Articular Cartilage Injuries in Pediatric and Adolescent Patients Undergoing Medial Meniscal Ramp Lesion Repair During Primary Anterior Cruciate Ligament Reconstruction: A Multicenter Study

Background: In young patients with anterior cruciate ligament (ACL) tears, the presence of a meniscal tear may be associated with articular cartilage damage. However, little is known about this potential association of ACL tears with medial meniscal ramp lesions (MMRLs) in pediatric and adolescent patients. Purpose: To investigate the characteristics and risk factors associated with the presence of an articular cartilage injury in a large multicenter cohort of pediatric and adolescent patients undergoing MMRL repair during primary ACL reconstruction (ACLR). Study Design: Retrospective cohort study; Level of evidence, 3. Methods: Patients aged <18 years who underwent MMRL repair during primary ACLR at 5 institutions between 2013 and 2025 were included. All MMRLs were diagnosed arthroscopically and were defined as partial or complete peripheral vertical/longitudinal tears of the posterior horn of the medial meniscus at or within 3 mm of the meniscocapsular junction in the red-red zone. The presence, location, and severity of arthroscopically identified articular cartilage injuries were categorized using the International Cartilage Repair Society classification. Patients with and without an articular cartilage injury were compared, and risk factors associated with its presence were identified using a multivariable logistic regression model. Results: A total of 189 pediatric and adolescent patients underwent MMRL repair during primary ACLR at a mean age of 16.1 ± 1.4 years (range, 12.0-17.9 years). An articular cartilage injury was identified arthroscopically in 101 patients (53%). Among these, 62% were localized to the medial femoral condyle (MFC), with most injuries classified as grade 1 (57%), followed by grade 2 (30%) and grade 3 (13%). Medial tibiofemoral (MFC and/or medial tibial plateau) articular cartilage injuries were significantly more frequent (62% vs 46%, respectively; P = .043) and of a higher grade ( P = .046) than lateral tibiofemoral (lateral femoral condyle and/or lateral tibial plateau) articular cartilage injuries. Obesity (odds ratio [OR], 3.0 [95% CI, 1.3-7.2]; P = .011), a lateral posterior tibial slope ≥12° (OR, 2.9 [95% CI, 1.4-5.8]; P = .003), delayed ACLR and MMRL repair for ≥3 months (OR, 2.4 [95% CI, 1.2-4.8]; P = .016), and age ≥16 years (OR, 2.1 [95% CI, 1.1-3.9]; P = .029) were significant risk factors for the presence of an articular cartilage injury at the time of surgery. Conclusion: In this multicenter study, an articular cartilage injury was arthroscopically identified in 53% of pediatric and adolescent patients undergoing MMRL repair during primary ACLR. The medial tibiofemoral compartment was most frequently affected, with the majority of articular cartilage injuries classified as grade 1 or 2 on the MFC. Obesity, a lateral posterior tibial slope ≥12°, delayed ACLR and MMRL repair for ≥3 months, and age ≥16 years were associated with a 2- to 3-fold increase in the odds of having an articular cartilage injury at the time of surgery. These findings underscore the importance of early diagnoses and timely surgical interventions in high-risk patients. Further research is warranted to evaluate the long-term clinical outcomes associated with articular cartilage injuries in this population.