ACL Reconstruction Using Rectus Femoris Tendon

Anterior Cruciate Ligament (ACL) reconstruction is a surgical procedure to restore knee stability following ligament rupture. This technique uses the rectus femoris tendon as a graft. Unlike traditional methods that harvest bulkier segment of the quadriceps tendon, this approach harvests a targeted layer, aiming to reduce donor site trauma while maintaining graft integrity.

The rectus femoris tendon graft is longer than both the standard quadriceps tendon and the partial thickness quadriceps tendon. This allows the graft to be folded into a thicker construct, which improves knee stability. The harvesting technique is minimally traumatic, helping to preserve surrounding tissue.

A new approach designed at Singapore General Hospital (SGH) in 2025, the Bidirectional Tendon Strip (BTS) technique, uses the rectus femoris (RF) tendon for ACL reconstruction. The BTS technique facilitates the harvest of a better graft, with lower morbidity, and therefore faster recovery. The RF tendon is favoured for its biomechanical robustness and biological integration potential. This method enables controlled graft harvesting with predictable thickness and length, suitable for a broad range of reconstructions, including ACL and PCL reconstruction.

This technique has been published and presented internationally. View full article for details.

What Happens during the ACL Surgery

The procedure is typically performed under general anaesthesia. The surgeon will:

• Make a small (2-3cm) incision to access rectus femoris tendon
• Harvest the graft using minimally invasive tools, preserving deeper muscle layers.
• Prepare the knee joint by removing remnants of the torn ACL.
• Insert the graft into the knee using arthroscopic guidance, anchoring it securely to the femur and tibia.
• Close the incision and apply sterile dressings.

Patients will undergo a clinical assessment including imaging (e.g. MRI) to confirm ACL rupture and evaluate suitability for this technique. SGH's experienced orthopaedic team will guide you through every step of your ACL surgery preparation to ensure optimal outcomes. Pre-operative instructions may include:

• Avoiding certain medications
• Fasting before surgery
• Arranging post-operative support and transport

Recovery typically involves:

• Pain management with prescribed medication
• Use of crutches or a knee brace as advised
• Physiotherapy to restore range of motion and strength
• Follow-up appointments to monitor healing

Patients are encouraged to follow rehabilitation protocols closely to optimise recovery and reduce the risk of re-injury. SGH's multidisciplinary team will support you throughout your ACL surgery recovery to ensure the best possible outcomes.

This technique builds on the advantages shown by research in this area of ACL surgery. It addresses the current shortcomings to give patients a better ACL graft, with faster recovery rates.

FAQs

Is this technique suitable for all ACL injuries?

It may be considered for patients requiring ACL reconstruction, especially those who could benefit from a less invasive graft harvest, with an emphasis of faster recovery. Suitability depends on individual anatomy and injury characteristics.

How does it differ from traditional ACL reconstruction?

Traditional methods often use hamstring or patellar tendon grafts. This technique uses a rectus femoris tendon, which may result in less post-operative pain and quicker rehabilitation

What are the pros and cons of the BTS technique?

Pros:

• Faster recovery
• Small incisions at areas that heal well and scar less
• Strong and long tendon suitable for a wide range of reconstructions·       Less anterior knee pain
• Less hamstring weakness 

Cons:

• Additional thigh incision (2-3cm)

How long does ACL surgery using rectus femoris tendon take at SGH?

The procedure typically takes 1-2 hours, depending on the complexity of your case. SGH's orthopaedic surgeons will discuss the expected duration during your pre-operative consultation.

Why does SGH use rectus femoris tendon for ACL reconstruction?

The rectus femoris tendon offers excellent strength and is suitable for patients who may not be candidates for other graft types. Our surgeons will determine if this technique is right for your specific ACL injury.

What makes SGH's approach to ACL surgery different?

SGH combines advanced surgical techniques with comprehensive rehabilitation programmes, ensuring patients receive expert care from initial consultation through full recovery after ACL surgery.

How soon can I return to sports after my ACL surgery at SGH?

Return to sports typically takes 6-12 months, depending on your healing progress and sport type. SGH's physiotherapy team will guide your rehabilitation to ensure safe return to activities.