ACL Graft: Quad Tendon Autograft

Quadriceps Tendon (aka “QT”) is the red-headed stepchild of ACL grafts.  In some ways it is like a hybrid version of the Bone-Patellar-Tendon Bone (BTB) and Hamstring Autograft (HS).  The quadriceps tendon connects the quadriceps muscles of the thigh to the upper part of the patella (kneecap).  With QT harvest, the surgeon removes a slip of the quadriceps insertion along with a bone plug from the upper part of the patella, so it has bone on one side of the graft, but is soft tissue on the other.   QT grafts have been in use for a long time, but has never really become one of the “big 2”.  It is possible that the reason for this is that it shares advantages and disadvantages of both bone and soft tissue grafts. 


  1. The QT graft typically will reliably afford the surgeon the opportunity to take a tissue graft of sufficient length and girth.
  2. Re-tear rates are comparable to bone-patellar tendon-bone (BTB) and hamstring autograft (HS) grafts.
  3. Graft-related anterior knee pain with kneeling, squatting and running is uncommon.


  1. The rate limiting step in healing is still the ‘soft tissue’ side of the graft, so the rapidity of rehabilitation is similar to HS, perhaps not a rapid as BTB.
  2. There are fewer long-term outcome studies looking at QT compared to BTB and HS, so some surgeons are not as familiar with the graft.
  3. There remains a slight risk of patella fracture associated with the bone plug harvest from the patella.

The Take Home Message:  While a growing number of surgeons are using QT for reasons varying from the want of larger grafts and evolutions in fixation techniques.  In my practice, I will consider QT when I am revising a failed ACL reconstruction.  The QT graft is a little like a “Hybrid Hatchback of grafts” – it actually does a lot pretty well, but not everything, not very ‘costly’ in terms of pain, but a lot of people just never think about buying one.