All-Inside versus Inside-Out Repair of Meniscal Ramp Lesions in Anterior Cruciate Ligament Reconstruction: A Prospective Comparative Study of Functional Outcomes

Abstract

Introduction: Meniscal ramp lesions are tears at the meniscocapsular junction of the posterior horn of the medial meniscus, occurring in 9–24% of patients with anterior cruciate ligament (ACL) injuries. These lesions are frequently missed on standard pre-operative magnetic resonance imaging (MRI), contributing to residual knee instability and increased graft failure rates. Two principal repair techniques exist: All-inside fixation using suture-based implants, and the inside-out technique using zone-specific cannulas. Comparative functional outcome data between these techniques are lacking, particularly from the Indian subcontinent. Materials and Methods: A prospective comparative study of 83 patients (mean age 28 ± 6.2 years; 68–72% male) undergoing arthroscopic ACL reconstruction at atertiary care center in Chennai from June 2021 to June 2025. A posteromedial portal was established in all cases. Patients with confirmed ramp lesions (n = 17) underwent repair by all-inside technique (Group A, n = 11) or inside-out technique (Group B, n = 6). Lysholm knee score, International Knee Documentation Committee (IKDC) subjective knee form, and Visual Analog Scale (VAS) for pain were recorded at baseline, 3, 6, and 12 months.
Statistical analysis used repeated-measures analysis of variance with Bonferroni correction. Results: Ramp lesions were identified in 17 of 83 patients (20.5%); pre-operative MRI missed 8 (47.1% missed diagnosis rate). Both groups showed significant improvement in all outcomes at 12 months (P < 0.001). Lysholm at 12 months: Group A 85.3 ± 6.8 versus Group B 83.7 ± 7.4 (P = 0.62). IKDC: 76.4 ± 7.1 versus 74.9 ± 8.2 (P = 0.68). VAS pain: 14.2 ±
8.1 mm versus 15.8 ± 9.3 mm (P = 0.71). No between-group differences were statistically significant. Operative time was significantly shorter in Group A (68.4 vs. 84.7 min, P = 0.02). Discussion: Both techniques produced
equivalent functional improvement exceeding minimum clinically important difference thresholds. All-inside repair demonstrated advantages in operative time and avoidance of a counter-incision. A notable finding was road traffic accident-dominant injury mechanism (62–70%), contrasting with sports-injury-dominant international series (76–82%). Conclusion: All-inside and inside-out repair techniques yield equivalent and clinically meaningful functional outcomes at 12 months. All-inside repair is recommended for Grade I-II lesions; inside-out repair for Grade III tears. Mandatory posteromedial portal assessment is recommended in all ACL reconstructions.