Combined Double Bundle Anterior Cruciate Ligament Reconstruction and Anterolateral Ligament Reconstruction Iñaki Mediavilla, M.D., Ph.D., Mikel Aramberri,

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Combined Double Bundle Anterior Cruciate Ligament Reconstruction and Anterolateral Ligament Reconstruction Iñaki Mediavilla, M.D., Ph.D., Mikel Aramberri, M.D., Ph.D., Giovanni Tiso, M.D., Jorge A. Murillo-González, Ph.D. Arthroscopy Techniques Volume 7, Issue 8, Pages e881-e886 (August 2018) DOI: 10.1016/j.eats.2018.04.011 Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

Fig 1 Diagram of technique performed on a right knee. A double-bundle anterior cruciate ligament reconstruction associated to an ALL reconstruction is developed. The fixation devices have been drawn in black. (ALL, anterolateral ligament; AM, anteromedial; PL, posterolateral.) Arthroscopy Techniques 2018 7, e881-e886DOI: (10.1016/j.eats.2018.04.011) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

Fig 2 Patient positioning: the patient is placed supine on an operative table in the standard arthroscopy position with a lateral post just proximal to the right knee at the level of the padded tourniquet. (LE, lateral epicondyle; GT, Gerdy tubercle; FH, fibula head.) Arthroscopy Techniques 2018 7, e881-e886DOI: (10.1016/j.eats.2018.04.011) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

Fig 3 Drilling tunnels (right knee). (A) Drilling of femoral AM tunnel (blue; gray circle, AM portal; red arrow, drilling direction). (B) Drilling of femoral PL-ALL tunnel (green; red arrow, drilling direction). (C) Drilling of tibial ACL tunnel (purple; red arrow, drilling direction). (D) Drilling of tibial ALL tunnel (light green; red arrow, drilling direction). (ALL, anterolateral ligament; AM, anteromedial; PL, posterolateral.) Arthroscopy Techniques 2018 7, e881-e886DOI: (10.1016/j.eats.2018.04.011) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

Fig 4 (A) Drilling of femoral PL and ALL tunnel (extra-articular view of the right knee): an outside-in femoral guide Maestro (Smith & Nephew) is inserted through the AM portal (black asterisk). The guide sleeve is pushed onto the lateral femoral cortex at the appropriate point marked for optimal ALL isometry (red asterisk). (B) Drilling of femoral PL and ALL tunnel (intra-articular view of the right knee): a guide pin is inserted through the lateral femoral condyle; its tip is located at the footprint area for the PL bundle (blue asterisk). The guide offset preserves a rear wall with respect to the anteromedial tunnel (red asterisk). (ALL, anterolateral ligament; PL, posterolateral.) Arthroscopy Techniques 2018 7, e881-e886DOI: (10.1016/j.eats.2018.04.011) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

Fig 5 Drilling of tibial anterolateral ligament tunnel (extra-articular view of the right knee). A standard tip aimer anterior cruciate ligament tibial guide is used. The guide sleeve is inserted through a skin incision at the midpoint between the Gerdy tubercle and fibular head and 1 cm distal to the joint line (blue asterisk). The tip of the guide is placed in the internal cortex in the entrance to the tibial tunnel (red asterisk). Arthroscopy Techniques 2018 7, e881-e886DOI: (10.1016/j.eats.2018.04.011) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

Fig 6 Graft passage and fixation (right knee). (A) Femoral PL-ALL graft (green) passage and fixation. (black arrow, passage direction; red arrow, fixation direction; red asterisk, PL-ALL fixation screw). (B) AM graft passage and femoral fixation (black arrow, passage direction; red asterisk, AM fixation device). (C) Tibial ACL graft fixation (red arrow, fixation direction; red asterisk, ACL fixation screw). (D) Tibial ALL graft passage and fixation (red arrow, fixation direction; red asterisk tibial ALL fixation screw). (ALL, anterolateral ligament; AM, anteromedial; PL, posterolateral.) Arthroscopy Techniques 2018 7, e881-e886DOI: (10.1016/j.eats.2018.04.011) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions