Quadriceps Tendon Grafts for Acl Reconstruction – Hype or Here to Stay?

By: Harris S. Slone, M.D. and W. Michael Pullen, M.D.

Quadriceps tendon (QT) autografts for anterior cruciate ligament (ACL) reconstruction are not new, but certainly a subject of renewed enthusiasm. Marshall et al. first described the use of QT grafts for ACL reconstruction in 1979.1 Twenty years later, John P. Fulkerson, M.D. subsequently described the use of all soft tissue central quadriceps free tendon grafts,2 quite similar to QT grafts commonly used with modern techniques. In the last five-10 years, the number of studies evaluating QT grafts for ACL reconstruction increased exponentially,3 and similar increases were seen with clinical utilization. Yet many questions remain regarding the use of QT grafts for ACL reconstruction: What is fueling the surge in popularity? Are there long-term consequences of harvesting from the QT? Is the enthusiasm for QT autografts all hype, or here to stay?

While long-term results of patella tendon and hamstring autograft ACL reconstruction are generally favorable, concerns exist regarding rerupture rates, donor site morbidity, variable rates of return to sport, graft-tunnel mismatch, cosmesis, graft size predictability and disruption of dynamic medial stabilizers. As a result, surgeons and investigators sought alternative graft options. QT autografts have long been recognized as a viable graft option, primarily utilized in the revision setting before gaining the now more widespread popularity as a primary graft option. Refinements of harvesting techniques, instrumentation and fixation options have allowed for an easier transition for surgeons who have become accustomed to patella tendon or hamstring grafts. As Orthopaedic Residents and Fellows are now more frequently exposed to QT ACL reconstruction during training, familiarity with this graft is only expected to increase.

Utilizing modern techniques, published clinical outcomes have been largely favorable, although long-term comparative results are still lacking. Of particular concern is a large study from the Danish Knee Ligament Registry, which recently demonstrated an increased risk of graft failure with QT grafts.4 While the results of this study should give us pause, they should also be interpreted within appropriate context. QT grafts accounted for only around 3% of the total grafts included and were more frequently used in higher risk patients; thus, some authors have raised concerns regarding statistical bias and selection bias.5 This study also included reconstructions performed as far back as 2005, long before modern fixation and harvest techniques. A follow-up study performed between 2012-2019 from the same registry showed failure rates similar to alternative autografts when surgery was performed at higher volume centers, and that there may be a “learning curve” effect with QT grafts.6 Other studies have demonstrated a greater loss of knee extensor strength with QT grafts as compared to hamstring grafts.7,8 Risk of patella fracture is likely increased when harvesting a bone plug from the proximal pole of the patella as compared to the distal pole.9 As a result, many surgeons favor using an all soft-tissue QT graft, with which the fracture risk associated with bone harvest is negated. Rare complications of impending compartment syndrome and rectus femoris retraction have also been reported.10

A distinct advantage of the QT graft is its versatility.11 The harvest can be tailored to remove only the length, width and depth that the surgeon desires, leaving normal anatomy in situ. Surgeons favoring “all-inside” techniques, full-length tibial tunnels, independent and transtibial drilling, single-bundle, double-bundle, suspensory fixation or aperture fixation can all be accommodated with QT grafts. The large volume of the native QT allows surgeons to harvest a single strand soft-tissue graft with predictable size. A recent systematic review suggests that there are no differences in clinical outcomes between full-thickness and partial-thickness graft harvests, allowing surgeons more flexibility and ease of harvest technique.12

Proceeding with caution should be encouraged when utilizing new technology. Metal-on-metal hip arthroplasty, synthetic ligaments for ACL substitution and modular hip arthroplasty systems, all which have now largely fallen out of favor, once started with great enthusiasm. Hype often has a negative connotation – but perhaps in the case of QT autografts for ACL reconstruction, hype simply reflects the excitement of surgeon’s personal experience and published results of this renewed technique. So in this case, hype could potentially be a good thing. The only way to know whether the enthusiasm is here to stay is whether QT grafts pass the test of time – which is the hardest test to pass.


  1. Marshall, J.L., Warren, R.F., Wickiewicz, T.L., Reider, B. “The Anterior Cruciate Ligament: A Technique of Repair and Reconstruction.” Clinical Orthopaedics and Related Research. 1979;(143):97-106.
  2. Fulkerson, J.P. “Central Quadriceps Free Tendon for Anterior Cruciate Ligament Reconstruction.” Operative Techniques in Sports Medicine. 1999;7(4):195-200.
  3. Heffron, W.M., Hunnicutt, J.L., Xerogeanes, J.W., et al. “Systematic Review of Publications Regarding Quadriceps Tendon Autograft Use in Anterior Cruciate Ligament Reconstruction.” Arthroscopy, Sports Medicine, and Rehabilitation. 2019;1(1):e93-e99. doi:10.1016/j.asmr.2019.09.001.
  4. Lind, M., Strauss, M.J., Nielsen, T., Engebretsen, L. “Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction Is Associated With High Revision Rates: Results From The Danish Knee Ligament Registry.” Knee Surgery, Sports Traumatology, Arthroscopy. 2020;28(7):2163-2169. doi:10.1007/s00167-019-05751-5.
  5. Ollivier, M., Jacquet, C., Pailhe, R., et al. “Higher Rerupture Rate in Quadriceps Tendon ACL Reconstruction Surgeries Performed in Denmark: Let's Return to the Mean.” Knee Surgery, Sports Traumatology, Arthroscopy. 2020;28(11):3655-3656. doi:10.1007/s00167-020-05961-2.
  6. Lind, M., Strauss, M.J., Nielsen, T., Engebretsen, L. “Low Surgical Routine Increases Revision Rates After Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction: Results From The Danish Knee Ligament Reconstruction Registry.” Knee Surgery, Sports Traumatology, Arthroscopy. 2020. doi:10.1007/s00167-020-06220-0.
  7. Fischer, F., Fink, C., Herbst, E., et al. “Higher Hamstring-to-Quadriceps Isokinetic Strength Ratio During the First Postoperative Months in Patients With Quadriceps Tendon Compared to Hamstring Tendon Graft Following ACL Reconstruction.” Knee Surgery, Sports Traumatology, Arthroscopy. 2018;26(2):418-425. doi:10.1007/s00167-017-4522-x.
  8. Johnston, P.T., Feller, J.A., McClelland, J.A., Webster, K.E. “Knee Strength Deficits Following Anterior Cruciate Ligament Reconstruction Differ Between Quadriceps and Hamstring Tendon Autografts.” Knee Surgery, Sports Traumatology, Arthroscopy. 2021:1-11. doi:10.1007/s00167-021-06565-0.
  9. Fu, F.H., Rabuck, S.J., West, R.V., Tashman, S., Irrgang, J.J. “Patellar Fractures After the Harvest of a Quadriceps Tendon Autograft With a Bone Block: A Case Series.” Orthopaedic Journal of Sports Medicine. 2019;7(3):2325967119829051. doi:10.1177/2325967119829051.
  10. Slone, H.S., Romine, S.E., Premkumar, A., Xerogeanes, J.W. “Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction: A Comprehensive Review of Current Literature and Systematic Review of Clinical Results.” Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2015;31(3):541-554. doi:10.1016/j.arthro.2014.11.010.
  11. Buerba, R.A., Boden, S.A., Lesniak, B. “Graft Selection in Contemporary Anterior Cruciate Ligament Reconstruction.” Journal of the AAOS Global Research Reviews. 2021. doi:10.5435/JAAOSGlobal-D-21-00230.
  12. Kanakamedala, A.C., de Sa, D., Obioha, O.A., et al. “No Difference Between Full-Thickness and Partial-Thickness Quadriceps Tendon Autografts in Anterior Cruciate Ligament Reconstruction: A Systematic Review.” Knee Surgery, Sports Traumatology, Arthroscopy. 2019;27(1):105-116. doi:10.1007/s00167-018-5042-z.
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