Age and chronic ACL injury are associated with reduced ramp-region vascularity during ACL reconstruction

To evaluate arthroscopic vascularity of the medial meniscus ramp region during anterior cruciate ligament (ACL) reconstruction and to identify factors associated with reduced ramp-region vascularity.

This retrospective cohort study reviewed consecutive patients who underwent primary ACL reconstruction between January 2020 and January 2026. Ramp-region vascularity was assessed arthroscopically using a transcondylar view from the anterolateral portal and dichotomized as adequate versus not adequate based on visible synovial vessels and hyperemia, without inducing iatrogenic bleeding. Chronic ACL injury was defined as surgery performed ≥12 months after injury. Univariate comparisons were performed, followed by Bayesian information criterion (BIC)-based multivariable logistic regression analysis to identify independent factors associated with reduced ramp-region vascularity.

A total of 192 patients were screened, and 126 patients were included for analysis. Ramp-region vascularity was adequate in 74 patients and not adequate in 52 patients. Patients with reduced vascularity were significantly older than those with adequate vascularity (47.0 ± 17.5 vs 30.6 ± 17.0 years, P < 0.001), and chronic injury was more common in the reduced vascularity group (29/52 vs 12/74, P < 0.001). In multivariable analysis, older age was independently associated with reduced vascularity (odds ratio [OR], 1.04 per year; 95% confidence interval [CI], 1.01-1.07; P = 0.004). Chronic injury (not chronic vs chronic: OR, 0.273; 95% CI, 0.094-0.790; P = 0.017), arthroscopically visible ramp lesions (OR, 0.170; 95% CI, 0.058-0.494; P = 0.001), and preoperative Lysholm score (OR, 1.03; 95% CI, 1.01-1.06; P = 0.010) were also retained in the final model.

Reduced ramp-region vascularity during ACL reconstruction was independently associated with older age and chronic ACL injury. Patient age and injury chronicity may help identify knees with a biologically unfavorable ramp environment.