1. What is the ACL (Anterior Cruciate Ligament)?
The ACL is one of four main ligaments of the knee that connects the femur to the tibia. The ACL's role is to stabilize your knee during quick start/stop and pivoting/cutting movements.
2.Do I need ACL surgery?
ACL reconstruction surgery stabilizes your knee and allows athletes to return to sports, especially the ones requiring cutting and pivoting (like soccer, football, rugby, ultimate frisbee, hockey, and basketball)or landing (volleyball, gymnastics, track & field, and skiing).
3. What happens if I don't have ACL surgery?
Athletes who return to play sports or active patients during daily activities are at risk of creating meniscal tears (shock absorbers in your knee)and cartilage defects (lining of your knee) potentially leading to early onset arthritis in the knee.
4. How long is the surgery?
ACL reconstructive surgery typically lasts about 1 hour and a half, depending on whether other procedures need to be performed at the same time (meniscal repair, cartilage repair).
It is an outpatient surgery, which means you get to go home the same day.
5. Is the surgery painful?
Typically, the procedure is well tolerated by most patients. You will see the Anesthesia doctor prior to your surgery to discuss the option of regional anesthesia - freezing of the nerves in your mid-thigh (adductor canal regional block), much like freezing when you go to the dentist. You also have the option of having the freezing in your groin (femoral nerve block) but this may affect the function of your quadriceps post-surgery. Dr. Nguyen's preference is the adductor canal block for this reason.
The regional nerve block is in addition to your general anesthetic - you go to sleep during the duration of your surgery.
Dr. Nguyen will also give you a post-surgery folder on the day of the surgery with a prescription for pain medication, anti-inflammatory and antibiotics to take after your procedure.
6. Graft Options -
Graft options include the hamstring graft, the bone patella bone (BTB) graft, the quadriceps tendon, and a donor (cadaver) allograft. Please ask Dr. Nguyen about the pros/cons of each graft.
6a - How are the 2 hamstring tendons (gracilis & semitendinosus) harvested?
Through a small incision at the front of the knee (see picture below). There are 2 remaining hamstring tendons (semimembranosus & biceps femoris) to strengthen during the rehabilitation phase.
7. What happens on the day of the surgery?
Please remember not to eat or drink (even water) after midnight the evening before your surgery.
a. Please arrive 3 hours prior to your surgery (so that nurses have adequate time to educate/prepare you for surgery).
b. Sign in at the registration desk at the front of the hospital with the registration clerks
c. Go to Day Surgery where the nurses will greet and prepare you for your procedure.
d. The Anesthesia doctor & the operating room nurses will accompany you to the operating room
e. Surgery takes about 1 hour or longer depending on what other procedures Dr. Nguyen needs to do in addition to the ACL reconstruction
f. You will then be transferred to the Post-Anesthetic Care Unit for about 1 hour for observation/monitoring. An X-ray of the your knee will be taken at this time.
g. A porter will transfer you back to Day Surgery to go over discharge details with the nurses for about 1 hour.
They will explain Dr. Nguyen's discharge folder in detail which includes the return appointment date/time (on the business card at the front of the folder), how to contact Dr. Nguyen, discharge instructions and what to expect for the next 10 days after surgery, your prescription for pain medication, antibiotics, and anti-inflammatories, and the rehabilitation protocol to give to your therapist.
h. Unless your had a cartilage repair done at the same time as your ACL reconstruction, you may put weight on your operative leg with the hinge brace locked in full extension. You may use crutches for balance and comfort.
i. Dr. Nguyen will call you the next day to see how you are doing and answer any questions you may have.
j. Dr. Nguyen's Clinical Assistants have given you a return appointment for suture removal 10 days after surgery.
Dr. Nguyen will go over the details of your ACL surgery at that time and show you the arthroscopic pictures of your procedure if requested.
1. General Information on ACL Reconstruction
2. The knee physical exam by Dr. Nguyen
3. Sports Medicine Review - the knee
4. Dr. Nguyen presenting on the knee at the 2018 University of Toronto Sports Medicine Conference
5. Video Animation of ACL Reconstruction using a Hamstring Autograft
6. Video animation of Sports Medicine surgical techniques
Hamstring graft harvest
All Inside Graftlink single tendon Semitendinosus graft
Quadriceps tendon graft
Quadriceps tendon graft
Anatomic placement of ACL tunnels
BTB #bonepatellabone #ACLsurgery
Anteromedial incision tip patella to TT
Cut ruler to 25 mm &mark boneblock (FTscrew20mm)
9 mm A doubleblade (total width 30mm) -err lateral
L Straight osc saw down by 1 cm w/ stopper
rectangle prox tibia. Xtra bone to graft patella @ end
1/4 inch curvedosteotome tease out bone block 25 mm
Trapezoid patella block 30 deg inclitn
Saw/small rongeur to contour boneblock
Bigger BB tibial side
Drill one hole in femur BB - pass #2F x 2 through samehole w/ mayo needle
2 perpendicular holes tibial bone block #2F & 1.3 suturetape
Over the top guide 6/7 mm
9 femreamer to30 mm
9 tibreamer (slide silverringsizer over reamer to protect soft tissue) 45 mm length (or length of tendinous portion of graft
Collect bone fromreamer w/forceps
Boneblock to edge of femsocket
Probe/grasper facilitate graft passage
Pull both fem/tib sides
Assess mismatch +/-pull femside
Nitinol wire inwolf
Cannulated conicaldilator onchuck
Tap linetoline for femur. Undersizetapby1on tibia
7 screw femur 8 screw tibia
Hold tension both fem/tib sutures when insert femscrew +/- softtissueprotector
Augment w/ anchor
To increase rotatory stability (decrease internal rotation) in ACL reconstructions
May be considered in high risk patients:
- female athletes
- revision ACL surgery
- high grade pivot shift
- increased posterior slope
- high risk pivoting/contact sports (soccer, rugby, football, etc.)
Modified Lemaire Technique
Position leg at 60 deg flexion
4-cm longitudinal incision 1 cm posterior to LFC, starting 2 cm proximal to Gerdy’s tubercle. Sweep fat posteriorly to identify posterior border of IT band & GT
Harvest 6 cm-long x 1 cm-wide strip from posterior 1/2 of ITB. Leave attached distally to Gerdy's tubercle, ensuring that the most
posterior fibers of the deep ITB (capsulo-osseous layer) remain intact.
Release deep attachments to the vastus lateralis off the proximal 6 cm of graft & place whipstitch in free end.
LCL identified (figure of 4) & small capsular incisions made anterior & posterior to LCL to dissect tract for graft passage
ITB graft passed beneath FCL staying extracapsular from distal to proximal & secured on the femur posterior & proximal to the lateral epicondyle (proximal to lateral head of gastrocnemius). Cauterize superolateral genicular artery prn.
Fixation can be achieved using a screw/suture anchor @ 60 deg knee flexion, neutral rotation.
Close IT band partially up to the level of transverse retinacular ligament
May be indicated in select patients:
3-proximal femoral avulsion #acltear
-quicker #rehabilitation -biological solution using native #acl - preservation of native neuromuscular ACL fibers which are useful for proprioception & #kneestability
Risks: - 1 #aclretear requiring formal #aclreconstruction - 2 Time loss before #returntoplay #returntosports
#internalbrace may increase success rate
#prp augmentation may be helpful in combination with a scaffold