AJSM - 2026-04-01 - Journal Article
The Rectus Femoris Tendon as a Graft for Combined ACL and Anterolateral Reconstruction: A Biomechanical Evaluation.
Mestriner MB, Reynolds A, Barrosso BG, Rêgo M, Cury RPL, Amis AA
Topics
Key Takeaway
Double-stranded rectus femoris (DRF) ultimate strength (1978 ± 338 N) is statistically equivalent to patellar tendon (1824 ± 557 N), and single-stranded rectus femoris (SRF) is equivalent to ITB (1445 ± 584 N vs. 819 ± 268 N), supporting rectus femoris as a single-donor source for combined ACL and anterolateral reconstruction.
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Summary
This cadaveric study tested whether rectus femoris tendon grafts could biomechanically substitute for patellar tendon (ACL) and ITB (anterolateral) grafts in combined reconstruction. Eight fresh-frozen knees each yielded four grafts (DRF, SRF, PT, ITB) tested to failure on a materials testing machine. DRF ultimate strength did not differ from PT (1978 vs. 1824 N; P=NS), and SRF did not differ from ITB (1445 vs. 819 N; P=NS), though both DRF and PT exceeded ITB in ultimate strength (P<.01) and SRF demonstrated higher elastic modulus than DRF (617 vs. 272 MPa; P<.05).
Key Limitation
Cadaveric specimens had a mean age of 49 years, which does not reflect the tendon mechanical properties of the young athletic population most likely to undergo this procedure, potentially overestimating graft compliance and underestimating ultimate strength in the target demographic.
Original Abstract
BACKGROUND
The rectus femoris (RF) tendon may be an option for combined anterior cruciate ligament (ACL) and anterolateral (AL) reconstruction utilizing a double-stranded (DRF) tendon for the ACL and a single-stranded tendon (SRF) for AL reinforcement; however, biomechanical data remain limited.
PURPOSE/HYPOTHESIS
This study aimed to biomechanically assess the DRF for ACL reconstruction using a patellar tendon (PT) graft and the SRF for AL reconstruction using an iliotibial band (ITB) graft. The hypothesis was that the biomechanical properties of the DRF graft would not differ from those of the PT graft, and the SRF graft would not differ from the ITB graft.
STUDY DESIGN
Controlled laboratory study.
METHOD
Eight fresh-frozen human knees were used: 2 male and 6 female, with a mean age of 49 years (range, 36-64 years). Each knee produced 4 grafts: DRF, SRF, PT, and ITB. Each graft was mounted in a materials test machine. The cross-sectional area was measured using alginate molding. After 10 preconditioning cycles to 250 N, each specimen was extended to failure at 100 mm/min. The Friedman test assessed differences between the 4 graft types using matched samples. The Dunn multiple-comparison test was used to examine differences among graft types.
RESULTS
The ultimate strengths (N) of the grafts were as follows: DRF, 1978 ± 338; SRF, 1445 ± 584; PT, 1824 ± 557; ITB, 819 ± 268 (DRF and PT >ITB; P < .01). The elastic moduli (MPa) were as follows: DRF, 272 ± 59; SRF, 617 ± 153; PT, 318 ± 90; ITB, 631 ±4 31 (DRF and PT<SRF; P < .05). The ultimate tensile stresses (MPa) were as follows: DRF, 51 ± 12; SRF, 89 ± 28; PT, 62 ± 19; ITB, 56 ± 24 (SRF > DRF; P < .05).
CONCLUSION
As hypothesized, the DRF graft exhibits mechanical properties that do not differ from those of the PT graft. Likewise, the SRF graft showed biomechanical properties that do not differ from those of the ITB graft. Therefore, this study supports the use of the RF graft for combined ACL and AL (anterolateral ligament or lateral extra-articular tenodesis) reconstruction.
CLINICAL RELEVANCE
The RF tendon graft is harvested before being merged with other layers, resulting in a longer graft (mean, 273 mm) suitable for folding. This does not create a full-thickness defect through the quadriceps. This approach allows combined ACL + AL reconstruction techniques and additional graft tissue for fixation.