Rectus Femoris Tendon Harvesting: Step-by-Step Open Technique

The rectus femoris tendon autograft has emerged as a reliable alternative to hamstring and patellar tendon grafts, providing a thick, robust structure with low donor-site morbidity. Its consistent anatomy allows predictable graft dimensions while potentially minimizing postoperative quadriceps weakness. Owing to its length, uniform thickness, and high tensile strength, the rectus femoris tendon represents a versatile option for ligament reconstructions requiring substantial graft integrity.

This technique is indicated for primary or revision ligament reconstructions that require a long, strong autograft-including combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstructions. It may also be applied in selected multiligament knee reconstruction scenarios.

With the patient in the supine position and the knee flexed to 80° to 90°, a 3 to 4 cm vertical incision is made over the lateral third of the quadriceps tendon, just proximal to the patella. After subcutaneous dissection, the fascia is incised longitudinally to expose the glistening rectus femoris tendon. The lateral border of the rectus femoris is identified and separated from the vastus lateralis, preserving a 2-mm rim for closure. A 10 mm-wide, full-thickness strip is marked and dissected from the underlying vastus intermedius. The tendon is released distally toward the patella to maximize length, then harvested proximally with a closed tendon stripper, yielding a 30 to 35 cm graft.

This approach consistently provides grafts of adequate diameter and length for single- or double-bundle reconstructions. We applied this technique in 25 patients undergoing combined ACL and ALL reconstruction, with no graft-harvesting-related complications. Isokinetic dynamometry demonstrated no clinically relevant quadriceps strength deficit at 6 months postoperatively compared with the contralateral limb.

This technique allows a safe and reproducible technique that provides high-quality autografts while preserving quadriceps strength. The proximal incision enhances identification of the rectus and vastus lateralis while minimizing the risk of arthrotomy. Careful distal and proximal dissection ensures optimal graft length and prevents rupture. The favorable structural characteristics and absence of measurable functional deficits support its use as a dependable option for both primary and revision ligament reconstructions.

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