Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction  Bertrand Sonnery-Cottet, M.D., Matt Daggett, D.O., M.B.A., Camilo Partezani Helito, M.D., Jean-Marie Fayard, M.D., Mathieu Thaunat, M.D.  Arthroscopy Techniques  Volume 5, Issue 6, Pages e1253-e1259 (December 2016) DOI: 10.1016/j.eats.2016.08.003 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 As shown in a right knee (lateral view), 3 stab incisions (blue ovals) are positioned in relation to the 3 bony landmarks for combined anterior cruciate ligament and anterolateral ligament reconstruction. One is placed on the femoral side, slightly proximal and posterior to the lateral epicondyle (LE). Two tibial stab incisions are subsequently positioned 8 mm below the joint line between the Gerdy tubercle (GT) and fibula head (FH). Arthroscopy Techniques 2016 5, e1253-e1259DOI: (10.1016/j.eats.2016.08.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 (A) As shown in a right knee (lateral view), 2 convergent bony tunnels are created through the tibial stab incision with a 4.5-mm drill. (B) The 2 tunnels are connected with a right-angled clamp. (C) A No. 2 suture is then passed in a retroverted fashion to create a loop for further anterolateral ligament graft passage. Arthroscopy Techniques 2016 5, e1253-e1259DOI: (10.1016/j.eats.2016.08.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Graft preparation for combined anterior cruciate ligament–anterolateral ligament reconstruction in a right knee. The harvested graft is composed of a tripled-over semitendinosus (ST) and a single strand of gracilis by first incising the gracilis (A), incorporating a doubled-over ST and gracilis (B), and then completing the graft preparation with the insertion of the ST still intact (C). Arthroscopy Techniques 2016 5, e1253-e1259DOI: (10.1016/j.eats.2016.08.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 (A) Outside-in femoral tunnel shown in a right knee (lateral view). The guide is introduced through the anteromedial portal. The tip of the guide is hooked at the proximal notch outlet with the guide target oriented toward the anterior cruciate ligament femoral insertion on the lateral wall of the lateral femoral condyle. The guide sleeve is pushed onto the lateral femoral cortex through the femoral stab incision to position a drill pin for femoral tunnel drilling. (B) The target of the tibial guide is placed onto the tibial anterior cruciate ligament remnant, as shown in a right knee (lateral view). The tibial guide sleeve is then pushed onto the tibial anteromedial cortex through the graft harvest incision to position a drill pin. Sequential reaming is performed, using first a 6-mm reamer followed by an incremental drill diameter. Arthroscopy Techniques 2016 5, e1253-e1259DOI: (10.1016/j.eats.2016.08.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Anterior cruciate ligament graft fixation (right knee, lateral view). (A) Tibial graft fixation with an interference screw. The graft is tensioned during interference screw insertion by pulling on the gracilis strand on the femoral side. (B) Femoral anterior cruciate ligament graft fixation with an interference screw. The gracilis strand emerging from the femoral stab incision is pulled toward the ground to pull down the iliotibial band split; the screw is then advanced through the stab incision. The knee is extended at 20° of flexion for fixation. Arthroscopy Techniques 2016 5, e1253-e1259DOI: (10.1016/j.eats.2016.08.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 (A) Passage of the anterolateral ligament (ALL) graft for combined anterior cruciate ligament (ACL)–ALL reconstruction in a right knee. After fixation of the ACL graft on the femur, the sutured gracilis graft goes beneath the iliotibial band to the posterior tibial hole; then the sutured graft is passed through the tibial bone tunnels and back proximally under the iliotibial band and out the lateral femoral tunnel incision, as shown in a lateral view (B) and frontal view (C) of a right knee in the supine position. (ST, semitendinosus.) Arthroscopy Techniques 2016 5, e1253-e1259DOI: (10.1016/j.eats.2016.08.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions