Clinical Outcomes After Medial Meniscal Ramp Lesion Repair and Anterior Cruciate Ligament Reconstruction in Pediatric and Adolescent Patients: A Multicenter Study With a Mean Follow-up of 5 Years.

Background: Medial meniscal ramp lesions (MMRLs) can occur in up to 28% of pediatric patients at the time of anterior cruciate ligament (ACL) reconstruction (ACLR). However, limited studies have examined the outcomes after combined MMRL repair and ACLR in this at-risk patient population. Purpose: To evaluate the mid-term clinical outcomes after MMRL repair and ACLR in pediatric and adolescent patients and investigate possible risk factors for a secondary medial meniscal surgery. Study Design: Case series, Level of evidence, 4. Methods: Patients <18 years old who underwent MMRL repair during primary ACLR between 2015 and 2022 at 5 institutions with a minimum of 2-year follow-up were included. MMRLs were defined as an arthroscopically diagnosed partial or complete peripheral vertical/longitudinal tear of the posterior horn of the medial meniscus at/or within 3 mm of the meniscocapsular junction that underwent repair at the time of ACLR. Postoperative outcome measures included subjective International Knee Documentation Committee (IKDC) scores, return to sport (RTS), patient satisfaction, complications, rate of secondary medial meniscal surgery, and other reoperations. Descriptive statistics were used to report the demographic characteristics, operative findings, and postoperative outcomes for the cohort. Risk factors were assessed for a secondary medial meniscal surgery. Results: A total of 54 patients who underwent MMRL repair during primary ACLR at a mean age of 16.1 years (range, 12.4-17.9 years) were included in this study. Most patients reported a sports-related injury (82%), with 52% occuring during American football or basketball participation. At the time of surgery, 50% of patients demonstrated a high-grade pivot-shift (grade 2 or 3) examination under anesthesia, and 59% were arthroscopically diagnosed with a concomitant lateral meniscal tear. A total of 48 MMRL repairs (89%) were performed using all-inside techniques, while 5 (11%) were performed using inside-out techniques, and only 3 (6%) patients underwent a concomitant lateral extra-articular procedure. The mean follow-up was 60 months (range, 24-118 months). Postoperatively, 11 (20%) patients underwent a secondary medial meniscal surgery at a mean of 14 months (range, 6-28 months) after the index procedure. All 11 patients were initially treated with all-inside MMRL repairs, and were arthroscopically diagnosed with a tear involving or extending into the initial repair site at the time of revision surgery. The majority of retears were complex morphologies that occurred in the setting of an intact ACL graft and were the result of acute trauma within the first 2 postoperative years. Six (55%) were treated with a medial partial meniscectomy, while 5 (45%) underwent revision repair. No significant risk factors were associated with the presence of a secondary medial meniscal surgery. Overall, the cohort demonstrated a mean IKDC score of 88 ± 12 (range, 41-100), and for those who wished to RTS, an RTS rate of 76%. Conclusion: In this multicenter cohort of pediatric and adolescent patients who underwent MMRL repair during primary ACLR, with a mean follow-up of 5 years, the rate of secondary medial meniscal surgery was 20%. Overall, while the subjective patient-reported outcome measures were cautiously reassuring, larger studies are needed to better understand the modifiable risk factors for MMRL repair failure after ACLR in pediatric patients.