The news that Danilo Gallinari would have ACL surgery and miss the remainder of the NBA season, as the Denver Nuggets announced on Jan. 21, isn't unusual in and of itself. What has many confused is the sequence of events that led to this. Gallinari injured his knee last April!
Understanding what happened has to start with the original injury. As with most ACL sprains, the injury itself was not a complete rupture of the ligament. Instead, it was a severe but incomplete sprain. This means that the ligament was in place, but compromised.
At low levels, it is possible for the ligament to heal without surgery. At higher levels, the ligament is very likely to fail with any stress, even with time off, and is usually reconstructed.
Think of a ligament like a rope. If you want to use that rope to pull something, it doesn't have to be pristine. It can have some fraying and be fine. It may even have some chunks out of it or a point where it snapped a bit and works, but you might not want to tow that expensive boat with it.
While surgeons vary on technique and philosophy, the general idea is the same with this kind of surgery. They harvest a replacement from the body, usually from the patellar tendon or the hamstring. They then replace the damaged ACL with the harvested tendon, trying to recreate as closely as possible the movement and function of the damaged original.
That normal type of surgery is what was done this week by the Nuggets' team ortho, Dr. Steve Traina. But this is the second knee surgery. Per Yahoo! Sports Adrian Wojnarowski, the first surgery, apparently done by Dr. Richard Steadman at his clinic in Vail, was performed using a technique called "healing response." It was a repair, not a reconstruction.
Steadman is a world-class doctor, probably best known for his development of the microfracture procedure. Much of his work is based on skiing, given his location and position as team physician for the U.S. Skiing Team. However, professional athletes of all kinds have long made the trip to see him, including Kobe Bryant and Tiger Woods.
The "healing response" is described in the Steadman-Hawkins Clinic's annual report from 2002. On page 14, the success of the surgery for Olympic skier Bode Miller is cited. The report states:
During Bode's meniscus repair, [Steadman] performed the "healing response." This arthroscopic procedure involves making three to 10 small "microfracture" holes in the bone at the femoral origin of the injured ACL. The blood clot from the bleeding bone captures the injured end of the ACL and eventually reattaches the ligament back to the bone.
Miller's success was stunning, as further quoted from the report:
Three weeks following his surgery, Bode was fully mobile and without need of a brace. Dr. Steadman suggested waiting another three weeks to determine whether the healing response would take. When the three weeks were up, the news was even more encouraging. "My ACL," said Bode, "was regrowing entirely on its own."
The success of the procedure for Miller is impressive—and remember, this is over a decade ago. While the procedure is not widely used or even well known, Steadman's method is the result of his research that also led to the much more widely used microfracture techniques. Indeed, it is merely an offshoot of that technique.
Steadman published a paper on the surgery's results in 2006 that stated a high rate of success, 77 percent, with the procedure, though it cited only 13 specific athletes over six years, reaching back to 1992. This indicates that the procedure itself requires a specific type of injury and patient.
It appears that Gallinari is one of the unlucky 23 percent. The failure of the healing response to take led him back to a more standard procedure and restarting the rehab on his damaged knee. The chance Gallinari took to return quickly and effectively didn't pan out. Nuggets fans would have liked it if it had worked.