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Microfracture knee surgery and its impact on the NBA

by - @AustinKent
Monday, July 26, 2010
Amare Stoudemire

Amar’e Stoudemire is an expensive bundle of generously damaged goods, so it comes as no surprise that the New York Knicks are guarding their most recent investment with a desperate passion that only a team weeks removed from the biggest heart-break in franchise history could. It all traces back to a certain microfracture knee surgery.

Give them credit first of all, for putting their free agency sorrows behind them and taking advantage of the consolation prize they were fortunate enough to land. He’s big, he’s powerful and he looks good with a beard. Just never mind that under that chiseled armor of sleek athleticism is a frame that doesn’t hold up well under stress. Not everybody can be as big, as powerful, as handsomely bearded and as durable as LeBron James, after all.

This week the Knicks announced that said investment would sit out the biggest tournament of the international basketball year for insurance reasons, leaving both stakeholders of American basketball and Mr. Stoudemire himself out in the cold heading into the longest months of the already tiresome NBA off-season. Sure Team USA lost some of its depth at the power forward position and Stoudemire lost an opportunity to showcase his talent for a new legion of fans, but that doesn’t matter; the preventative damage control exercised by the suddenly committed Knicks more than justifies the decision, especially considering all the work that has been done in order to keep those knees in functional shape.

You wouldn’t necessarily expect a team that had so recently hit rock bottom to turn around and demonstrate caution with their de facto franchise stud after failing the biggest and longest transaction gamble in NBA history. It’s an uncharacteristic 180, but more importantly, it’s a sign that maybe this whole free agency saga is one of the best things that could have happened to the franchise. They’re ready to put down that tub of ice cream and get on with their life.

When Stoudemire underwent microfracture knee surgery in 2005, doctors performed one of the most mysterious surgeries available to our generation’s professional athletes. You can understand New York’s concern. The list of those who have underwent the procedure and bounced back to the level they were pre-surgery (or at least near it) is Nate Robinson-small. Stoudemire and perhaps Jason Kidd are the most notable examples of players who’ve had close to or similar success, while players like Anfernee Hardaway, Chris Webber and Allan Houston make up a far more depressing list of stars that would never again return to their pre-surgery form.

But this isn’t some questionable witch doctor solution for restoring expired cartilage, as every year passes more and more peer-reviewed literature and knowledge surrounds the potentially career-altering procedure.

Championed by Doctor Richard Steadman in the late 1980s, microfracture surgery involves the use of stem cells to rebuild articular cartilage. As Steadman himself put it in 2000, “(the) goal is to recreate the structures of the knee that protect it from impact and provide stability”.

In layman’s terms, it taps into a joint surface in the knee that releases a substance that oozes out and forms new cartilage where the old, broken down stuff used to be. Healthy cartilage, of course, lines the bones that make up the athlete’s joints and plays a major role in the pain-free movement of basically every part of the body.

Stoudemire, much like Webber, Houston, and Hardaway before him, had already been playing on worn down or damaged tissue and though the microfracture procedure is a far cry from a guarantee, it’s often the only option for athletes whose cartilage is more or less defective.

In a 2003 article posted in the Journal of Rheumatology, Doctors James Hoi Po Hui and Anthony Marchie described how cartilage-related injuries are some of the most debilitating injuries in North America. Management of cartilage lesions and defects not only help minimize pain, but can get athletes back in game condition.

Among those forms of cartilage management is marrow stimulation and specifically microfracture surgery. According to Hui and Marchie, the arthroplastic procedure (which means to relieve pain and restore movement) involves rebuilding cartilage with stem cells released from the inside of the bone.

Stem cells, the real hero of this story, are undifferentiated cells produced within bone marrow that have the potential to develop into any number of specific cell types within the human body. As tissues develop, stem cells mature into whatever their environment requires them to be; from brain cells to blood cells and anything in between. In our case they form the cells that make up fibrocartilage.

By clearing the knee’s surface of any pre-existing lesions and damage, doctors prepare the patient’s joint for the stimulation of new cartilage growth. Then, by scratching as many small holes in the athlete’s subchondral bone plate as possible without jeopardizing the integrity of the bone (usually 3-4 mm apart, according to Hui and Marchie) they allow otherwise stationary stem cells to seep out and eventually form cartilage that will replace the damaged cartilage.

As much as we, and especially the NBA franchise owners who invest hundreds of millions of dollars into athletes, would like it to, the body doesn’t naturally re-grow cartilage. But, by stimulating the release of stem cells, doctors can convince it to. The catch? While athlete’s typically wear down an abundant form of cartilage called hyaline cartilage, the cartilage that forms from the newly released stem cells is, as we mentioned earlier, fibrocartilage. The latter is a type particularly more rigid than the one it is used to replace. As a result, patients can pretty much expect that their knees will never feel the same.

Microfracture surgery is a process which involves extensive rehabilitation, but serves as a last ditch effort for players who might otherwise have to consider retirement. Although the recovery rate is limited, the fact that players like Jason Kidd, and now apparently Stoudemire, can come back and make long-lasting impressions on teams is a testament to advances the relatively new procedure has made over the course of the past 20 years.

A lot of the success of the surgery depends on how willing a patient is to adhere to a strict rehabilitation schedule. Other factors can be out of their control entirely. Steadman himself acknowledges that a large part of the success of the operation depends on the athlete’s natural joint alignment.

Given the countless doctors and researchers who focus solely on issues pertaining to bones and movement, much can be (and has been) written about microfracture surgery, yet we’re really only scratching the surface of what this technology can do. The medical advances available in the early 1990s may not have been enough to restore the career of Penny Hardaway to the point we had all hoped it might, but even in the 15 years since, progress has been abundantly clear.

For Stoudemire and the Knicks, the fact that the five-time All-Star hasn’t fallen off the radar entirely is a victory in itself, so there really is no reason to test fate, even if that means making the decision to forfeit the opportunity to play internationally under the guise of an insurance complication. After all, regardless of how much progress has been made over the course of the past 20 years, the fact that he needed the surgery in the first place hasn’t changed.

For more information on Dr. Richard Steadman and microfracture knee surgery, consider the following…

Interview with Dr. Richard Steadman

The Journal of Rheumatology

The Journal of Orthopaedic Surgery and Research

Austin Kent
is the founder and Editor-in-Chief of

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