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ACL is to Microfracture as Public Enemy is to...

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For some time now, I've been fascinated by micro-fracture surgery.  Not necessarily the mechanics of it, or the impact on the game, or even just understanding what the heck it is (although those are all interesting subjects).  No, there's been one question that has bugged me since at least Kenyon Martin and Amare Stoudemire - namely, what did NBA athletes do with these injuries BEFORE micro-fracture surgery?

Via True Hoop, I read a thorough post on We Rite Goode comparing micro-fracture surgery today to ACL surgery in the early 90s.  The point, and it's well-taken, is that ACL surgery is no longer a career death sentence (as techniques for the surgery and rehab have improved), and micro-fracture surgery is moving in the same direction, as players like Jason Kidd and Amare Stoudemire put up all pro numbers post-surgery.  

But there is still much mystery surrounding the procedure.  Hand's up, who thinks micro-fracture surgery is designed to repair tiny fractures in a players knees?  Don't be shy.  I assumed it was something like that until relatively recently, but I now know that the micro-fractures in the title are part of the remedy, not part of the injury.  Go figure.  

Others have described the procedure itself much more eloquently, like this post from Henry on True Hoop after Oden's surgery, but to paraphrase - micro-fracture surgery is performed to repair damaged cartilage in a knee.  Specifically, after the damage is cleaned up, tiny punctures are made in the end of the bone (these are the micro-fractures) to spur the growth of cartilage-like tissue to provide the cushioning that was lost when the actual cartilage was damaged and removed.  

But the comparison of the history of ACL injuries and those leading to MF surgery actually serves to illustrate my confusion.  ACL injuries are obvious - you know them when they happen, usually because of the crumpled body of a promising young Clipper player writhing under the basket.  We know why ACL surgery is necessary - players with ACL tears can barely stand, forget about running and jumping.

And in the We Rite Goode post, tracing the history of the surgery to Mitch Kupchak is interesting as well.  Knee injuries occurred long before Mitch Kupchak in 1981.  Surgeries were performed, and damaged ligaments repaired, one way or another.  Elgin Baylor (the other NBA GM in LA) had a major knee injury in 1965 but returned to play until 1971.  Gale Sayers suffered major ligament damage in 1968, and led the NFL in rushing in 1969.  Knee surgeries at that time were crude and intrusive, splaying the entire knee open to gain access to the damaged areas, but they still happened.  Because of course, the injuries happened.  

By comparison, there is no catastrophic, traumatic, stomach-turning moment that causes an injury that requires micro-fracture surgery.  Greg Oden was the number 1 pick in the draft, an invitee to Team USA camp (he missed because of his tonsils, not because of his knee, if you'll recall), and a pending rookie-of-the-year / superstar one moment, and then out for the season the next.  And it wasn't the result of a pick-up game injury.  He had some swelling, and then, boom - the M word.

The trend toward younger and younger players opting for the surgery is interesting, if not disturbing.  It's one thing when Penny Hardaway or Jason Kidd or Chris Webber opts for a procedure that could prolong an already long, successful career.  But why are 19 and 20 year old kids (Amare, Oden, Spencer Hawes) getting micro-fracture surgery?  Or more to my point, what were these kids doing before 1997?  Did we just never hear about them because their careers were ended before they got out of college?  Or did they play through some pain?  And if they played through pain, how much was their effectiveness diminished?

Back in day, if you suffered some cartilage damage, you might have some cartilage removed, and then go back out and play the next season (or the next month after arthroscopic techniques were developed).  We've all heard the stories of NBA players finishing their careers with 'bone on bone' in their knees - near as I can tell, these are the guys that are getting micro-fracture surgery today.  

But to the untrained eye (specifically mine) it feels a little like a medical procedure for it's own sake.  We've seen enough of the 'bad' MF experiences (CWebb, Penny, Houston, Mashburn) that any time a player undergoes the procedure, there's a fear that they could be done, and an assumption that they will be significantly diminished.  But isn't that arguably worse than what happened to guys with cartilage damage before MF surgery?  They still played, they suffered more pain (and took more cortisone shots), they weren't as explosive as they had been, but they were still good.  Why are players voluntarily missing entire seasons to undergo a procedure that, on the surface, appears no more successful than 'playing with the pain'?  

Like I said, I'm confused by it.  And I readily admit that I'm no expert - I'm probably missing something very obvious.  Maybe, for instance, the procedure is likely to significantly improve these guys lives post basketball - maybe all those guys limping around 'bone on bone' for 30 or 40 years after they retire from the NBA are completely miserable, and certainly a year off now for an improved 30 years down the road seems like a reasonable trade.  

But it all strikes me as incongruous.  I can understand worrying about Shaun Livingston's future because I watched his knee implode.  But Greg Oden wasn't doing anything.  One can't help but wonder if the micro-fracture cure is not worse than the disease.