Doctors still searching for effective treatment of cartilage damage

CLEMSON —Friends and family assembled at Da’Quan Bowers’ childhood home in Bamberg to celebrate the Clemson football star’s expected selection in the first round of the 2011 NFL Draft. In the family’s backyard, tents housed flat-screen televisions and barbeque for the draft-day party. Much of the community was present and eager to celebrate along with Bowers, projected by some to be the No. 1 prospect in the draft.

But as night came, as player after player greeted NFL commissioner Roger Goodell on the stage at Radio City Music Hall in New York, and as the first round ended, Bowers remained unselected.

Bowers, a defensive end who led the country with 151/2 sacks and 26 tackles for loss as a junior. had been projected as a top 10 pick months earlier. But that was before his injured knee became a source of major concern for NFL teams.

Bowers watched his free-fall mostly from the solitude of his room. There were reasons he was not in New York that night like the majority of projected early first-rounders. He was aware of the extent of NFL teams’ fears.

Surgeons can fix pitchers’ faulty elbows in baseball. “Tommy John” surgery is routinely a success. Orthopedic surgeons can make star running backs who have suffered torn anterior cruciate ligaments nearly as good as new. But cartilage damage is one physical ailment all the nation’s best sports medicine minds have yet to solve.

Bowers said he slid in the draft because NFL teams thought they would be unable to fix his knee. Despite Bowers’ assurances that he did not have cartilage damage, they worried what damage had occurred during his junior season at Clemson.

“Some teams thought I wouldn’t last three years,” said Bowers, who tore his Achilles tendon this offseason. “Some teams thought I wouldn’t make it through training camp.”

Dr. David Geier, director of sports medicine at MUSC in Charleston, said finding a cure for damaged cartilage is sports medicine’s holy grail.

“(A solution) would revolutionize sports medicine,” Geier said. “We’re a long way off.”

A solution would also help the general population as articular cartilage injuries affect an estimated 900,000 Americans each year.

Difficult to repair
Bowers lay flat in the bed of his apartment during his junior year at Clemson. He grimaced as he tried to fully extend his knee. He tried every position to relieve pain in his knee, but it continued to throb.

What few on campus knew is Bowers played the last seven games of the 2010 season with a torn meniscus in his right knee.

A meniscus acts as a shock absorber. The crescent-shaped pad of fibro-cartilage disperses friction in the knee joint between the tibia and the femur. NFL teams were not so much skeptical of the health of his meniscus, rather what it protected: articular cartilage.

Articular cartilage coats the ends of the tibia and femur at their meeting point in the knee. It is white in color, firm but slippery to the touch, and just several millimeters thick. The cartilage is like the lubricant in an engine, allowing for smooth mobility and flexibility in the joint and preventing painful bone-on-bone contact. And once the thin coating is damaged it can be difficult and often impossible to repair.

A major factor why cartilage fails to heal is the lack of blood supply.

With Tommy John surgery or an ACL repair, the repaired ligaments have the benefit of blood supply in the healing process. But with cartilage there is no blood supply. With no blood supply it limits the body’s natural healing capabilities.

“We have very few ways to make cartilage grow again,” Geier said. “Even with these surgeries where we inject cartilage cells, they just don’t work that well, especially in athletes. Once these guys get an articular cartilage injury, it dramatically shortens their careers. If we can figure that out it will change people’s careers.”

NFL concerns
During the pre-draft process, Bowers tried to convince teams he did not have articular cartilage damage. Even with MRI images, NFL doctors weren’t sure. Bowers said some teams were leery he had undergone microfracture surgery or that he would require the procedure, a risky surgery that is seen by many experts as ineffective and a last-chance solution to repair cartilage damage.

“That’s what scared teams off,” said Bower, who eventually was selected by the Tampa Bay Bucs with the 51st pick in the draft.

Bowers did not alleviate concern when he struggled through his pro day at Clemson in the spring. He ran the 40-yard dash in4.9 seconds, and looked labored in his movements.

Pro teams had good reason to exercise caution. Former No. 1 NBA draft pick Greg Oden had cartilage damage and is out of basketball. Allen Houston’s NBA career was cut short by the same type of injury.

Even after Tampa Bay drafted Bowers, the team seemed skeptical about his ability to stay healthy.

“There’s something going on, but there’s nothing degenerative going on,” Bucs general manager Mark Dominik said. “There’s no debate in terms of there being inflammation or a problem. But because he’s young, the way he’s built, there’s certain things we look at that make me comfortable that this kid is going to play longer than people think.”

Microfracture surgery
Dr. Richard Steadman is credited with developing microfracture surgery, one of the few surgical procedures that has improved some athletes’ cartilage injuries.

Steadman played football under Bear Bryant at Texas A&M, but after a couple seasons he left the team to focus on medicine. His particular interest was knee injuries.

Steadman was in the right place at the right time. In the early 1980s, arthroscopic surgery was becoming an option in cartilage treatment.

“It allowed us to actually look at the cartilage,” said Steadman, who lives in Vail, Colo. “It seemed we had a much a better opportunity not to be invasive. We didn’t have to open the knee up to get to the area we wanted to treat. That allowed us to think of a procedure that allowed cartilage to form.”

Steadman experimented with an idea: drill tiny holes into the knee cap, allow the bone marrow to flow into the effected area of cartilage, forming a sort of scar tissue offering an approximate version of articular cartilage. Steadman experimented with the surgery on horses at Colorado State and seemed to have success.

“My idea was to do an operation that would add new cells that would come from the bone marrow, and they would populate the defect in the cartilage,” Steadman said.

Steadman saids 85 percent of his microfracture patients return to their former athletic activities. But many other experts doubt its effectiveness.

A University of Pennsylvania study followed 24 NBA players who had microfracture surgery from 1997 to 2006. Eight of the 24 players never played again. Fourteen of the 24 players played for more than one year, but the group saw their points and minutes decline.

The American Journal of Sports Medicine commissioned a study of 3,100 microfracture patients and found the procedure was often helpful in the short term, the first 24 months following surgery, but the technique did not produce noticeable long-term benefits. In comparison, the success rate to repair an ACL tear for a running back or basketball player and the success rate of Tommy John surgery are around 90 percent.

The list of failed microfracture patients is extensive, and the critics include Geier.

“Greg Oden is the poster child,” Geier said. “There’s a lot of sports medicine guys that think it’s a terrible surgery.”

But Geier believes science will find a solution.

“We’ll ultimately figure it out,” he said. “There’s so much research going into that, so much money that’s going into that. But we are not close to that right now.”