ACL Surgery

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's Clinical Assistants will email  you  post-surgery instructions on the day of the surgery with a prescription for pain medication, stool softener and antibiotics to take after your procedure. Please take 1 Tylenol 500 mg + 1 Advil 400 mg (if no contraindications) + pain med every 4 hours + ice machine for the first 2 days to be comfortable post surgery

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 (2-3 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, tough rehab, tightness, 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, tough rehab

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 instructions in detail which includes the return appointment date/time, how to contact Dr. Nguyen (416-742-3736  info@nguyensportsmed.com , 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 via a private number to see how you are doing and answer any questions you may have. 

8. Suture Removal Day at the Fracture Clinic

 Dr. Nguyen's Clinical Assistants have given you a return appointment for suture removal 10 days after surgery at the fracture clinic at Etobicoke General Hospital

Dr. Nguyen will go over the details of your ACL surgery at that time. 

 Wound care after suture removal:

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

- 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 

9. Follow-up appointments at the Sports Medicine Clinic on Bloor

 Dr. Nguyen would like you to see you 2 weeks after your suture removal date at his  Sports Medicine Clinic on Bloor to ensure you have full range of motion and to teach you the 10 stages of the ACL / Meniscus rehab protocol. 

He will test you every 4 to 6 weeks depending on your progress. 

Please schedule these appointments with his 2 Clinical Assistants. 

10.Graduation Day (average 9 months)

If you have reached stage 10 of the ACL / Meniscus Rehab protocol (4 perfect single leg hops onto a trampoline) then congratulations! You have worked hard for this day. You may ease back into your competitive sport on a gradual basis with incremental level of intensity, complexity and risk taking. 

Please remember to do the evaluation so that Dr. Nguyen and his team can continue to improve in taking care of ACL athletes.