The Arthroscope: The Little Tool That Saves Careers
Editor’s note: This is the seventh in The MMQB’s series NFL 95: A History of Pro Football in 95 Objects, commemorating the 95th season of the NFL in 2014. Through the start of training camp in July, The MMQB will unveil one long-form story on an artifact of particular significance to the history of the NFL, accompanied by other objects that trace the rise of professional football in America, from the NFL’s founding in a Hupmobile dealership in Canton in 1920 to its place today at the forefront of American sports and popular culture.
Billy Sims ran through defenders. He launched himself over them. Once, he karate-kicked one squarely in the face (it was legal at the time). He was the Lions’ great running hope before Barry Sanders, whetting Detroit fans’ appetite for seeing a guy in a No. 20 jersey racking up 1,000-yard seasons.
Then came Oct. 21, 1984, a road game at Minnesota during Sims’ fifth NFL season. He switched shoes several times during warmups, struggling to get comfortable on the Metrodome’s artificial turf. Turns out, the turf was the only thing that could stop him that afternoon. It was another 100-yard day for Sims, who took his 22nd carry midway through the third quarter. The play was a handoff around right end, and his right leg—the one he’d previously thrust like a black belt—got stuck. It twisted as he got tackled, cueing an explosion inside his knee joint.
“Will I miss the rest of the game?” Sims wondered at the time. He didn’t make it back onto the field that day, or ever again. At age 29, his career was over.
“Had it not been for that injury, not to brag, [but] I might have had the chance to make the Hall of Fame,” Sims says today. “Had the technology back then been like it is now, I probably would have gotten a few more years. But, I didn’t.”
Recently, Sims has had good reason to consider the hypothetical. Another running back came along—you may have heard of him—with almost identical credentials: a son of Texas, record-setter at the University of Oklahoma, first-round pick. Adrian Peterson also tore the anterior cruciate ligament in his knee during his fifth professional season.
Sims’ injury was career-ending. Peterson’s was the prelude to his 2,000-yard MVP season in 2012. No two football injuries are the same, but there is one big difference between these two cases: The use of the arthroscope.
* * *
The instrument itself is relatively simple: a thin tube about the size of a pencil, with a magnifying lens and a light source. The arthroscope is not much more than a foot long, but its impact on the NFL has been much grander. “The biggest revelation in sports medicine in the last 50 years, no question,” says James Andrews, the orthopedic surgeon whose clinic in Gulf Breeze, Fla., is a hub for many of pro football’s top players.
Since the arthroscope came into use in North America in the mid-1960s, the game has changed. Players routinely get “scoped”—now part of the lexicon for even casual fans—to have injured joints examined or cleaned out, sometimes returning to the game in as quickly as two weeks. A generation of specialists for knees, and pretty much every joint, has been spawned. A torn ACL can now be repaired in 63 minutes, and today’s athletes usually do not wonder if such an injury will be career-ending, but rather how they can return like Peterson, who was back on the field and en route to a rushing title nine months after his injury.
This didn’t happen all at once, of course. The arthroscope at first drew skepticism from some of America’s top surgeons, who wondered about the value of plunging a metal probe with a light bulb at the end into an injured knee joint. That’s how the early versions worked. Surgeons had to lean over to peer through the eyepiece, and there was the risk of the bulb short-circuiting or, worse, shattering inside the knee.
Masaki Watanabe is considered the father of modern arthroscopy. The Japanese orthopedic surgeon took advantage of electronics and optics industry booms in his country post-World War II to create a reproducible model. The conduit to North America was Robert Jackson, an orthopedist from Toronto who traveled to Tokyo to study with Watanabe in 1964. He returned with the No. 21 Arthroscope his teacher had developed—No. 21, because 20 models had preceded it.
“And that was the first time it was ever really seen here,” says Andrews. He caught the wave at the right time, as did Russell Warren, Giants team physician and past surgeon-in-chief at Manhattan’s Hospital for Special Surgery. The fact that both men are among the top surgeons treating NFL players today is more than a coincidence. They were finishing their residencies and going into practice in the late 1960s and early 1970s, and were among the early group of American surgeons to get their hands on an arthroscope. The next step was figuring out how it could best be used.
Joints had been something of a black box, but the arthroscope shined a light—literally—on the interwoven anatomy of ligaments, tendons, cartilage and the shock-absorbing menisci. In the 1970s, the instrument was simply used for diagnosis. Surgeons worked their way up to repairing injuries arthroscopically, with the scope and other instruments inserted into joints through small external incisions.
“There was a guy in Salt Lake City who started trying to do surgery, taking out simple things, loose bodies; then he started trying to take out meniscus tears,” Warren says. “I remember flying out there. He cut one off, and the thing disappeared in the joint. Couldn’t find it. He looked around for 30 minutes. Finally, he gave up.”
Lanny Johnson, a surgeon in Michigan and one of the pioneers of arthroscopic surgery in the U.S., offered fellow orthopedists some advice in those days: “You probably have to look at 50 knees through an arthroscope before you have any idea what you are looking at, and at least 100 knees before you should attempt the most simplistic surgical procedure.”
Fiber-optic light cables replaced the bulb at the end of the arthroscope in the 1970s. Around the same time, video cameras were attached to the eyepiece of the scope and hooked up to a television monitor, so the view inside could be broadcast to everyone in the operating room. The scope was also linked to a “fluid management system,” a fancy way of saying pump, by which sterile saline solution could be cycled through the joint to give the surgeon a clear view inside—better than the previous technique of injecting fluid every so often with a syringe.
Arthroscopes became reliable, and then routine, and then invaluable, underscoring a frank reality of NFL history: The career outlook for players after injury has depended, largely, on the decade in which they played.
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Adrian Peterson sometimes gets a dose of perspective while walking through an airport. It’s happened more than once: An older man who played football in another era will spot the Vikings running back and congratulate him on his remarkable return from knee surgery. Then, the stranger will share his own experience.
“He’ll pull up his pants sleeve and show me the scars on his leg. They’re like seven, eight inches long, on both sides of the knee; looks like Frankenstein,” Peterson says. “I’m thinking he broke everything, his shin bone and knee cap, had a total knee replacement. He’ll say, ‘No, this was ACL and MCL tears, like you.’ ”
The NFL was established in 1920, and for at least the first five decades, doctors didn’t know how to fix the ACL. They didn’t really even know the importance of that pinkie-sized piece of tissue that connects the femur to the tibia and allows athletes to cut and jump. Warren examined Frank Gifford well after his 13-year Giants career ended in 1964, and was surprised to feel looseness in one of the Hall of Famer’s knees—the telltale sign of an ACL tear. “He said, ‘Well, I used to just cut differently,’ ” Warren recalls. “But ACLs ended a lot of careers, because most guys can’t do that.”
The arthroscope changed the way injuries to most joints are treated, from the knee to the shoulder to the elbow to the ankle. But the first changes happened with knee injuries, the leading cause of missed time for football players.
Those “Frankenstein” incisions Peterson has seen in older players used to be par for the course in knee surgery. Step two was dislocating the kneecap to move it out of the way. The only way into the knee at that time was to fillet it open, but slicing through inches of flesh traumatized the surrounding muscles and brought infection risk. Patients had to stay in the hospital for a week (today, it’s an outpatient procedure) and the leg was encased in a cast for six to eight weeks, resulting in stiffness and muscle atrophy that was sometimes permanent (today, they leave in a brace and can begin rehab the next morning). Once the surgeons were inside the joint, it was a bit of a guessing game.
Damaged parts were either taken out or haphazardly mended, wreaking the kind of havoc that stole once-in-a-generation talents like Bears legend Gale Sayers. His career ended in 1972, at age 29, after ligament damage and surgery to both knees forced him to call it quits. Sports Illustrated’s Tim Layden wrote in 2010 about the remnants the surgeon found when Sayers needed a left knee replacement thirty-some years later: no ACL, almost no cartilage, a chunk of his tibia sawed off and an MCL that had been sewn or stapled.
The arthroscope, in contrast, gave surgeons a way into joints that was only about 4.5 millimeters long—the diameter of the tip that is used for knee and shoulder surgeries. The scope enters the joint through one so-called poke hole, giving the surgeon a view inside, and other instruments are then inserted through additional tiny incisions to do work, like a mechanical shaver that bites away and suctions out damaged tissue. The last frontier was refining techniques to do minimally invasive reconstructive surgery, like replacing a torn ACL with a graft, with the aid of the arthroscope.
The view from the arthroscope on the TV screen in an operating room looks a bit like an underwater dive to a shipwreck, with saline solution rushing through the joint and flakes of debris from the injury floating around. That analogy is apt: Arthroscopic surgery is equipment being plunged below the surface to explore the damage and see how it can be cleaned up or fixed.
When Sims’ injury happened in 1984, surgeons were still trying to master the “fixing” part for ACL surgery. “It was at that cusp,” says Robert Teitge, the Lions’ team physician at the time, who operated on Sims. “We didn’t have complete confidence we could do everything [arthroscopically].” The arthroscope was used to assess the damage inside Sims’ knee and take out loose cartilage. But the ACL still had to be replaced with an open procedure, through an incision a few inches long on the top of his right knee (the kneecap, however, no longer had to be dislocated). Sims recalls the surgery taking seven hours.
Sims’ injury was more extensive than just an ACL tear, and he would have faced a challenging road back even today. He also had a torn lateral collateral ligament and significant damage to the meniscus and the articular cartilage that cushions the bones. But today, the most critical part of his surgery—replacing the ACL—would have been completed arthroscopically, meaning a smoother, more accurate and less invasive route to placing the graft in his knee. And, perhaps, a different end result.
“I was going to try to give it a go and come back, but it was too painful to run,” says Sims, who today devotes his time to his Billy Sims BBQ franchise. “With my running style, I knew I wasn’t going to be satisfied with that. I dove over the top a lot, pushed off on that leg a lot, cutting low. You just don’t change your running style and be successful as a running back. So, I knew it was time to hang it up.”
* * *
The biggest revelation in sports medicine in the last 50 years is still no panacea. No instrument has eliminated a surgeon’s fundamental challenge: duplicating the body’s normal anatomy.
“You’ve got to remember,” Andrews says in a refreshing moment of frankness, “there’s nothing that can’t be made worse with a surgical procedure.” But with the arthroscope, there are a lot more things that can get better.
Consider: Giants quarterback Eli Manning had arthroscopic ankle surgery on April 10 to debride, or clean out, the joint after a high ankle sprain suffered in December, and was back on the practice field in late May. Other proof: The rigorous medical vetting process of would-be NFL players at the annual scouting combine now passes more than 90 percent of players who have had an ACL injury while playing, Warren says; in the early 1980s, before ACLs could be repaired arthroscopically, about 85 percent of players who’d had an ACL injury were flunked.
Peterson’s leap from ACL injury to MVP has become the stuff of legend, which risks making this major surgery seem less so. He has his scars, like where his ACL was created from cutting out the middle third of his patella tendon, and he endured many miserable Minnesota winter days until his body’s natural healing ability and his rigorous work ethic started to make a difference. But this statement is without hyperbole: By the end of that 2012 MVP season, Peterson was running with an explosiveness he wouldn’t have been able to regain so quickly—or at all—if he’d had an open knee surgery that sliced through his muscles and tendons. With arthroscopic ACL surgery, Peterson was able to squeeze the quadriceps muscle above his injured knee in his first rehab session the next morning.
In another era, the 1960s, 1970s, or even the 1980s, what would his outlook have been? “Not so good, probably,” says Andrews, who performed Peterson’s surgery. “A good athlete like that may have been able to compromise and make some adjustments and still be competitive, but it certainly wouldn’t be as good of an outcome as you have today.”
Earlier this year, Peterson and Sims were side by side at an autograph signing in Chicago. Sims signs memorabilia pretty much only for his playing days at Oklahoma, and not for his time in the NFL. He shared his experience with Peterson, really just to congratulate him. Peterson, who spent his collegiate career chasing Sims’ Oklahoma records, coming up 73 yards short of his career rushing mark, couldn’t help but ponder.
“I always think about guys who had their careers shortened by knee injuries, especially great running backs. Billy Sims. Gale Sayers,” Peterson says. “If his career wasn’t shortened, what could he have done? It would have been spectacular.”
And therein lies a simple inspiration for Peterson to make the most of his place in history. He already has more than 10,000 yards toward Emmitt Smith’s NFL career rushing mark—and the chance to keep chasing.
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