Step-by-Step Arthroscopic Assessment of the Anterolateral Ligament of the Knee Using Anatomic Landmarks  Assem “Mohamed Nour Eldin” Zein, M.D.  Arthroscopy Techniques  Volume 4, Issue 6, Pages e825-e831 (December 2015) DOI: 10.1016/j.eats.2015.08.002 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Intraoperative photographs and arthroscopic images of a patient in the supine position with a tourniquet applied to the thigh of his left lower limb. (A) The surgeon applies a varus force (arrow) to the left lower leg to open the lateral compartment. The arthroscope is introduced in the lateral compartment through the high anterolateral portal (viewing portal). The arthroscopic view shows the opened lateral compartment of the left knee in the same patient. (B) The limb is positioned in the figure-of-4 position. The lateral border of the foot is placed on the opposite leg, and a varus force is applied to the distal thigh by an assistant. The arthroscope is introduced into the lateral gutter through the anterolateral portal (viewing portal). The arthroscopic view shows the anatomic landmarks between the lateral femoral condyle and the lateral border of the lateral meniscus. The synovial bulge is present anterior to the bare area of the LM and anterior to the popliteus tendon (PT), with space between them. (FC, lateral femoral condyle; LM, lateral meniscus; LTP, lateral tibial plateau.) Arthroscopy Techniques 2015 4, e825-e831DOI: (10.1016/j.eats.2015.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Arrangement of the 3 lateral structures—popliteus tendon (PT), anterolateral ligament (ALL), and lateral collateral ligament (LCL)—in the lateral gutter. (A-E) Arthroscopic views of the lateral gutter structures when viewed from inside. Panels A-D show the left knee, whereas panel E shows the right knee. The patient is supine; the arthroscope is introduced through a high anterolateral portal while the limb is in the figure-of-4 position. The 3 lateral structures lie in different planes, and their fibers run in different directions, so they can be identified from each other. (F) Diagram of an anterolateral view of the right knee showing the arrangement of the lateral knee structures. Panel F reprinted with permission.3 (FC, femoral condyle.) Arthroscopy Techniques 2015 4, e825-e831DOI: (10.1016/j.eats.2015.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Arthroscopic view of the right knee from a high anterolateral portal. The patient is supine with the limb in the figure-of-4 position. Pulling with a probe on the bare area (arrow) of the lateral meniscus (LM) through the standard anteromedial portal can help to identify the anterolateral ligament (ALL). (FC, femoral condyle; PT, popliteus tendon.) Arthroscopy Techniques 2015 4, e825-e831DOI: (10.1016/j.eats.2015.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 The intraoperative photograph shows a top view of a patient in the supine position with the right lower limb in the figure-of-4 position. The surgeon stands on the right side of the patient with the assistant applying a varus force to the distal thigh to open the lateral compartment. The arthroscope is introduced through a high anterolateral portal. Internal rotation of the tibia can be applied by another assistant or by the surgeon. The arthroscopic views show a lax anterolateral ligament (ALL) and a tightened ALL with internal rotation of the tibia in the same patient. (AM, anteromedial; FC, femoral condyle; LM, lateral meniscus; PT, popliteus tendon.) Arthroscopy Techniques 2015 4, e825-e831DOI: (10.1016/j.eats.2015.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 (A) Intraoperative photograph of a patient in the supine position with a tourniquet applied to the thigh of his left lower limb. An assistant applies a varus force to the left lower thigh to open the lateral compartment. The arthroscope is introduced in the lateral gutter through a high anterolateral portal (viewing portal). A direct portal can be created under direct vision of the anterolateral ligament (ALL) by using an 18-gauge needle and transillumination. (B) Arthroscopic view of the same patient showing the needle used to properly locate the direct portal on the lateral gutter structures. (C) Arthroscopic view of the same patient showing assessment of the proximal part of the ALL through the direct portal. (FC, femoral condyle; LM, lateral meniscus; PT, popliteus tendon.) Arthroscopy Techniques 2015 4, e825-e831DOI: (10.1016/j.eats.2015.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 (A) Arthroscopic view of the left knee from the anterolateral portal. The patient is supine, and the limb is in the figure-of-4 position. A probe is used through the standard anteromedial portal to elevate the lateral meniscus (LM). (B) Arthroscopic view of the same patient showing the popliteus tendon (PT) in the popliteal hiatus under the lateral meniscus. The popliteus tendon serves as a landmark to identify the tibial attachment of the anterolateral ligament. (C) Arthroscopic view of the same patient with probing of the capsule and the reinforcing anterolateral ligament (star) anterior to the popliteus tendon, as well as inspection of the lateral recess. (D) Arthroscopic view of the same patient showing tightness of the capsule and reinforcing anterolateral ligament (ALL) with tibial internal rotation. (TP, tibial plateau.) Arthroscopy Techniques 2015 4, e825-e831DOI: (10.1016/j.eats.2015.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 (A) Superior view of the tibial plateau of the left knee of a cadaveric specimen showing the course of the anterolateral ligament (asterisk) arising from the lateral femoral condyle (LFC) and inserting into the lateral meniscus (LM) and showing its relation with the popliteus tendon (Pop). The lateral tibial plateau (LTP) and medial tibial plateau (MTP) are also shown. Reprinted with permission.3 (B) Inside view of the lateral section of the right knee of a cadaveric specimen showing a triangular image with a distal base formed by the tibia, popliteus tendon (2), and meniscal portion of the anterolateral ligament (1). Reprinted with permission.2 (C) Arthroscopic view of the right knee viewed from a high anterolateral portal with the limb in the figure-of-4 position showing a triangular image with a distal base formed by the tibia, popliteus tendon (PT, 2), and meniscal portion of the anterolateral ligament (ALL, 1). (FC, lateral femoral condyle.) Arthroscopy Techniques 2015 4, e825-e831DOI: (10.1016/j.eats.2015.08.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions