Advantages of The Quad Tendon Graft for ACL Reconstruction

Advantages of The Quad Tendon Graft for ACL Reconstruction

More And More Athletes Are Opting To Use The Quad Tendon Graft In Reconstructing The ACL.  

So, when we fix an ACL, we actually have to take out the old ACL and put something new in to replace it.  Historically, the patellar tendon graft has been the most widely used graft of choice, and still is. However, the quad tendon graft is an intriguing option for ACL reconstruction that may have more desirable outcomes.

Things are changing though.  The patellar tendon grafts have also had a significantly higher incidence of prolonged patellar tendinitis after surgery. Almost 1 in 10 have to delay their return to sport because of this issue.  

There has also been a reported higher incidence of scar tissue and subsequent arthritis with the use of the patellar tendon.  

Why use it?  Because of a lower incidence of re-tearing when compared to the hamstring or a cadaver graft.  

REFINING THE RIGHT FIT FOR YOUR ACL GRAFT CHOICE: Consider the quadriceps tendon graft. 

 Female athletes and athletes under the age of 25 are prime candidates for quad tendon graft ACL reconstruction.

Female athletes and athletes under the age of 25 are prime candidates for quad tendon graft ACL reconstruction.

Consider the Quad Tendon graft for your ACL reconstruction if:

1. You Already Have A History Of Patellar Tendonitis Or Patellar Tendon Issues.  

In this case, use of a patellar tendon graft can aggravate this and may not be the best graft choice.

2. You Are A Young (<25 Yo) Athlete.

Cadaver grafts have an unacceptably high re-rupture rate in this group. If you are under the age of twenty five, consider the quad tendon graft. 

3. You Are Congenitally Loose Jointed And Prone To Hyper-Extension (We Have Tests For That).  

Here's how to tell. 

1. Can you bend your thumb down to touch the front of your forearm?

2. Can you bend your pinky finger back more than 90 degrees at the knuckle?

3. Do your elbows hyperextend more than 10 degrees?

4. Do your knees hyperextend more than 10 degrees?

5. Can you touch your palms flat on the ground when you bend over to touch the ground?

With the first four of these having a right and left component, there are a total of 9 points possible. A score of 7/9 or more means you are congenitally loose jointed!

For more on this topic, click here.

4. Your Are A Female Athlete. 


Perhaps because it is more common for females to be loose jointed  and have patellar tendonitis, we will recommend the quad tendon graft more often for our female athletes. 

For more information specific to female athletes, click here.

5. You Have A High Grade MCL Tear. 

There are concerns about using a hamstring graft in athletes with a significant tear to their MCL, as the graft we utilize may help stabilize the medial side (inner) of the knee in conjunction with the MCL.


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Lots of good choices here, but each graft choice has plusses and minuses.  

So why does the Quad Tendon graft for ACL reconstruction have a lower incidence of post surgical tendinitis?

Most likely, it is because the tendon is attached to the elastic quadriceps muscle above while the patellar tendon is suck between two bones, the patella and the tibia, giving it much less pliability or give,  during our rehab exercises.  

If you can have similar outcomes between the patellar tendon and quad tendon grafts for reconstructing the ACL, but have less post operative complications like scar tissue, arthritis or tendonitis, why wouldn’t you?

If you are having an ACL reconstruction, certainly consider the quad tendon graft

Please see below for supporting research on this topic. 

Supporting Research:

Is Quadriceps Tendon Autograft a Better Choice Than Hamstring Autograft for Anterior Cruciate Ligament Reconstruction? A Comparative Study With a Mean Follow-up of 3.6 Years - Etienne Cavaignac, Benoit Coulin, Philippe Tscholl, Nik Nik Mohd Fatmy, Victoria Duthon, Jacques Menetrey, 2017

Arthroscopy. 2014 May;30(5):593-8. doi: 10.1016/j.arthro.2014.01.012. Epub 2014 Mar 14.

Is quadriceps tendon a better graft choice than patellar tendon? a prospective randomized study.

Lund B1, Nielsen T1, Faunø P1, Christiansen SE1, Lind M2.

Author information

1. Division of Sports Trauma, University Hospital of Aarhus, Aarhus, Denmark.

2. Division of Sports Trauma, University Hospital of Aarhus, Aarhus, Denmark. Electronic address:



The purpose of this randomized controlled study was to compare knee stability, kneeling pain, harvest site pain, sensitivity loss, and subjective clinical outcome after primary anterior cruciate ligament (ACL) reconstruction with either bone-patellar tendon-bone (BPTB) or quadriceps tendon-bone (QTB) autografts in a noninferiority study design.


From 2005 to 2009, a total of 51 patients were included in the present study. Inclusion criteria were isolated ACL injuries in adults. Twenty-five patients were randomized to BPTB grafts and 26 to QTB grafts. An independent examiner performed follow-up evaluations 1 and 2 years postoperatively. Anteroposterior knee laxity was measured with a KT-1000 arthrometer (MEDmetric, San Diego, CA). Anterior knee pain was assessed clinically and by knee-walking ability. Knee Injury and Osteoarthritis Outcome Score (KOOS) and subjective International Knee Documentation Committee (IKDC) score were used for patient-evaluated outcome.


Anterior knee laxity was equal between the 2 groups with KT-1000 values of 1.1 ± 1.4 mm and 0.8 ± 1.7 mm standard deviation (SD) at follow-up in QTB and BPTB groups, respectively (P = .65), whereas positive pivot shift test results were seen less frequently (14% compared with 38%, respectively; P = .03). Anterior kneeling pain, evaluated by the knee walking ability test, was significantly less in the QTB group, with only 7% of patients grading knee walking as difficult or impossible compared with 34% in the BPTB group. At 1 and 2 years' follow-up, there was no difference between the 2 groups in subjective patient-evaluated outcome. The IKDC score was 75 ± 13 patients and 76 ± 16 SD at 1-year follow-up in QTB and BPTB groups, respectively (P = .78). At 2 years, 12 patients were lost to follow-up, resulting in 18 in the BPTB group and 21 in the QTB group.


The use of the QTB graft results in less kneeling pain, graft site pain, and sensitivity loss than seen with BPTB grafts; however, similar anterior knee stability and subjective outcomes are seen. The results of this study show that QTB is a viable option for ACL reconstruction.


Level II, randomized controlled clinical trial.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results.

Slone HS1, Romine SE2, Premkumar A2, Xerogeanes JW3.

Author information



The autograft of choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Recently, there has been an increase in interest in the quadriceps tendon as an autologous graft option for ACL reconstruction. The purposes of this study were to provide an in-depth review of quadriceps tendon anatomy, histology, and biomechanics and to synthesize reported clinical outcomes of ACL reconstructions using quadriceps tendon autografts. We hypothesize that (1) published studies on the anatomic, histologic, and biomechanical data regarding the quadriceps tendon support its use as a graft option for ACL reconstruction and (2) clinical outcomes of ACL reconstruction using quadriceps tendon autograft have similar clinical outcomes to bone-patellar tendon-bone autografts with less donor-site morbidity.


We performed a comprehensive review of the literature regarding the anatomy, histology, and biomechanical studies of the quadriceps tendon, as well as a systematic review of clinical studies (Level of Evidence I-III) evaluating outcomes after ACL reconstruction using quadriceps tendon autograft. Stability outcomes, functional outcomes, range of motion, patient satisfaction, morbidity, and complications were comprised.


Fourteen studies were included in the review of clinical results, including 1,154 ACL reconstructions with quadriceps tendon autograft. Six studies directly compared quadriceps tendon autografts (n = 383) with bone-patellar tendon-bone autografts (n = 484). Stability outcomes (Lachman, pivot-shift, and instrumented laxity testing), functional outcomes (International Knee Documentation Committee and Lysholm scores), overall patient satisfaction, range of motion, and complications were similar between quadriceps tendon and other graft options. Less donor-site morbidity was seen in patients who underwent quadriceps tendon ACL reconstructions.


Use of the quadriceps tendon autograft for ACL reconstruction is supported by current orthopaedic literature. It is a safe, reproducible, and versatile graft that should be considered in future studies of ACL reconstruction.

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