Meniscocapsular ramp lesions in the paediatric knee: A review of diagnosis and surgical management

Table 1 Summary of magnetic resonance imaging findings significantly associated with meniscal ramp lesions in paediatric anterior cruciate ligament injuries, adapted from Nguyen et al[11]

MRI finding	Incidence (ramp vs no ramp), %	P value	Association with ramp lesion
Junctional T2 high/fluid-like signal	77.1 vs 24.0	< 0.001	Strongly associated
Peripheral meniscal irregularity	74.3 vs 38.0	< 0.001	Strongly associated
Meniscocapsular ligament tear	57.1 vs 16.0	< 0.001	Strongly associated
Medial tibial plateau oedema (mid zone)	68.6 vs 46.0	0.04	Associated

Table 2 Arthroscopic classification of ramp lesions by Thaunat et al[31]

Classification	Anatomical description (adapted from Thaunat et al[31])	Stability assessment
Type I	Meniscocapsular detachment, with meniscotibial ligament injury	Stable (meniscus remains reduced)
Type II	Partial superior tear of the PHMM with meniscotibial ligament injury	Stable (meniscus remains reduced)
Type III	Partial inferior tear of the PHMM with meniscotibial ligament injury. Also referred to as the hidden lesion as it may not be visualised by standard Gilquist view	Unstable on probing
Type IV	Complete tear of the PHMM with meniscotibial ligament injury	Unstable on probing
Type V	Complete double tear with meniscotibial ligament injury	Unstable (gross displacement)

PHMM: Posterior horn of the medial meniscus.

Table 3 Comparison of all-inside and inside-out ramp repair techniques

Techniques	All-inside[38,39]	Inside-out[40]
Advantages	Less invasive, no posterior incision required, potentially faster surgical time	Allows for multiple sutures, more precisely placed sutures, in either vertical or oblique mattress patterns, providing superior compression. Lower risk of iatrogenic meniscal damage from smaller needles
Disadvantages	Device size may be cumbersome in smaller paediatric knees	Requires a separate posteromedial incision and carries a higher risk of injury to the saphenous nerve
	Larger needle bores can cause a “cheese-wire” effect on the meniscus, although no evidence in literature details this; effects may be amplified in the softer, more vascularized pediatric meniscus. Risk of anchor-related complications (synovitis, chondral damage)
Technical Considerations	Requires knee flexion and valgus force to open the medial compartment	Careful posteromedial portal creation with transillumination to identify the saphenous vessel (and therefore nerve), and blunt dissection/introduction
	Precise needle depth control to avoid over-penetration

Table 4 Summary of contemporary research reporting surgical techniques and their outcomes

Ref.	Study design	Number of patients	Repair technique	Follow-up duration	Key findings
Moran et al[1], 2026	Multicenter cohort	124 (paediatric/adolescent)	All-inside/inside-out	5 years	20% re-operation rate, all in the all-inside repair group. Higher articular cartilage injury rate with repair highlights technical difficulty
Bernardini et al[5], 2021	Cohort study	103 (paediatric)	All-inside (FasT-Fix)	24 months	20% prevalence found; all-inside repair reported as effective in children
Malatray et al[6], 2018	Cohort study	56 (paediatric/adolescent)	Suture-based (various)	30 months	23.2% prevalence; 40% of lesions missed without systematic posteromedial exploration