Arthroscopic Identification of the Anterolateral Ligament of the Knee

Abstract

Intense interest has focused on the recent description of the anterolateral ligament of the knee. Advancing knowledge of its anatomy and function is leading to a realization of its importance in the rotatory control of the tibia in anterior cruciate ligament injuries. Reconstruction of this structure will increasingly become an important goal during anterior cruciate ligament reconstruction. However, preoperative assessment of this ligament is difficult. Clinical assessment of rotatory laxity has poor reproducibility, and it is difficult to define using current imaging techniques. This article is the first to describe a safe and reproducible arthroscopic technique to allow identification and examination of the anterolateral ligament of the knee. With the knee at 90° of flexion, the arthroscope is introduced through the anterolateral portal to allow clear visualization of the lateral gutter. Under direct vision, an accessory portal is made over the inferior limit of the lateral gutter. A shaver is then introduced through this portal and used to debride this synovial recess and define the anterolateral ligament. This allows the surgeon to examine the integrity of the anterolateral ligament, in particular its femoral insertion. If required, this additional information can facilitate the performance of a more accurate and effective extra-articular reconstruction.

Fig 1

Accessory portal placement in a right knee. The arthroscope is introduced through the anterolateral portal and positioned in the lateral gutter. (A) A needle is placed proximally and anteriorly to the LCL insertion in the lateral gutter under direct arthroscopic vision. (B) A stab incision is performed directly over the hole from the needle to create the superolateral accessory portal. (C) The shaver is introduced through the accessory portal, and the arthroscope is placed in the lateral gutter to perform synovial debridement. (FH, fibular head.)

Fig 2

Cadaveric study in a right knee. (A) Cadaveric dissection of ALL (asterisk). (B) Arthroscopic view of the 3 lateral structures with a 70° arthroscope (slack ALL). (C) Knee after anatomic dissection (tight ALL). From distally to proximally, the popliteus tendon (PT), ALL (asterisk), and LCL are clearly identified (B, C). (FH, Fibular Head; Gt, Gerdy's tubercle.)