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November 29, 2007
Fixing Agent Zero
The Gilbert Arenas Injury

by Kevin Pelton and Will Carroll

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Did Agent Zero undergo a new secret procedure, one that will have him back on the court in three months when it has cost others a full year? Is Gilbert Arenas actually some kind of superman, an alien with healing powers far beyond those of mortal men? How will the Wizards will fare without the NBA's most valuable blogger

Arenas underwent knee surgery last week, a combination procedure designed to fix the current, acute problem and to try and minimize the damage down the line. The surgery, performed by Wizards team orthopaedist Marc Connell, had two major elements. In the first, Connell repaired the medial meniscus, the small layer of cartilage between the femur and tibia, the large weight-bearing bones of the upper and lower leg, respectively. In the second, he used microfracture techniques on the head of the fibula, the smaller bone in the lower leg. Microfracture, in which small holes are punched or cut into bone to stimulate bleeding and, hopefully, a healing response (along with creating a "blood bed," a large clot that functions as both nutrition for the area and as cushion) occurs at the site.

It is important to note that Arenas was recovering from a lateral meniscus repair performed in the offseason. Arenas never fully recovered, seeing swelling and pain in the area with activity. It is this surgery that is notable much more than the current procedures, and in fact may be more important, period. In this image, you can see the location of the structures involved. This image is of the right knee from above and forward, with the medial (inside) meniscus on the right and the fibula's head on the right (lateral aspect). When the lateral meniscus was repaired--or, more likely, removed--the jumping, running and stopping likely caused some bone-on-bone contact inside Arenas' knee, especially at the extreme lateral aspect where the fibula is located. This is where the microfracture comes into play.

Unlike other microfracture surgeries, which are normally performed on the tibial plateau (the large, flattish part of the tibia where most weight bearing occurs), the fibula will not require as much recovery time. That said, if the microfracture does not do what it was intended--create healing at the site as well as cushioning--then Agent Zero will find himself back at square one. The longer-term concern is that, absent a complete meniscus on either side, Arenas is more likely to have arthritic changes, continued swelling and a significant negative effect on his skills.

While it is impossible to make an apples-to-apples comparison of the microfracture surgery performed on Arenas to the more well-known applications of the technique on players such as Amaré Stoudamire and Greg Oden, it's also not necessary. Arenas' knees are simply breaking down under the stress of his activity, as proven by continued, chronic swelling and the reduction of function in the twice-repaired meniscus complex. The three-month recovery quoted by the Wizards is extremely aggressive--most physicians interviewed for this piece felt that six months was a more likely scenario--but none would rule it out. "Pain tolerance is what it will come down to," said one orthopaedist who regularly performs this type of surgery on skiers. Arenas may be able to come back from this on his schedule, but for his career, the clock is ticking.

That should make for an interesting summer for Arenas, who holds a player option on the final year of his contract. It was a foregone conclusion entering the season that Arenas would become a free agent and sign a new, more lucrative contract. Teams will surely be more reluctant to throw around that kind of money given the uncertain future of Arenas' knee. It may make more sense for him to play out his contract and try to go into free agency on a more positive note.

For the Wizards, the question now becomes whether they can stay in the playoff hunt for a possible Arenas return late in the season, or even survive the entire year without him. That task began to look a lot more doable when Washington won its first three games without Arenas, extending its winning streak to six games. Wins over Portland, Philadelphia and Charlotte, however, aren't noteworthy. Going into Dallas and handing the Mavericks their first home loss of the season, as the Wizards did Monday night, will make the rest of the NBA pay attention. The victory brought Washington to 4-2 without Arenas and 7-7 on the season.

A closer look at the Wizards since Arenas was injured indicates it may be tough for them to keep up their current pace. Over the first six games without him, Washington was torched on defense, allowing 115.4 points per 100 possessions, which would be the NBA's worst Defensive Rating over the course of the season. The Wizards have won because their offense has been even more potent, putting up at least 110 points in each of the last six games and posting a 122.5 Offensive Rating that would be the NBA's best by 8.0 points per 100 possessions had it been maintained the whole season.

Certainly, getting better on offense isn't the expected effect of losing a player who finished third in the NBA in scoring in 2006-07. Then again, with two recent All-Stars in Caron Butler and Antawn Jamison, who averaged a combined 38.9 points per games last season, the Wizards are better equipped to replace their leading scorer than most teams would be.

Butler and Jamison have been brilliant since Arenas' injury, averaging 24.3 and 29.0 points, respectively. More striking has been their efficiency. Butler has hit 11 three-pointers at a 64.7% clip and has a 65.7% True Shooting Percentage; Jamison is hitting 56.3% from the field and has a True Shooting Percentage just behind Butler's at 64.5%. Last year, their True Shooting Percentages were 53.7% and 54.5%, respectively, and both players will have a very tough time maintaining their efficiency. As they cool down, so too will the unsustainably-hot Wizards offense.

The better sign for the Wizards has to be the performance of young reserves Andray Blatche and Nick Young. Blatche, who has flashed potential in his first two years out of high school, has averaged 15.4 points, 9.9 rebounds and 3.7 blocks per 40 minutes this season. Blatche and Brendan Haywood give the Wizards an underrated combination at center. Young has gotten more minutes since Arenas' injury and has averaged 10.8 points per game in that period, showing three-point range and the ability to get to the free-throw line.

Washington must feel lucky now to have a veteran backup for Arenas in Antonio Daniels, the team's third guard the last two seasons. Daniels is averaging 12.3 points and 7.5 assists since Arenas went down, posting the kind of terrific assist-to-turnover ratio (4.09) he has been known for throughout his career. The worry is that Daniels is logging heavy minutes, nearly 40 a night, typically absorbs a lot of contact and has dealt with meniscus problems of his own in the past. Daniels has missed just five games the last two seasons, but he's never in his career played 30 minutes a night. If he goes down, the Wizards have only journeyman Roger Mason, Jr. to play the point.

With two quality scorers, a veteran point guard and emerging youngsters, the Wizards have enough talent to survive losing their superstar. However, Washington did not have a lot of room for error even with Arenas in the lineup, not with a defense that was one of the league's worst last season and has shown little improvement this year. This Wizards group has enough talent to hang around the playoff race and give themselves a chance if Arenas is able to return. Without him, they'll be hard-pressed to continue their streak of three postseason appearances.

Kevin Pelton is an author of Basketball Prospectus. You can contact Kevin by clicking here or click here to see Kevin's other articles.

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Headlines You Won't Fi... (11/30)

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