All-Inside Bicruciate Ligament Reconstruction Technique: A Focus on Graft Tensioning Sequence

Bicruciate ligament (BCL) reconstructions are challenging procedures. One of the main operative goals is to stabilize the knee in the correct anterior-posterior position. We present an all-inside arthroscopic BCL reconstruction technique using hamstring tendon grafts. Ipsilateral semitendinosus (ST) and gracilis tendons are used for TriLink (Arthrex, Naples, FL) double-bundle posterior cruciate ligament (PCL) reconstruction and contralateral ST tendon is used for GraftLink (Arthrex) single-bundle anterior cruciate ligament (ACL) reconstruction. The use of instruments for retrograde reaming and devices for adjustable cortical suspensory fixation allows for a safe, reproducible all-inside BCL reconstruction by simplifying these difficult steps. To minimize the risk of anterior-posterior malposition, the ACL graft is first tensioned with the knee in full extension, ensuring a neutral anteroposterior positioning of the tibia under the femur. The PCL anterolateral bundle can then be independently tensioned with the knee at 90° of flexion, and the posteromedial bundle at 30° of flexion, while applying an anterior translation to the tibia to reduce the posterior drawer without any risk of overcorrection. The purpose of this Technical Note was to describe an all-inside BCL reconstruction with a specific focus on the graft tensioning sequence.