Nguyen Sports Medicine
Nguyen Sports Medicine
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  • About Dr. Nguyen
  • Clinical Assistants
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  • ACL Surgery
  • SportsFractureClinic
  • ACL Rehab
  • PRP Injections
  • PRP Injections 2
  • Hyaluronic gel Injections
  • Sports Medicine Symposium
  • Pediatric ACL Surgery
  • Meniscus Surgery
  • Meniscus Surgery 2
  • Medical Education
  • Health Law
  • MPFL reconstruction
  • Osteochondral OCD repair
  • Sports Trauma
  • OATS Cartilage Transfer
  • More
    • Home
    • About Dr. Nguyen
    • Clinical Assistants
    • SportsMed MiniFellowship
    • ACL Surgery
    • SportsFractureClinic
    • ACL Rehab
    • PRP Injections
    • PRP Injections 2
    • Hyaluronic gel Injections
    • Sports Medicine Symposium
    • Pediatric ACL Surgery
    • Meniscus Surgery
    • Meniscus Surgery 2
    • Medical Education
    • Health Law
    • MPFL reconstruction
    • Osteochondral OCD repair
    • Sports Trauma
    • OATS Cartilage Transfer

  • Home
  • About Dr. Nguyen
  • Clinical Assistants
  • SportsMed MiniFellowship
  • ACL Surgery
  • SportsFractureClinic
  • ACL Rehab
  • PRP Injections
  • PRP Injections 2
  • Hyaluronic gel Injections
  • Sports Medicine Symposium
  • Pediatric ACL Surgery
  • Meniscus Surgery
  • Meniscus Surgery 2
  • Medical Education
  • Health Law
  • MPFL reconstruction
  • Osteochondral OCD repair
  • Sports Trauma
  • OATS Cartilage Transfer

ACL Surgery

Minimally Invasive, Arthroscopic Assisted, Anatomical Anterior Cruciate Ligament (ACL) Reconstruction (Anteromedial Portal Technique)

FREQUENTLY ASKED QUESTIONS

  

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. 


1b How does Dr. Nguyen know that I have an ACL tear)?

He will perform a special physical examination test in the  clinic called the Lachman test (see video below)

 

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).

Dr. Nguyens decision-making triangle:


A.  Does the patient have instability? ‘I can’t play Doc - my knee gives out.

B. Does the knee physical exam show instability? 

Lachman’s test, anterior drawer test, pivot shift test, Lever’s test.

C. Does the MRI show an ACL tear?


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, or a donor (cadaver) allograft.  Dr. Nguyen can perform any of the above graft options for you. 

All graft options work. Each has pros/cons. 


1. Hamstring: single tendon (semitendinosus) used (3 hamstring tendons remaining), smallest incision, least amount of pain after surgery, no pain in front of knee, long track record

Cons: hamstring pain/weakness when knee flexed > 90 deg


2. Quadriceps tendon: smaller incision than BTB, does not see pressure during kneeling, can harvest any size, commonly used in ACL revisions

Cons: quadriceps pain, harvest site pain/ weakness


3. Bone -Patella-Bone tendon graft (BTB): faster incorporation (bone), long track record, can harvest any size

Cons: highest incidence of anterior knee pain (up to 30%) and kneeling pain, biggest incision, risks of patella fracture/tendon rupture, risk of patellofemoral arthritis not seen with the other 2 grafts 


4. Allograft (donor/cadaver): no harvest site pain/weakness, can choose any size/preparation type

Cons: longer incorporation, higher risk of re-rupture (especially in younger athletes), potential increased risk of infection/disease transmission



6a - How is hamstring tendon  semitendinosus) harvested? 

Through a small incision at the front of the knee (see picture below). There are 3 remaining hamstring tendons (gracilis, semimembranosus & biceps femoris) to strengthen during the rehabilitation phase. 


6b. What are the general risks of surgery?

Infection, pain, stiffness, nerve/artery injury, anesthesia complications (5%)


6c. What is the success rate of ACL surgery?

If you are compliant/diligent with Dr. Nguyen's postoperative rehab protocol & graduate from his 10 rehab functional testing stages at an average 9 months post-surgery, the re-injury rate is 6%.


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.
k. Wound care after suture removal:

- can shower with soap/water x 5 secs over white steri-strips 24 hrs after surgery

- cover incisions w/ tensor band x 2 weeks after suture removal 

-discontinue tensor band wrapping 2 weeks after suture removal & can shower all day over knee

-can bath/swim/go in lake all day 4 weeks after suture removal 

Click on the education links below for more information on your upcoming ACL surgery:

  

1. General Information on ACL Reconstruction
 

http://orthoinfo.aaos.org/topic.cfm?topic=A00549


2. The knee physical exam by Dr. Nguyen


 http://sportmedschool.com/knee-exam/ 


3. Sports Medicine Review - the knee


http://sportmedschool.com/sports-medicine-review-knee-review/ 


4. Dr. Nguyen presenting on the knee at the 2018 University of Toronto Sports Medicine Conference 


http://sportmedschool.com/2018-uoft-sports-medicine-conference/



5. Video Animation of ACL Reconstruction using a Hamstring Autograft
 

http://content.understand.com/Players/Default/Animation.aspx?PresentationID=b7668aca-1b4a-44c3-aa36-4447f9ffa1cd&Index=5&CustomerID=f0d53a46-95e9-4aee-aaaf-d14d836db183&LanguageID=6574fa28-0a40-49af-88c8-3ce366c8c580


6. Video animation of Sports Medicine surgical techniques
 

http://www.orthoillustrated.com/

Lachman test for diagnosing ACL tears

Lachman test: most sensitive test for #acltear

Dr. Nguyen’s technique (from #balletdancer to #football linebacker 

Supine

Thigh supported on table

Straddle securely distal #tibia

20 deg #knee flexion 

3 fingers on distal femur - relax hamstrings + posterior force 

3 fingers on proximal tibia @ pes insertion

Snapping motion in opposite directions 

Grading

A= firm endpoint, B= no endpoint 

Grade 1: 3-5 mm translation 

Grade 2 A/B: 5-10mm translation 

Grade 3 A/B: > 10mm translation


ACL graft options

Hamstring graft harvest 

All Inside Graftlink single tendon Semitendinosus graft

Quadriceps tendon graft

Quadriceps tendon graft 

Show More

ACl Graft Options

Quadriceps autograft harvest

All Inside Quadriceps Autograft ACL Reconstruction

Show More

Clinical example - Hamstring ACL Reconstruction

Normal Knee Anatomy

Normal Knee Anatomy

Normal Knee Anatomy

ACL Footprint

Normal Knee Anatomy

Normal Knee Anatomy

Femoral and Tibial Tunnels

Anatomic placement of ACL tunnels

Drilling of ACL graft sockets

.

Arthroscopic Views of ACL surgical steps

Anatomic localization of ACL origin

Accessory anteromedial femoral tunnel drilling

Accessory anteromedial femoral tunnel drilling

Accessory anteromedial femoral tunnel drilling

Accessory anteromedial femoral tunnel drilling

Accessory anteromedial femoral tunnel drilling

Femoral suspensory fixation

Accessory anteromedial femoral tunnel drilling

Femoral suspensory fixation

ACL Femoral Socket Length Maximization

ACL Femoral Socket Length Maximization

ACL Femoral Socket Length Maximization

ACL Femoral Socket Length Maximization

ACL Post-Op X-rays

ACL Femoral Socket Length Maximization

ACL Femoral Socket Length Maximization

BTB (Bone-Patella-Bone) ACL reconstruction

BTB Surgery

1 of 6 graft options for #acltear

Lateral extra-articular tenodesis (LET)

Indications

To increase rotatory stability (decrease internal rotation) in ACL reconstructions

May be considered in high risk patients: 

- female athletes

- hyperlaxity

- revision ACL surgery

- high grade pivot shift

- increased posterior slope

- high risk pivoting/contact sports (soccer, rugby, football, etc.)


Technique

Modified Lemaire Technique

tubercle, ensuring that the most


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

Lateral Extra-Articular Tenodesis (LET) surgical steps

Post ACL surgery incisions

 

2 small arthroscopy incisions: suture removed 8 days after surgery 1 anteromedial portal incision: suture removed 8 days after surgery 1 harvest/procedure incision (arrow) : dissolvable suture, trimmed 8 days after surgery

Post ACL surgery incisions

ACL Repair

Indications

May be indicated in select patients:

1-#youngathletes, #skeletallyimmature 

2-#acuteinjury 

3-proximal femoral avulsion #acltear 

4-#partialacltear 

Potential benefits:

-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 

Surgical pearls:

#internalbrace may increase success rate

#prp augmentation may be helpful in combination with a scaffold

ACL Repair - Surgical Steps

All-Inside ACLPCLReconstruction Surgery - Tibial Tunnel Creation

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  • About Dr. Nguyen
  • Clinical Assistants
  • SportsMed MiniFellowship
  • ACL Surgery
  • SportsFractureClinic
  • ACL Rehab
  • PRP Injections
  • PRP Injections 2
  • Hyaluronic gel Injections
  • Sports Medicine Symposium
  • Pediatric ACL Surgery
  • Meniscus Surgery
  • Meniscus Surgery 2
  • Medical Education
  • Health Law
  • MPFL reconstruction
  • Osteochondral OCD repair
  • Sports Trauma
  • OATS Cartilage Transfer