High Sensitivity with High False Positive Rate in MRI for Detection of Ramp Lesions Associated with ACL Rupture
DOI:
https://doi.org/10.63403/re.v32i1.374Keywords:
Knee, Arthroscopy, Ramp Lesion, Magnetic Resonance ImagingAbstract
Introduction: Meniscal ramp lesions are present in up to 24% of ACL injuries. MRI is considered unreliable as a diagnostic method with a sensitivity between 48% and 71%.
Purpose: to retrospectively determine the sensitivity and specificity of MRI in the preoperative detection of ramp lesions in patients undergoing ACL reconstruction (ACLR), comparing groups with and without arthroscopic confirmation.
Materials and methods: retrospective, comparative cohort study. Patients operated on between December 2018-2019 were included. A fellowship-trained knee surgeon blindly compared the preoperative images and the MRI reports of a group of patients with an arthroscopically confirmed ramp lesion (group 1) with a matched group without said lesion (group 2). The following variables were recorded: presence of a ramp lesion, medial meniscus injury, presence of bone bruising, and lateral meniscus injury. Sensitivity, specificity and logistic regression analysis were performed. A p <0.05 was established as significant.
Results: a total of 281 ACLR were performed, 33 patients formed group 1 and 39, group 2. The 72 MRIs were analyzed, together with 56 reports. A ramp lesion was found in 81% of patients in group 1, and in 21% of group 2 (false positives). Statistically significant results included: detecting the ramp lesion on MRI (p<0.001), presence of a lateral meniscus injury (p=0.03), and a reported medial meniscal lesion (p=0.002). MRI showed a sensitivity of 81% (CI 65-93%) and a sensitivity of 79% (CI 64-91%).
Conclusion: MRI has high sensitivity (82%) and moderate specificity (79%) for the detection of ramp lesions of the internal meniscus in patients undergoing ACL reconstruction, with an incidence of 11%. Patients with an external meniscus lesion were 5 times more likely to present a ramp lesion. A correct MRI analysis is indispensable for the detection and adequate preoperative planning of ramp lesions.
Level of evidence: Level IV, therapeutic case series
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Sonnery-Cottet B, Conteduca J, Thaunat M, Gunepin FX, Seil R. Hidden lesions of the posterior horn of the medial meniscus: a systematic arthroscopic exploration of the concealed portion of the knee. Am J Sports Med. 2014 Apr;42(4):921-926. doi: https://www.doi.org/10.1177/0363546514522394.
Borchers JR, Kaeding CC, Pedroza AD, Huston LJ, Spindler KP, Wright RW; MOON Consortium and the MARS Group. Intra-articular findings in primary and revision anterior cruciate ligament reconstruction surgery: a comparison of the MOON and MARS study groups. Am J Sports Med. 2011 Sep;39(9):1889-1893. doi: https://www.doi.org/10.1177/0363546511406871.
Thaunat M, Ingale P, Penet A, Kacem S, Haidar I, Bauwens PH, et al. Ramp lesion subtypes: prevalence, imaging, and arthroscopic findings in 2156 anterior cruciate ligament reconstructions. Am J Sports Med. 2021 Jun;49(7):1813-1821. doi: https://www.doi.org/10.1177/03635465211006103.
Balazs GC, Greditzer HG 4th, Wang D, Marom N, Potter HG, Marx RG, et al. Ramp lesions of the medial meniscus in patients undergoing primary and revision ACL reconstruction: prevalence and risk factors. Orthop J Sports Med. 2019 May 15;7(5):2325967119843509. doi: https://www.doi.org/10.1177/2325967119843509.
Chahla J, Dean CS, Moatshe G, Mitchell JJ, Cram TR, Yacuzzi C, LaPrade RF. Meniscal ramp lesions: anatomy, Incidence, diagnosis, and treatment. Orthop J Sports Med. 2016 Jul 26;4(7):2325967116657815. doi: https://www.doi.org/10.1177/2325967116657815.
Greenaway M, Walton E, Gibson D, Le Roux A, Yates P, Ebert J, et al. Meniscal "ramp" lesions: surgical incidence and the development of magnetic resonance imaging diagnostic criteria. Arthrosc Sports Med Rehabil. 2020 Jun 13;2(4):e309-e314. doi: https://www.doi.org/10.1016/j.asmr.2020.03.003.
Kim SH, Lee SH, Kim KI, Yang JW. Diagnostic accuracy of sequential arthroscopic approach for ramp lesions of the posterior horn of the medial meniscus in anterior cruciate ligament-deficient knee. Arthroscopy. 2018 May;34(5):1582-1589. doi: https://www.doi.org/10.1016/j.arthro.2017.12.008.
DePhillipo NN, Cinque ME, Chahla J, Geeslin AG, Engebretsen L, LaPrade RF. Incidence and detection of meniscal ramp lesions on magnetic resonance imaging in patients with anterior cruciate ligament reconstruction. Am J Sports Med. 2017 Aug;45(10):2233-2237. doi: https://www.doi.org/10.1177/0363546517704426.
Kumar N, Spencer T, Hochman E, Cote M, Arciero R, Edgar C. Is edema at the posterior medial tibial plateau indicative of ramp lesion? an examination of 852 patients with anterior cruciate ligament reconstruction. Orthop J Sports Med. 2018 Jul;6(7 Suppl 4): 2325967118S0013. doi: https://www.doi.org/10.1177/2325967118S00132.
Koo B, Lee SH, Yun SJ, Song JG. Diagnostic performance of magnetic resonance imaging for detecting meniscal ramp lesions in patients with anterior cruciate ligament tears: a systematic review and meta-analysis. Am J Sports Med. 2020 Jul;48(8):2051-2059. doi: https://www.doi.org/10.1177/0363546519880528.
DePhillipo NN, Moatshe G, Chahla J, Aman ZS, Storaci HW, Morris ER, et al. Quantitative and qualitative assessment of the posterior medial meniscus anatomy: defining meniscal ramp lesions. Am J Sports Med. 2019 Feb;47(2):372-378. doi: https://www.doi.org/10.1177/0363546518814258
Bollen SR. Posteromedial meniscocapsular injury associated with rupture of the anterior cruciate ligament: a previously unrecognised association. J Bone Joint Surg Br. 2010 Feb;92(2):222-223. doi: https://www.doi.org/10.1302/0301-620X.92B2.22974.
D'Ambrosi R, Di Maria F, Ursino C, Ursino N, Di Feo F, Formica M, et al. Magnetic resonance imaging shows low sensitivity but good specificity in detecting ramp lesions in children and adolescents with ACL injury: a systematic review. J ISAKOS. 2024 Jun;9(3):371-377. doi: https://www.doi.org/10.1016/j.jisako.2023.12.005.
Liu X, Feng H, Zhang H, Hong L, Wang XS, Zhang J. Arthroscopic prevalence of ramp lesion in 868 patients with anterior cruciate ligament injury. Am J Sports Med. 2011 Apr;39(4):832-837. doi: https://www.doi.org/10.1177/0363546510388933.
Moteshakereh SM, Zarei H, Nosratpour M, Zaker Moshfegh M, Shirvani P, Mirahmadi A, et al. Evaluating the diagnostic performance of MRI for identification of meniscal ramp lesions in ACL-deficient knees: a systematic review and meta-analysis. J Bone Joint Surg Am. 2024 Jun 19;106(12):1117-1127. doi: https://www.doi.org/10.2106/JBJS.23.00501.
Peltier A, Lording T, Maubisson L, Ballis R, Neyret P, Lustig S. The role of the meniscotibial ligament in posteromedial rotational knee stability. Knee Surg Sports Traumatol Arthrosc. 2015 Oct;23(10):2967-2973. doi: https://www.doi.org/10.1007/s00167-015-3751-0.
Stephen JM, Halewood C, Kittl C, Bollen SR, Williams A, Amis AA. Posteromedial meniscocapsular lesions increase tibiofemoral joint laxity with anterior cruciate ligament deficiency, and their repair reduces laxity. Am J Sports Med. 2016 Feb;44(2):400-408. doi: https://www.doi.org/10.1177/0363546515617454.
DePhillipo NN, Moatshe G, Brady A, Chahla J, Aman ZS, Dornan GJ, et al. Effect of meniscocapsular and meniscotibial lesions in ACL-deficient and ACL-reconstructed knees: a biomechanical study. Am J Sports Med. 2018 Aug;46(10):2422-2431. doi: https://www.doi.org/10.1177/0363546518774315.
Ahn JH, Bae TS, Kang KS, Kang SY, Lee SH. Longitudinal tear of the medial meniscus posterior horn in the anterior cruciate ligament-deficient knee significantly influences anterior stability. Am J Sports Med. 2011 Oct;39(10):2187-2193. doi: https://www.doi.org/10.1177/0363546511416597.
DePhillipo NN, Engebretsen L, LaPrade RF. Current trends among us surgeons in the identification, treatment, and time of repair for medial meniscal ramp lesions at the time of ACL surgery. Orthop J Sports Med. 2019 Feb 22;7(2):2325967119827267. doi: https://www.doi.org/10.1177/2325967119827267.
Arner JW, Herbst E, Burnham JM, Soni A, Naendrup JH, Popchak A, et al. MRI can accurately detect meniscal ramp lesions of the knee. Knee Surg Sports Traumatol Arthrosc. 2017 Dec;25(12):3955-3960. doi: https://www.doi.org/10.1007/s00167-017-4523-9.
Yeo Y, Ahn JM, Kim H, Kang Y, Lee E, Lee JW, et al. MR evaluation of the meniscal ramp lesion in patients with anterior cruciate ligament tear. Skeletal Radiol. 2018 Dec;47(12):1683-1689. doi: https://www.doi.org/10.1007/s00256-018-3007-4.
Hatayama K, Terauchi M, Saito K, Aoki J, Nonaka S, Higuchi H. Magnetic resonance imaging diagnosis of medial meniscal ramp lesions in patients with anterior cruciate ligament injuries. Arthroscopy. 2018 May;34(5):1631-1637. doi: https://www.doi.org/10.1016/j.arthro.2017.12.022.
Hash TW 2nd.Magnetic resonance imaging of the knee. Sports Health. 2013 Jan;5(1):78-107. doi: https://www.doi.org/10.1177/1941738112468416.
Kim SH, Seo HJ, Seo DW, Kim KI, Lee SH. Analysis of risk factors for ramp lesions associated with anterior cruciate ligament injury. Am J Sports Med. 2020 Jun;48(7):1673-1681. doi: https://www.doi.org/10.1177/0363546520918207.
Malatray M, Raux S, Peltier A, Pfirrmann C, Seil R, Chotel F. 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 Apr;26(4):1074-1079. doi: https://www.doi.org/10.1007/s00167-017-4471-4.
Kunze KN, Wright-Chisem J, Polce EM, DePhillipo NN, LaPrade RF, Chahla J. Risk factors for ramp lesions of the medial meniscus: a systematic review and meta-analysis. Am J Sports Med. 2021 Nov;49(13):3749-3757. doi: https://www.doi.org/10.1177/0363546520986817.
Sonnery-Cottet B, Praz C, Rosenstiel N, Blakeney WG, Ouanezar H, Kandhari V, et al. 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 Nov;46(13):3189-3197. doi: https://www.doi.org/10.1177/0363546518800717.
Bernholt DL, DePhillipo NN, Crawford MD, Aman ZS, Grantham WJ, LaPrade RF. Incidence of displaced posterolateral tibial plateau and lateral femoral condyle impaction fractures in the setting of primary anterior cruciate ligament tear. Am J Sports Med. 2020 Mar;48(3):545-553. doi: https://www.doi.org/10.1177/0363546519895239.
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Copyright (c) 2025 Tomás D. Gorodischer, Juan P. Zícaro, Carlos H. Yacuzzi, Matías Costa-Paz
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