Felipe Silveira Martins

Recurrent patellar instability may persist after isolated medial patellofemoral ligament reconstruction, particularly in cases with instability beyond early knee flexion. Recent evidence has emphasized the role of the medial patellotibial ligament as a secondary stabilizer contributing to patellofemoral stability at higher degrees of flexion. As a result, combined reconstruction of the medial patellofemoral ligament and medial patellotibial ligament has emerged as a promising strategy to restore more physiologic patellar kinematics. This technical note describes a reproducible technique for combined medial patellofemoral ligament and medial patellotibial ligament reconstruction using a single rectus femoris tendon autograft harvested from the superficial layer of the quadriceps tendon. The technique is soft‐tissue‐based and physeal‐sparing and avoids bone tunnels, making it particularly suitable for skeletally immature patients. The rectus femoris graft provides sufficient length, favorable biomechanical properties, low donor‐site morbidity, and satisfactory cosmetic results through a minimally invasive approach.

Purpose: This narrative review synthesises the anatomical, biomechanical, and clinical evidence on the rectus femoris tendon as an autograft for knee ligament reconstruction. Methods: A literature search was conducted in PubMed and Google Scholar up to June 2026 with no language restrictions. A total of 35 articles describing the rectus femoris tendon as a graft for knee ligament reconstruction were included. Results: Cadaveric studies demonstrated consistent morphometric dimensions, with a mean tendon length of approximately 30 cm and graft diameters ranging from 8 to 11 mm. Biomechanical testing across four independent cadaveric studies showed that the doubled rectus femoris provides load‐to‐failure within the range of established anterior cruciate ligament grafts. Multiple harvesting techniques have been described, using the identification of a fat layer between the rectus femoris and the intermediate layer as the primary landmark. The graft has been applied to isolated anterior cruciate ligament reconstruction, combined anterior cruciate ligament and anterolateral or anteromedial ligament reinforcement, posterior cruciate ligament reconstruction, and revision surgery. Early clinical series reported functional outcomes comparable to hamstring tendon autografts, with low donor‐site morbidity. Isokinetic evaluation showed no difference in extensor performance between rectus femoris and hamstring tendon groups at six months. Intraoperative complications included capsular violations and premature graft amputations, concentrated in initial cases and without clinical repercussions. The current clinical evidence is limited to level III and IV studies, with a maximum mean follow‐up of approximately 3.5 years in revision settings and 3 years in primary reconstruction, demonstrating improvement in patient‐reported outcomes and knee stability. Conclusion: The rectus femoris tendon is a viable autograft for knee ligament reconstruction, with consistent anatomy, adequate biomechanical properties, and early clinical results comparable to hamstring tendon autografts. It should be considered in individualised graft selection. Level of Evidence: Level V.

Background: The rectus femoris tendon has recently gained attention as a promising soft tissue autograft for anterior cruciate ligament (ACL) reconstruction. However, there is limited information regarding its graft dimensions, harvesting technique, and safety profile. Purpose: To evaluate the dimensions of the rectus femoris tendon graft in patients undergoing ACL reconstruction, identify anthropometric predictors of graft size, describe key technical steps for safe harvesting, and report intraoperative complications. Study Design: Case series; Level of evidence, 4. Methods: A total of 211 consecutive patients undergoing ACL reconstruction with rectus femoris tendon autograft were prospectively enrolled across multiple centers. Graft dimensions—length and diameter in 2- and 3-strand configurations—were recorded intraoperatively. Correlations between graft size and patient anthropometry were assessed, and a multivariable regression model was developed to predict graft length. Intraoperative complications during graft harvesting were also documented. Results: The mean graft length was 30.8 ± 3.4 cm, with 99.1% measuring ≥24 cm. Mean diameters were 8.1 ± 0.6 mm (2-strand) and 9.3 ± 0.7 mm (3-strand), with only 1.4% of 3-strand grafts measuring <8 mm. Patient height showed the strongest correlation with graft length (r = 0.563). Complications occurred in 11.4% of cases, mostly minor and during the early adoption phase of this technique. Conclusion: The rectus femoris tendon provides consistent and predictable graft dimensions suitable for multistrand ACL reconstruction, including in patients at higher risk of undersized soft tissue grafts. These morphometric findings support its potential as an autograft option and provide a basis for preoperative planning. Clinical outcomes and donor-site morbidity require evaluation in future studies.