Risk of Quadriceps Rupture Following ACL Reconstruction with Quadriceps Tendon Autograft
Quadriceps tendon rupture following ACL reconstruction using quadriceps autograft is exceedingly rare, with no reported cases in the available high-quality literature, making it a safe graft choice with lower overall graft failure rates compared to hamstring autografts. 1, 2, 3
Evidence on Quadriceps Rupture Risk
The available evidence demonstrates an excellent safety profile for quadriceps tendon autografts:
No documented cases of quadriceps tendon rupture were reported in systematic reviews examining over 1,154 ACL reconstructions using quadriceps tendon autograft 1
A study of 57 patients over age 50 (mean age 54.9 years) followed for minimum 2 years reported zero cases of quadriceps tendon rupture despite this being a higher-risk age group 3
The quadriceps tendon demonstrates robust biomechanical properties that support its use, with adequate remaining tendon tissue after harvest to maintain extensor mechanism integrity 1
Comparative Graft Safety Profile
When comparing overall graft-related complications, quadriceps tendon autografts demonstrate superior outcomes:
Graft rupture rates are significantly lower with quadriceps tendon (2.8%) compared to hamstring tendon (4.9%), with odds of revision surgery 2.7 times greater in hamstring grafts 2
In pediatric populations, quadriceps tendon shows even more pronounced advantages with graft rupture rates of 3.5% versus 12.4% for hamstring autografts (p < 0.001) 4
Highly active patients treated with quadriceps autografts experience fewer ipsilateral graft ruptures (5.0%) compared to hamstring autografts (11.1%) 2
Donor Site Morbidity Considerations
The quadriceps tendon harvest site demonstrates minimal complications:
Donor-site morbidity is less than bone-patellar tendon-bone autografts, with only 4 of 67 patients (6%) reporting moderate kneeling pain and 1 patient (1.5%) reporting harvest-site tenderness at mean 41-month follow-up 5
Quadriceps strength recovery reaches 82% of contralateral limb at 1 year and 89% at 2 years postoperatively 5
No significant changes in patellar position or congruence angle occur after quadriceps tendon harvest 5
Rehabilitation Implications
While quadriceps rupture is not a documented concern, rehabilitation should still protect the donor site appropriately:
Isometric quadriceps exercises can be safely initiated in the first 2 postoperative weeks without compromising stability or increasing donor site complications 6
Closed kinetic chain exercises should be prioritized from week 2 to mitigate patellofemoral stress while allowing safe quadriceps loading 7
Open kinetic chain exercises can be introduced as early as 4 weeks postoperatively in a restricted range of motion (90-45°) 6
Early mobilization within the first week is critical for range of motion recovery without increasing risk of extensor mechanism complications 6, 7
Clinical Decision-Making Algorithm
For patients requiring ACL reconstruction, quadriceps tendon autograft should be strongly considered based on:
Lower graft failure rates compared to hamstring autografts, particularly in young, highly active patients 2, 4
Absence of documented quadriceps rupture risk across all age groups and activity levels 1, 5, 3
Minimal donor site morbidity with faster strength recovery than patellar tendon grafts 1, 5
Excellent functional outcomes with Lysholm scores and return to sport rates comparable to or better than other autograft options 2, 4, 3
Common Pitfalls to Avoid
Do not avoid quadriceps tendon autograft due to unfounded concerns about quadriceps rupture, as this complication is not supported by the literature 1, 3
Do not delay early mobilization and quadriceps activation out of excessive caution, as early exercises are safe and beneficial for outcomes 6
Do not assume all autografts have equivalent graft failure rates, as quadriceps tendon demonstrates statistically significant advantages over hamstring grafts 2, 4