If you’re facing ACL reconstruction, one of the most important decisions your surgeon will make is graft selection, the tissue used to rebuild your torn ligament. For more than 30 years, the patellar tendon (bone-patellar tendon-bone, or BTB) has been considered the gold standard. It remains an excellent graft with decades of proven results, and I still use it for the right patients and situations.
But there’s a growing body of high-quality evidence that another option, the quad tendon autograft, may offer equal or superior outcomes with fewer trade-offs. Here’s what the research says, and why quad tendon has become my preferred graft for many of my ACL reconstructions.
Patellar Tendon: A Proven Graft with Known Trade-Offs
BTB has earned its reputation. It provides strong bone-to-bone healing in the tunnels, has decades of long-term follow-up data, and delivers excellent clinical results across thousands of studies. For certain patients, particularly those requiring bone-to-bone fixation or in revision scenarios, BTB remains my graft of choice.
The trade-offs are well-documented: some patients develop anterior knee pain or persistent kneeling discomfort at the harvest site. These aren’t rare complications. They’re part of the conversation I have with every patient when discussing graft options during their consultation.
Quad Tendon: The Biomechanical Advantages
The biomechanical profile of the quad tendon graft is striking. Compared to a patellar tendon graft of the same width, the quad tendon provides twice the cross-sectional area, is 1.8 times thicker, demonstrates 38% greater load to failure (2,186 N vs. 1,581 N), and offers 68% greater stiffness (466 vs. 278 N/mm). Histological analysis has also shown approximately 20% more collagen fibrils per cross-sectional area compared to patellar tendon, with a significantly higher fibril-to-interstitium ratio (Shani et al., Arthroscopy, 2016; Hadjicostas et al., Knee Surg Sports Traumatol Arthrosc, 2008).
In plain terms: it’s a bigger, stronger, stiffer graft with greater collagen density, and it comes with significantly less harvest-site pain than BTB. For a comprehensive overview of knee injury treatment options, understanding these biomechanical differences is essential for making an informed decision.
What the Clinical Data Shows
Biomechanics tell part of the story, but what matters most is how patients actually do after surgery. The clinical evidence is increasingly clear.
Quad tendon vs. patellar tendon (BTB): A network meta-analysis of 2,962 patients across 32 randomized controlled trials found quad tendon superior on key outcome measures compared to both BTB and hamstring autografts for primary ACL reconstruction. QT demonstrated similar stability and return-to-sport rates as BTB, with lower donor site morbidity and less kneeling pain (Yang et al., International Orthopaedics, 2020).
Quad tendon vs. hamstring: A systematic review of 15 studies encompassing 1,154 patients found a re-rupture rate of just 2.5% for quad tendon compared to 8.7% for hamstring (p = 0.01). Quad tendon also showed lower donor site complications (17.6% vs. 26.2%) and better rotational stability as measured by pivot shift. Critically, no outcome in these studies favored hamstring over quad tendon (Hurley et al., Journal of ISAKOS, 2022).
An earlier comparative study by Cavaignac et al. (Am J Sports Med, 2017) showed similar findings at a mean 3.6-year follow-up: QT patients achieved significantly better Lysholm and KOOS scores than hamstring patients, with superior KT-1000 stability measurements and a trend toward better pivot-shift control. These results across multiple studies consistently support quad tendon as at least equivalent and often superior to hamstring autograft.
Why I Prefer Quad Tendon for Many of My ACL Reconstructions
This isn’t a theoretical preference. Our group has studied the quad tendon graft, published on it, and presented the data at national and international meetings. In our own three-autograft Biodex comparison study (Hughes, Burnham et al., Orthopaedic Journal of Sports Medicine, 2019), we evaluated isokinetic strength outcomes across quad tendon, BTB, and hamstring autografts. That work contributed to the growing evidence base supporting QT as a primary graft option.
One important finding from our study: patients with quad tendon grafts did demonstrate clinically meaningful quadriceps asymmetry in the early postoperative period compared to BTB and hamstring groups. This underscores the importance of targeted rehabilitation protocols that emphasize quadriceps strengthening and structured recovery exercises after quad tendon ACL reconstruction. With appropriate rehab, these differences resolve, and the long-term outcomes are excellent.
A common patient concern is whether the quad tendon regrows after harvest. The evidence suggests it does. I’ve written about this in detail in a separate article: Does the Quad Tendon Regrow After ACL Reconstruction?
Most recently, at AAOS 2026 in New Orleans, we presented our work on amnion-application-to-the-quad-tendon-harvest-site-during-quad-tendon-acl-reconstruction/”>biologic augmentation of the quad tendon harvest site using amniotic matrix. This represents the next step in optimizing donor site recovery and further reducing the already favorable morbidity profile of this graft. I also use biologics and regenerative medicine techniques in other areas of my practice to support healing and recovery.
For many of my patients, from high school athletes to professionals, quad tendon gives us a strong, reliable graft with the least harvest-site morbidity and an excellent long-term outcome profile. I still use BTB when the clinical situation calls for it. Every patient and every knee is different, and graft selection should always be individualized. But when I look at the totality of the evidence, quad tendon has earned its place as a primary option, not just an alternative. For patients with complex knee injuries that also involve the anterolateral ligament, meniscus tears, or cartilage damage, graft selection is just one piece of a comprehensive reconstruction plan.
The Bottom Line
Every graft decision I make starts with one question: what gives this patient the best chance to return to full activity and compete at a high level for the longest period of time? The biomechanical data, the clinical outcomes, and the growing body of systematic reviews all point in the same direction. Quad tendon autograft is not the graft of the future. It’s the graft of right now.
Patients also considering less invasive options should know about the ACL repair with BEAR implant, which may be appropriate for certain acute ACL tears. During your consultation, we’ll discuss all available options and determine the best approach for your specific injury and goals.
If you’re considering ACL reconstruction and want to discuss graft options specific to your situation, contact our office to schedule a consultation. Learn more about Dr. Burnham and his approach to sports medicine and complex knee reconstruction.
References
- Shani RH, Umpierez E, Nasert M, Hiza EA, Xerogeanes J. Biomechanical comparison of quadriceps and patellar tendon grafts in anterior cruciate ligament reconstruction. Arthroscopy. 2016;32(1):71-75.
- Hadjicostas PT, Soucacos PN, Koleganova N, Krohmer G, Berger I. Comparative and morphological analysis of commonly used autografts for anterior cruciate ligament reconstruction with the native ACL. Knee Surg Sports Traumatol Arthrosc. 2008;16(12):1099-1107.
- Yang XG, Wang F, He X, et al. Network meta-analysis of knee outcomes following anterior cruciate ligament reconstruction with various types of tendon grafts. Int Orthop. 2020;44(2):365-380.
- Hurley ET, Mojica ES, Kanakamedala AC, et al. Quadriceps tendon has a lower re-rupture rate than hamstring tendon autograft for anterior cruciate ligament reconstruction: a meta-analysis. J ISAKOS. 2022;7(2):87-93.
- Hughes JD, Burnham JM, Hirsh A, Musahl V, Fu FH, Irrgang JJ, Lynch AD. Comparison of short-term Biodex results after anatomic anterior cruciate ligament reconstruction among 3 autografts. Orthop J Sports Med. 2019;7(5):2325967119847630.
- Xerogeanes JW. Quadriceps tendon graft for anterior cruciate ligament reconstruction: the graft of the future! Arthroscopy. 2019;35(3):696-697.
- Slone HS, Romine SE, Premkumar A, Xerogeanes JW. Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results. Arthroscopy. 2015;31(3):541-554.
- Cavaignac E, Coulin B, Tscholl P, et al. 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. Am J Sports Med. 2017;45(6):1326-1332.
- Burnham JM. Biologic augmentation of quad tendon harvest site with amniotic matrix. Presented at AAOS 2026, New Orleans, LA. [Read more]
Dr. Burnham is a board-certified orthopedic surgeon and sports medicine specialist at Ochsner Sports Medicine Institute in Baton Rouge, Louisiana. Recognized for his expertise in complex knee reconstruction, ACL surgery, and advanced shoulder procedures, Dr. Burnham combines cutting-edge research with personalized patient care. As a published researcher and active member of the American Academy of Orthopaedic Surgeons, he specializes in helping athletes and active individuals return to peak performance through both surgical and non-surgical treatments. For appointments or consultations, click CONTACT US.
Frequently Asked Questions About Quad Tendon ACL Reconstruction
Quad tendon autograft ACL reconstruction uses a portion of the patient’s own quadriceps tendon (the large tendon above the kneecap) to rebuild a torn anterior cruciate ligament. This graft is harvested from the same knee and provides a strong, thick tissue with excellent biomechanical properties for ligament reconstruction.
Biomechanical studies show quad tendon provides twice the cross-sectional area, 38% greater load to failure, and 68% greater stiffness compared to patellar tendon grafts of the same width. Clinical outcomes are similar between the two grafts, but quad tendon is associated with less anterior knee pain and kneeling discomfort at the harvest site.
A 2022 meta-analysis of 15 studies found a re-rupture rate of 2.5% for quad tendon compared to 8.7% for hamstring autograft (p = 0.01). This lower re-rupture rate, combined with lower donor site complications, makes quad tendon an attractive option for many patients.
Evidence suggests the quad tendon does regenerate after harvest. Read more in our detailed article: Does the Quad Tendon Regrow After ACL Reconstruction?
Recovery timelines are similar to other ACL graft types, typically 9 to 12 months before return to sport. Patients with quad tendon grafts may need specific rehabilitation protocols emphasizing quadriceps strengthening in the early months after surgery, as some studies have shown temporary quadriceps weakness compared to other graft types during the first 5 to 8 months.