Comparative Biomechanical Strength of Autografts for Ligament Reconstruction: Quadriceps, Rectus Femoris, Peroneus Longus, Patellar, Hamstring quadruple, Hamstring braided, and Iliotibial Band.

Comparative Biomechanical Strength of Autografts for Ligament Reconstruction: Quadriceps, Rectus Femoris, Peroneus Longus, Patellar, Hamstring quadruple, Hamstring braided, and Iliotibial Band. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Biomechanical Strength of Autografts for Ligament Reconstruction: Quadriceps, Rectus Femoris, Peroneus Longus, Patellar, Hamstring quadruple, Hamstring braided, and Iliotibial Band. Márcio Bezerra Gadelha Lopes, Diego Ariel de Lima, Jonatas Brito Alencar Neto, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8715724/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Selecting the optimal autograft for knee ligament reconstruction is a critical factor influencing graft strength, surgical strategy, and postoperative outcomes. Although patellar and hamstring tendons are traditionally preferred, emerging options—including quadriceps, rectus femoris, peroneus longus, braided hamstrings, and iliotibial band (ITB)—have gained attention. However, direct biomechanical comparison under standardized conditions remains limited. Hypothesis: It was hypothesized that the four emerging grafts (rectus femoris, peroneus longus, braided hamstrings, and ITB) would demonstrate ultimate load to failure comparable to the three traditional autografts, with potential mechanical advantages for the rectus femoris and peroneus longus tendons. Study Design: Controlled laboratory biomechanical study. Methods: Fifty-eight grafts were harvested from adult cadaveric donors (all male; mean age, 35 ± 5 years). Seven autograft types were evaluated: full thickness quadriceps, double strand rectus femoris, double strand peroneus longus, patellar (soft-tissue portion of the bone–patellar–tendon–bone), quadruple strand hamstring (parallel and braided configurations), and iliotibial band. Each graft was fixed in polyurethane foam blocks with titanium interference screws and tested to failure in a universal testing machine (EMIC DL 10000) at 10 mm/min. Ultimate load to failure (N) was compared among groups using one-way ANOVA with Tukey’s post hoc analysis (α = 0.05). Results: Significant between-group differences were observed (p < 0.001). The full-thickness quadriceps tendon demonstrated the highest ultimate load (2302.9 ± 79.7 N), significantly exceeding all other grafts. The peroneus longus tendon showed high resistance (1991.3 ± 160.3 N), greater than patellar, hamstring-parallel, rectus femoris, and ITB grafts (p 0.05). Braided hamstrings demonstrated an 8.2% increase over parallel hamstrings (1821.8 ± 11.7 N vs 1683.8 ± 80.5 N), though not statistically significant. The ITB demonstrated the lowest resistance (749.1 ± 155.4 N; p < 0.001). Conclusion: All autografts tested, with the exception of the iliotibial band, demonstrated biomechanical adequacy for knee ligament reconstruction with respect to ultimate load to failure. The full thickness quadriceps and double strand peroneus longus tendons exhibited the greatest mechanical strength, while the double strand rectus femoris and braided quadruple strand hamstring configurations showed similar properties to patellar tendon and parallel quadruple strand hamstring. Anterior cruciate ligament Autologous graft Biomechanics Mechanical strength Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Knee ligament reconstruction is among the most frequent procedures in sports orthopaedics, and graft selection remains one of its most decisive factors for surgical success. The choice of autograft directly affects mechanical stability, biological incorporation, and postoperative recovery. Traditionally, the hamstring and bone–patellar–tendon–bone (BPTB) autografts have been the mainstay for anterior cruciate ligament (ACL) and other ligament reconstructions. However, alternative grafts such as the quadriceps, rectus femoris, and peroneus longus tendons have gained attention as viable options offering comparable mechanical strength and potentially reduced donor-site morbidity 3 , 18 , 32 , 37 . Previous biomechanical investigations have reported promising results for some of these grafts, yet most studies have analyzed only one or two tendons under heterogeneous conditions of specimen preparation, fixation, and testing methodology. This variability limits direct comparisons and weakens clinical translation. In particular, the rectus femoris tendon—representing the superficial layer of the quadriceps complex—has recently emerged as an autograft candidate due to its adequate length, consistent diameter, and favorable biomechanical properties 3 , 7 , 14 , 18 , 33 . Similarly, the peroneus longus tendon has demonstrated tensile resistance comparable to traditional hamstring grafts, with minimal effect on ankle strength and function 3 , 18 , 32 , 39 . In contrast, the iliotibial band (ITB) has historically been used as a reinforcement graft in lateral extra-articular procedures—such as the modified Lemaire technique and its variations—rather than as a primary intra-articular graft. Its limited cross-sectional area and lower tensile resistance may restrict its application to adjunctive stabilization rather than ligament reconstruction itself 18 , 20 . A comprehensive comparative evaluation under standardized conditions is therefore essential to guide graft selection based on biomechanical performance. The purpose of this cadaveric study was to compare the ultimate load to failure among seven autografts for ligament reconstruction — three commonly used and well described in the literature (full thickness quadriceps, patellar, and hamstring tendons) and four emerging options (rectus femoris, peroneus longus, braided hamstrings, and iliotibial band tendons) — using identical fixation and testing protocols. We hypothesized that the four emerging grafts would demonstrate failure load properties comparable to those of the three conventional grafts, with a potential mechanical advantage for the rectus femoris and peroneus longus tendons under standardized testing conditions. MATERIALS AND METHODS Study Design and Ethical Approval This anatomical experimental study was approved by an independent institutional Research Ethics Committee and conducted in accordance with international ethical standards and the Declaration of Helsinki. Graft collection was authorized by a certified national forensic institute, and all biomechanical testing was carried out in a university engineering laboratory equipped for orthopaedic mechanical research. All procedures involving human biological material complied with national and institutional ethical regulations (Resolutions CNS 441/2011 and 466/2012; Operational Norm CNS 001/2013). Written consent for tissue donation was obtained from the donors’ families, and the final disposal of specimens followed biosafety and traceability standards at an authorized facility. Specimens and Inclusion Criteria Twelve knees from six fresh adult cadaveric donors were included. The specimens corresponded to the first six cadavers whose families provided authorization for anatomical research, in accordance with institutional and legal procedures. No selection criteria related to sex, age, body habitus, or anthropometric characteristics (such as body mass index, weight, or height) were applied. Cadavers presenting traumatic or degenerative lesions that interfered with graft dissection were excluded. Because of local legal and logistical procedures, tissue retrieval could only occur 6 to 12 hours after death, following family authorization and completion of the autopsy report. During this period, cadavers were kept at room temperature. This delay was consistent among all samples and is recognized as a methodological limitation. After collection, the specimens were stored at − 20°C and thawed for 12 hours at room temperature before testing. No additional hydration protocol was applied after thawing. Graft Harvesting Three incisions were made to obtain the grafts: a median anterior incision at the knee, a lateral thigh incision, and a lateral ankle incision. After dissection by planes, the following grafts were harvested (Fig. 1 ): 12 × Peroneus longus tendons (folded in half: double strand configuration) 12 × Iliotibial bands (fascia lata) (10 mm width, doubled over) 12 × Patellar tendons (BPTB), soft-tissue portion only, 10 mm width 6 × Rectus femoris tendons (folded in half: double strand configuration) 4 6 × Quadriceps tendons, full-thickness, 10 mm width × full thickness 6 × Hamstring tendons (gracilis + semitendinosus): quadruple strand configuration, parallel arrangement 6 × Hamstring tendons (gracilis + semitendinosus) - quadruple strand braided arrangement 2 For nomenclature purposes, the term “quadriceps tendon” refers to a full-thickness graft harvested without a bone plug. All grafts were kept moist with sterile gauze during dissection and preparation. Preparation of Test Samples To simulate clinical conditions of ligament reconstruction, each graft was mounted in two polyurethane foam blocks (ABNT NBR 15678:2020; Nacional Ltda, São Paulo, Brazil), representing the femoral and tibial tunnels. The blocks had the following properties: Dimensions: 100 × 100 × 30 mm Density: 40 pcf (0.96 g/cm³) Color: brown Tunnel: 30 mm length through the center of the 100 × 100 mm face, with a diameter matching the graft diameter. A trained orthopaedic surgeon performed all fixation procedures. Each block was drilled with a tunnel corresponding to the graft diameter, allowing 3 cm of free graft between the blocks. Titanium interference screws (30 mm length, diameter equal to graft; ASTM F136 alloy, Traumédica®, São Paulo, Brazil) were inserted from outside to inside using a Kirschner wire as a guide to ensure alignment. The final configuration was Screw–Block–Graft–Block–Screw (Fig. 2 ). Mechanical Testing All tests were performed using a universal testing machine (EMIC DL 10000, São José dos Pinhais, PR, Brazil) in axial traction mode (Fig. 2 ). Each construct was clamped with vice-type jaws at both ends, and the upper assembly was secured by a transverse steel pin aligned with the load axis. A pre-load of approximately 50 N was applied to align the construct and eliminate slack. Testing was performed under displacement control at a rate of 10 mm/min until graft rupture or slippage occurred. The objective was to measure static ultimate load to failure; cyclic loading and stiffness analysis were not included, as they were beyond the scope of this study and are suggested for future research. Load–displacement data were continuously recorded. The ultimate load to failure (N) was defined as the maximum force before a sudden drop on the curve. All failures occurred by tendon rupture, not by slippage of the fixation construct. Biosafety Compliance All procedures involving human biological material were conducted in accordance with international ethical principles and national biosafety regulations. The study protocol complied with the principles established in national resolutions governing research involving human material, which define ethical standards, storage, use, and disposal of biological specimens for scientific purposes. Family members of all donors provided written informed consent authorizing tissue collection and temporary storage for research. The final disposal of biological material was carried out in an authorized facility, following biosafety and traceability standards to ensure safety, compliance, and transparency throughout all stages of the study. Statistical Analysis The primary variable analyzed was ultimate load to failure (N). Data normality was verified using the Shapiro–Wilk test. Between-group comparisons were performed using one-way ANOVA, followed by Tukey’s post-hoc test for multiple comparisons. All results were expressed as mean ± standard deviation (SD) and 95% confidence intervals (CI). Statistical significance was set at p < 0.05. Effect size (η²) was calculated to assess the magnitude of group differences. A post-hoc power analysis based on group means and SDs demonstrated a statistical power of 95.8% for the one-way ANOVA (α = 0.05), with a total of 58 samples distributed among seven groups. All analyses were performed using SPSS v28 (IBM Corp., Armonk, NY, USA) and GraphPad Prism v9.0 (GraphPad Software, San Diego, CA, USA). RESULTS A total of 58 tendon grafts were obtained from 12 knees of six fresh cadaveric donors (all male; mean age, 35 ± 5 years). The primary biomechanical variable analyzed was the ultimate load to failure (N). Two specimens were damaged during dissection and handling—one iliotibial band and one hamstring (parallel configuration)—and were therefore excluded from the final analysis. Significant differences in failure load were found among the graft groups (one-way ANOVA, p < 0.001; F-value = 139.48). Multiple comparisons using Tukey’s post-hoc test demonstrated: The full thickness quadriceps tendon (10 mm × full thickness) showed the highest mean ultimate load (2302.9 ± 79.7 N), significantly greater than all other grafts ( p < 0.001 for all pairwise comparisons). The double strand peroneus longus tendon configuration presented high resistance (1991.3 ± 160.3 N), statistically greater than the patellar ( p = 0.0003), quadruple strand hamstring-parallel configuration ( p = 0.0001), double strand rectus femoris configuration ( p = 0.0015), and iliotibial band ( p < 0.001) groups. The patellar tendon reached a mean failure load of 1734.7 ± 136.2 N, with no significant differences compared to the double strand rectus femoris configuration (1713.9 ± 56.1 N) or quadruple strand hamstring-parallel configuration (1683.8 ± 80.5 N) grafts ( p > 0.05). Quadruple strand hamstring tendons parallel vs. braided showed similar results. The braided configuration exhibited a mean ultimate load of 1821.8 ± 11.7 N, an average increase of 8.2% compared with the parallel configuration (1683.8 ± 80.5 N), without statistical significance ( p = 0.2967). The doubled over iliotibial band (fascia lata) showed the lowest mean resistance (749.1 ± 155.4 N), significantly lower than all other groups ( p < 0.001 for all comparisons). All specimens failed by tendon rupture rather than slippage of the fixation system. Titanium interference screws maintained stable fixation in the polyurethane blocks, without visible deformation or loosening. Table 1 and Fig. 3 summarizes the descriptive data for each group. Qualitative Observations Distinct patterns were observed in the load–displacement curves of the tested grafts. Uniform, single strand grafts such as the quadriceps and patellar tendons demonstrated smooth sinusoidal curves, with maximum load typically reached near 10 mm of displacement (Fig. 3 ). Table 1 Ultimate Load to Failure of Autologous Graft Configurations. N = Newtons Graft Type n Mean (N) SD (N) 95% CI Lower (N) 95% CI Upper (N) Full thickness quadriceps 6 2302.9 79.7 2219.3 2386.5 Double strand peroneus longus 12 1991.3 160.3 1889.5 2093.2 Quadruple strand hamstring - braided 5 1821.8 11.7 1807.3 1836.3 Patellar tendon 12 1734.7 136.2 1648.1 1821.3 Double strand rectus femoris 6 1713.9 56.1 1655.1 1772.7 Quadruple strand hamstring - parallel 6 1683.8 80.5 1599.3 1768.2 Iliotibial band (doubled over) 11 749.1 155.4 644.7 853.5 Multistrand grafts such as the parallel quadruple strand hamstring, double strand rectus femoris, and iliotibial band doubled over exhibited plateau-like curves approaching the failure point, whereas the braided quadruple strand hamstring displayed a broader plateau during peak load, characterized by an initial fiber realignment followed by progressive accommodation of the braided strands, resulting in greater displacement before rupture (Fig. 4 ). DISCUSSION The main finding of this cadaveric biomechanical study was that the full thickness quadriceps tendon exhibited the highest ultimate load to failure among all autografts tested (2302.9 ± 79.7 N). With the exception of the iliotibial band (749.1 ± 155.4 N), all other tendon configurations —the peroneus longus, hamstring (braided and parallel), patellar (soft-tissue portion), and rectus femoris—showed resistance levels comparable to or exceeding the mechanical strength typically reported for the native ACL, which ranges between 1700 and 2100 N 6,10,24,26 . These results indicate that most of the tested grafts can provide sufficient structural integrity for ligament reconstruction in the knee joint. Our sample consisted of 58 tendons, with an average of 7.8 per group, which is consistent with other biomechanical studies in the literature, generally ranging from 6 to 12 per group 3 , 5 , 14 , 18 , 23 , 28 , 33 , 38 . The superior mechanical strength of the full thickness quadriceps tendon found in this study is consistent with that reported by Shani et al. 29 , who observed a mean failure load of 2186 N for the quadriceps compared to 1580 N for the patellar tendon ( p = 0.045). This difference has been attributed to the greater cross-sectional area of the quadriceps tendon and to its collagen fiber orientation, which may distribute the tensile load more efficiently. Similar results were reported by Xerogeanes 36 , who demonstrated that the quadriceps tendon contains approximately 20% more collagen fibrils per cross-sectional area than the patellar tendon, supporting up to 70% higher load at failure under similar geometric conditions. However, some studies report no difference comparing full thickness quadriceps tendon with patellar tendon and quadruple strand hamstrings 33 . It is important to note that the results may not be the same for the common used partial thickness quadriceps graft, not evaluated in the current study, already proved to be biomechanically weaker in other studies 33 . Hart et al. 14 also reported no significant differences in failure load between quadriceps, hamstring, and patellar tendons, a finding that partially diverges from our results. This discrepancy can be explained by differences in specimen characteristics: Hart’s study used cadavers with a mean age of 75 years, whereas our sample involved younger donors with a mean age of 35 years 14 . Tendon mechanical strength can be affected by age and sex, being decreased in female patients and also older patients, which likely contributed to the lower loads observed in that study 31 . Regarding the hamstring grafts, our results align with those of Urchek and Karas 35 , who found no significant difference in failure load between hamstring and quadriceps grafts. However, they reported greater stiffness for the hamstring graft (1148 ± 339 N/mm) than for the quadriceps (808 ± 173 N/mm; p = 0.04) 35 . Although our study focused solely on four-strand constructs and did not measure stiffness, this difference emphasizes that graft configuration —number of strands, braiding, and length—strongly influences mechanical performance 31 . Tis 2002 had demonstrated that braided hamstrings showed inferior mechanical strenght and stiffness comparing to parallel configuration, a result different from our findings 34 . In our series, braiding of the hamstring graft resulted in a considerable 8.2% increase in peak load compared with the parallel configuration, although this difference was not statistically significant. Even so, the increase in cross-sectional area associated with braiding may provide a biomechanical advantage in surgical situations where thinner tendons (< 8 mm) are encountered. This observation is consistent with reports suggesting that hamstring grafts smaller than 8 mm are associated with a higher risk of postoperative failure 1 , 9 , 11 . Authors such as Park et al. 22 and Samitier and Vinagre 27 have described a four-strand braiding technique. According to these authors, braiding a four-strand hamstring autograft may increase the graft diameter by approximately 1 to 1.5 mm; however, it is associated with a shortening of approximately 5 to 10 mm. The rectus femoris graft also exhibited mechanical performance comparable to the patellar and hamstring grafts, with no statistically significant differences. These findings are consistent with the observations of Chivot et al. 8 , who showed that the superficial lamina of the quadriceps tendon—corresponding to the rectus femoris portion—presents tensile properties similar to those of the hamstring tendons. Although their study found equivalent strength and stiffness between the superficial quadriceps layer and the iliotibial band, our data demonstrated inferior resistance for the ITB, suggesting that ITB may not be suitable as a primary intra-articular graft. Importantly, biomechanical evidence published in 2025 by Pineda et al. 25 further supports the mechanical viability of the rectus femoris tendon. In a paired cadaveric comparison, Pineda et al. 25 reported that double-stranded rectus femoris grafts exhibit ultimate stress comparable to patellar tendon grafts (46.4 ± 10.5 MPa vs 52.9 ± 9.7 MPa; p = 0.184), despite demonstrating lower absolute load to failure (885.9 ± 52.3 N vs 1278.7 ± 207.5 N; p < 0.001) and greater elongation at failure (1.2% vs 0.2%; p < 0.001). These findings reinforce that, although rectus femoris grafts may show lower structural resistance when used in a double-strand configuration, their intrinsic tissue-level strength closely approximates that of the patellar tendon, supporting their use as a clinically relevant soft-tissue autograft option. In contrast, the mechanical performance of the peroneus longus tendon was notably high in our study (1991.3 ± 160.3 N), surpassing most traditional grafts, including the patellar and hamstring tendons. This is in agreement with recent reports positioning the peroneus longus as a reliable autograft option. Opoku et al. 21 demonstrated that the peroneus longus tendon has stiffness comparable to or higher than hamstring tendons, while maintaining similar diameters and minimal donor-site morbidity. Furthermore, several studies have reported favorable clinical and biomechanical outcomes supporting its use, demonstrating that double strand peroneus longus constructs can sustain tensile loads exceeding 4000 N - values comparable to those of 3,15,17,18,30 . An important consideration when interpreting absolute strength values is the effect of cross-sectional geometry. The quadriceps grafts in our study were used at full thickness (aproximately 8 mm), whereas patellar grafts measured around 5 mm. If adjusted for area, the stress (N/mm²) of the patellar tendon could approximate or even exceed that of the quadriceps tendon, as suggested by Chivot et al. 8 . This reinforces the idea that while the quadriceps tendon is biomechanically robust, the patellar tendon remains highly efficient in load-bearing per unit area. Contrary to the authors’ initial hypothesis, the iliotibial band presented the lowest load to failure (749.1 ± 155.4 N), significantly inferior to all other grafts, indicating that it may not be an appropriate option for primary intra-articular ligament reconstruction. However, its anatomical characteristics and low donor-site morbidity make it clinically useful for extra-articular procedures, particularly for anterolateral reinforcement techniques such as those of Lemaire and its modern modifications 19 . These findings are consistent with current biomechanical and clinical evidence supporting the ITB’s role in controlling rotational instability and reducing graft elongation in combined ACL reconstructions 12 , 13 , 16 . Thus, from a purely biomechanical standpoint, we have at least six strong graft options, all of which can be considered viable for knee ligament reconstructions. Moreover, the iliotibial band demonstrated good potential for use as an extra-articular reinforcement. Of course, this study has several limitations and should not be used as the sole guideline for clinical decision-making. Furthermore, additional studies are warranted to validate and expand upon these findings. Limitations and Future Directions Several limitations of this study must be acknowledged. The time between death and tissue collection (6–12 hours at room temperature) may have influenced the mechanical properties of the grafts, although this delay was consistent across all specimens. Only male cadavers were included, which limits generalizability regarding sex-related differences in tendon properties. Some groups had small sample sizes (e.g., five braided hamstring grafts), which could reduce statistical sensitivity. Moreover, the absence of stiffness and cyclic-loading evaluations restricts the interpretation of elastic and fatigue behavior. The use of polyurethane blocks, although standardized and compliant with NBR 15678:2020, does not perfectly reproduce the mechanical characteristics of human bone and graft–bone interface dynamics. Despite these limitations, this study provides a comprehensive comparative analysis of six commonly used autografts under uniform testing conditions. The quadriceps and peroneus longus tendons demonstrated the highest absolute failure loads, while the iliotibial band exhibited inferior resistance but remains relevant for extra-articular reinforcement procedures. The findings contribute to the growing body of biomechanical evidence guiding graft selection for primary and revision ligament reconstructions and highlight potential directions for future research, including stiffness characterization, cyclic fatigue testing, and in vivo clinical validation of emerging graft options. CONCLUSION All autografts tested, with the exception of the iliotibial band, demonstrated biomechanical adequacy for knee ligament reconstruction with respect to ultimate load to failure. The full thickness quadriceps and double strand peroneus longus tendons exhibited the greatest mechanical strength, while the double strand rectus femoris and braided quadruple strand hamstring configurations showed similar properties to patellar tendon and parallel quadruple strand hamstring. Abbreviations ACL Anterior Cruciate Ligament EMIC universal testing machine DL 10000 ITB Iliotibial Band BPTB Bone–Patellar–Tendon–Bone N Newton SD Standard Deviation CI Confidence Interval. Declarations Authors Márcio Bezerra Gadelha Lopes; Diego Ariel de Lima; Jonatas Brito de Alencar Neto; Sergio Marinho de Gusmão Canuto; Renata Clazzer; Camilo Partezani Helito; Carlos Eduardo da Silveira Franciozi Hypothesis It was hypothesized that the four emerging grafts (rectus femoris, peroneus longus, braided hamstrings, and ITB) would demonstrate ultimate load to failure comparable to the three traditional autografts, with potential mechanical advantages for the rectus femoris and peroneus longus tendons. Study Design Controlled laboratory biomechanical study. Results Significant between-group differences were observed (p < 0.001). The full-thickness quadriceps tendon demonstrated the highest ultimate load (2302.9 ± 79.7 N), significantly exceeding all other grafts. The peroneus longus tendon showed high resistance (1991.3 ± 160.3 N), greater than patellar, hamstring-parallel, rectus femoris, and ITB grafts (p 0.05). Braided hamstrings demonstrated an 8.2% increase over parallel hamstrings (1821.8 ± 11.7 N vs 1683.8 ± 80.5 N), though not statistically significant. The ITB demonstrated the lowest resistance (749.1 ± 155.4 N; p < 0.001). Conclusion All autografts tested, with the exception of the iliotibial band, demonstrated biomechanical adequacy for knee ligament reconstruction with respect to ultimate load to failure. The full thickness quadriceps and double strand peroneus longus tendons exhibited the greatest mechanical strength, while the double strand rectus femoris and braided quadruple strand hamstring configurations showed similar properties to patellar tendon and parallel quadruple strand hamstring. Declarations Ethics approval and consent to participate This cadaveric biomechanical study was approved by the Research Ethics Committee of the UERN - UNIVERSIDADE DO ESTADO DO RIO GRANDE DO NORTE, Brazil (CAAE: 82811424.2.0000.5294). All procedures were conducted in accordance with national regulations and international ethical standards for research involving human biological material and complied with the principles of the Declaration of Helsinki. Written informed consent for tissue donation and research use was obtained from the legal representatives (next of kin) of all donors. Consent for publication Not applicable. Funding This study received no external funding from public agencies, commercial entities, or nonprofit organizations. All laboratory procedures and biomechanical testing resources were provided by the authors’ institutions. Author Contribution MBGL, DAL, and CESF conceived and designed the study. MBGL, JBAN, and SMGC performed graft harvesting and specimen preparation. DAL, RC, and CPH conducted the biomechanical testing and data acquisition. DAL and MBGL performed the statistical analysis. DAL drafted the manuscript. All authors critically revised the manuscript, approved the final version, and agree to be accountable for all aspects of the work. Acknowledgement The authors gratefully acknowledge the essential technical support provided by Zoroastro Torres Vilar, Rodrigo Nogueira de Codes, Macleane Ferreira Leite Monteiro, and Antonio Fabrício de Almeida, whose expertise in mechanical engineering and operation of the EMIC testing system was indispensable for the execution of the biomechanical experiments. Their contributions were fundamental to the successful completion of this research project. Data Availability The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. References Ariel de Lima D, Helito CP, de Gusmão Canuto SM. 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Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthrosc J Arthrosc Relat Surg. 2014;30(7):882–90. Dargel J, Gotter M, Mader K, Pennig D, Koebke J, Schmidt-Wiethoff R. Biomechanics of the anterior cruciate ligament and implications for surgical reconstruction. Strateg Trauma Limb Reconstr. 2007;2(1). 10.1007/s11751-007-0016-6 . Fan L, Zhang L, Tang J, Xu Z, Fu W. Comparison of clinical outcomes between hamstring tendon autografts and hybrid grafts in ACL reconstruction: a systematic review and meta-analysis. J Orthop Surg Res. 2024;19(1):809. Getgood A, Hewison C, Bryant D, et al. No Difference in Functional Outcomes When Lateral Extra-Articular Tenodesis Is Added to Anterior Cruciate Ligament Reconstruction in Young Active Patients: The Stability Study. Arthrosc - J Arthrosc Relat Surg. 2020;36(6). 10.1016/j.arthro.2020.02.015 . Getgood AMJ, Bryant DM, Litchfield R, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020. 10.1177/0363546519896333 . Hart D, Gurney-Dunlop T, Leiter J, et al. Biomechanics of hamstring tendon, quadriceps tendon, and bone–patellar tendon–bone grafts for anterior cruciate ligament reconstruction: a cadaveric study. Eur J Orthop Surg Traumatol. 2023;33(4). 10.1007/s00590-022-03247-6 . He J, Tang Q, Ernst S, et al. Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sport Traumatol Arthrosc. 2021;29:2869–79. Inderhaug E, Stephen JM, Williams A, Amis AA. Biomechanical Comparison of Anterolateral Procedures Combined with Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2017;45(2). 10.1177/0363546516681555 . Joshi S, Shetty UC, Salim MD, Meena N, Kumar S, Rao VKV. Peroneus longus tendon autograft for anterior cruciate ligament reconstruction: a safe and effective alternative in nonathletic patients. Niger J Surg. 2021;27(1):42–7. Malige A, Baghdadi S, Hast MW, Schmidt EC, Shea KG, Ganley TJ. Biomechanical properties of common graft choices for anterior cruciate ligament reconstruction: A systematic review. Clin Biomech. 2022;95. 10.1016/j.clinbiomech.2022.105636 . Manze CJS, da Cunha Luciano R, Helito CP et al. Over-the-Loop Technique for Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Tenodesis: Enhancing Rotational Stability With a Single Femoral Tunnel. Arthrosc Tech. 2025:103570. McAleese T, Murgier J, Cavaignac E, Devitt BM. A review of Marcel Lemaire’s original work on lateral extra-articular tenodesis. J ISAKOS. 2024;9(3):431–7. Opoku M, Abdramane AM, Abdirahman A, Fang M, Li Y, Xiao W. Can peroneus longus tendon autograft become an alternative to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of comparative studies. J Orthop Surg Res. 2025;20(1):719. Park HY, Gardner B, Kim JY, et al. Four-Strand Hamstring Diamond Braid Technique for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2021;10(4). 10.1016/j.eats.2021.01.011 . Paschos NK, Gartzonikas D, Barkoula NM, et al. Cadaveric Study of Anterior Cruciate Ligament Failure Patterns Under Uniaxial Tension Along the Ligament. Arthrosc - J Arthrosc Relat Surg. 2010;26(7). 10.1016/j.arthro.2009.12.013 . Pasurka M, Falck T, Kubach J, et al. Comparison of In Vivo Stiffness of Tendons Commonly Used for Anterior Cruciate Ligament Reconstruction – A Shear Wave Elastography Study. Acad Radiol. 2024;31(8). 10.1016/j.acra.2024.01.037 . Pineda T, Sewpaul Y, Morin V, Jacquet C, Horteur C, Ollivier M. The rectus femoris tendon demonstrates comparable ultimate stress to the patellar tendon: A paired biomechanical study. Knee Surg Sport Traumatol Arthrosc. 2025. Runer A, Keeling L, Wagala N, et al. Current trends in graft choice for anterior cruciate ligament reconstruction – part I: anatomy, biomechanics, graft incorporation and fixation. J Exp Orthop. 2023;10(1). 10.1186/s40634-023-00600-4 . Samitier G, Vinagre G. Hamstring Braid Graft Technique for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2019;8(8). 10.1016/j.eats.2019.03.022 . Sasaki N, Farraro KF, Kim KE, Woo SLY. Biomechanical evaluation of the quadriceps tendon autograft for anterior cruciate ligament reconstruction: A cadaveric study. Am J Sports Med. 2014;42(3). 10.1177/0363546513516603 . Shani RH, Umpierez E, Nasert M, Hiza EA, Xerogeanes J. Biomechanical comparison of quadriceps and patellar tendon grafts in anterior cruciate ligament reconstruction. Arthrosc J Arthrosc Relat Surg. 2016;32(1):71–5. Shi FD, Hess DE, Zuo JZ, et al. Peroneus Longus Tendon Autograft is a Safe and Effective Alternative for Anterior Cruciate Ligament Reconstruction. J Knee Surg. 2019;32(8). 10.1055/s-0038-1669951 . Shumborski S, Salmon LJ, Monk C, Heath E, Roe JP, Pinczewski LA. Allograft Donor Characteristics Significantly Influence Graft Rupture After Anterior Cruciate Ligament Reconstruction in a Young Active Population. Am J Sports Med. 2020;48(10). 10.1177/0363546520938777 . Soleymanha M, Soleymani Nejad A, Keyhani S, Vosoughi F, LaPrade RF, Tollefson LV. Peroneus longus tendon harvest for ACL reconstruction yields good functional outcome of the ankle: A systematic review and meta-Analysis. Knee Surg Sport Traumatol Arthrosc. 2025. Strauss MJ, Miles JW, Kennedy ML, et al. Full thickness quadriceps tendon grafts with bone had similar material properties to bone-patellar tendon-bone and a four-strand semitendinosus grafts: a biomechanical study. Knee Surg Sport Traumatol Arthrosc. 2022;30(5). 10.1007/s00167-021-06738-x . Tis JE, Klemme WR, Kirk KL, Murphy KP, Cunningham B. Braided hamstring tendons for reconstruction of the anterior cruciate ligament: A biomechanical analysis. Am J Sports Med. 2002;30(5). 10.1177/03635465020300050901 . Urchek R, Karas S. Biomechanical Comparison of Quadriceps and 6-Strand Hamstring Tendon Grafts in Anterior Cruciate Ligament Reconstruction. Orthop J Sport Med. 2019;7(10). 10.1177/2325967119879113 . Xerogeanes JW. Quadriceps Tendon Graft for Anterior Cruciate Ligament Reconstruction: THE GRAFT OF THE FUTURE! Arthrosc - J Arthrosc Relat Surg. 2019;35(3). 10.1016/j.arthro.2019.01.011 . Xerogeanes JW, Mitchell PM, Karasev PA, Kolesov IA, Romine SE. Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement. Am J Sports Med. 2013;41(10):2392–9. Zamarra G, Fisher MB, Woo SLY, Cerulli G. Biomechanical evaluation of using one hamstrings tendon for ACL reconstruction: A human cadaveric study. Knee Surg Sport Traumatol Arthrosc. 2010;18(1). 10.1007/s00167-009-0911-0 . Zhao J, Huangfu X. The biomechanical and clinical application of using the anterior half of the peroneus longus tendon as an autograft source. Am J Sports Med. 2012;40(3). 10.1177/0363546511428782 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8715724","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":590682983,"identity":"5f518bf1-96c8-4123-b2d2-f94c080d77c7","order_by":0,"name":"Márcio Bezerra Gadelha Lopes","email":"","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Márcio","middleName":"Bezerra Gadelha","lastName":"Lopes","suffix":""},{"id":590682984,"identity":"fc8edbbc-3d0d-4d18-b5e9-0aa796b51d7f","order_by":1,"name":"Diego Ariel de Lima","email":"data:image/png;base64,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","orcid":"","institution":"Universidade Federal Rural do Semi-Árido","correspondingAuthor":true,"prefix":"","firstName":"Diego","middleName":"Ariel","lastName":"de Lima","suffix":""},{"id":590682987,"identity":"aa9d12fe-a48c-46d3-8899-a0584422e4a7","order_by":2,"name":"Jonatas Brito Alencar Neto","email":"","orcid":"","institution":"Clínica Articular","correspondingAuthor":false,"prefix":"","firstName":"Jonatas","middleName":"Brito Alencar","lastName":"Neto","suffix":""},{"id":590682988,"identity":"b1fee02f-0b32-44a7-8972-0b6203095009","order_by":3,"name":"Sergio Canuto","email":"","orcid":"","institution":"Ortoclínica","correspondingAuthor":false,"prefix":"","firstName":"Sergio","middleName":"","lastName":"Canuto","suffix":""},{"id":590682989,"identity":"3e2e1063-42cd-40f9-b46f-c8ecfdd60f34","order_by":4,"name":"Renata Clazzer","email":"","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Renata","middleName":"","lastName":"Clazzer","suffix":""},{"id":590682990,"identity":"081f1136-37bd-4571-9a63-1b9ad66fbbf0","order_by":5,"name":"Camilo Partezani Helito","email":"","orcid":"","institution":"Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Camilo","middleName":"Partezani","lastName":"Helito","suffix":""},{"id":590682991,"identity":"948a1955-6916-416f-8e92-91db481e5b14","order_by":6,"name":"Carlos Eduardo Franciozi","email":"","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"Eduardo","lastName":"Franciozi","suffix":""}],"badges":[],"createdAt":"2026-01-28 03:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8715724/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8715724/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102760982,"identity":"9b7878cb-e0f5-44cd-9b40-098d728788bf","added_by":"auto","created_at":"2026-02-16 10:33:47","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":386466,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical approach to the knee for harvesting the rectus femoris tendon graft.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8715724/v1/b198bacca6ca8c5dcf3e5d1f.jpeg"},{"id":102760981,"identity":"d05b8760-e947-47fc-b065-79301ff22350","added_by":"auto","created_at":"2026-02-16 10:33:47","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":299765,"visible":true,"origin":"","legend":"\u003cp\u003eMechanical Testing. \u003cstrong\u003eA.\u003c/strong\u003e Preparation of full thickness quadriceps tendon grafts for biomechanical testing and fixation setup using polyurethane blocks and titanium interference screws in the EMIC DL 10000 universal testing machine. \u003cstrong\u003eB.\u003c/strong\u003e Axial tensile testing of tendon grafts performed in the EMIC DL 10000 universal testing machine. \u003cstrong\u003eC.\u003c/strong\u003e Rectus femoris tendon graft harvested for biomechanical testing.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8715724/v1/41479b3b841370252c65cfaf.jpeg"},{"id":102760984,"identity":"8df8df84-d14a-4230-b727-153674783cd4","added_by":"auto","created_at":"2026-02-16 10:33:47","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":130584,"visible":true,"origin":"","legend":"\u003cp\u003eUltimate load to failure of different autologous graft configurations. Units expressed in Newtons (N).\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8715724/v1/3627cd9f5e2bc88cb734e098.jpeg"},{"id":102962845,"identity":"c18e86e3-5297-4f7b-8227-0e99cd260bc8","added_by":"auto","created_at":"2026-02-19 04:11:38","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":171024,"visible":true,"origin":"","legend":"\u003cp\u003eLoad–displacement curves of the tested grafts \u003cstrong\u003eA.\u003c/strong\u003e representative patellar tendon sample. \u003cstrong\u003eB.\u003c/strong\u003eRepresentative rectus femoris tendon sample. \u003cstrong\u003eC.\u003c/strong\u003e Representative parallel hamstring tendon sample. \u003cstrong\u003eD.\u003c/strong\u003e Representative braided hamstring tendon sample.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8715724/v1/93560a067acf4556614fe1d7.jpeg"},{"id":104397227,"identity":"1f57c199-9580-4678-8d02-67791bc7246b","added_by":"auto","created_at":"2026-03-11 11:45:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1739686,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8715724/v1/a1d5783b-91d8-40d2-b842-c1c59e63e03d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Biomechanical Strength of Autografts for Ligament Reconstruction: Quadriceps, Rectus Femoris, Peroneus Longus, Patellar, Hamstring quadruple, Hamstring braided, and Iliotibial Band.","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eKnee ligament reconstruction is among the most frequent procedures in sports orthopaedics, and graft selection remains one of its most decisive factors for surgical success. The choice of autograft directly affects mechanical stability, biological incorporation, and postoperative recovery. Traditionally, the hamstring and bone\u0026ndash;patellar\u0026ndash;tendon\u0026ndash;bone (BPTB) autografts have been the mainstay for anterior cruciate ligament (ACL) and other ligament reconstructions. However, alternative grafts such as the quadriceps, rectus femoris, and peroneus longus tendons have gained attention as viable options offering comparable mechanical strength and potentially reduced donor-site morbidity \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePrevious biomechanical investigations have reported promising results for some of these grafts, yet most studies have analyzed only one or two tendons under heterogeneous conditions of specimen preparation, fixation, and testing methodology. This variability limits direct comparisons and weakens clinical translation. In particular, the rectus femoris tendon\u0026mdash;representing the superficial layer of the quadriceps complex\u0026mdash;has recently emerged as an autograft candidate due to its adequate length, consistent diameter, and favorable biomechanical properties \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSimilarly, the peroneus longus tendon has demonstrated tensile resistance comparable to traditional hamstring grafts, with minimal effect on ankle strength and function \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. In contrast, the iliotibial band (ITB) has historically been used as a reinforcement graft in lateral extra-articular procedures\u0026mdash;such as the modified Lemaire technique and its variations\u0026mdash;rather than as a primary intra-articular graft. Its limited cross-sectional area and lower tensile resistance may restrict its application to adjunctive stabilization rather than ligament reconstruction itself \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. A comprehensive comparative evaluation under standardized conditions is therefore essential to guide graft selection based on biomechanical performance.\u003c/p\u003e \u003cp\u003eThe purpose of this cadaveric study was to compare the ultimate load to failure among seven autografts for ligament reconstruction \u0026mdash; three commonly used and well described in the literature (full thickness quadriceps, patellar, and hamstring tendons) and four emerging options (rectus femoris, peroneus longus, braided hamstrings, and iliotibial band tendons) \u0026mdash; using identical fixation and testing protocols.\u003c/p\u003e \u003cp\u003eWe hypothesized that the four emerging grafts would demonstrate failure load properties comparable to those of the three conventional grafts, with a potential mechanical advantage for the rectus femoris and peroneus longus tendons under standardized testing conditions.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Ethical Approval\u003c/h2\u003e \u003cp\u003e This anatomical experimental study was approved by an independent institutional Research Ethics Committee and conducted in accordance with international ethical standards and the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eGraft collection was authorized by a certified national forensic institute, and all biomechanical testing was carried out in a university engineering laboratory equipped for orthopaedic mechanical research.\u003c/p\u003e \u003cp\u003e All procedures involving human biological material complied with national and institutional ethical regulations (Resolutions CNS 441/2011 and 466/2012; Operational Norm CNS 001/2013). Written consent for tissue donation was obtained from the donors\u0026rsquo; families, and the final disposal of specimens followed biosafety and traceability standards at an authorized facility.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSpecimens and Inclusion Criteria\u003c/h3\u003e\n\u003cp\u003eTwelve knees from six fresh adult cadaveric donors were included. The specimens corresponded to the first six cadavers whose families provided authorization for anatomical research, in accordance with institutional and legal procedures. No selection criteria related to sex, age, body habitus, or anthropometric characteristics (such as body mass index, weight, or height) were applied. Cadavers presenting traumatic or degenerative lesions that interfered with graft dissection were excluded.\u003c/p\u003e \u003cp\u003eBecause of local legal and logistical procedures, tissue retrieval could only occur 6 to 12 hours after death, following family authorization and completion of the autopsy report. During this period, cadavers were kept at room temperature. This delay was consistent among all samples and is recognized as a methodological limitation.\u003c/p\u003e \u003cp\u003eAfter collection, the specimens were stored at \u0026minus;\u0026thinsp;20\u0026deg;C and thawed for 12 hours at room temperature before testing. No additional hydration protocol was applied after thawing.\u003c/p\u003e\n\u003ch3\u003eGraft Harvesting\u003c/h3\u003e\n\u003cp\u003eThree incisions were made to obtain the grafts: a median anterior incision at the knee, a lateral thigh incision, and a lateral ankle incision. After dissection by planes, the following grafts were harvested (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e12 \u0026times; Peroneus longus tendons (folded in half: double strand configuration)\u003c/p\u003e \u003cp\u003e12 \u0026times; Iliotibial bands (fascia lata) (10 mm width, doubled over)\u003c/p\u003e \u003cp\u003e12 \u0026times; Patellar tendons (BPTB), soft-tissue portion only, 10 mm width\u003c/p\u003e \u003cp\u003e6 \u0026times; Rectus femoris tendons (folded in half: double strand configuration) \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e6 \u0026times; Quadriceps tendons, full-thickness, 10 mm width \u0026times; full thickness\u003c/p\u003e \u003cp\u003e6 \u0026times; Hamstring tendons (gracilis\u0026thinsp;+\u0026thinsp;semitendinosus): quadruple strand configuration, parallel arrangement\u003c/p\u003e \u003cp\u003e6 \u0026times; Hamstring tendons (gracilis\u0026thinsp;+\u0026thinsp;semitendinosus) - quadruple strand braided arrangement\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFor nomenclature purposes, the term \u0026ldquo;quadriceps tendon\u0026rdquo; refers to a full-thickness graft harvested without a bone plug. All grafts were kept moist with sterile gauze during dissection and preparation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003ePreparation of Test Samples\u003c/h3\u003e\n\u003cp\u003eTo simulate clinical conditions of ligament reconstruction, each graft was mounted in two polyurethane foam blocks (ABNT NBR 15678:2020; Nacional Ltda, S\u0026atilde;o Paulo, Brazil), representing the femoral and tibial tunnels. The blocks had the following properties:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDimensions: 100 \u0026times; 100 \u0026times; 30 mm\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDensity: 40 pcf (0.96 g/cm\u0026sup3;)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eColor: brown\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTunnel: 30 mm length through the center of the 100 \u0026times; 100 mm face, with a diameter matching the graft diameter.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eA trained orthopaedic surgeon performed all fixation procedures. Each block was drilled with a tunnel corresponding to the graft diameter, allowing 3 cm of free graft between the blocks. Titanium interference screws (30 mm length, diameter equal to graft; ASTM F136 alloy, Traum\u0026eacute;dica\u0026reg;, S\u0026atilde;o Paulo, Brazil) were inserted from outside to inside using a Kirschner wire as a guide to ensure alignment. The final configuration was Screw\u0026ndash;Block\u0026ndash;Graft\u0026ndash;Block\u0026ndash;Screw (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eMechanical Testing\u003c/h3\u003e\n\u003cp\u003eAll tests were performed using a universal testing machine (EMIC DL 10000, S\u0026atilde;o Jos\u0026eacute; dos Pinhais, PR, Brazil) in axial traction mode (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Each construct was clamped with vice-type jaws at both ends, and the upper assembly was secured by a transverse steel pin aligned with the load axis.\u003c/p\u003e \u003cp\u003eA pre-load of approximately 50 N was applied to align the construct and eliminate slack. Testing was performed under displacement control at a rate of 10 mm/min until graft rupture or slippage occurred. The objective was to measure static ultimate load to failure; cyclic loading and stiffness analysis were not included, as they were beyond the scope of this study and are suggested for future research.\u003c/p\u003e \u003cp\u003eLoad\u0026ndash;displacement data were continuously recorded. The ultimate load to failure (N) was defined as the maximum force before a sudden drop on the curve. All failures occurred by tendon rupture, not by slippage of the fixation construct.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBiosafety Compliance\u003c/h2\u003e \u003cp\u003e All procedures involving human biological material were conducted in accordance with international ethical principles and national biosafety regulations.\u003c/p\u003e \u003cp\u003e The study protocol complied with the principles established in national resolutions governing research involving human material, which define ethical standards, storage, use, and disposal of biological specimens for scientific purposes.\u003c/p\u003e \u003cp\u003eFamily members of all donors provided written informed consent authorizing tissue collection and temporary storage for research. The final disposal of biological material was carried out in an authorized facility, following biosafety and traceability standards to ensure safety, compliance, and transparency throughout all stages of the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe primary variable analyzed was ultimate load to failure (N). Data normality was verified using the Shapiro\u0026ndash;Wilk test. Between-group comparisons were performed using one-way ANOVA, followed by Tukey\u0026rsquo;s post-hoc test for multiple comparisons.\u003c/p\u003e \u003cp\u003eAll results were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and 95% confidence intervals (CI). Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Effect size (η\u0026sup2;) was calculated to assess the magnitude of group differences.\u003c/p\u003e \u003cp\u003eA post-hoc power analysis based on group means and SDs demonstrated a statistical power of 95.8% for the one-way ANOVA (α\u0026thinsp;=\u0026thinsp;0.05), with a total of 58 samples distributed among seven groups.\u003c/p\u003e \u003cp\u003eAll analyses were performed using SPSS v28 (IBM Corp., Armonk, NY, USA) and GraphPad Prism v9.0 (GraphPad Software, San Diego, CA, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 58 tendon grafts were obtained from 12 knees of six fresh cadaveric donors (all male; mean age, 35\u0026thinsp;\u0026plusmn;\u0026thinsp;5 years). The primary biomechanical variable analyzed was the ultimate load to failure (N). Two specimens were damaged during dissection and handling\u0026mdash;one iliotibial band and one hamstring (parallel configuration)\u0026mdash;and were therefore excluded from the final analysis.\u003c/p\u003e \u003cp\u003eSignificant differences in failure load were found among the graft groups (one-way ANOVA, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; F-value\u0026thinsp;=\u0026thinsp;139.48). Multiple comparisons using Tukey\u0026rsquo;s post-hoc test demonstrated:\u003c/p\u003e \u003cp\u003eThe full thickness quadriceps tendon (10 mm \u0026times; full thickness) showed the highest mean ultimate load (2302.9\u0026thinsp;\u0026plusmn;\u0026thinsp;79.7 N), significantly greater than all other grafts (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all pairwise comparisons).\u003c/p\u003e \u003cp\u003eThe double strand peroneus longus tendon configuration presented high resistance (1991.3\u0026thinsp;\u0026plusmn;\u0026thinsp;160.3 N), statistically greater than the patellar (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0003), quadruple strand hamstring-parallel configuration (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0001), double strand rectus femoris configuration (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0015), and iliotibial band (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) groups.\u003c/p\u003e \u003cp\u003eThe patellar tendon reached a mean failure load of 1734.7\u0026thinsp;\u0026plusmn;\u0026thinsp;136.2 N, with no significant differences compared to the double strand rectus femoris configuration (1713.9\u0026thinsp;\u0026plusmn;\u0026thinsp;56.1 N) or quadruple strand hamstring-parallel configuration (1683.8\u0026thinsp;\u0026plusmn;\u0026thinsp;80.5 N) grafts (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eQuadruple strand hamstring tendons parallel vs. braided showed similar results. The braided configuration exhibited a mean ultimate load of 1821.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7 N, an average increase of 8.2% compared with the parallel configuration (1683.8\u0026thinsp;\u0026plusmn;\u0026thinsp;80.5 N), without statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.2967).\u003c/p\u003e \u003cp\u003eThe doubled over iliotibial band (fascia lata) showed the lowest mean resistance (749.1\u0026thinsp;\u0026plusmn;\u0026thinsp;155.4 N), significantly lower than all other groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all comparisons).\u003c/p\u003e \u003cp\u003eAll specimens failed by tendon rupture rather than slippage of the fixation system. Titanium interference screws maintained stable fixation in the polyurethane blocks, without visible deformation or loosening. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the descriptive data for each group.\u003c/p\u003e \u003cp\u003eQualitative Observations\u003c/p\u003e \u003cp\u003eDistinct patterns were observed in the load\u0026ndash;displacement curves of the tested grafts. Uniform, single strand grafts such as the quadriceps and patellar tendons demonstrated smooth sinusoidal curves, with maximum load typically reached near 10 mm of displacement (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUltimate Load to Failure of Autologous Graft Configurations. N\u0026thinsp;=\u0026thinsp;Newtons\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraft Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003cp\u003e(N)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003cp\u003e(N)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003cp\u003eLower (N)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003cp\u003eUpper (N)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull thickness quadriceps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2302.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e79.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2219.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2386.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDouble strand peroneus longus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1991.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e160.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1889.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2093.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuadruple strand hamstring - braided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1821.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1807.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1836.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatellar tendon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1734.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e136.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1648.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1821.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDouble strand rectus femoris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1713.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1655.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1772.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuadruple strand hamstring - parallel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1683.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1599.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1768.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIliotibial band (doubled over)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e749.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e155.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e644.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e853.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMultistrand grafts such as the parallel quadruple strand hamstring, double strand rectus femoris, and iliotibial band doubled over exhibited plateau-like curves approaching the failure point, whereas the braided quadruple strand hamstring displayed a broader plateau during peak load, characterized by an initial fiber realignment followed by progressive accommodation of the braided strands, resulting in greater displacement before rupture (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe main finding of this cadaveric biomechanical study was that the full thickness quadriceps tendon exhibited the highest ultimate load to failure among all autografts tested (2302.9\u0026thinsp;\u0026plusmn;\u0026thinsp;79.7 N). With the exception of the iliotibial band (749.1\u0026thinsp;\u0026plusmn;\u0026thinsp;155.4 N), all other tendon configurations \u0026mdash;the peroneus longus, hamstring (braided and parallel), patellar (soft-tissue portion), and rectus femoris\u0026mdash;showed resistance levels comparable to or exceeding the mechanical strength typically reported for the native ACL, which ranges between 1700 and 2100 N \u003csup\u003e6,10,24,26\u003c/sup\u003e. These results indicate that most of the tested grafts can provide sufficient structural integrity for ligament reconstruction in the knee joint. Our sample consisted of 58 tendons, with an average of 7.8 per group, which is consistent with other biomechanical studies in the literature, generally ranging from 6 to 12 per group \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe superior mechanical strength of the full thickness quadriceps tendon found in this study is consistent with that reported by Shani et al.\u003csup\u003e29\u003c/sup\u003e, who observed a mean failure load of 2186 N for the quadriceps compared to 1580 N for the patellar tendon (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045). This difference has been attributed to the greater cross-sectional area of the quadriceps tendon and to its collagen fiber orientation, which may distribute the tensile load more efficiently. Similar results were reported by Xerogeanes\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e, who demonstrated that the quadriceps tendon contains approximately 20% more collagen fibrils per cross-sectional area than the patellar tendon, supporting up to 70% higher load at failure under similar geometric conditions. However, some studies report no difference comparing full thickness quadriceps tendon with patellar tendon and quadruple strand hamstrings \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. It is important to note that the results may not be the same for the common used partial thickness quadriceps graft, not evaluated in the current study, already proved to be biomechanically weaker in other studies \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHart et al.\u003csup\u003e14\u003c/sup\u003e also reported no significant differences in failure load between quadriceps, hamstring, and patellar tendons, a finding that partially diverges from our results. This discrepancy can be explained by differences in specimen characteristics: Hart\u0026rsquo;s study used cadavers with a mean age of 75 years, whereas our sample involved younger donors with a mean age of 35 years \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Tendon mechanical strength can be affected by age and sex, being decreased in female patients and also older patients, which likely contributed to the lower loads observed in that study \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRegarding the hamstring grafts, our results align with those of Urchek and Karas \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, who found no significant difference in failure load between hamstring and quadriceps grafts. However, they reported greater stiffness for the hamstring graft (1148\u0026thinsp;\u0026plusmn;\u0026thinsp;339 N/mm) than for the quadriceps (808\u0026thinsp;\u0026plusmn;\u0026thinsp;173 N/mm; p\u0026thinsp;=\u0026thinsp;0.04) \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Although our study focused solely on four-strand constructs and did not measure stiffness, this difference emphasizes that graft configuration \u0026mdash;number of strands, braiding, and length\u0026mdash;strongly influences mechanical performance \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTis 2002 had demonstrated that braided hamstrings showed inferior mechanical strenght and stiffness comparing to parallel configuration, a result different from our findings \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. In our series, braiding of the hamstring graft resulted in a considerable 8.2% increase in peak load compared with the parallel configuration, although this difference was not statistically significant. Even so, the increase in cross-sectional area associated with braiding may provide a biomechanical advantage in surgical situations where thinner tendons (\u0026lt;\u0026thinsp;8 mm) are encountered. This observation is consistent with reports suggesting that hamstring grafts smaller than 8 mm are associated with a higher risk of postoperative failure \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Authors such as Park et al.\u003csup\u003e22\u003c/sup\u003e and Samitier and Vinagre\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e have described a four-strand braiding technique. According to these authors, braiding a four-strand hamstring autograft may increase the graft diameter by approximately 1 to 1.5 mm; however, it is associated with a shortening of approximately 5 to 10 mm.\u003c/p\u003e \u003cp\u003eThe rectus femoris graft also exhibited mechanical performance comparable to the patellar and hamstring grafts, with no statistically significant differences. These findings are consistent with the observations of Chivot et al.\u003csup\u003e8\u003c/sup\u003e, who showed that the superficial lamina of the quadriceps tendon\u0026mdash;corresponding to the rectus femoris portion\u0026mdash;presents tensile properties similar to those of the hamstring tendons. Although their study found equivalent strength and stiffness between the superficial quadriceps layer and the iliotibial band, our data demonstrated inferior resistance for the ITB, suggesting that ITB may not be suitable as a primary intra-articular graft. Importantly, biomechanical evidence published in 2025 by Pineda et al.\u003csup\u003e25\u003c/sup\u003e further supports the mechanical viability of the rectus femoris tendon. In a paired cadaveric comparison, Pineda et al.\u003csup\u003e25\u003c/sup\u003e reported that double-stranded rectus femoris grafts exhibit ultimate stress comparable to patellar tendon grafts (46.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 MPa vs 52.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7 MPa; p\u0026thinsp;=\u0026thinsp;0.184), despite demonstrating lower absolute load to failure (885.9\u0026thinsp;\u0026plusmn;\u0026thinsp;52.3 N vs 1278.7\u0026thinsp;\u0026plusmn;\u0026thinsp;207.5 N; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and greater elongation at failure (1.2% vs 0.2%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings reinforce that, although rectus femoris grafts may show lower structural resistance when used in a double-strand configuration, their intrinsic tissue-level strength closely approximates that of the patellar tendon, supporting their use as a clinically relevant soft-tissue autograft option.\u003c/p\u003e \u003cp\u003eIn contrast, the mechanical performance of the peroneus longus tendon was notably high in our study (1991.3\u0026thinsp;\u0026plusmn;\u0026thinsp;160.3 N), surpassing most traditional grafts, including the patellar and hamstring tendons. This is in agreement with recent reports positioning the peroneus longus as a reliable autograft option. Opoku et al.\u003csup\u003e21\u003c/sup\u003e demonstrated that the peroneus longus tendon has stiffness comparable to or higher than hamstring tendons, while maintaining similar diameters and minimal donor-site morbidity. Furthermore, several studies have reported favorable clinical and biomechanical outcomes supporting its use, demonstrating that double strand peroneus longus constructs can sustain tensile loads exceeding 4000 N - values comparable to those of \u003csup\u003e3,15,17,18,30\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAn important consideration when interpreting absolute strength values is the effect of cross-sectional geometry. The quadriceps grafts in our study were used at full thickness (aproximately 8 mm), whereas patellar grafts measured around 5 mm. If adjusted for area, the stress (N/mm\u0026sup2;) of the patellar tendon could approximate or even exceed that of the quadriceps tendon, as suggested by Chivot et al. \u003csup\u003e8\u003c/sup\u003e. This reinforces the idea that while the quadriceps tendon is biomechanically robust, the patellar tendon remains highly efficient in load-bearing per unit area.\u003c/p\u003e \u003cp\u003eContrary to the authors\u0026rsquo; initial hypothesis, the iliotibial band presented the lowest load to failure (749.1\u0026thinsp;\u0026plusmn;\u0026thinsp;155.4 N), significantly inferior to all other grafts, indicating that it may not be an appropriate option for primary intra-articular ligament reconstruction. However, its anatomical characteristics and low donor-site morbidity make it clinically useful for extra-articular procedures, particularly for anterolateral reinforcement techniques such as those of Lemaire and its modern modifications\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. These findings are consistent with current biomechanical and clinical evidence supporting the ITB\u0026rsquo;s role in controlling rotational instability and reducing graft elongation in combined ACL reconstructions \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThus, from a purely biomechanical standpoint, we have at least six strong graft options, all of which can be considered viable for knee ligament reconstructions. Moreover, the iliotibial band demonstrated good potential for use as an extra-articular reinforcement. Of course, this study has several limitations and should not be used as the sole guideline for clinical decision-making. Furthermore, additional studies are warranted to validate and expand upon these findings.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eSeveral limitations of this study must be acknowledged. The time between death and tissue collection (6\u0026ndash;12 hours at room temperature) may have influenced the mechanical properties of the grafts, although this delay was consistent across all specimens. Only male cadavers were included, which limits generalizability regarding sex-related differences in tendon properties. Some groups had small sample sizes (e.g., five braided hamstring grafts), which could reduce statistical sensitivity. Moreover, the absence of stiffness and cyclic-loading evaluations restricts the interpretation of elastic and fatigue behavior. The use of polyurethane blocks, although standardized and compliant with NBR 15678:2020, does not perfectly reproduce the mechanical characteristics of human bone and graft\u0026ndash;bone interface dynamics.\u003c/p\u003e \u003cp\u003eDespite these limitations, this study provides a comprehensive comparative analysis of six commonly used autografts under uniform testing conditions. The quadriceps and peroneus longus tendons demonstrated the highest absolute failure loads, while the iliotibial band exhibited inferior resistance but remains relevant for extra-articular reinforcement procedures. The findings contribute to the growing body of biomechanical evidence guiding graft selection for primary and revision ligament reconstructions and highlight potential directions for future research, including stiffness characterization, cyclic fatigue testing, and in vivo clinical validation of emerging graft options.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAll autografts tested, with the exception of the iliotibial band, demonstrated biomechanical adequacy for knee ligament reconstruction with respect to ultimate load to failure. The full thickness quadriceps and double strand peroneus longus tendons exhibited the greatest mechanical strength, while the double strand rectus femoris and braided quadruple strand hamstring configurations showed similar properties to patellar tendon and parallel quadruple strand hamstring.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnterior Cruciate Ligament\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003euniversal testing machine DL 10000\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eITB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIliotibial Band\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBPTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBone\u0026ndash;Patellar\u0026ndash;Tendon\u0026ndash;Bone\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNewton\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eAuthors\u003c/h2\u003e \u003cp\u003eM\u0026aacute;rcio Bezerra Gadelha Lopes; Diego Ariel de Lima; Jonatas Brito de Alencar Neto; Sergio Marinho de Gusm\u0026atilde;o Canuto; Renata Clazzer; Camilo Partezani Helito; Carlos Eduardo da Silveira Franciozi\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eHypothesis\u003c/h2\u003e \u003cp\u003eIt was hypothesized that the four emerging grafts (rectus femoris, peroneus longus, braided hamstrings, and ITB) would demonstrate ultimate load to failure comparable to the three traditional autografts, with potential mechanical advantages for the rectus femoris and peroneus longus tendons.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy Design\u003c/strong\u003e \u003cp\u003eControlled laboratory biomechanical study.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSignificant between-group differences were observed (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The full-thickness quadriceps tendon demonstrated the highest ultimate load (2302.9\u0026thinsp;\u0026plusmn;\u0026thinsp;79.7 N), significantly exceeding all other grafts. The peroneus longus tendon showed high resistance (1991.3\u0026thinsp;\u0026plusmn;\u0026thinsp;160.3 N), greater than patellar, hamstring-parallel, rectus femoris, and ITB grafts (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Patellar (1734.7\u0026thinsp;\u0026plusmn;\u0026thinsp;136.2 N), rectus femoris (1713.9\u0026thinsp;\u0026plusmn;\u0026thinsp;56.1 N), and hamstring-parallel (1683.8\u0026thinsp;\u0026plusmn;\u0026thinsp;80.5 N) grafts exhibited comparable strength (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Braided hamstrings demonstrated an 8.2% increase over parallel hamstrings (1821.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7 N vs 1683.8\u0026thinsp;\u0026plusmn;\u0026thinsp;80.5 N), though not statistically significant. The ITB demonstrated the lowest resistance (749.1\u0026thinsp;\u0026plusmn;\u0026thinsp;155.4 N; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConclusion\u003c/strong\u003e \u003cp\u003eAll autografts tested, with the exception of the iliotibial band, demonstrated biomechanical adequacy for knee ligament reconstruction with respect to ultimate load to failure. The full thickness quadriceps and double strand peroneus longus tendons exhibited the greatest mechanical strength, while the double strand rectus femoris and braided quadruple strand hamstring configurations showed similar properties to patellar tendon and parallel quadruple strand hamstring.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eDeclarations\u003c/h2\u003e\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e This cadaveric biomechanical study was approved by the Research Ethics Committee of the UERN - UNIVERSIDADE DO ESTADO DO RIO GRANDE DO NORTE, Brazil (CAAE: 82811424.2.0000.5294). All procedures were conducted in accordance with national regulations and international ethical standards for research involving human biological material and complied with the principles of the Declaration of Helsinki. Written informed consent for tissue donation and research use was obtained from the legal representatives (next of kin) of all donors.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study received no external funding from public agencies, commercial entities, or nonprofit organizations. All laboratory procedures and biomechanical testing resources were provided by the authors\u0026rsquo; institutions.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMBGL, DAL, and CESF conceived and designed the study. MBGL, JBAN, and SMGC performed graft harvesting and specimen preparation. DAL, RC, and CPH conducted the biomechanical testing and data acquisition. DAL and MBGL performed the statistical analysis. DAL drafted the manuscript. All authors critically revised the manuscript, approved the final version, and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors gratefully acknowledge the essential technical support provided by Zoroastro Torres Vilar, Rodrigo Nogueira de Codes, Macleane Ferreira Leite Monteiro, and Antonio Fabr\u0026iacute;cio de Almeida, whose expertise in mechanical engineering and operation of the EMIC testing system was indispensable for the execution of the biomechanical experiments. Their contributions were fundamental to the successful completion of this research project.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAriel de Lima D, Helito CP, de Gusm\u0026atilde;o Canuto SM. Combined Reconstruction of the Anterior Cruciate Ligament and Anterolateral Ligament: Triple-Strand Braided Hamstring Graft for the Anterior Cruciate Ligament and Gracilis Strand for the Anterolateral Ligament With a Single Femoral Tunnel. 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J Knee Surg. 2019;32(8). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0038-1669951\u003c/span\u003e\u003cspan address=\"10.1055/s-0038-1669951\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShumborski S, Salmon LJ, Monk C, Heath E, Roe JP, Pinczewski LA. Allograft Donor Characteristics Significantly Influence Graft Rupture After Anterior Cruciate Ligament Reconstruction in a Young Active Population. Am J Sports Med. 2020;48(10). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0363546520938777\u003c/span\u003e\u003cspan address=\"10.1177/0363546520938777\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoleymanha M, Soleymani Nejad A, Keyhani S, Vosoughi F, LaPrade RF, Tollefson LV. Peroneus longus tendon harvest for ACL reconstruction yields good functional outcome of the ankle: A systematic review and meta-Analysis. Knee Surg Sport Traumatol Arthrosc. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrauss MJ, Miles JW, Kennedy ML, et al. Full thickness quadriceps tendon grafts with bone had similar material properties to bone-patellar tendon-bone and a four-strand semitendinosus grafts: a biomechanical study. Knee Surg Sport Traumatol Arthrosc. 2022;30(5). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00167-021-06738-x\u003c/span\u003e\u003cspan address=\"10.1007/s00167-021-06738-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTis JE, Klemme WR, Kirk KL, Murphy KP, Cunningham B. Braided hamstring tendons for reconstruction of the anterior cruciate ligament: A biomechanical analysis. 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Am J Sports Med. 2012;40(3). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0363546511428782\u003c/span\u003e\u003cspan address=\"10.1177/0363546511428782\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Anterior cruciate ligament, Autologous graft, Biomechanics, Mechanical strength","lastPublishedDoi":"10.21203/rs.3.rs-8715724/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8715724/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eSelecting the optimal autograft for knee ligament reconstruction is a critical factor influencing graft strength, surgical strategy, and postoperative outcomes. Although patellar and hamstring tendons are traditionally preferred, emerging options—including quadriceps, rectus femoris, peroneus longus, braided hamstrings, and iliotibial band (ITB)—have gained attention. However, direct biomechanical comparison under standardized conditions remains limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypothesis: \u003c/strong\u003eIt was hypothesized that the four emerging grafts (rectus femoris, peroneus longus, braided hamstrings, and ITB) would demonstrate ultimate load to failure comparable to the three traditional autografts, with potential mechanical advantages for the rectus femoris and peroneus longus tendons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design: \u003c/strong\u003eControlled laboratory biomechanical study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eFifty-eight grafts were harvested from adult cadaveric donors (all male; mean age, 35 ± 5 years). Seven autograft types were evaluated: full thickness quadriceps, double strand rectus femoris, double strand peroneus longus, patellar (soft-tissue portion of the bone–patellar–tendon–bone), quadruple strand hamstring (parallel and braided configurations), and iliotibial band. Each graft was fixed in polyurethane foam blocks with titanium interference screws and tested to failure in a universal testing machine (EMIC DL 10000) at 10 mm/min. Ultimate load to failure (N) was compared among groups using one-way ANOVA with Tukey’s post hoc analysis (α = 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eSignificant between-group differences were observed (p \u0026lt; 0.001). The full-thickness quadriceps tendon demonstrated the highest ultimate load (2302.9 ± 79.7 N), significantly exceeding all other grafts. The peroneus longus tendon showed high resistance (1991.3 ± 160.3 N), greater than patellar, hamstring-parallel, rectus femoris, and ITB grafts (p \u0026lt; 0.01). Patellar (1734.7 ± 136.2 N), rectus femoris (1713.9 ± 56.1 N), and hamstring-parallel (1683.8 ± 80.5 N) grafts exhibited comparable strength (p \u0026gt; 0.05). Braided hamstrings demonstrated an 8.2% increase over parallel hamstrings (1821.8 ± 11.7 N vs 1683.8 ± 80.5 N), though not statistically significant. The ITB demonstrated the lowest resistance (749.1 ± 155.4 N; p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eAll autografts tested, with the exception of the iliotibial band, demonstrated biomechanical adequacy for knee ligament reconstruction with respect to ultimate load to failure. The full thickness quadriceps and double strand peroneus longus tendons exhibited the greatest mechanical strength, while the double strand rectus femoris and braided quadruple strand hamstring configurations showed similar properties to patellar tendon and parallel quadruple strand hamstring.\u003c/p\u003e","manuscriptTitle":"Comparative Biomechanical Strength of Autografts for Ligament Reconstruction: Quadriceps, Rectus Femoris, Peroneus Longus, Patellar, Hamstring quadruple, Hamstring braided, and Iliotibial Band.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-16 10:33:36","doi":"10.21203/rs.3.rs-8715724/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-17T23:57:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270519497993957499272899657070618213215","date":"2026-04-24T05:33:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"262722284432602042214853544518766639616","date":"2026-03-21T16:42:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65203061132588058087295005337049083924","date":"2026-03-12T11:01:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280873108260084122013433212266134753170","date":"2026-02-13T06:37:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-10T21:15:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-10T21:02:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-09T17:10:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-06T21:14:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-02-06T21:09:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"30482d3a-99de-4e58-b653-400bca0c5a23","owner":[],"postedDate":"February 16th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-17T23:57:19+00:00","index":129,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T10:33:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-16 10:33:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8715724","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8715724","identity":"rs-8715724","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}