Arthrex Quad ACL Reconstruction: Technique and Recovery

If your ACL tear has been graded and surgery is on the table, one of the first questions your surgeon will ask is which graft to use. Over the last decade, the quadriceps tendon autograft, harvested and fixed using Arthrex instrumentation such as the QuadPro tendon harvester and TightRope fixation system, has become one of the most talked about options in ACL reconstruction. It is not a new ligament in itself. It is a graft source, paired with a surgical system, that many surgeons now consider alongside the more traditional hamstring and bone patellar tendon bone (BTB) grafts.

This guide explains what Arthrex quad ACL reconstruction actually involves, how it compares with other graft choices, what the surgery and recovery look like step by step, and what it typically costs in India. If you already know your tear grade, you may want to read our guide on ACL tear grades and treatment first to understand whether surgery is the right path for you.

Quick Summary

• Arthrex quad ACL reconstruction uses the quadriceps tendon, taken from just above the kneecap, as the graft for a torn ACL.

• The Arthrex QuadPro harvester allows the tendon to be removed through a small 2 to 3 cm cut instead of a long open incision.

• Fixation typically uses Arthrex TightRope and FiberTag implants on the femoral side and a bio composite screw on the tibial side.

• The graft is thicker and stronger on average than a hamstring graft, with comparable clinical outcomes in most studies.

• Full recovery and return to pivoting sports generally takes 8 to 9 months, similar to other ACL graft options.

• Cost in India for ACL reconstruction with a quad tendon autograft and Arthrex implants generally sits in a similar range to hamstring graft surgery, with the final figure depending on the hospital, implants chosen, and whether other procedures are combined.

Understanding the ACL Tear and Why Graft Choice Matters

The anterior cruciate ligament sits deep inside the knee joint and stops the shin bone from sliding too far forward under the thigh bone. Once it tears completely, it does not heal back on its own the way a sprained ankle ligament might. For anyone who wants to return to running, cutting, pivoting sports, or simply wants a stable knee for daily life, reconstruction with a new graft is usually the recommended route.

The graft is essentially spare tissue from your own body (or occasionally donor tissue) that is threaded through drilled tunnels in the thigh bone and shin bone to recreate the job the original ACL was doing. Surgeons have three main autograft sources to choose from: the hamstring tendons at the back of the thigh, the central strip of the patellar tendon with a bone block on either end (BTB), and the quadriceps tendon just above the kneecap. Each has a different thickness, healing pattern, and donor site trade off, which is why the choice of graft is one of the most important decisions in planning your surgery, alongside understanding how an ACL tear differs from a PCL or LCL tear.

What Is Arthrex Quad Tendon ACL Reconstruction?

Quad tendon ACL reconstruction uses a strip of the quadriceps tendon, the thick band of tissue that connects the quadriceps muscle to the top of the kneecap, as the replacement graft for the torn ACL. Arthrex is the medical device company whose harvesting instruments and fixation implants are widely used to perform this procedure, which is why the technique is often referred to in surgical circles simply as "the Arthrex quad technique" or "QuadPro ACL reconstruction."

Traditionally, harvesting the quad tendon required a longer incision above the kneecap, which limited its popularity compared to the hamstring graft. Arthrex changed this with the QuadPro tendon harvester, a specialised instrument that cores out a cylindrical strip of tendon through a small vertical incision, usually 2 to 3 cm in length. This minimally invasive approach is one of the main reasons quad tendon grafts have grown in popularity over the past several years, alongside a growing body of research showing outcomes comparable to hamstring and BTB grafts.

The Arthrex QuadPro System: Key Technology Behind the Technique

A few components make up the modern Arthrex quad ACL reconstruction setup:

• QuadPro tendon harvester: A tubular cutting instrument available in different diameters (roughly 8 mm to 11 mm) that allows the surgeon to harvest a graft matched to the patient's anatomy and knee size, through a small incision.

• FiberTag with TightRope implant: Because a quad tendon graft has only one bony end (unlike a BTB graft), it needs a strong soft tissue anchor point. The FiberTag suture construct grips the tendon end, which is then suspended on the femoral side using an adjustable loop TightRope button.

• BioComposite interference screw: Used on the tibial side to compress the graft securely inside the bone tunnel.

• All-inside GraftLink technique (optional): In some cases, especially where a smaller, all soft tissue graft is preferred, surgeons use titanium buttons on both the femoral and tibial sides instead of a screw, which can reduce tunnel size and preserve more bone stock.

Together, this system is designed to make quad tendon harvest more reproducible and less invasive than older open techniques, while still delivering a graft that is generally thicker in cross sectional area than a standard hamstring graft.

Quad Tendon vs Hamstring vs BTB Graft: How Do They Compare

This is usually the question patients care about most, and it is also where a lot of online content stays vague. Here is a side by side look based on current clinical literature and surgical experience.

Large systematic reviews comparing quadriceps and hamstring tendon autografts have generally found no significant difference in patient reported outcomes or graft failure rates between the two, which means the "better" graft often comes down to individual anatomy, sport, and surgeon preference rather than one option being universally superior. If your hamstring tendons are thin on imaging, or if this is a revision surgery after a previous graft failed, the quad tendon is frequently the preferred option because of its larger, more predictable size.

For a broader look at how grafts are chosen based on your specific tear pattern, our ACL treatment options page covers hamstring, BTB, quad tendon, and peroneal tendon grafts in more detail.

Who Is a Good Candidate for Quad Tendon ACL Reconstruction

Quad tendon ACL reconstruction with the Arthrex system is generally considered for:

• Patients undergoing revision ACL surgery after a previous hamstring or BTB graft has failed.

• Athletes and active individuals whose hamstring tendons are found to be thin or inadequate on MRI or during surgery.

• Patients who want to avoid the anterior knee pain sometimes associated with BTB grafts.

• Younger, high demand athletes in pivoting sports who need a thicker, high strength graft.

• Patients undergoing combined procedures, such as ACL reconstruction with a meniscus repair, where graft strength and reliable fixation matter.

It is generally not the first choice for patients who play sports requiring deep, repeated kneeling (such as wrestling or certain forms of manual labour), since a small number of patients report kneeling discomfort at the harvest site, though this tends to be less pronounced than with a BTB graft.

Step by Step: How the Arthrex Quad ACL Reconstruction Procedure Is Performed

1. Pre-operative planning: Your surgeon reviews MRI imaging, examines knee stability, and confirms graft choice, sometimes finalising the decision to use quad tendon only after checking hamstring thickness during early surgery.

2. Anaesthesia and positioning: The surgery is usually performed under spinal or general anaesthesia, with the patient positioned to allow arthroscopic access to the knee.

3. Diagnostic arthroscopy: A camera is inserted through a small portal to confirm the ACL tear and check the meniscus and cartilage for associated damage, similar to a standard knee arthroscopy procedure.

4. Quad tendon harvest: A small vertical incision is made above the kneecap. The QuadPro harvester is used to core out a cylindrical strip of tendon of the required length and diameter, preserving the remaining tendon structure to support knee extension.

5. Graft preparation: The harvested tendon is prepared on the back table. A FiberTag suture construct is whipstitched into the tendon end to allow it to be attached to the TightRope implant.

6. Tunnel drilling: Anatomic femoral and tibial tunnels are drilled arthroscopically, positioned to match the native ACL footprint as closely as possible for the best rotational stability.

7. Graft passage and fixation: The graft is passed through the tunnels. The TightRope button is flipped and secured on the outer femoral cortex, and the tibial side is fixed using a BioComposite interference screw or an all-inside button, depending on the technique chosen.

8. Tensioning and closure: The graft is tensioned through a full range of motion to confirm stability before the small incisions are closed with sutures.

The entire procedure typically takes between 60 and 90 minutes, and in most centres in India, it is performed as a short-stay procedure with a hospital admission of one to two days.

Benefits of the Arthrex Quad Tendon Technique

• Small, cosmetically favourable incision compared to older open quad harvest techniques.

• Consistently large graft diameter, which is useful when hamstring tendons are undersized.

• Strong suspensory fixation using proven TightRope technology, which has been used in a very large number of ACL procedures worldwide.

• Preserves the hamstring muscles, which can be valuable for athletes in sports that rely heavily on hamstring strength.

• Good option for both primary and revision ACL surgery.

Risks and Possible Complications

As with any ACL reconstruction, there are risks to be aware of, and your surgeon should walk you through these in detail before your operation:

• Temporary quadriceps weakness or a feeling of tightness above the kneecap during early recovery.

• Numbness around the harvest site, which is usually minor and improves over time.

• General surgical risks including infection, blood clots, and stiffness, which apply to any knee arthroscopy procedure.

• Rare risk of patella fracture if the tendon is harvested too deep or too wide, which is why surgeon experience with the QuadPro system matters.

• Graft re-tear, particularly if return to sport happens before adequate strength and stability are confirmed on testing.

Recovery Timeline and Rehabilitation

Recovery follows a broadly similar pattern to other ACL grafts, with slightly more attention paid to quadriceps activation in the first few weeks because of the harvest site.

Physiotherapy plays a central role throughout this timeline. Our detailed guide on physical therapy for ACL tear and our ACL surgery recovery do's and don'ts article both cover this in more depth. Many patients also ask about bracing during the return to activity phase, which is addressed in our guide on knee brace versus knee sleeve for ACL tear.

Cost of Arthrex Quad ACL Reconstruction in India

Cost is one of the most searched questions around this surgery, and it is also one of the hardest to answer with a single number, because it depends on several variables:

• Hospital and city: Costs in metro cities like Bangalore, Mumbai, and Delhi tend to be higher than in smaller cities, though quality of care and surgeon experience matter more than location alone.

• Implants used: Arthrex TightRope, FiberTag, and BioComposite screws are premium implants, and their cost forms a meaningful part of the total bill.

• Type of room and length of stay: A general ward stay costs less than a private room, and most patients are discharged within one to two days.

• Combined procedures: If meniscus repair, cartilage treatment, or additional ligament work is needed at the same time, the overall cost rises accordingly.

• Insurance coverage: Most major health insurance plans in India cover ACL reconstruction as a medically necessary procedure, which can significantly reduce out of pocket expense.

As a general guide, ACL reconstruction surgery in India (across graft types, including quad tendon with Arthrex fixation) typically ranges from around 1.5 lakh to 3.5 lakh rupees, though this is only an indicative range and not a quotation. The most reliable way to get an accurate figure is a consultation, where your surgeon can review your MRI, examine your knee, and give you a personalised cost estimate based on your specific case. You can book an appointment to get this assessment done.

Success Rates and Clinical Evidence

Quad tendon autografts have been studied extensively over the last several years, and the consensus from meta-analyses and randomised trials is reassuring. Comparative studies between quadriceps and hamstring tendon autografts have generally reported similar patient reported outcome scores, similar knee stability on testing, and comparable graft failure rates between the two groups. In revision ACL surgery specifically, quad tendon grafts are increasingly favoured because of their thickness and because they leave the hamstring tendons untouched in case they are needed for a future procedure.

That said, published outcomes reflect averages across many patients and surgical teams. Individual results depend heavily on surgical technique, tunnel placement accuracy, and how well a patient follows the rehabilitation protocol, which is why choosing an experienced knee arthroscopy surgeon matters as much as the graft choice itself.

Why Choose Sports Orthopedics Institute for Your ACL Reconstruction

Sports Orthopedics Institute is led by Dr. Naveen Kumar L.V, Chief of Orthopedics and Sports Medicine at Manipal Hospital, who holds fellowships and qualifications from the UK, Italy, and Portugal, and has over 26 years of experience in advanced arthroscopy and joint reconstruction. With more than 10,000 successful surgical procedures performed, the team has hands-on experience across all ACL graft options, including Arthrex quad tendon reconstruction, hamstring grafts, and BTB grafts, allowing your treatment plan to be built around your knee rather than a one-size-fits-all protocol.

Every patient is guided through pre-surgical planning, the procedure itself, and a structured rehabilitation pathway with close follow-up, so that recovery stays on track from week one through return to sport.

Frequently Asked Questions

What is Arthrex quad ACL reconstruction? 

It is ACL reconstruction surgery that uses a strip of the quadriceps tendon, harvested using Arthrex's QuadPro instrument system, as the replacement graft. Fixation is typically done using Arthrex TightRope and FiberTag implants.

Is quad tendon graft better than hamstring graft for ACL reconstruction? 

Neither is universally better. Most studies show comparable outcomes between the two in terms of stability and function. The quad tendon graft is generally thicker and is often preferred for revision surgery or when hamstring tendons are found to be thin.

How painful is quad tendon harvest compared to hamstring or BTB graft harvest? 

Most patients report harvest site discomfort that is manageable with standard pain medication and improves within a few weeks. It is generally considered less painful long term than BTB harvest, particularly with regard to kneeling discomfort.

How long does recovery take after Arthrex quad ACL reconstruction? 

Most patients can walk without a brace by 6 weeks, jog by around 3 to 4 months, and return to pivoting or contact sport by 8 to 9 months, provided rehabilitation milestones and strength tests are met.

Can quad tendon ACL reconstruction be done for revision surgery? 

Yes, it is one of the most commonly used grafts for revision ACL reconstruction because of its larger, more predictable diameter and because it leaves the hamstring tendons available if needed later.

Does harvesting the quad tendon weaken the knee permanently? 

No, in the vast majority of patients quadriceps strength returns close to normal within 4 to 6 months with consistent physiotherapy, since only a strip of the tendon is taken and the rest of the extensor mechanism remains intact.

What is the cost of ACL reconstruction with a quad tendon graft in India? 

Costs generally range from approximately 1.5 lakh to 3.5 lakh rupees depending on the hospital, city, implants used, and whether additional procedures such as meniscus repair are performed at the same time. A consultation is the only way to get an accurate, personalised estimate.

Is Arthrex quad ACL reconstruction covered by health insurance in India? 

Most major health insurance providers in India cover ACL reconstruction as a medically necessary orthopedic procedure. Coverage details vary by policy, so it is worth confirming directly with your insurer.

How is the QuadPro technique different from older quad tendon harvest methods? 

Older techniques required a longer open incision above the kneecap. The QuadPro tendon harvester allows the same graft to be taken through a much smaller vertical incision, usually 2 to 3 cm, making the procedure less invasive and more cosmetically favourable.

Conclusion

Arthrex quad ACL reconstruction has earned its place as a genuine first line graft option, not just a backup for revision cases. The combination of a thick, reliable tendon graft with minimally invasive harvesting and proven TightRope fixation gives surgeons a technique that performs comparably to hamstring and BTB grafts across most outcome measures, while offering specific advantages for certain patients and certain sports. The right graft for you depends on your anatomy, your sport, and whether this is a first-time or revision surgery, which is best worked out in a detailed consultation with an experienced knee surgeon.

If you are weighing your ACL reconstruction options, you can book an appointment with Sports Orthopedics Institute for a personalised assessment and graft recommendation.

Resource: For further technical reading on the Arthrex QuadPro system and quad tendon graft biomechanics, see Arthrex's official clinical resource page: arthrex.com/knee/quad-tendon-graft-acl-reconstruction.

This article is for general educational purposes and does not replace a consultation with a qualified orthopedic surgeon. Every knee and every ACL tear is different, and treatment should always be personalised after a physical examination and imaging review.