Abstract
Background:
The rectus femoris tendon autograft has emerged as a reliable alternative to hamstring and patellar tendon grafts, providing a thick, robust structure with low donor-site morbidity. Its consistent anatomy allows predictable graft dimensions while potentially minimizing postoperative quadriceps weakness. Owing to its length, uniform thickness, and high tensile strength, the rectus femoris tendon represents a versatile option for ligament reconstructions requiring substantial graft integrity.
Indication:
This technique is indicated for primary or revision ligament reconstructions that require a long, strong autograft—including combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstructions. It may also be applied in selected multiligament knee reconstruction scenarios.
Technique Description:
With the patient in the supine position and the knee flexed to 80° to 90°, a 3 to 4 cm vertical incision is made over the lateral third of the quadriceps tendon, just proximal to the patella. After subcutaneous dissection, the fascia is incised longitudinally to expose the glistening rectus femoris tendon. The lateral border of the rectus femoris is identified and separated from the vastus lateralis, preserving a 2-mm rim for closure. A 10 mm-wide, full-thickness strip is marked and dissected from the underlying vastus intermedius. The tendon is released distally toward the patella to maximize length, then harvested proximally with a closed tendon stripper, yielding a 30 to 35 cm graft.
Results:
This approach consistently provides grafts of adequate diameter and length for single- or double-bundle reconstructions. We applied this technique in 25 patients undergoing combined ACL and ALL reconstruction, with no graft-harvesting-related complications. Isokinetic dynamometry demonstrated no clinically relevant quadriceps strength deficit at 6 months postoperatively compared with the contralateral limb.
Discussion/Conclusion:
This technique allows a safe and reproducible technique that provides high-quality autografts while preserving quadriceps strength. The proximal incision enhances identification of the rectus and vastus lateralis while minimizing the risk of arthrotomy. Careful distal and proximal dissection ensures optimal graft length and prevents rupture. The favorable structural characteristics and absence of measurable functional deficits support its use as a dependable option for both primary and revision ligament reconstructions.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Keywords
Video Transcript
Background
The rectus femoris tendon autograft is gaining popularity for anterior cruciate ligament (ACL) reconstruction, driven by refined harvesting techniques that minimize soft-tissue dissection and reduce donor-site morbidity.2,3,6 It provides a long, uniform, and robust graft suitable for single and multiligament reconstructions. 8
The superficial location of the tendon allows for minimal muscle violation, preserving the vastus medialis, vastus intermedius, and joint capsule. 4 Early clinical studies report comparable functional outcomes and stability to standard autografts, supporting its role as a reliable, low-morbidity alternative.1,7
Technique Description
Normally, a tourniquet is not required for this technique. The patient is positioned supine, with the knee flexed to approximately 80°. We begin by marking the quadriceps tendon and dividing it into 3 equal thirds. A 3-cm vertical incision is made over the lateral third of the quadriceps, slightly proximal to the superior pole of the patella. Subcutaneous tissues are dissected down to the quadriceps fascia, which is incised longitudinally.
Blunt dissection then exposes the white, glistening rectus femoris tendon. This location facilitates visualization of the lateral border of the vastus lateralis and the lateral edge of the rectus femoris tendon. An incision is made between these 2 structures, and a 2-mm rim of rectus femoris is left to facilitate closure later.
Once these structures are clearly identified, the desired 10-mm graft width is measured and marked using a sterile ruler. At this level, identifying the correct plane between the rectus femoris and the vastus intermedius is easier.
The rectus femoris tendon averages 3 to 4 mm in thickness at this point, which makes it easier to maintain a superficial dissection. In contrast, harvesting too close to the patella increases the risk of entering the joint, since the distal insertions of both tendons converge at that level. The rectus femoris is carefully separated from the underlying vastus intermedius. Dissection is then continued distally until reaching the superior pole of the patella, where the tendon is completely released from its insertion. This technique preserves the full functional length of the graft.
To facilitate proximal extraction, the tendon is mobilized for approximately 10 to 12 cm using scissors. Once adequately freed, a tendon stripper is introduced and advanced proximally toward the greater trochanter. This allows smooth and atraumatic removal of the graft while minimizing the risk of inadvertent transection. This bidirectional approach ensures safe and efficient harvest of a long, uniform graft. To improve traction and control, traction sutures may be placed along the tendon's distal edge.
The rectus femoris tendon typically provides a length of 32 to 35 cm, offering sufficient material for primary ACL reconstruction, revision cases, or combined ACL + anterolateral ligament (ALL) and multiligament procedures.2,6 Here you can see the length of our grafts, which usually measure 34 cm. Finally, the residual edge of the rectus femoris is sutured side to side with the vastus lateralis.
This is how we prepare our graft for the combined ACL + ALL reconstruction: the ACL portion has a diameter of around 9 to 10 mm, and the ALL portion has a diameter of 7 to 8 mm.
Results
We applied this technique in 25 patients undergoing combined ACL and ALL reconstruction. During a 12-month follow-up period, no complications related to graft harvesting were observed. Moreover, isokinetic dynamometry at 6 months postoperatively demonstrated no clinically relevant difference in quadriceps strength compared with the contralateral limb.
This is an example of a patient 3 months post surgery. This is an example from one of our patients; however, a similar pattern is consistently observed across the entire cohort. When assessed using dynamometry, the quadriceps maximum strength at 3 months postoperatively demonstrated a 13% deficit compared with the contralateral limb. By 6 months postoperatively, this interlimb difference had decreased to 1.3%, indicating near-complete recovery of maximal strength.
Discussion
The advantages are as follows: it provides a long, strong autograft with consistent morphology; it allows single-site harvest for ACL + ALL reconstruction or multiligament reconstructions2,6; it avoids morbidity associated with hamstring or patellar tendon grafts; it maintains quadriceps integrity, preserving the vastus medialis and intermedius 4 ; and it is minimally invasive, with a small incision and excellent cosmetic outcome.5,8
Potential Complications are as follows: capsular breach/inadvertent arthrotomy; arthroscopy fluid extravasation; bleeding/hematoma formation; injury to the vastus medialis; and donor-site morbidity. 3
Footnotes
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
