In recent years arthroscopy has also been used as a corrective measure in minor afflictions in which bits of cartilage are loose in the tissues of the knee. Arthroscopy is used to flush liquid through the knee, which washes out the debris causing the pain or disability.
Says Dr. Nicholas, "We are right 75% to 80% of the time with just an X ray, and a thorough history and examination. Adding an arthrogram we gain another 8% or so accuracy. Combining them all with the arthroscope, we can get up to 98% precise diagnosis of what is wrong."
Surgical techniques have been advancing rapidly, too. For many years the major problem was to find a way to stabilize torn ligaments. Relatively primitive surgery to accomplish this was begun during World War I, but the first breakthrough did not occur until the late 1930s, with Dr. Don O'Donoghue of Oklahoma City, widely known in the U.S. as the "father of knee surgery," in the forefront of this work.
Dr. O'Donoghue is still in active practice—and in great demand by top athletes. (He has performed two operations on the right knee of Willis Reed, the new coach of the New York Knicks.) Dr. O'Donoghue has seen revolutionary changes in knee treatment since he began practicing nearly 50 years ago. "The only known treatment for many years was to put a knee in a cast and hope the injury would go away in a few weeks," he says. "Knee surgery was seldom done in the early '30s. There was a general feeling that when you got to the surgeon with your knee, your day of athletic competition was over. Then I began to notice that people who demanded surgery, because of the seriousness of their injury, got better results than people who were less seriously hurt and didn't have surgery. Then we got involved in some experimental work—ligament repair on dogs, for example. We felt we could then prove it was clinically possible for it to work on humans. It wasn't easy. Some people called us knife-happy."
In 1949 Dr. O'Donoghue published a paper, now considered a classic, on the case histories of 25 University of Oklahoma athletes who had major surgical repair on their knees and were able to play again. "That is when the concept finally arrived," he says, "that a doctor should do everything he could to make the player well enough to decide himself whether he wanted to go back to playing."
Dr. O'Donoghue's pioneering work was followed by other breakthroughs. Dr. Slocum recalls, "The concept of having ligaments repaired, not just in the forward-and-backward plane, but also in the side-to-side plane, was not arrived at until the early 1960s, when the theory of rotational instability was introduced. That led to a whole new line of thinking and the development of new techniques in the last 15 years."
As Dr. Nicholas puts it, "Surgery now has been developed to the point where any competent orthopedist can do it. You don't have to go flying off to some far-off wizard to have knee surgery."
However, the fact that surgery is so much more a matter of routine does not mean that it is a cure-all. Excruciatingly painful arthritic knees may occur in middle age after major surgery. Irritation and inflammation of the joint is difficult to avoid in many cases after the removal of cartilage. Thus, there are tough decisions for doctors—and athletes—to make every time surgery is contemplated. "The doctor represents the player," says Dr. Kerlan, "not the management, and he should play a kind of medical father to an athlete. We aren't just interested in patching a man up so he can play more. We have to consider what goes on after the stresses of athletics. We have to think of the rest of a man's life. These people are young. They have 40 or 50 years left to live. They could spend it all in constant pain. But when a player is a professional, his future depends on earning money while he can play. It's a critical period—10 or 15 years of earning power that can make him secure for life. So the players say, I know my knee is hurt, and I know there's a serious risk if you operate again, but I have to go ahead with it. I have to play, this is my life.'
"A doctor may argue with him and tell him, 'You may end up with lots of arthritic pain if we operate.' But these fellows say, 'I don't care.' "
The pressures on superstars to continue playing, no matter what the cost in pain and trauma and future mobility, are great indeed. Recalls Dr. Levinthal, who was a consultant for the Bears when Halas sent Butkus to him in 1968, "I examined him and said, 'This knee won't stand pro football. Nor will it stand the routine trauma of life.' His knees were worn out. They were bone-to-bone. He'd worn out the inner cartilage. The semilunar cartilage was torn. There was irritation on the surface of the femur. Every move would be painful. He said to me, 'When do you want to operate?' I said, 'I won't do it.' "