contribute to knee instability if untreated. Traditional repair methods use posteromedial portals, but newer approaches, such as the all-inside technique through anterior arthroscopic portals with pie-crusting of the posterior oblique ligament (POL), offer improved access and reduced morbidity. This study aimed to assess the clinical outcomes, return-to-sport rates, and failure rates of this technique compared to established methods.
A retrospective analysis included 54 patients (mean age: 29.1 years) who underwent ramp lesion repair using the all-inside technique between January 2019 and December 2022. Clinical outcomes were evaluated with the IKDC score, Lysholm score, and Tegner activity scale. Failure was defined as the need for revision surgery.
At a mean follow-up of 30.7 months, patients had a mean IKDC score of 81.5 ± 7.1 and Lysholm score of 94.5 ± 7.4. The Tegner activity scale declined slightly from 7.2 ± 1.2 preoperatively to 6.8 ± 1.3 postoperatively. All patients returned to sport within 9.2 ± 2.5 months, with a failure rate of 12.9 % and an average revision time of 13.1 ± 8.2 months.
The all-inside technique for ramp lesion repair via anterior portals provides excellent clinical outcomes and return-to-sport rates, with failure rates comparable to other methods. This minimally invasive approach offers improved access, reduced morbidity, and a reliable option for managing ramp lesions in ACL-injured patients.
IV.
Keywords
Ramp lesion
Arthroscopy
All-inside
Repair
return to sport
Meniscus
1 Introduction
Ramp lesions, first described by Strobel, are meniscosynovial or meniscocapsular tears located at the posterior horn of the medial meniscus. These lesions are commonly associated with anterior cruciate ligament (ACL) injuries and have been reported to occur in approximately 9.3 %–17 % of such cases.1–3 Despite their relatively high incidence, ramp lesions often go undiagnosed due to the inherent limitations in visualizing the posteromedial corner of the knee using standard anterior arthroscopic portals.4 This diagnostic challenge represents a critical issue, as failure to identify and adequately repair ramp lesions can contribute to anteroposterior knee instability, secondary medial meniscal damage, and early failure of ACL reconstruction.5,6
Over the years, numerous surgical techniques have been proposed to repair ramp lesions. One of the most widely utilized approaches involves the use of a posteromedial portal and a suture hook for lesion visualization and repair. The trans-septal portal technique has also been introduced, allowing enhanced access to the posterior compartment while employing a hook device through the posteromedial portal.8–10 More recently, Choi et al. proposed a technique that utilizes anterior arthroscopic portals in conjunction with the pie-crusting of the medial collateral ligament (MCL) to improve access to the posteromedial compartment.11,12 Despite these advancements, there remains no clear consensus regarding the superiority of one technique over another, nor is there a universally recognized gold standard for ramp lesion repair. Some authors have expressed concerns about the effectiveness of anterior portal-based techniques, citing a higher risk of repair failure.7
The lack of consensus in the literature highlights a significant gap in the current understanding of the optimal surgical approach for ramp lesions. Additionally, limited evidence compares the clinical outcomes and complication rates associated with different repair techniques. Developing effective, minimally invasive strategies that ensure optimal repair outcomes while reducing morbidity remains a key area of focus in orthopedic research.
The aim was to evaluate the clinical outcomes, return to sports activities, and suture failure rates associated with ramp lesion repair using an all-inside repair technique through anterior arthroscopic portals. The hypothesis was that this technique would yield clinical results comparable to or superior to other established meniscal repair methods while offering reduced morbidity and reliable functional outcomes.
2 Materials and methods
2.1 Study design and ethical approval
This study was designed as a multi-center retrospective case series, utilizing data from a prospectively collected database. A single surgeon performed all surgical procedures between January 2019 and December 2022. Ethical approval was obtained from the institutional review board, and all patients provided informed consent before inclusion. The study was conducted by the principles outlined in the Declaration of Helsinki.
2.2 Inclusion and exclusion criteria
Patients included in the study had confirmed ramp lesions. They met at least one of the following criteria: complete anterior cruciate ligament (ACL) injury, partial ACL lesions with residual instability, lateral meniscus tears, or ACL revision reconstruction. Exclusion criteria included suspected ramp lesions not confirmed arthroscopically, patients with less than one year of follow-up from surgery, those with prior open or arthroscopic surgeries for intra-articular lesions, and ramp lesions treated using alternative surgical techniques. Ramp lesions were classified according to the Thaunat classification system.4
2.3 Data extraction
Demographic, clinical, and surgical data were extracted from the database, including lesion characteristics, details of surgical techniques, and postoperative outcomes. Data on the time to return to sport and postoperative complications were stratified to analyze differences in recovery trajectories. Postoperative evaluations were conducted during outpatient visits and included clinical assessments alongside patient-reported questionnaires. Clinical outcomes were assessed using the Lysholm Knee Score13 and the International Knee Documentation Committee (IKDC) Objective Score.14 Return to sports (RTS) activity was evaluated using the Tegner Activity Scale,15 comparing the pre-injury and postoperative activity levels. Time to return to sport was analyzed, specifically focusing on patients without postoperative complications. Failures were defined as persistent clinical medial knee pain with positive meniscal tests that required subsequent partial meniscectomy. All postoperative complications were recorded.
2.4 Surgical technique
All procedures were carried out with the patient in the supine position and the knee flexed to 90°. A tourniquet was applied to the operative limb, and arthroscopy was performed to confirm the presence of ramp lesions. The pie-crusting of the posterior oblique ligament (POL) was performed to improve visualization of the posterior horn of the medial meniscus and reduce iatrogenic cartilage damage (Figs. 1 and 2).
The stability of the posterior horn of the medial meniscus was evaluated using an arthroscopic probe from both anterior and trans-notch views. Surgical repair was recommended for unstable posterior horn lesions, inadequate contact between the posterior horn and the posterior capsule, or tears longer than 1 cm. Repairs were performed using the all-inside suture technique with the FAST-FIX™ 360 Meniscal Repair System (Smith + Nephew), adjusting the number of sutures based on the tear size. Optimal stability and contact between the posterior horn and the capsule were confirmed during the operation.
In concurrent ACL reconstruction cases, graft selection was tailored to individual patient characteristics such as age, sex, and activity level. Grafts included hamstrings, quadriceps tendon, and bone-patellar tendon bone. The modified "over-the-top" technique described by Marcacci was also utilized.16 At the end of the procedure, an intra-articular injection of 7 % ropivacaine (10 mL) and tranexamic acid (15 mL) was administered. No postoperative drainage was used.
2.5 Postoperative rehabilitation protocol
Postoperative rehabilitation followed a standardized protocol. Patients were instructed to begin non-weight-bearing motion immediately after surgery, with knee flexion restricted to 90° for the first four weeks. During this period, partial weight-bearing with crutches and a range of motion between 0° and 90° were allowed. For patients with additional meniscal lesions, such as radial or root tears, weight-bearing was prohibited for 40 days, with knee flexion restricted to 90° for the first four weeks.
After four weeks, a full non-weight-bearing motion was permitted, while weight-bearing knee flexion remained limited to 90° for five months. Full weight-bearing flexion was allowed after this period. Jogging was permitted at six months, and in cases involving ACL reconstruction, return to sport was allowed between eight and ten months. No braces were used during the rehabilitation process.
2.6 Statistical analysis
Descriptive statistics were calculated for demographic, clinical, and surgical data. Continuous variables were expressed as means ± standard deviations (SD), while categorical variables were presented as frequencies and percentages. A Kaplan-Meier survival analysis was conducted to evaluate the survivorship of ramp lesion repair, with failure defined as the need for revision surgery. The survival curve provided insights into the timing and frequency of failures over the follow-up period. Statistical analyses were performed using R software (version 4.1.3, R Core Team, Vienna, Austria).
3 Results
3.1 Patient demographics and clinical characteristics
A total of 65 patients were initially enrolled in the study. Of these, two patients (3.2 %) were excluded due to undergoing posteromedial hook repair, 5 (7.8 %) were unavailable for clinical evaluation, and 4 (6.4 %) were lost to follow-up. Consequently, 54 patients met the inclusion criteria and were included in the final analysis (Fig. 3). The cohort consisted of 40 males (74.0 %) and 14 females (26.0 %), with a mean age of 29.1 years (SD ± 10.4, range 13–56). The operated knee was the right knee in 30 cases (55.6 %) and the left knee in 24 cases (44.4 %). The mean follow-up duration was 30.7 months (range 12–58). Detailed demographic data and clinical characteristics are summarized in Table 1.
| Characteristics | Values |
| Included patients, N (%) | 54 |
| Age (years) Mean ± SD | 29.1 ± 10.4 |
| Age range (years) | 13–56 |
| Sex (Male), N (%) | 40 (74.0) |
| Sex (Female), N (%) | 14 (26.0) |
| Operated knee (Right), N (%) | 30 (55.6) |
| Operated knee (Left), N (%) | 24 (44.4) |
| Mean follow-up (months) | 30.7 |
| Follow-up range min-max (months) | 12–58 |
3.2 Ramp lesion characteristics and associated pathologies
Ramp lesions were associated with ACL injuries in 87.0 % of cases (n = 47), of which 10 patients (21.3 %) experienced a re-rupture of the ACL. In 7 patients (12.9 %), Ramp lesions occurred due to rotational instability of the knee following ACL reconstruction. In 21 cases, it was possible to classify the ramp lesions: 2 cases (9.5 %) were Type II, 6 cases (28.6 %) were Type III, 4 cases (19.0 %) were Type IV, and 9 cases (42.9 %) were Type V. Rotational instability of the knee, as assessed by a positive pivot shift test, was identified in 35 patients (64.8 %) post-injury.
3.3 Surgical techniques
All patients underwent ramp lesion repair using the all-inside suture technique with the FAST-FIX™ 360 Meniscal Repair System (Smith + Nephew), with an average of 2.2 ± 0.9 sutures per procedure. ACL reconstruction was performed in 47 patients, with the most common technique being the all-inside anatomical reconstruction (n = 43). Hamstring grafts were utilized in 31 cases, quadriceps tendon in 11 cases, and bone-patellar tendon-bone (BPTB) grafts in 5 cases. Lateral tenodesis was performed in 29 patients (54.7 %) using the modified Arnold-Cocker technique. Detailed information on surgical techniques and procedures is available in Table 2.
| Procedure/Technique | Cases (n) | Percentage (%) |
| ACL Reconstruction (All-inside) | 43 | 79.6 |
| Marcacci Over-the-Top ACL Reconstruction | 4 | 7.4 |
| Hamstring Graft | 31 | 57.4 |
| Quadriceps Tendon Graft | 11 | 20.4 |
| Bone-Patellar Tendon-Bone Graft | 5 | 9.3 |
| Ramp lesion sutures per procedure (Mean ± SD) | 2.2 ± 0.9 | – |
| Lateral tenodesis | 29 | 54.7 |
| Lateral tenodesis (Arnold Cocker) | 22 | 75.9 |
| Lateral tenodesis (Marcacci) | 4 | 13.8 |
| Lateral tenodesis (Lemaire) | 3 | 10.3 |
| Concomitant lateral meniscus tears | 17 | 32.1 |
| Root lesion of lateral meniscus (unstable) | 4 | – |
| Root lesion of lateral meniscus (stable) | 3 | – |
3.4 Clinical outcomes and return to sport
Postoperative outcomes demonstrated significant improvements in clinical scores. The mean IKDC score was 81.5 ± 7.1, and the Lysholm score was 94.5 ± 7.4 at the final follow-up. All patients (100 %) returned to sports activities. The Tegner Activity Scale showed a mean pre-injury score of 7.2 ± 1.2 and a mean postoperative score of 6.8 ± 1.3 at 30.3 months follow-up. The average time to return to sport was 9.2 ± 2.5 months (Table 3).
| Patient-Reported Outcome Measures (PROMS) | Value, Mean ± SD |
| Postoperative IKDC Score (Mean ± SD) | 81.5 ± 7.1 |
| Postoperative Lysholm Score (Mean ± SD) | 94.5 ± 7.4 |
| Pre-surgery Tegner Score (Mean ± SD) | 7.2 ± 1.2 |
| Post-surgery Tegner Score (Mean ± SD) | 6.8 ± 1.3 |
| Mean time to return to sport (months) | 9.2 ± 2.5 |
3.5 Survivorship analysis and complications
The Kaplan-Meier survival curve indicated a failure rate of 12.9 % for ramp lesion repair at a mean follow-up of 30.7 months. Failures occurred, on average, after 13.1 ± 8.2 months (range 3–25). Causes of failure included re-tear of the ramp lesion during rehabilitation (n = 1), non-healing of the medial meniscus with persistent symptoms (n = 2), and reinjury during sports activities after return to play (n = 4). Details of failure cases are visualized in the survival curve (Fig. 4).
Overall, complications were rare. One patient (1.8 %) experienced a combined reinjury of the medial meniscus and ACL at 42 months postoperatively, which was attributed to a new meniscal tear in a different area. Three patients (5.6 %) had ACL reconstruction failure. Two patients (3.8 %) required additional surgeries for exostosis removal, and two patients (3.8 %) developed medial collateral ligament (MCL) laxity. Other complications included lateral meniscus tears (white-white zone) in two cases (3.6 %) and medial flexor tendinopathy in one case (1.8 %). A detailed summary of complications is provided in Table 4.
| Failure rate and Complications | Cases |
| Ramp lesion repair failure rate, % | 12.9 % |
| Failure rate (Time to failure, months), Mean ± SD | 13.1 ± 8.2 |
| Re-injury of medial meniscus with ACL re-injury, N (%) | 1 (1.8 %) |
| Anterior cruciate ligament reconstruction failure, N (%) | 3 (5.6 %) |
| Further surgery for exostosis removal, N (%) | 2 (3.8 %) |
| Medial collateral ligament laxity, N (%) | 2 (3.8 %) |
| Lateral meniscus white-white tears, N (%) | 1 (1.8 %) |
4 Discussion
The main finding of the present study is that repairing Ramp lesions through anterior arthroscopic portals with the all-inside suture technique, combined with pie-crusting of the posterior oblique ligament (POL), is a reliable and practical approach. This technique achieved high survivorship rates of 87.1 % at an average follow-up of 30.7 months, with a total failure rate of 12.9 %. The clinical outcomes were favorable, as demonstrated by mean IKDC and Lysholm scores of 81.5 and 94.5, respectively, and a return-to-sport rate of 100 %. These findings align with previous literature suggesting that Ramp lesion repair leads to excellent functional outcomes and high healing rates when performed with appropriate techniques.17–22 Moreover, the study highlighted the critical role of addressing rotational instability, often exacerbated by Ramp lesions, to optimize knee function and reduce failure rates.
The study demonstrated that rotational instability was present in 64.8 % of patients with Ramp lesions, as assessed via the pivot shift test. This finding emphasizes the role of Ramp lesions in exacerbating internal tibial rotation, which contributes to functional instability. Lateral extra-articular tenodesis was performed in 54.7 % of patients, particularly those with high functional demands. These results support prior studies that identified the relationship between Ramp lesions, increased rotational instability, and the necessity of lateral tenodesis to restore stability.23–25 Interestingly, the absence of lateral tenodesis in most suture failure cases in this study further corroborates its importance in preventing secondary meniscal injuries.17,26–28
A significant challenge in Ramp lesion repair is achieving adequate visualization of the posterior horn of the medial meniscus. Several authors advocate for posteromedial portals to ensure optimal visualization and complete lesion closure.7,29–32 However, in this study, pie-crusting of the POL was employed to improve access through anterior portals, demonstrating its efficacy in achieving comparable healing rates to those reported with posteromedial techniques.33,34 Despite this, the study acknowledges findings from Thaunat et al. and Grousopoulos et al. which suggest higher failure rates for anterior portal repairs compared to posteromedial approaches.27,36 Ensuring proper visualization remains a critical factor in successful Ramp lesion repair.
The clinical outcomes of this study are consistent with prior research.20,22,28,35,36 Mean IKDC and Lysholm scores of 81.5 and 94.5 demonstrate significant functional recovery, with scores aligning with those reported in studies focused on the all-inside suture technique.20,28 The Tegner Activity Scale showed a modest decrease from 7.2 ± 1.2 preoperatively to 6.8 ± 1.3 postoperatively, consistent with reductions reported in similar studies.36–38 The high survivorship rate of 87.1 % aligns with the results of Chen et al. who reported an 87 % healing rate using the Fast-Fix device through anterior portals.22
The total failure rate in this study was 12.9 %, which is lower than the rates reported in the literature, ranging from 14.8 % to 19.1 %.39,40 Failures were primarily attributed to knee sprains during rehabilitation, persistent medial knee pain due to incomplete healing, and reinjuries after returning to sports. Notably, five of six failure cases did not involve lateral tenodesis, reinforcing its role in reducing secondary meniscectomy rates.27 These findings highlight the importance of addressing rotational instability alongside Ramp lesion repair to minimize failure risks.
Complications in this study were infrequent but noteworthy. Two cases of chronic medial collateral ligament (MCL) injuries were described. In one case, the patient also experienced ACL reconstruction failure and Ramp lesion repair with significant valgus stress instability. In the other case, anteromedial instability was reported during follow-up despite an intact ACL and medial meniscus. Recent studies, such as that by Willinger et al. have demonstrated a close correlation between MCL injuries, Ramp lesions, and bone bruises, suggesting further investigation into the timing and management of MCL lesions in conjunction with Ramp repairs.41
The present study has notable strengths. First, it is one of the few studies to comprehensively evaluate Ramp lesion repair's clinical outcomes and survivorship using the all-inside technique through anterior arthroscopic portals. Second, all surgeries were performed by a single experienced surgeon, ensuring consistency in surgical technique and minimizing variability. Third, using standardized outcome measures, such as the IKDC and Lysholm scores and a detailed analysis of failure rates and complications, provides robust and clinically relevant data. Lastly, the study addresses an important and underexplored topic in orthopedic surgery, contributing valuable insights into managing Ramp lesions, particularly concerning optimizing rotational stability and visualizing lesions through anterior portals.
This study has several limitations that should be considered when interpreting the results. First, the study's retrospective nature and the absence of a control group limit the data analysis's robustness and the findings' generalizability. Second, the small sample size reduces the statistical power and the ability to detect subtle differences between patient subgroups. Future research should address these limitations by expanding the sample size and incorporating a control group to strengthen the conclusions. Additionally, a prospective database is currently being compiled, enabling further studies to validate the findings of this case series and explore the efficacy of different surgical techniques with greater statistical rigor.
5 Conclusion
The present study confirms that repairing Ramp lesions using the all-inside technique through anterior arthroscopic portals achieves excellent clinical outcomes and high rates of return to sport. The failure rate observed in this study was comparable to that of other established surgical techniques, including the posteromedial portal and trans-septal approaches. These findings highlight the reliability and efficacy of the anterior repair approach, particularly when combined with pie-crusting of the posterior oblique ligament, to optimize visualization and repair. However, further studies with larger prospective cohorts and control groups are needed to confirm these results and to deepen our understanding of Ramp lesion pathology and its optimal management.
CRediT authorship contribution statement
Antonio Clemente: Conceptualization, Writing – original draft. Domenico Zaccari: Writing – original draft, Data curation, Methodology, Investigation. Federico Verdone: Writing – original draft, Data curation, Methodology. Glauco Loddo: Investigation, Visualization. Francesco Bosco: Data curation, Visualization, Supervision. Francesco Saccia: Investigation, Visualization, Supervision.
Guardian/patient's consent
Not Applicable.
Ethical statement
The study was conducted following the ethical standards of the Declaration of Helsinki (1964).
Funding statement
This research did not involve any specific grants from commercial, public, or non-profit sector funding agencies.
References
- Ramp lesions in ACL deficient knees in children and adolescent population: a high prevalence confirmed in intercondylar and posteromedial exploration. Knee Surg Sports Traumatol Arthrosc. 2018;26(4):1074-1079.
- [Google Scholar]
- Classification and surgical repair of ramp lesions of the medial meniscus. Arthrosc Tech. 2016;5(4):e871-e875.
- [Google Scholar]
- Posteromedial meniscocapsular lesions increase tibiofemoral joint laxity with anterior cruciate ligament deficiency, and their repair reduces laxity. Am J Sports Med. 2016;44(2):400-408.
- [Google Scholar]
- The FasT-fix repair technique for ramp lesion of the medial meniscus. Knee Surg Relat Res. 2015;27(1):56-60.
- [Google Scholar]
- Ramp lesions: an unrecognized posteromedial instability? Clin Sports Med. 2020;39(1):69-81.
- [Google Scholar]
- Meniscal ramp lesion repair by a trans-septal portal technique. Arthrosc Tech. 2017;6(4):e1379-e1386.
- [Google Scholar]
- Meniscal ramp lesion repair using the FasT-fix technique: evaluating healing and patient outcomes with second-look arthroscopy. J Knee Surg. 2018;31(8):710-715.
- [Google Scholar]
- Examining techniques for treatment of medial meniscal ramp lesions during anterior cruciate ligament reconstruction: a systematic review. Arthroscopy. 2020;36(11):2921-2933.
- [Google Scholar]
- Medial meniscal ramp lesion repair through anterior portals using a medial collateral ligament pie-crusting technique. Arthrosc Tech. 2021;10(4):e1073-e1077.
- [Google Scholar]
- Different techniques for the management of meniscal ramp lesions using standard anterior portals. Arthrosc Tech. 2019;9(1):e39-e44.
- [Google Scholar]
- The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med. 2009;37(5):890-897.
- [Google Scholar]
- Knee injury and Osteoarthritis Outcome Score or International Knee Documentation Committee Subjective Knee Form: which questionnaire is most useful to monitor patients with an anterior cruciate ligament rupture in the short term? Arthroscopy. 2013;29(4):701-715.
- [Google Scholar]
- The use of the Tegner Activity Scale for articular cartilage repair of the knee: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2011;19(4):604-614.
- [Google Scholar]
- Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons: a review. Curr Rev Musculoskelet Med. 2011;4(2):73-77.
- [Google Scholar]
- Epidemiological evaluation of meniscal ramp lesions in 3214 anterior cruciate ligament-injured knees from the santi study group database: a risk factor analysis and study of secondary meniscectomy rates following 769 ramp repairs. Am J Sports Med. 2018;46(13):3189-3197.
- [Google Scholar]
- Arthroscopic prevalence of ramp lesion in 868 patients with anterior cruciate ligament injury. Am J Sports Med. 2011;39(4):832-837.
- [Google Scholar]
- Ramp lesions associated with ACL injuries are more likely to be present in contact injuries and complete ACL tears. Knee Surg Sports Traumatol Arthrosc. 2018;26(4):1080-1085.
- [Google Scholar]
- Searching for the best treatment for ramp lesions: a systematic review and network meta-analysis. Cureus. 2023;15(7)
- [Google Scholar]
- How to repair medial meniscal ramp lesions: a systematic review of surgical techniques. J Exp Orthop. 2024;11(3)
- [Google Scholar]
- Greater knee rotatory instability after posterior meniscocapsular injury versus anterolateral ligament injury: a proposed mechanism of high-grade pivot shift. Orthop J Sports Med. 2023;11(9)
- [Google Scholar]
- The clinical application of machine learning models for risk analysis of ramp lesions in anterior cruciate ligament injuries. Am J Sports Med. 2023;51(1):107-118.
- [Google Scholar]
- Combining an anterolateral complex procedure with anterior cruciate ligament reconstruction reduces the graft reinjury rate and improves clinical outcomes: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med. 2024;52(8):2129-2147.
- [Google Scholar]
- Failure rates of repaired bucket-handle tears of the medial meniscus concomitant with anterior cruciate ligament reconstruction: a cohort study of 253 patients from the santi study group with a mean follow-up of 94 months. Am J Sports Med. 2023;51(3):585-595.
- [Google Scholar]
- Suture hook versus all-inside repair for longitudinal tears of the posterior horn of the medial meniscus concomitant to anterior cruciate ligament reconstruction: a matched-pair analysis from the santi study group. Am J Sports Med. 2022;50(9):2357-2366.
- [Google Scholar]
- Clinical study on the arthroscopic refreshing treatment of anterior cruciate ligament injury combined with stable medial meniscus ramp injury. J Musculoskelet Neuronal Interact. 2017;17(2):108-113.
- [Google Scholar]
- Ramp lesion in anterior cruciate ligament injury: a review of the anatomy, biomechanics, epidemiology, and diagnosis. Knee Surg Relat Res. 2023;35(1):23.
- [Google Scholar]
- What is the failure rate after arthroscopic repair of bucket-handle meniscal tears? A systematic review and meta-analysis. Am J Sports Med. 2022;50(6):1742-1752.
- [Google Scholar]
- Meniscus tears treatment: the good, the bad and the ugly-patterns classification and practical guide. World J Orthoped. 2023;14(4):171-185.
- [Google Scholar]
- Meniscal ramp lesion repair without the need for a posteromedial portal. Arthrosc Tech. 2024;13(4)
- [Google Scholar]
- Ramp lesions of the medial meniscus. Curr Rev Musculoskelet Med. 2023;16(5):173-181.
- [Google Scholar]
- The pie-crust surgical technique for medial collateral ligament release: enhancing visualization of the medial compartment in knee arthroscopy. Ann Jt. 2024;9:14.
- [Google Scholar]
- Repair of meniscal ramp lesions through a posteromedial portal during anterior cruciate ligament reconstruction: outcome study with a minimum 2-year follow-up. Arthrosc J Arthrosc Relat Surg. 2016;32:2269-2277.
- [Google Scholar]
- Outcomes of lateral meniscal oblique radial tear repair compared with intact meniscus after ACL reconstruction: a cohort study. Orthop J Sports Med. 2023;11(12)
- [Google Scholar]
- In elite athletes with meniscal injuries, always repair the lateral, think about the medial! A systematic review. Knee Surg Sports Traumatol Arthrosc. 2023;31(6):2500-2510.
- [Google Scholar]
- Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: a systematic review and meta-analysis with a minimum follow-up of 5 years. Knee Surg Sports Traumatol Arthrosc. 2022;30(7):2267-2276.
- [Google Scholar]
- Meniscal repair outcome in 3829 patients with a minimum follow-up from 2 Years up to 5 Years: a meta-analysis on the overall failure rate and factors influencing failure. Am J Sports Med. 2024;52(3):822-831.
- [Google Scholar]
- Medial meniscal ramp lesions in ACL-injured elite athletes are strongly associated with medial collateral ligament injuries and medial tibial bone bruising on MRI. Knee Surg Sports Traumatol Arthrosc. 2022;30(5):1502-1510.
- [Google Scholar]