Bicruciate lesion biomechanics, Part 2—treatment using a simultaneous tensioning protocol: ACL fixation first is better than PCL fixation first to restore tibiofemoral orientation



An uncommon technique for bicruciate ligament reconstruction involving simultaneous tensioning of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) grafts with ACL graft fixation first has been pointed out as superior to the “gold-standard” PCL graft fixation first. The purpose of this study was to compare tibiofemoral biomechanics between ACL fixation first and PCL fixation first in a simultaneous tensioning protocol for bicruciate ligament reconstruction.


12 fresh-frozen cadaveric knees (six matched pairs) were tested using a custom testing system. Neutral tibial position representing tibiofemoral orientation, anterior–posterior (AP) tibial translation, varus–valgus laxity, and internal-external rotation were measured using a Microscribe 3DLX at 0°, 30°, 60°, and 90° of knee flexion. The following knee conditions were evaluated: intact, bicruciate deficient and following bicruciate reconstruction. A simultaneous tensioning protocol was used for bicruciate reconstruction and PCL fixation first was compared to ACL fixation first. PCL graft fixation was always performed at 90° of flexion and ACL graft fixation was always performed at full extension.


ACL fixation first achieved a tibiofemoral orientation closer to the intact knee than PCL fixation first at 90° flexion (1.8 ± 1.6 mm versus 6.1 ± 3.2 mm, p = 0.016). PCL fixation first had a larger decrease in AP translation than ACL fixation first at 30° flexion (64.6 ± 3.5% vs. 58.3 ± 2.4%, p = 0.01). No significant differences were found for varus/valgus, external–internal rotation decrements after bicruciate reconstruction nor for AP translation, varus/valgus and internal/external rotation increase after bicruciate lesion comparing ACL fixation first to PCL fixation first.


Bicruciate ligament reconstruction using a simultaneous tensioning protocol with ACL fixation first resulted in a closer to normal tibiofemoral orientation. This study will help guide surgeons in decision making for the graft tensioning protocol and fixation sequence in a bicruciate ligament reconstruction.

Level of evidence

V therapeutic study.

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The authors would like to specially thank Arthrex for instruments and material supply, and FAPESP for financial support. The human cadaveric specimens were obtained through the University of California, Irvine Willed Body Program. Also, the authors would like to thank Andrea Moon, Felipe Huizar, Mike Shroder, Roseli Paschoa, Leonardo Adeo Ramos, Luiz Felipe Ambra, Thiago Bernardes Bastos, Leonardo José Bernardes Albertoni, Antonio Altenor Bessa de Queiroz, Mario Ferretti, Marcus Vinícius Malheiros Luzo, Flavio Faloppa, Rodrigo Antonio Brant Fernandes, Juan Carlos Martinez, Mark Humayun, and Paulo Rodrigues. Without the help, support, orientation and enthusiasm of all aforementioned people, this work would not be possible.


This study was funded by São Paulo Research Foundation (FAPESP) grant number 2015/10317-7. Franciozi CE received post-doctoral scholarship from FAPESP supporting his scientific activities at the University of Southern California during 2015–2016, grant number 2015/08952-6. Carvalho RT received financial support from FAPESP while performing his Ph.D. activities at University of Southern California during 2016.

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Correspondence to Carlos Eduardo Franciozi.

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Conflict of interest

Carlos Eduardo Franciozi and Rene Jorge Abdalla received fees for speaking or for organizing an educational program and fee for consulting from Smith & Nephew in the past five years, not related to this study. James Eugene Tibone acts as a consultant for Arthrex but do not receive any money from them, not any related to this study. The remaining authors declare no conflict of interest.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. This study was approved by The Federal University of São Paulo – UNIFESP – Institutional Review Board, number of Ethical Committee Approval: 45827413.5.0000.5505.

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Franciozi, C.E., de Carvalho, R.T., Itami, Y. et al. Bicruciate lesion biomechanics, Part 2—treatment using a simultaneous tensioning protocol: ACL fixation first is better than PCL fixation first to restore tibiofemoral orientation. Knee Surg Sports Traumatol Arthrosc 27, 2936–2944 (2019).

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  • Bicruciate ligament injury
  • ACL
  • Anterior cruciate ligament
  • PCL
  • Posterior cruciate ligament
  • Biomechanics
  • Translation
  • Varus–valgus
  • Tibial rotation
  • Ligament reconstruction
  • Multi-ligament knee injury
  • Knee dislocation
  • Knee laxity
  • Hyperextension