ACL Reconstruction Step by Step: Quadriceps Tendon (Quad) Graft

Medically reviewed by M. Brett Raynor, M.D., board-certified orthopaedic sports medicine surgeon. Updated October 2026.

This animation walks through how I reconstruct a torn ACL with a quadriceps tendon graft. Once it tears, the ACL typically doesn't heal on its own, so instead of repairing it I make a new one. After checking the knee under anesthesia, I look inside through two small poke-hole incisions and clear out the torn ligament. Through a short incision just above the kneecap, I take a strip from the center of your quadriceps tendon, with no bone, and close the tendon back together. The graft is set up on adjustable loops so I can tension it precisely. I make a socket in the thigh bone and a tunnel in the shin bone, pull the graft up into place, and hold it with a small button on each bone, with an anchor below backing up the fixation.

 

In this video

  • 0:00 The ACL and how it tears
  • 0:23 Checking the knee under anesthesia
  • 0:37 Small incisions and a look inside
  • 1:00 Clearing out the torn ACL
  • 1:11 Taking the quadriceps tendon graft
  • 1:41 Making the socket in the thigh bone
  • 2:01 Making the tunnel in the shin bone
  • 2:12 Pulling the new ligament into place
  • 2:29 The new ACL
  • 2:44 Closing the incisions

Common questions

Why does a torn ACL need to be reconstructed?

Once it tears, the ACL typically doesn't heal on its own. Instead of sewing it back together, I make a new ligament and place it right where the old one was.

Where does the new ACL come from with a quadriceps tendon graft?

From your own quadriceps tendon, just above the kneecap. Through a short incision, I take a strip from the center of the tendon, with no bone. A harvester slides up the tendon and cuts a graft exactly the right length and size, and then I close the tendon back together with strong stitches.

How is the new ligament held in place?

The graft is set up on adjustable loops so I can tension it precisely. A small button goes through the thigh bone and flips, so it can't pull back through, and pulling the strands draws the graft up into the socket. A button on the shin bone holds the bottom end at just the right tension, and an anchor below it backs up the fixation.

How are the incisions closed?

Each small poke-hole incision is closed with a single stitch. The incisions above the kneecap and on the shin are closed with dissolving stitches under the skin and skin glue.

Full transcript

This is the knee. The anterior cruciate ligament, or ACL, runs through the middle of the joint and keeps the tibia, or shin bone, from sliding and twisting out from under the femur, or thigh bone. Once it tears, the ACL typically doesn't heal on its own. Once you're asleep, I check the knee one more time. This shifting is called a pivot shift, and it's exactly what we're here to fix. It's what you feel that makes your knee feel unstable with cutting, pivoting, and twisting activities. I start with two small poke-hole incisions, one on each side of the patellar tendon in the front of the knee. One is for the camera and the other is for my instruments. First I look at everything inside the knee: the meniscus, the cartilage, and the other ligaments. A small motorized shaver clears out the torn ACL. This is what I see through the camera. Then I clear out the other end, up on the femur, or thigh bone. For the graft, I make a short incision just above the kneecap and I go down through all the layers to the tendon. Your new ligament comes from the quadriceps tendon, just above the kneecap. I take a strip from the center of the tendon, with no bone. A harvester slides up the tendon and cuts a graft exactly the right length and size. Then I close the tendon back together with strong stitches. The graft is set up on adjustable loops so I can tension it precisely. Then a guide lets me place a flexible pin right in the center of where your ACL started on the femur. A flexible reamer then is used to make a socket in the femur. Next, a smaller flexible reamer is used to poke a hole in the lateral cortex that will allow the fixation button to pass through. Next, we drill a tunnel in the tibia, or shin bone. A small button goes through the bone and flips, so it can't pull back through. Pulling these strands draws the graft up into the socket on the thigh bone. Then a button on the shin bone holds the bottom end at just the right tension. An anchor below it backs up the fixation. The knee is now fully stable and moves fully. Inside, the new ligament sits right where the old one was, held by small buttons on the bone. Each small poke-hole incision is closed with a single stitch. The incisions above the kneecap and down on the shin are closed with dissolving stitches under the skin and skin glue.

Related

This video and page are general education and are not a substitute for an evaluation of your own knee, shoulder or hip.

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