All-Inside Bicruciate Ligament Reconstruction Technique: A Focus on Graft Tensioning Sequence  Mathieu Thaunat, M.D., Gilles Clowez, M.D., Colin G. Murphy, M.D., Antoine Desseaux, M.D., Tales Guimaraes, M.D., Jean Marie Fayard, M.D., Bertrand Sonnery-Cottet, M.D.  Arthroscopy Techniques  Volume 6, Issue 3, Pages e655-e660 (June 2017) DOI: 10.1016/j.eats.2017.01.012 Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 1 Patient setup, right knee. The patient is placed supine on an operative table with a lateral post just proximal to the knee, at the level of the padded tourniquet, and a foot roll to prevent the hip from externally rotating and to keep the knee flexion at 90°. In this way, the knee can be moved freely through the full range of motion. A C-arm is positioned to ensure that a good lateral view of the knee can be obtained. Arthroscopy Techniques 2017 6, e655-e660DOI: (10.1016/j.eats.2017.01.012) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 2 PCL TriLink graft (Arthrex). The ST graft is quadrupled in a Y-shape configuration to obtain a trifurcate graft with 2 double-stranded femoral limbs and 1 quadrupled stranded tibial limb. Each limb is loaded with a TightRope (Arthrex). One femoral limb replicates the posteromedial femoral bundle and the other one the anterolateral femoral bundle. (PCL, posterior cruciate ligament; ST, semitendinosus.) Arthroscopy Techniques 2017 6, e655-e660DOI: (10.1016/j.eats.2017.01.012) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 3 Right knee: ACL and PCL sockets. Tibial and femoral sockets are performed with a FlipCutter (Arthrex). For the ACL graft: a 20 mm long femoral socket and a 30 mm long tibial socket are generally performed to allow adequate graft tensioning. For the PCL graft: 2 femoral sockets 20 mm long performed. A 35-mm tibial socket is drilled—25 mm for the graft and an additional 10 mm to prevent potential graft laxity contributing to size inaccuracy. (ACL, anterior cruciate ligament; PCL, posterior cruciate ligament.) Arthroscopy Techniques 2017 6, e655-e660DOI: (10.1016/j.eats.2017.01.012) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 4 Sequence of graft tensioning, left knee (arthroscopic view). (A and B) Tensioning the ACL graft first in full extension restores the anatomic tibial step-off. (C and D) The knee is then placed at 90° of flexion, and with maximum anterior drawer, the AL bundle is fixed. (The ACL graft allows avoiding overcorrection when reducing the posterior drawer.) (E and F) The knee is placed between 0° and 30° of flexion according to its isometric behavior, maintaining the anterior drawer, and the PM bundle is tightened. (ACL, anterior cruciate ligament; AL, anterolateral; MFC, medial femoral condyle; PCL, posterior cruciate ligament; PM, posteromedial.) Arthroscopy Techniques 2017 6, e655-e660DOI: (10.1016/j.eats.2017.01.012) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 5 Postoperative radiographs, left knee. (A) Anteroposterior view; (B) profile view. Arthroscopy Techniques 2017 6, e655-e660DOI: (10.1016/j.eats.2017.01.012) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions