The Rectus Femoris Tendon Graft: The Lego of Autografts in Knee Surgery

Camilo P. Helito, MD, PhD, Prof, BRAZIL Andre Giardino Moreira Da Silva, MD, BRAZIL Diego Ariel De Lima, MD, PhD, BRAZIL

ISAKOS eNewsletters   Current Perspective 2025   Not yet rated

A New Paradigm in Autograft Selection

In the landscape of anterior cruciate ligament (ACL) reconstruction, autograft choice remains a cornerstone of surgical planning. While hamstring tendons (HT), bone-patellar tendon-bone (BPTB), and quadriceps tendon (QT) autografts have dominated for decades, a renewed focus has emerged on a refined and promising alternative: the rectus femoris tendon graft (RFG), harvested from the superficial layer of the quadriceps.

This graft is long, strong, and consistently accessible through a safe surgical plane. But beyond its anatomy and strength, its greatest asset may be its versatility—making it the orthopedic equivalent of a Lego block. It can be adapted, segmented, and configured for a wide variety of ligament reconstructions.

Historical Perspective: Rediscovering the “Forgotten” Graft

Although quadriceps tendon grafts date back to the late 1970s and 1980s, the idea of specifically harvesting the superficial rectus femoris layer resurfaced with renewed interest in the past decade. In 2014, Fink et al.¹ described a minimally invasive harvesting technique for quadriceps tendon grafts that intentionally preserved deeper layers while still capturing the robust superficial component. This pivotal work laid the groundwork for later adaptations targeting the rectus femoris, establishing clear anatomical planes, low morbidity profiles, and consistent graft quality.

Building on Fink’s foundation, Raman et al.² (2022) and Thamrongskulsiri et al.³ (2022) refined the approach, developing dedicated protocols to harvest the superficial rectus femoris tendon, typically using small (2-2.5 cm) vertical or transverse incisions and routine surgical instruments—thereby stripping away complexity while maintaining yield and safety 

By 2024, Barroso et al.⁴ took it a step further by successfully applying the rectus femoris graft in combined ACL and anterolateral (ALL) reconstructions, using minimally invasive techniques and standard instrumentation—demonstrating both structural integrity and rotational control. In parallel, Rêgo et al.⁵ and a broader coalition of Brazilian knee specialists integrated the graft into multiligament reconstructions, such as repairs of the ACL plus the posterior cruciate ligament (PCL) and repairs of the ACL plus the anteromedial oblique ligament (AOL), often referring to this approach as “the forgotten graft” in editorials that highlighted its rediscovery and renaissance .

Today, the rectus femoris tendon has been revived as a distinct, modular graft source—consistent in length (28 to 40 cm), thickness, and biomechanical profile—thanks to its recognition as a separate anatomical lamina, safe harvesting strategies, and growing clinical evidence. Its revival reflects a return to a once-forgotten anatomical opportunity, now reimagined for modern reconstructive versatility.

What Makes the Rectus Femoris Tendon Unique?

Clinically, early functional outcomes have been encouraging: isokinetic testing at 6 months has revealed robust flexor recovery and no persistent extensor weakness, supporting reliable return-to-sport decisions. The combination of reliable yield, harvesting safety, and biomechanical strength makes the RFG a truly compelling option. Biomechanical testing has placed the tensile strength of the rectus femoris tendon on par with or exceeding that of traditional grafts. Reports have shown full-thickness quadriceps layers (including the RF) reaching ~2,000 N—equal to or better than the native ACL (~1,725 to 2,000 N), and similar to bone-patellar tendon-bone and hamstring constructs. The RFG stands out for its anatomical independence as it is harvested without disrupting deeper quadriceps fibers or the extensor mechanism. Cadaveric and clinical studies have confirmed that this layer can be safely obtained via a small incision (~3 cm), preserving the integrity of the vastus intermedius and minimizing postoperative morbidity.

Building With It: Clinical Applications of the RFG

The RFG stands out for its remarkable modularity, allowing it to be adapted across a wide spectrum of ligament reconstructions. Intra-articularly, it serves reliably in standard ACL reconstructions and can be used in a single or double-bundle configuration for PCL reconstruction. Its generous length and diameter also make it an excellent option for revision ACL or PCL procedures, particularly in patients lacking viable hamstring tendons.

Beyond isolated ligament repair, the RFG can be split or shaped to address combined procedures. It has been successfully used in combined ACL-ALL and ACL-AOL reconstructions, either via graft bifurcation or tunnel-sharing. For multiligament knee injuries, a single RFG may suffice for reconstructing the ACL and PCL, and even for supplementing medial or lateral structures, such as in cases involving the medial collateral ligament (MCL) or lateral collateral ligament (LCL).

The RFG’s versatility extends to soft-tissue reinforcements and augmentations. The RFG has been used for medial patellofemoral ligament (MPFL) reconstructions and has been proposed for ACL augmentations in skeletally immature patients, situation in which all-soft-tissue constructs are preferred. Although still experimental, its potential use for upper extremity ligament reconstructions—such as in the shoulder or elbow—highlights its structural and anatomical flexibility.

This level of adaptability is rare among autografts. In essence, the RFG offers a "one graft fits all" solution that is capable of addressing diverse surgical demands through a single, reliable harvest.

Safety, Predictability and Practical Advantages

The harvest is safe, with a clear dissection plane and minimal donor-site morbidity. Intraoperative studies have shown that even in cases of partial amputation or suboptimal trajectory, a second usable graft can be harvested from the same structure, thereby avoiding conversion to another site.

From a technical standpoint, the harvest is straightforward and requires no specialized instruments beyond those commonly available for hamstring tendon procedures. However, a long, rigid, and with a at least 8-mm aperture tendon stripper is recommended. The clear dissection plane between the rectus femoris and the vastus intermedius helps prevent complications. When difficulties do arise—such as partial graft amputation or incorrect trajectory—they are usually manageable, and a second viable graft can often be salvaged from the same tendon, avoiding the need for an alternative donor site.

Furthermore, the superficial harvest site allows for excellent cosmesis and a low risk of nerve or vascular injury. Surgeons familiar with hamstring harvests typically find the RFG technique to be intuitive and quickly adoptable. The combination of anatomical reliability, intraoperative consistency, and low complication rates makes the RFG not only a biomechanically sound choice but also a practical and safe option in everyday surgical settings.

Graft Harvest: Rectus Femoris

The harvest of the rectus femoris tendon follows for a straightforward and reproducible technique that preserves the integrity of the extensor mechanism. Through a 3-cm longitudinal incision placed just proximal to the superior pole of the patella—at the junction between the lateral and middle thirds of the quadriceps tendon—the superficial lamina of the rectus femoris is easily identified. A 10 to 12-mm-wide segment is then carefully dissected and mobilized along approximately 8 cm in the proximal direction, ensuring that the intermediate and deep layers of the quadriceps tendon remain untouched. With the knee flexed to 20°, a closed tendon stripper is used to complete the proximal release of the graft.

The distal end is whipstitched using nonabsorbable sutures, facilitating controlled passage and tensioning. Typically, the graft is folded asymmetrically, allowing for at least 9 cm of usable ACL component length with a final diameter of 8 to 9 mm or more. After preparation, the donor site is closed in layers, resulting in minimal morbidity and excellent cosmetic outcomes. This technique offers a balance between technical simplicity and structural reliability, making the rectus femoris tendon both a practical and elegant graft source (Figures 1, 2, and 3).

Figure 1. Graft harvest: rectus femoris. A. The skin incision is made over the superior pole of the patella at the junction between the lateral and middle thirds for rectus femoris tendon harvest. B. A cleavage plane is developed approximately 3 cm proximal to the patella. A 10-mm-wide graft is outlined with two parallel incisions in the superficial layer and is detached distally from the patella. The free end is whipstitched with nonabsorbable sutures. C. The dissection is extended proximally for about 8 cm using scissors, preserving the intermediate and deep layers. With the knee flexed to 20°, the graft is harvested using a closed tendon stripper.

Figure 2. Graft harvest: rectus femoris.

Figure 3. The harvested rectus femoris tendon is placed on the preparation table. Excess muscle fibers and irregularities are removed.

The Time to Rethink the Default

For decades, graft selection in knee ligament reconstruction has adhered to a predictable formula: hamstring tendons for low morbidity, bone-patellar tendon-bone for strength, and quadriceps tendon for volume. This triad has shaped training, technique, and expectations. But the rectus femoris tendon graft (RFG) challenges that orthodoxy.

Combining the structural strength of traditional grafts with the ease of soft-tissue harvest and the adaptability of modular constructs, the RFG introduces a new logic—one based on versatility, predictability, and creativity. It is not merely an alternative graft; it is a flexible platform, capable of being split, shaped, and scaled to fit a range of procedures—from single-ligament reconstructions to complex multiligament scenarios.

In an era of personalized surgery and increasing demand for precision solutions, the RFG offers something rare: one graft, one site, many possibilities. More than a substitute, it is a strategy. A Lego-like solution for surgeons who think beyond the tunnel.

References

1. Fink C, Herbort M, Abermann E, Hoser C. Minimally invasive harvest of a quadriceps tendon graft with or without a bone block. Arthrosc Tech. 2014;3(4):e509-e513.
2. Raman R, Mishra BN, Sen A. A minimally invasive and simple technique of superficial quadriceps tendon graft harvesting. Arthrosc Tech. 2022;11(12):e2347-e2355.
3. Thamrongskulsiri N, Limskul D, Tanpowpong T, Kuptniratsaikul S, Itthipanichpong T. Minimally Invasive Harvesting of Triple-Fold Superficial Layer Quadriceps Autograft for Knee Ligament Reconstruction. Arthrosc Tech. 2023;12(12). doi:10.1016/j.eats.2023.07.051
4. Barroso BG, Canuto SM de G, Helito CP, Rêgo MCF, Martins FS, Rêgo MCF. Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Using the Superficial Layer Quadriceps Tendon Graft: Surgical Technique Description. Arthrosc Tech. 2024;13(10):103067. doi:10.1016/j.eats.2024.103067
5. Rêgo MCF, Barroso BG, Helito CP, et al. Combined anterior cruciate ligament and anteromedial oblique ligament reconstruction using the rectus femoris tendon: Description of surgical technique. Arthrosc Tech. 2025;14(2):103224.

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