Minimally Invasive Anterolateral Ligament Reconstruction of the Knee Patrick A. Smith, M.D., Jordan A. Bley, B.A.  Arthroscopy Techniques  Volume 5, Issue 6, Pages e1449-e1455 (December 2016) DOI: 10.1016/j.eats.2016.08.017 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Supine, right knee. Marks are made on the knee after percutaneous palpation by the surgeon. The fibular head (F), Gerdy tubercle (G), lateral epicondyle (LE), and joint line (—) are all marked with methylene blue to direct the incisions and subsequent guide-pin drilling. Arthroscopy Techniques 2016 5, e1449-e1455DOI: (10.1016/j.eats.2016.08.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Left knee—anatomic dissection. The more proximal red pin delineates position of the easily palpable lateral intermuscular septum. Just distal to this landmark is the easily palpable lateral gastrocnemius tubercle. Arthroscopy Techniques 2016 5, e1449-e1455DOI: (10.1016/j.eats.2016.08.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Supine, right knee. Through small incisions, guide pins are drilled into the femur and tibia to direct graft placement. The tibial guide pin is drilled midway between the fibular head and the Gerdy tubercle approximately 1.5 cm below the lateral joint line. The femoral guide pin is drilled proximal and posterior to the lateral epicondyle at the palpable gastrocnemius tubercle—a landmark distal to the lateral intermuscular septum. Optimal guide pin placement will result in length changes of 3-4 mm as the knee is extended. Arthroscopy Techniques 2016 5, e1449-e1455DOI: (10.1016/j.eats.2016.08.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 Left knee—anatomic dissection. The previously described landmarks of the lateral intermuscular septum and lateral gastrocnemius tubercle are marked by the red pins. The femoral attachment of the lateral collateral ligament (LCL) is marked by the green pin. The native anterolateral ligament (ALL) femoral attachment is marked by the blue pin and the lateral epicondyle by the white pin. There is good clearance from the lateral gastrocnemius tubercle to the LCL femoral attachment. Also, note that the lateral gastrocnemius tubercle landmark is just proximal to the native ALL attachment point. Arthroscopy Techniques 2016 5, e1449-e1455DOI: (10.1016/j.eats.2016.08.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Supine, right knee. Isometry is assessed by passing a suture along the same path as the graft deep to the iliotibial band from the femoral side to the tibial side. The knee is then moved from flexion to full hyperextension. If the length change is not in the 3-4 mm range, the femoral pin should be moved further posteriorly, as usually the tibial position is accurate because of the more reliable tibial insertion of the anterolateral ligament based on the easily palpable Gerdy tubercle and fibular head landmarks. Once the correct positioning in located, the suture is removed. Arthroscopy Techniques 2016 5, e1449-e1455DOI: (10.1016/j.eats.2016.08.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 Left knee—anatomic dissection. The femoral guide pin is drilled at the lateral gastrocnemius tubercle landmark (red pin). Note relation of femoral attachment of the native anterolateral ligament (ALL) (blue pin); the lateral collateral ligament (LCL) femoral attachment (green pin); and the lateral epicondyle (white pin). The tibial guide pin is drilled at the native ALL attachment here approximately 1.5 cm below the lateral joint line halfway between the Gerdy tubercle landmark and the center of the fibular head. A suture is wrapped around the femoral pin and clamped at the tibial pin to check isometry, with, again, the expected pattern being nonisometric lengthening of 3-4 mm in extension. Arthroscopy Techniques 2016 5, e1449-e1455DOI: (10.1016/j.eats.2016.08.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 Supine, right knee. The anterolateral graft is secured on the femur with a 4.75-mm BioComposite SwiveLock anchor (Arthrex). The location proximal and posterior to the lateral epicondyle centered at the lateral gastrocnemius tubercle avoids the risk of iatrogenic injury to the lateral collateral ligament during drilling and fixation. (ALL, anterolateral ligament.) Arthroscopy Techniques 2016 5, e1449-e1455DOI: (10.1016/j.eats.2016.08.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 Supine, right knee. The anterolateral graft is fixated on the tibia while the knee is in hyperextension with a 7.0-mm BioComposite Forked SwiveLock anchor (Arthrex). The graft is secured at the anatomic location of the anterolateral ligament (ALL) midway between the fibular head and the Gerdy tubercle. Arthroscopy Techniques 2016 5, e1449-e1455DOI: (10.1016/j.eats.2016.08.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 Left knee—anatomic dissection. Final anterolateral ligament (ALL) graft position is seen clearly posterior and proximal to the lateral epicondyle (white pin). Other pertinent lateral landmarks are the lateral intermuscular septum (most proximal red pin), the lateral gastrocnemius tubercle as the landmark for the femoral graft attachment site (more distal red pin), the native ALL attachment site (blue pin), and finally the lateral collateral ligament (LCL) femoral attachment site (green pin). The tibial graft attachment is halfway between the Gerdy tubercle and the center of the fibular head. Final graft position potentially duplicates path of both the native ALL and the capsulo-osseous fibers of the iliotibial band (deep to retractor). Arthroscopy Techniques 2016 5, e1449-e1455DOI: (10.1016/j.eats.2016.08.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions