The rectus femoris tendon autograft in knee ligament reconstruction: Anatomy, biomechanics, clinical applications and results-A narrative review.

Abstract

The quadriceps tendon has gained significant momentum as a graft source for knee ligament reconstruction, with the isolated harvest of its superficial layer-the rectus femoris tendon-rapidly emerging as a popular technical refinement. This shift has been driven largely by practical considerations: the cost and limited availability of proprietary instrumentation promoted for partial quadriceps tendon harvesting, combined with the appeal of a familiar, hamstring-like workflow using standard tendon strippers. As a result, numerous surgical technique descriptions have appeared in recent years. However, the enthusiasm surrounding this graft has outpaced the evidence supporting it. This narrative review critically appraises the current state of knowledge regarding the rectus femoris tendon autograft by evaluating its anatomical basis, biomechanical properties and the first available clinical outcomes. Anatomical studies confirm the rectus femoris tendon as a consistent superficial layer separated from the deep vastus intermedius by a distinct cleavage plane, facilitating reproducible harvest. Biomechanically, the isolated graft demonstrates ultimate stress comparable to the patellar tendon, yet exhibits significantly higher elasticity, raising unresolved questions about long-term graft creep and laxity. Early clinical comparative studies report functional outcomes equivalent to hamstring tendon autografts in primary anterior cruciate ligament reconstruction, and folded soft-tissue quadriceps grafts show promising re-rupture rates in the revision setting. Despite these encouraging findings, the existing literature is predominantly Level III and IV evidence with short-term follow-up, and the heterogeneous definitions of 'quadriceps tendon graft' across studies preclude any formal meta-analysis of this specific graft entity. While the rectus femoris tendon autograft holds considerable potential as a versatile option for primary, revision and complex multi-ligament reconstruction, high-powered randomized controlled trials with long-term follow-up are needed to determine whether it truly represents a paradigm shift or merely a technical variation. LEVEL OF EVIDENCE: Level V, narrative review.