Unusual case of ACL Repair plus Ramp Lesion Repair


Sebastian is an interesting and pretty unique case. He is a 16 year old lad who is an elite motocross cyclist, and he came to see me after and injury when he came off his motocross bike two months earlier, twisting his right knee, rupturing his ACL and also tearing the medial meniscus - sustaining a so-called ramp lesion.

Sebastian is quite unique in my practice because not only could I repair the acl (rather than reconstruct) it, but he also had this "ramp" lesion of the medial meniscus which I was able to stitch up. This is a newly recognised lesion and his repair went well as has his recovery.

Ramp lesion of medial meniscus

This straight-on shot of Sebastian's MRI demonstrates the menisci showing as the dark areas sandwiched between the rounded ends of the femur bone and the flattened ends of the tibia bone. On the right hand side, however, the medial meniscus reveals is a little white area representative of the tear (red circle).

Ramp lesion of medial meniscus

The MRI scan shows the back of the knee, and you can see the vertical ramp tear at the meniscocapsular junction (circled in red).

Sebastian's meniscus looked as though it would be reparable and he underwent his surgery in October 2017. The ramp lesion was probed through a posteromedial portal - in other words I had a look using the telescope in the back of the knee and could see quite clearly that he had torn his meniscus.

Then introducing the scope from the front I used some newly-developed products that allow access from the back of the knee to stitch this meniscus up. What we have seen is that this really helps the ACL surgery to be successful, and without addressing this particular problem the ACL surgery will frequently end in failure.I was delighted that I was able to repair both the ACL and the meniscus.

Repair of anterior cruciate ligament

As you will know if you have been reading other posts here, modern ACL repair is also a very new technique and if it is successful it allows patients to get back to normal activities much more quickly than a traditional reconstruction.

Video taken during surgery shows the lassoed stump of the torn ACL being pulled back up into the notch (see stills below).

Meniscus tear
Meniscal ramp repair

The lasso circles and secures the ACL stump while the free ends are pulled up and out at the top of the notch and fixed against the bone of the femur.

ACL repair
post op ACL repair
Post op ACL repair

The two X-rays - from the front and from the side - show the small fixation devices.

He has had very little pain since the time of the surgery and regained a full range of motion in the matter of a few weeks.He is desperately keen to get back to his motocross but I have asked him to hold off until February 2018.I am delighted with how well his ACL and ramp lesion has proceeded up to now.


1. Meniscal Ramp Lesions

Sebastian says -

"I damaged my knee in July 2017 and having waited for ages for the NHS to sort it out (still waiting for an appointment actually), my parents made an appointment with Professor Wilson. Following diagnostics and a consultation I was told I had ruptured the ACL and damaged the meniscus. I compete at national level in my sport so this news was devastating, I was given two choices: a standard operation which uses part of the hamstring to re-construct the ACL, rehab 9-12 months or try a relatively new procedure - 'autograft anterior cruciate ligament reconstruction' using a nylon cord, rehab 4 months. We went for the latter on 03.10.17 as I needed to be back to full recovery by the start of the season in March 2018.
"The operation was successful, I had little swelling and bruising and recovery time has been fast, I am now back to full function, skipping, running, downhill mountain biking etc no problems at all. I will be back competing for the beginning of the season in March as promised.
I believe I am the youngest person to have this operation along with the meniscectomy so wanted to share my experience.
"Thanks to Professor Wilson for his advise and expertise, without him I would not be doing what I love to do, can't recommend him & his team enough!!"

adrian wilson

Adrian Wilson

The 'ramp' is is where the posterior third of the medial meniscus is anchored to the capsule at the very back of the knee. A tear here has been called the 'hidden lesion' because up until recently it has been a part of the meniscus that we haven't been assessing in the way that we should.

Romain Seil was the first surgeon to properly describe the ramp lesion and Bertrand Sonnery-Cottet and other French surgeons then popularised repairing this. Because of my close ties to both Romain and Bertrand I've seen first hand this lesion being dealt with and again it's very interesting how travelling the world and meeting these ever-pioneering surgeons teaches you so much about your own practice.

menisco-capsular tear

This illustration shows a meniscocapsular tear on the medial side of the knee. A ramp lesion is a tear involving the meniscocapsular area at the back of the meniscus behind these rounded condyles of the femur bone.

These three images below show the repair of the ramp lesion -


In this first image you can see the sharp tip of the knife (top right) creating the postero-medial portal and enabling access to the ramp lesion

Meniscal ramp repair

The second and third image show the ramp lesion sutured.

Meniscal ramp repair

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1 comment
Samuel Pegram says January 18, 2018

Only MRI Scans can confirm whether the surgery will be helpful or not. In this case, the knee seems to have developed a more severe internal fracture. This could not be treated without conducting a surgery.

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