ACL Reconstruction — Quadriceps Tendon Graft

Why this approach — at MOS

The quadriceps tendon has become a more prominent part of our graft selection conversation over the past several years, particularly for patients who want autograft tissue but have reasons to avoid patellar tendon harvest. The growing body of comparative literature — including the Mouarbes et al. meta-analysis in AJSM showing equivalent outcomes to BPTB and hamstring grafts — gives us confidence that this is a well-supported choice for a wide range of patients.

We find the quadriceps tendon especially useful in three settings: younger patients with large anatomy who benefit from the large graft cross-section; patients who kneel frequently and want to avoid the anterior knee pain associated with BPTB harvest; and revision ACL reconstruction cases where the prior surgery used the patellar tendon and an autograft source is still needed.

Our harvest technique prioritizes tendon and bone preservation. We harvest only the central third, leaving equal amounts of tendon on each side of the donor site, and close the harvest defect carefully to minimize the risk of quadriceps tendon dehiscence. In our experience, quadriceps weakness in the early postoperative weeks is manageable with a well-structured PT protocol, and most patients recover quad strength progressively over the first 3–4 months.

Patients recovering from quadriceps tendon ACL reconstruction at our Montgomery County offices work with physical therapists familiar with the specific demands of this graft — particularly the early quad activation protocol, which differs somewhat from the patellar tendon protocol.

Who is a candidate?

Indications

• Competitive or recreational athletes with a complete ACL tear who want autograft reconstruction with a large-diameter graft
• Patients who want to avoid the kneeling discomfort and anterior knee pain associated with patellar tendon harvest
• Patients undergoing revision ACL reconstruction where the patellar tendon or hamstring was used previously and the quadriceps tendon is the available autograft source
• Younger patients (under 25) where autograft is strongly preferred and quadriceps tendon is selected based on anatomy or patient preference
• Patients with anatomic factors that make patellar tendon harvest unfavorable (narrow tendon, prior patellar tendinopathy)

Contraindications / Less Preferred Situations

• Patients with prior quadriceps tendon repair or significant quadriceps tendon pathology at the harvest site
• Patients in whom quadriceps weakness during recovery is poorly tolerated (certain occupational demands)
• Skeletally immature patients where harvest near the superior patellar physis requires additional planning
• Patients who have already undergone bilateral quadriceps tendon harvest (rare revision scenario)

Conservative Treatment First

ACL reconstruction is not appropriate for every patient with a torn ACL. Lower-demand patients who do not participate in pivoting activities and experience no functional instability may manage well with physical therapy focused on strengthening the muscles around the knee. At Maryland Orthopedic Specialists, every patient with an ACL tear undergoes a thorough discussion of surgical versus non-surgical management, and reconstruction is recommended only when the patient's functional demands, instability symptoms, or associated injuries make surgery the clearly superior choice.

When reconstruction is indicated and quadriceps tendon is the selected graft, the discussion shifts to harvest technique, fixation method, and rehabilitation protocol — all of which are individualized.

The procedure

What Is ACL Reconstruction with a Quadriceps Tendon Graft?

Quadriceps tendon ACL reconstruction uses the central third of the quadriceps tendon — the large tendon above the kneecap — to replace the torn ACL. It can be harvested with or without a patellar bone plug and provides a larger cross-sectional area than either the patellar tendon or hamstring graft, with growing evidence of outcomes comparable to traditional gold-standard options.

The quadriceps tendon is the broad, flat tendon formed by the convergence of the four quadriceps muscles (rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius). It attaches to the top of the patella and is one of the thickest tendons in the body. The central third of this tendon — roughly 8–10 mm wide — is harvested for ACL reconstruction. The harvest can include a bone plug taken from the superior pole of the patella (creating a hybrid bone-tendon graft, similar in concept to BPTB) or can be purely soft tissue.

The graft's most clinically significant attribute is its cross-sectional area. Multiple studies have shown that the quadriceps tendon graft is larger in cross-section than either the BPTB graft or a quadrupled hamstring graft for most patients. A larger graft diameter correlates with a greater contact area inside the bone tunnel, which may contribute to healing and mechanical properties. In addition, the harvest site is proximal to the patella — away from the anterior knee surface — which avoids the kneeling pain and infrapatellar numbness that can follow patellar tendon harvest.

The quadriceps tendon graft has seen a significant increase in use over the past decade as clinical series and comparative studies have accumulated. A systematic review and meta-analysis by Mouarbes et al. published in the American Journal of Sports Medicine found no significant differences in failure rate, instrumented laxity, or patient-reported outcomes between quadriceps tendon, BPTB, and hamstring autografts, with the quadriceps tendon showing less harvest-site pain than BPTB.

What Happens During Quadriceps Tendon ACL Reconstruction?

The procedure is performed as outpatient surgery under general or spinal anesthesia.

Step 1 — Graft harvest. A vertical incision approximately 3–4 cm is made just above the patella. The central third of the quadriceps tendon is harvested to a length of 7–10 cm. If a bone plug is desired, a rectangular block of bone is taken from the superior pole of the patella at the same time. The tendon graft is prepared on the back table: trimmed to appropriate diameter, tubularized with whip-stitch sutures, and sized to the tunnel diameter.

Step 2 — Arthroscopic joint inspection. Arthroscopic portals allow the surgeon to inspect the entire knee joint — menisci, articular cartilage, PCL, and synovium. Concurrent pathology (meniscus tears, chondral lesions) is addressed before graft placement.

Step 3 — Tunnel drilling. Bone tunnels are drilled at the anatomic ACL footprints on the tibia and femur. Femoral tunnel placement is typically performed via an anteromedial portal to achieve anatomic positioning. Tunnel diameter is matched to graft size.

Step 4 — Graft passage and fixation. The quadriceps tendon graft is pulled through the tibial tunnel and up into the femoral tunnel. If a patellar bone plug is present, it is fixed in the femoral tunnel with an interference screw. The soft-tissue tibial end is fixed with an interference screw, cortical button, or combined fixation. Graft tension is set with the knee in approximately 20–30 degrees of flexion.

Step 5 — LET augmentation (if indicated). For high-risk patients meeting LET criteria — young age, significant pivot-shift, high-demand sport — a lateral extra-articular tenodesis can be added during the same procedure. See the ACL Reconstruction overview page for details on LET.

Step 6 — Closure. Incisions are closed and the knee is wrapped in a compressive dressing with a hinged brace applied. Patients are discharged home the same day.

Recovery timeline

Frequently Asked Questions