On a knee to know basis

Young NBA players dropping with knee injuries. Promising teams forced to shelve playoff hopes. Once-foreign medical lingo becoming increasingly commonplace.

Sound familiar?

Yes, I'm talking about December 1990.

Oh--you thought I meant Greg Oden and Sean May, of the Blazers and the Bobcats? Well, I won't minimize their recent microfracture surgeries; they've just lost a year off their young careers, may never regain full strength, and their teams have scaled back present and future ambitions. And for a while this week, it looked like they'd have company from California (beyond Brian Giles), but Tom Ziller reports the good news that sore-kneed Spencer Hawes dodged a bullet (or did he? I thought the docs might still get in and find that the knee was worse than expected. Let's hope not.)

But as bad as microfracture seems today--one Sacramento Bee story called it a "dirty word among NBA players"--almost exactly a decade after John Stockton was pro basketball's patient zero, it really is the rescue operation that its billed to be. And I'm not saying that because Amaré had a good year.

Rather, compared to the early days of ACL reconstruction, microfracture's track record isn't so shabby.


Alright--let's back up a second. To understand where we are with microfracture, just revisit 1990, when a rash of ACL injuries struck young NBA stars and terrified the league's executives.

And who could blame them? At that point, there had been only four "successful" ACL reconstructions in a decade, if you want to be generous. Current Lakers GM Mitch Kupchak had been the first guy to really make it back, after several years of rehabilitation from his 1981 injury--but he was no longer a 14 ppg, 8 rpg starter, but a backup big man off the bench. Bernard King is considered the patron saint of ACL recovery, but although it's well-documented how he changed his game and re-emerged as a major scorer in Washington, it's less well-know that he didn't come close to his previous level of efficiency. Derek Smith also had returned, but never recaptured his promising young career, while no one would ever knew how good Danny Manning could be, as his ACL tore during his rookie year.

Instead, the list of players who lost their careers to ACL tears--dotted with names such as Billy Cunningham, Doug Collins, and Jamaal Wilkes--seems nearly endless. (Although who knew that a rookie Patrick Ewing suffered an ACL tear? Hubie Brown's taxicab confessions to Henry Abbott aside, there's zero record of this).

And why is the ACL tear so damaging? It's because the ligaments align the leg's upper and lower parts, enabling players to make sudden moves and quick changes in direction. It should go without saying that lateral quickness is essential when competing against the world's best athletes, almost all of whom have blazingly fast reaction times (compared to the quickness gap between the average D-1 basketball player and NBA player, Gilbert Arenas and Steve Blake actually aren't that far away from each other.) Unfortunately, ACLs rarely heal after a tear and don't grow back once they're gone.

Responses vary by surgeon and patient, but competitive athletes usually need an ACL reconstruction, which is incredibly intensive and requires grafting, not to mention months of therapy and strengthening, and no guarantees of returning to previous levels of performance. This was a young Ric Bucher writing about Tim Hardaway's 1993 ACL surgery, a technique that's still in practice.

[The surgery] involves replacing the ligament, located in the center of the knee, usually with a slice of a larger ligament. The substitute ligament is attached through holes drilled in the femur and tibia, or shin and thigh bones, and the knee needs time to properly adapt to the substitute.

Yeesh. Even I know that taking a ligament from another part of the body increases the damage--two areas now need to recover from operation.

So when 1990 rolled around--and up-and-comers Ron Harper, Mark Price, and Johnny Dawkins tore their ACLs in relative succession--it was cause for legitimate concern. Then-Bucks GM John Steinmiller called the ACL "the `in' injury"--like calling bird flu the "in" virus, I guess--before suggesting a league investigation into basketball shoes and weight training as potential culprits. Sports Illustrated ran a story on the "ACL fraternity," focusing on the woes of the guys who'd lost their careers to the injury.

The performance chart below really says it all. Of this 12-player cohort--which spans the range of older guys to younger prospects, from big men to short guards, and from scorers to distributors--the average decline in performance post-ACL reconstruction was more than 21%. And these players are culled from the lucky ones who made it back.

Really (foreshadowing John Stockton), only Mark Price was able to return at and even improve on his previous level of performance in that 16-year period--even Eric Williams as recently as 1997 was never the same. And quite unfairly, it seemed like the ACL had a nasty happen of tearing just as a player was enjoying or coming off a career year. For the implications of those declines, look no further than the trajectory of Ron Harper's career; his most comparable players regressed from a pre-injury Scottie Pippen and Clyde Drexler to a post-injury Ty Corbin and Tony Campbell.

But because Price and Harper and Dawkins all returned with some success, by 1992 the threat of a torn ACL had begun its downgrade from career crisis to a serious-but-surmountable injury. Today, it's a significant medical risk that we just accept. Nene returned from an ACL tear to have the best year of his career in 2006-2007. NBA player Leon Powe tore his ACL twice--before he got drafted. Nenad Kristic has yet to play a game following last year's ACL injury, and John Hollinger still thinks it's a defensible idea to sign him now. Few waves were made this summer when NBA first-round prospect Brandon Rush pulled out with a torn ACL, while this piece looks at all of the college players whose ppg went up after rehabbing.

And why has ACL reconstruction stopped setting off alarms? Because the more procedures they did, the docs gained experience and got better. (It's a proven medical fact.) The rehab programs grew more comprehensive and targeted. Not to mention, understanding spread that an injured player could make it back. (Another reason why, performance aside, Bernard King was a trailblazer.)

So what's emerged to terrify the NBA in the ACL's place? The spectre of microfracture.

Here's what we know: Microfracture's been performed on more than 20 NBA players. The procedure is designed to fix loose cartilage, which TrueHoop's Abbott does a nice job of explaining. And thanks to Bethlehem Shoals this is what it looks like.

Here's what we also know: That players who undergo microfracture don't see the performance drop that the comparably early ACL reconstruction patients experienced.

For this 13-player cohort--again, a range of players as with the ACL group, and only players who have since returned--the average decline in performance was half that of the ACL early cohort (Note that * represents years that the player either did not play or has yet to play).

Now, here are the many caveats--microfracture focuses on a totally different part of the knee, so comparing it to ACL reconstruction is like weighing apples and oranges, or cartilage and ligament. And has been widely noted, you either tear your ACL or you don't; with microfracture, so much depends on the size of the lesion and the age of the player, and so on--it's not a stretch to say that performance widely varies because the injury itself is all over the map. Finally, this isn't to ignore that microfracture doesn't fix everyone; Terrell Brandon and Jamal Mashburn never came back, while you'd have to be blind to notice that Chris Webber and Kenyon Martin...heck, even Amaré...weren't quite the players they were.


Back in the 1990s, fans and players were starting to rationalize and understand ACL reconstructions after 7-8 players returned; as we've surpassed that point with microfracture, it's time to do away with fears of it as a "death sentence." More importantly, for a procedure that's very much in progress (one recent major breakthrough was made because an athlete was too lazy to go to rehab--yet recovered faster and better), the first decade's outcomes have to be encouraging, as clinicians will only get better. Oden going under the knife isn't Penny in 1997 or 2001, nor even Allan Houston in 2004. And by the time that undetermined big man in 2012 needs microfracture--who knows how far along microfracture surgery will be...or really, why we'll even bother with it, when we have stem cells.

Update: I've been called out before for not reading Dave Berri, and looks like I've done it again. Oops. His post-Oden surgery post just focuses on the post-op performance of microfracture patients rather than the evolution of orthopedic surgery--i.e., he's tying his post to reality--and given that he's a statmaster, it's definitely worth a read.

Labels: , , , , , ,

posted by Doctor Dribbles @ 07:21,


At October 10, 2007 at 8:56 AM, Blogger Crucifictorious said...

Good stuff. But here's what I still don't get and wonder if you can answer: What happened to the guys who needed a micro-fracture surgery but it was too early to get one? Did they play on, bone-on-bone, or were they usually forced to retire early?

Because that might be a nice addition to your argument...that not only is micro-fracture surgery a more successful procedure than generally thought, but keeps guys in the game, too.

I think Elgin Baylor is the most-cited case of a pro basketball player with a cartilage-less knee, but he had a 13-year career, with 11 very effective years, so there's no way he's worst-case scenario.

At October 10, 2007 at 11:12 AM, Anonymous Anonymous said...

Before microfracture surgery, cartilage damage was treated in much the same way, but with cruder tools. Instead of using lasers to drill the holes in the cartilage, they used actual drills, for example. I think the Henry Abbot link in the article leads to another article that describes this procedure.

At October 10, 2007 at 12:50 PM, Blogger Xanthippas said...

Wow...incredible post.

Would you care to do the same analysis of ACL repair and Microfracture for soccer players?

At October 10, 2007 at 1:58 PM, Anonymous Doctor Dribbles said...

Cruc, the NBA landscape's dotted with guys who ended up playing with bone-on-bone knees--guys like Muggsy Bogues and Nick Van Exel come to mind--but in some cases, that was because of ligament injury too and not just articular cartilage damage. Players who would have been microfracture candidates, however, were guys like Mark Alarie and Luc Longley, serivceable big men who basically lost the last five-eight years of their careers because of torn cartilage.

Anon, thanks for pointing Cruc in the right direction with the added info.

Xanthippas, thanks for the kind words. Kind enough to motivate a follow-up post for soccer? Hmm...the Dr. is for a player-hoopin' degree--not that other kind of dribbles--and I'm less certain what statistical measures are considered legit in footy. But in reading up on microfracture, it was clear that the procedure is emerging as a legitimate option (as you no doubt know), with very well-known stars like Michael Owen increasingly going under Dr. Steadman's knife.

At October 10, 2007 at 5:34 PM, Anonymous Anonymous said...

why are point g's less affected by traumatic knee injuries? the charts show stockton and price staying great or even getting better, while hardaway and kidd didn't drop by much. the bigger players are the ones who have the bigger falls, but I thought pt g's needed lateral quickness more than any other players.

At October 11, 2007 at 12:21 PM, Blogger Jarrett Carter said...

Did anybody ever tell you, you could easily take out ESPN's TMQ if you wanted to?

At October 11, 2007 at 2:45 PM, Anonymous mingusmonk said...

Please tell me this thrilling article is just a teaser to the feature on Sports Hernias.

At October 12, 2007 at 2:28 AM, Anonymous Doctor Dribbles said...

Anon, that's a great question. Some of those point guards could hang out on the perimeter and pick their spots to penetrate, so it's not like they were jumping and banging most plays down the court. Mark Price and John Stockton didn't really play vertical games, either; having deadly range from outside helped compensate for fewer forays into the lane. But it is a worthy question, and I'm honestly not sure.

And speaking of being unsure--Jarrett, is a comparison to TMQ guy such a good thing?

Mingusmonk...now there's an idea.

At December 2, 2007 at 6:28 PM, Anonymous felix said...

but wouldn't you rather have OATS than trying to grow cartilage that's more like scar tissue?
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At April 5, 2008 at 7:35 PM, Blogger Conrad said...

YEAH what's the comparison between oats (osteo articular transplants) and microfracture?

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