1. Combined Anatomic Reconstruction of the Anterior Cruciate and Anterolateral Ligaments Using Hamstring Graft Through a Single Femoral Tunnel and With a Single Femoral Fixation 
Assem “Mohamed Noureldin” Zein, M.D., Mohamed Ali, M.D., Hesham Ali, M.D., Ahmed Nady Saleh Elsaid, M.D., Alaa Zenhom Mahmoud, M.D., Mohamed K. Osman, M.D., Amr Mohamed Mohamed Soliman, M.D. 
Arthroscopy Techniques 
Volume 6, Issue 3, Pages e567-e577 (June 2017)
DOI: /j.eats
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

2. Fig 1
Surgical landmarks. (A) Lateral image of the right knee with the patient in the supine position showing the landmarks for ALL reconstruction. The dotted red line represents the course of the ALL; the blue line represents the joint line. (B) Front image of the right knee with the patient in supine position showing the landmarks for the arthroscopic portals. (AAM, accessory anteromedial portal; ALL, anterolateral ligament; FH, fibular head; GT, Gerdy's tubercle; HAL, high anterolateral portal; HAM, high anteromedial portal; LFE, lateral femoral epicondyle; TT, tibial tuberosity.)
Arthroscopy Techniques 2017 6, e567-e577DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

3. Fig 2
Steps of hamstring graft harvesting and preparation from the right leg; the patient is in the supine position. (A) Semitendinosus and gracilis tendons are identified and harvested with an open striper (red arrow) through a small incision in the proximal tibia. (B) The 2 tendons are released from their proximal attachment. (C) The length of the 2 tendons is measured. (D) The diameter is measured. (Lt, left; Rt, right.)
Arthroscopy Techniques 2017 6, e567-e577DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

4. Fig 3
Knee position and arthroscopic landmarks for femoral and tibial tunnel position. (A) Image of the right knee with the leg hanging off the table and the foot supported by the surgeon's knee while viewing through the HAL portal with the standard tibial guide in the accessory anteromedial portal. (B) Arthroscopic view of the right knee showing the tip of the standard ACL tibial guide in the anatomic tibial footprint of the ACL while viewing through the HAL portal. (C) Arthroscopic view of the right knee while viewing through the HAL portal showing the tip of the tibial guide pin in the anatomic tibial footprint of the ACL in line with the posterior border of the anterior horn lateral meniscus (AHLM). (D) Image of the right knee of the patient in the supine position with the knee flexed at 90° and the foot resting on the table while viewing through the high anteromedial portal showing the medial wall of the lateral femoral condyle. (E) Arthroscopic view of the right knee while viewing through the high anteromedial portal showing the medial wall of the lateral femoral condyle. The red line represents the Resident ridge, the yellow line represents the Cruciate ridge, and the yellow star represents the anatomic ACL femoral attachment. (F) Arthroscopic view of the right knee while viewing through the high anteromedial portal showing the medial wall of the lateral femoral condyle with the radiofrequency marking the femoral anatomic point of the ACL. (ACL, anterior cruciate ligament; HAL, high anterolateral portal; HAMP, high anteromedial portal; LFC, lateral femoral condyle; MFC, medial femoral condyle; PCL, posterior cruciate ligament; RF, radiofrequency; Rt, right.)
Arthroscopy Techniques 2017 6, e567-e577DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

5. Fig 4
Knee position while localizing the femoral anatomic point of the anterolateral ligament (ALL) on the lateral wall of the lateral femoral condyle. (A) Image of the right (Rt) knee with the patient in the supine position, the knee flexed at 90°, and the foot resting on the table; skin and iliotibial band (ITB) are incised down to bone. Skin incision is centered over the previously determined skin landmark for the femoral anatomic point of the ALL on the lateral wall of the lateral femoral condyle (red arrow). (B) Image of the right knee with the patient in the supine position, the knee flexed at 90°, and the foot resting on the table; the femoral ALL landmark can be marked on the bone proximal and posterior to the lateral femoral epicondyle (LFE) with an electric cautery after incising the skin and ITB down to bone.
Arthroscopy Techniques 2017 6, e567-e577DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

6. Fig 5
Steps of outside-in ACL femoral tunnel creation. (A) Top view of the right knee, with the patient in the supine position, the knee flexed at 90°, and the foot resting on the table; the arthroscope is introduced through the high anteromedial portal (HAMP) and the tip of the standard ACL tibial guide inserted through the high anterolateral portal while its sheath rests on the lateral femoral cortex. (B) Arthroscopic view of the right knee showing the tip of the standard ACL tibial guide in the anatomic femoral footprint of the ACL while viewing through the HAMP. (C) Lateral view of the right knee, with the patient in the supine position, the knee flexed at 90°, and the foot resting on the table with outside-in drilling of the femoral guide pin. (D) Lateral view of the right knee, with the patient in the supine position, the knee flexed at 90°, and the foot resting on the table with outside-in drilling of the femoral tunnel with a drill bit of the same graft size. (E, F) Top and arthroscopic views of the same right knee showing curette protection while creating the femoral tunnel while viewing through the HAMP. (ACL, anterior cruciate ligament; LFC, lateral femoral condyle; PCL, posterior cruciate ligament; Rt, right.)
Arthroscopy Techniques 2017 6, e567-e577DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

7. Fig 6
Arthroscopic views for clearing of the femoral tunnel and creation of the tibial tunnel. (A) Arthroscopic view of the right knee while viewing through the high anteromedial portal with the shaver introduced from outside into the femoral tunnel to clear it from bone debris. (B) Arthroscopic view of the right knee while viewing through the high anterolateral (HAL) portal with a curette introduced through the accessory anteromedial portal over the tibial guide pin for protection while creating the tibial tunnel. (C) Arthroscopic view of the right knee while viewing through the HAL portal with the shaver introduced from outside into the tibial tunnel to clear it from bone debris and soft tissue. (LFC, lateral femoral condyle.)
Arthroscopy Techniques 2017 6, e567-e577DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

8. Fig 7
Wire loop passage and measurement of the required length for ACL and ALL reconstruction. (A) Arthroscopic view of the left knee while viewing through the high anterolateral portal with a probe introduced through the accessory anteromedial portal to pull the wire loop from the posteriorly located femoral tunnel aperture to the more anteriorly located tibial tunnel aperture where it can be easily retrieved with a grasper or a probe. (B) Top view of the left knee showing 2 wire loops retrieved through the tibial tunnel from inside the knee joint. (C) Top view of the left knee showing the first wire loop used to shuttle an Ethibond strand to measure the total length required for ACL and ALL reconstruction; the second wire loop is left in place for later pulling of the graft. (D) Top view of the left knee showing the total length required for ACL and ALL reconstruction (the length between artery forceps 1 and 2). (ACL, anterior cruciate ligament; ALL, anterolateral ligament; LFC, lateral femoral condyle; Lt, left.)
Arthroscopy Techniques 2017 6, e567-e577DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

9. Fig 8
Passage and fixation of the ACL graft. (A-C) Images of the right knee showing a wire loop that is used to shuttle the Ethibond for pulling the graft till the limbs of the U-shaped loop that is used for tibial fixation of the ACL rest on the tibial cortex. (D) Image of the right knee showing outside-in fixation of the ACL with a 25-mm biodegradable screw of the same tunnel size; the screw is inserted in the proximal or anterior half of the tunnel (red arrow). (E) Lateral image of the distal cadaveric right femur showing the site of the femoral tunnel (white circle) and its relation (proximal and posterior) to the lateral femoral epicondyle (LFE). The 2 small blue circles represent the optimal site for screw insertion in the femoral tunnel. The optimal site is the anterior or proximal half of the tunnel. The red lines represent the extra-articular part of the graft that will be used for ALL reconstruction. (F) Arthroscopic view of the right knee while viewing through the high anterolateral portal with a probe assessing the ACL tension. (ACL, anterior cruciate ligament; ALL, anterolateral ligament; LFC, lateral femoral condyle; Rt, right.)
Arthroscopy Techniques 2017 6, e567-e577DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

10. Fig 9
Steps of ALL reconstruction in the right knee with the patient in the supine position and knee flexed at 90°. (A) Evaluation of the length of the extra-articular part of the graft that is used for ALL reconstruction. (B) Routing of the graft under the iliotibial band (ITB). (C) The standard ACL tibial guide used to drill a guide pin for the tibial tunnel of the ALL. (D) The direction of the ALL tibial tunnel is away from the ACL tibial tunnel. (E) A 4.5-mm drill bit is used to create the ALL tibial tunnel all-through. (F) A drill bit of the same graft size is used to widen the ALL tibial tunnel for a depth of approximately 30 mm. (G) ALL graft fixation with an interference screw while traction is applied medially (yellow arrow). (H) A drain is inserted into the graft harvest incision and inside the joint. (I) An ice bag is wrapped around the knee. (ACL, anterior cruciate ligament; ALL, anterolateral ligament; Rt, right.)
Arthroscopy Techniques 2017 6, e567-e577DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

11. Fig 10
(A) Postoperative anteroposterior and (B) lateral radiographs of the right knee showing the U-shaped loop used for ACL tibial fixation resting on the tibial cortex, and the staple and the interference screw used for ALL tibial fixation. (C) Postoperative anteroposterior and (D) lateral radiographs of the right knee of another case showing the U-shaped loop used for ACL tibial fixation resting on the tibial cortex, and an interference screw for ALL tibial fixation (a biodegradable screw can be used). (ACL, anterior cruciate ligament; ALL, anterolateral ligament.)
Arthroscopy Techniques 2017 6, e567-e577DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions