A Simple, Anatomical, and Reproducible Technique for Harvesting a Partial-Thickness Layered Rectangular Quadriceps Tendon-Bone Autograft: Using Standard Surgical Instruments.

Anatomic anterior cruciate ligament reconstruction (ACLR) aims to replicate the native 3-dimensional architecture of the anterior cruciate ligament (ACL), including its fiber orientation and insertion site, to restore normal knee biomechanics. The anatomic rectangular tunnel ACLR technique, pioneered by Shino et al., creates rectangular tunnels that better replicate the native ACL's fiber alignment compared with conventional round tunnels. Recently, the quadriceps tendon-bone autograft has gained attention because of its large cross-sectional area, strong tensile properties, and lower incidence of anterior knee pain compared with bone-patellar tendon-bone grafts. This technical note describes a layered quadriceps tendon-bone harvesting technique that preserves the third tendon layer while harvesting a sufficient graft with a rectangular bone block. The method uses minimal instruments and relies on anatomical landmarks to ensure reproducibility and graft quality. Benefits of this technique include anatomical reconstruction of the ACL, decreased graft-tunnel mismatch, potential for reduced tunnel widening, and favorable healing as the result of bone-to-bone integration. Limitations include the technical complexity of tendon harvesting, risk of patellar fracture, and a steep learning curve. With appropriate anatomical knowledge and surgical experience, this approach can be a reliable and effective option for anatomic ACLR.