Thaunat Mathieu, Fayard Jean-Marie, Freychet Benjamin, Vieira Thais Dutra, Sonnery-Cottet Bertrand
FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, Centre Orthopédique Santy, Lyon, France.
Video J Sports Med. 2021 Feb 24;1(1):2635025421994592. doi: 10.1177/2635025421994592. eCollection 2021 Jan-Feb.
Ramp lesions are longitudinal lesions of the meniscocapsular complex of the posterior horn of the medial meniscus. These lesions are poorly recognized, difficult to diagnose, and require specific arthroscopic exploration. Ramp lesions are typically associated with anterior cruciate ligament rupture and have important biomechanical consequences as they result in increased anterior tibial translation and external rotation. Suture hook repair through the posteromedial portal is safe and provides a high healing rate.
Spontaneous healing of ramp lesions is rarely observed, and repair is indicated for all lesions with the involvement of meniscotibial ligament. The choice of a posteromedial repair technique with vertical suture performed under visual control allows restoration of the continuity of meniscotibial ligament and effective healing of these lesions.
Standardized arthroscopic exploration with systematic visualization of the posteromedial compartment using the transnotch technique is a crucial point to diagnose these lesions. The use of transillumination and a needle allows to palpate the lesion with the tip of the needle in case of doubt (hidden lesion) before performing the posteromedial portal safely. By using the transnotch vision and by introducing the instruments through the posteromedial portal, debridement with the shaver and repair with the hook of the lesion are performed under visual control. Vertical repair is performed by taking care to pass the hook through the meniscotibial ligament by perforating the deep face of the capsular portion and anterior portion of the ramp lesion. Similarly, it is recommended not to catch too much meniscal tissue on the anterior margin side to remain in the red zone and not to perforate the meniscus in the avascular zone to avoid secondary lesions caused by the "cheese wire" effect of the sutures in the white zone.
This technique has allowed us to reduce our percentage of secondary meniscectomy after ramp lesion repair from 25% using a standard arthroscopic exploration and meniscal repair technique through the anterior portal to 11.3% using a arthroscopic exploration and repair technique through the posteromedial portal at 4 years of follow-up.
DISCUSSION/CONCLUSION: Systematic use of the transnotch vision and repair through the posteromedial portal are recommended for the management of these lesions, which demonstrate serious mechanical and clinical consequences.
斜坡状损伤是内侧半月板后角半月板-关节囊复合体的纵向损伤。这些损伤难以识别、诊断困难，需要进行特定的关节镜探查。斜坡状损伤通常与前交叉韧带断裂相关，并且由于会导致胫骨前移和外旋增加而具有重要的生物力学影响。通过后内侧入路进行缝线钩修复是安全的，且愈合率高。
斜坡状损伤很少能自发愈合，对于所有累及半月板-胫骨韧带的损伤均需进行修复。选择在直视下进行垂直缝合的后内侧修复技术可恢复半月板-胫骨韧带的连续性，并使这些损伤有效愈合。
使用经髁间切迹技术对后内侧间室进行系统可视化的标准化关节镜探查是诊断这些损伤的关键。在安全建立后内侧入路之前，如有疑问（隐匿性损伤），可使用透照法和针头，用针尖触诊损伤部位。通过经髁间切迹视野并通过后内侧入路插入器械，在直视下用刨刀进行清创，用钩子修复损伤。进行垂直修复时，需注意使钩子穿过半月板-胫骨韧带，方法是穿透斜坡状损伤的关节囊部分和前部的深层。同样，建议在前缘侧不要抓取过多的半月板组织，以使其保留在红区，并且不要在无血管区穿透半月板，以避免因白色区缝线的“奶酪丝”效应导致继发性损伤。
该技术使我们在斜坡状损伤修复后二次半月板切除术的比例从使用标准关节镜探查和通过前入路进行半月板修复技术时的25%，降至使用后内侧入路关节镜探查和修复技术在4年随访时的11.3%。
讨论/结论：对于这些具有严重力学和临床后果的损伤，建议系统使用经髁间切迹视野并通过后内侧入路进行修复。
