Pavel Bure in 1998 (in a jersey I somehow forgot existed)

 

Pavel Bure spent twelve years in the NHL with three different teams. Along the way he earned the Calder Trophy, the Rocket Richard (twice), and finally this week election to the Hockey Hall of Fame. Bure holds a place on most “what-if” lists – what would a post-lockout Bure have accomplished? Would an already impressive career have been flat-out ridiculous? Thanks to two ACL reconstructions and a torn meniscus, the what-ifs will stay what-ifs. Canucks (and Panthers and Rangers) fans may want to spare their own feelings and turn away as I break down the knee injuries that stopped Bure in his (very speedy) tracks.

The ACL: Significantly more important than Pierre McGuire thinks.

Pierre added to my enjoyment of the draft last week with his assertion that an ACL tear isn’t a big deal like it used to be. The anterior cruciate ligament (ACL) is absolutely a big deal. It connects the femur (upper leg) to the tibia (lower leg), and keeps the knee stable by preventing the lower leg from rotating too far or from sliding forward out from under the upper leg.

 

The ACL in its natural habitat (PL = posterolateral, AM = anteromedial; fancy words for where it's attached)

 

The ACL’s job is obvious when you consider that the test for an ACL tear – the anterior drawer – involves a kindly doctor grabbing hold of the lower leg and yanking on it to see if it slides out from under the knee (like a drawer). That test is as gross and painful as it sounds if you’re the owner of the torn ACL in question.

 

The Lachman test - a slightly more tame version of the anterior drawer (which still sucks mightily)

 

An ACL tear can happen as a result of a direct blow to the knee, a sudden change in direction, or a hard landing. In Bure’s case, he tore his right ACL in November of 1995 in a game against the Chicago Blackhawks after an awkward hit and/or grab and/or fall (depending on who you ask). Chicago’s Steve Smith grabbed Bure by the head (or just lightly hit him), leading to his skate sticking between the ice and boards and an awkward fall. This led to his first reconstruction, and the end of his season.

How to build your own ACL (but not really)

If you’re not a very active person with no need to move very quickly or change direction in a hurry, you can probably live quite happily with a torn ACL. A knee brace and some physio to strengthen the muscles around your knee and you’ll be back to the mall-walkers club in no time. If you’re an NHL hockey player (or really anyone other than an inactive grandma/pa), that’s not an option. You need an ACL. ACLs don’t like to be repaired, so they have to be replaced. You can find a replacement ligament in a few places – various places on your own leg, or from a cadaver. Studies have shown that you can get similar outcomes whether it’s your own graft or a dead guy graft in terms of post-op function. In Bure’s case, a portion of his own hamstring tendon was used to reconstruct his ACL.

But don’t you need your hamstring?

Yes, of course. The good news is you’ve got an extra little bit of hamstring that you’re not really using (the semitendinosus), that makes for a brand-new ACL that’s really quite strong. Problematically, it turns out that harvesting those extra hamstring pieces affects the strength of the knee joint, particularly the flexor muscles (the ones that bend aka flex the knee). This is part of the reason rehabbing an ACL reconstruction takes so long, and why it’s still a big deal now (just like it was in 1995).

The extra hamstring piece is folded back on itself a few times, and is attached to the femur and the tibia in any one of a few different ways (screws in the bone, absorbable screws in the bone, sutures wrapped around screws in the bone, etc). The repair is generally done arthroscopically (through several tiny incisions), and you’ll go home the same day. There you’ll suffer through six long months of sucky rehab.

Sucky Rehab

For the first three to six weeks, you’ll be in a super-comfortable, really attractive knee immobilizer. Like apparently every piece of medical equipment in the world, you can buy one on Amazon if you’re so inclined. You’ll be on crutches with minimal weightbearing for about a month. Despite all that, your doctor will want you doing simple (painful) range-of-motion exercises right away. You’ll hate your doctor, and that’s okay. Mostly that’s okay because you’ll hate your physical therapist even more since they’re the ones that will scream at you while you try to avoid bending your knee. Within four to six weeks you’ll hope to have full range of motion back, and can begin very light strengthening. It’ll be ten to twelve weeks before you can even think about jogging. You may be fitted for a functional brace (a bendy one that you’ll wear during sports to support the joint), and after about four to six months you might be able to return to your sport of choice.

Back to Bure

Bure missed several games in the 96-97 season thanks to a concussion/whiplash issue, and later said he’d tried to play through to make up for having missed most of the previous season. After his dramatic move from Vancouver to Florida, Bure strained his right knee in January of 1999, but managed to only miss three weeks. The “strain” was more likely another ACL tear, and on March 3rd a collision with Adam Foote of the Avs finished the job (and his season). Another reconstruction followed, and he was back skating in the preseason for 1999-00. That season proved to be a big one, with an All-Star nod, All-Star MVP, and the first of his two Rocket Richard trophies.

Bure’s time with the Rangers was short, as 2002 proved to be the year his knees would finally give up on him. A preseason knee tweak kept him out for only three games, and then a collision with Buffalo’s Curtis Brown shut him down completely. Arthroscopy of both knees revealed that both ACLs were intact, but his left meniscus was torn.

More knee parts: The meniscus

 

These are your menisci. You'll want to keep them, because having them removed sucks (and living without them sucks even more).

 

The menisci are pads of cartilage that sit on top of the tibia and cushion the knee joint. Tears are fairly common, happening when a bent knee is twisted. Meniscus repairs can range from the relatively simple – shaving off small shredded bits or suturing together tears – to the distinctly complex – complete meniscectomy (that’s bad news). Bure’s repair was on the simpler end of the spectrum, as team physicians expected him to return by the end of January. They were mostly right, as he returned in February and finished out the season.

Before the 2003-04 season Bure was still having pain in his reconstructed knee despite spending the offseason rehabbing like a fiend in an attempt to be ready for the last year of his contract with the Rangers. His fiendishness didn’t pay off, and he failed his physical. At the age of 32, Pavel Bure was done. His knee was getting worse, not better. He went unclaimed on waivers, sat out the 2004-05 lockout with everyone else, and then retired, citing knee problems as the reason.

 

Pavel Bure’s knees provide for a pretty exhaustive tour of lower-extremity orthopedic procedures. Those knees carried him through twelve years of outstanding play in the NHL, and now have finally gotten him a well-deserved spot in the Hockey Hall of Fame. It’s probably best not to speculate on the what-ifs, and focus on the fact that he put up multiple seasons of impressive numbers and had several impressive world, Olympic and NHL accomplishments with a set of not-so-impressive (read: total junk) knees.

Psst…

If anyone needs me I’ll be over here totally speculating on the what-ifs.