The mending of Medranda

When Jimmy Medranda limped from the field in May of 2018, nobody expected it would be the last time they saw him for the season. It ended up being over a year before Sporting Kansas City fans would see him step back across the white line.

A full year without playing feels like a lifetime.

There is never a good time for any injury, but this particular timing was especially poor. Medranda had really been coming in to his own with Sporting KC. It was his sixth season and his playing time had increased the previous two years. After just a handful of games his first three seasons, he played in 28 games in 2016 and 33 in 2017 and it looked like he was going to be a regular starter for 2018.

In his first few seasons, Medranda played all over the field; winger, midfielder and on defense. He was speedy, aggressive, strong, a skilled dribbler and passer and a terrific 1-v-1 defender. He had also improved his defensive positioning. While he was clearly one of the versatile players manager Peter Vermes loves, the 24-year-old appeared to have locked down the starting left back spot.

A minor knock in the 2018 preseason slowed down his preparation for the season and forced him to come off the bench for the first four games, but he ended up starting the next eight matches. In those 12 appearances he scored twice and added an assist, working well in what was developing into a potent attack for Sporting KC.

Defensively the team did not start as well as expected. In Sporting KC’s first four games, they gave up an average of 2.25 goals with Medranda on the bench before subbing in. In the eight games Medranda started, the team only allowed 4 goals (.5 per game) with 5 shutouts.

The eighth game he started he could not finish. Medranda limped from the field and was officially subbed off in the 36^th minute.

Hard to diagnose

It was clear that Medranda was experiencing pain in his knee and that there was inflammation. What was not clear was the root cause. MRIs and all the scans and examinations showed no torn ligaments, tendons or any other damage.

Since there was not a specific injury to treat, it was determined that he needed rest to let it heal. It may have felt better, and the inflammation reduced, but it did not go away. With it not getting better and further tests still inconclusive, the medical team sent him to a doctor in Los Angeles to have exploratory surgery in August.

What could not be seen in scans was clear when they looked in on the cartilage and bone. MRIs can only give so much info and are not 100% conclusive all of the time. The inflammation was obvious on the scans, but the exploratory surgery clearly showed the real problem. The issue was a defect in the cartilage covering the femur, a loose divot in Medranda’s cartilage near the kneecap.

When the doctor went in and poked the flap of cartilage, they could see it was dissociated from the bone and that there was a loose fragment.

The underlying issue was now clear.

How to fix?

Injuries like this are not uncommon. They may be hard to diagnose at times, but many athletes have some form of a similar issue. Location, size, severity and specific activity vary and so do the methods used to fix them if they even need to be fixed.

If you are an average, go to the office person with limited physical activity, there may not be much treatment other than for inflammation and pain. But the higher up the athlete chart you go, the more likely there will be an attempt to resolve the issue.

A fairly standard process has been to do Microfracture Surgery on professional athletes. In this process, the surgeon pokes the underlying bone with a needle or drill (or some appropriate medical term). The resulting bleeding allows marrow and stem cells to leak through to the surface, filling in the hole in the cartilage. It is supposed to then form new cartilage, developing from a “super-clot”.

This procedure has been around since the 1980’s and has been used many times with many case studies. Microfracture Surgery has a relatively short recovery time, as little as three months in some cases. The problem is the success rate for high end athletes is relatively low.

Some research suggests that it was used too often in cases that were not good candidates but in the end, it only helped a limited number of high level athletes return to close their original form.

OATS

What Sporting Kansas City’s medical staff decided in consultation with Medranda and one of the best surgeons for this type of injury was to do osteochondral allograft transplantation surgery (OATS).

There are two slightly different procedures known at OATS. Osteochondral allografting transplant and osteochondral autograft transfer. Both are similar and are also known as mosaicplasty.

In both versions, the problem area of the cartilage is cleaned up, trimmed smooth and a corresponding portion of the bone below removed. Then a piece of articular cartilage and the attached bone are cut out matching the size and shape of that spot and placed in the hole. In some cases the microfracture process will be used in the hole to speed up the bone on bone healing.

The key difference in the two versions is where the replacement cartilage and bone come from. In the autograft version, a replacement piece is harvested from areas of the patient’s knee that do not bear much weight.

The allograft method that was performed on Medranda is when the replacement piece comes from a cadaver and not his own knee. This method was chosen because as he is a high-level athlete, removing some of his own bone could weaken the entire knee or prolong healing.

When the surgery involves the allograft transplant from a cadaver, not just any cadaver will do. The medical team made sure that the cadaver had very similar traits to Medranda. Size, weight, and shape was all part of the criteria considered to find the best fit with the best chance for success.

Video showing one form of OATS and the tools used.

Why go all the way to LA?

The surgery was performed by Dr. Bert Mandelbaum in Los Angeles. Sporting KC’s Sports Medicine Director Kurt Andrews was previously with the LA Galaxy and they used Dr. Mandelbaum. There was already a good working relationship in place between Andrews and Dr. Mandelbaum but that was not the only reason. Dr. Mandelbaum is known as one of the best to perform this procedure on high level athletes and he has been doing it for over a decade. FIFA, MLS, U.S. Soccer, USA Gymnastics, and Pepperdine University are some of the organizations that use Dr. Mandelbaum for their athletes or in an advisory role.

Sporting KC wanted the best for a player that they value and see having a bright future in the club.

Patience

The hardest thing for an athlete is not being able to play. The next hardest is to not even be able to train to get better, stronger, more skilled and most importantly, back in the game.

Because of the type and severity of the surgery, Sporting KC’s staff took Medranda’s recovery very seriously and very delicately. They followed a plan, making sure to give him the time to heal, checking it, before moving on to the next step.

For Medranda it was tough watching his teammates train and play every day. Slowly progressing from crutches with a brace where he could not bend his knee (except when a trainer allowed it), to being able to stand and walk with a brace on. Slowly moving to doing rehab in the gym to light running and doing ball work on his own under the careful eye of the training staff.

Months after the surgery, he eventually started to rejoin the team at the beginning of training. At first just warming up, running around with his teammates brought a smile. Then a few weeks later actually playing in small games with limited contact and eventually to full training.

Vermes praised Medranda’s work to get back on the field but made sure to give credit to Andrews and the rest of the staff. “Talk about the staff and all the time and effort they put in to bring him back, it was a lot on everybody’s part for sure,” Vermes explained. “The medical staff did a great job bringing him back and being smart about how we get him back on the field because we haven’t put him in any situation that would cause him risk.”

Back in action

On May 26^th, just over a year since he had subbed out, Medranda stepped up to the line as Yohan Croizet subbed off. The crowd noticed. They knew he had been gone for a year and they rewarded him with a cheer as loud if not louder than any of the three goals that gave Sporting KC the win that day over Seattle.

Officially it was just 1 minute but there was some stoppage time and the young Colombian almost made the most of it when he took a shot that went off the near post, bounced off the Seattle keeper Stefan Frei and out. An inch of difference and it would have almost made for a fairytale ending but for Medranda it was enough to just be back on the field. “It’s been a year, I worked so hard to be here I am just enjoying my comeback,” he said quietly.

A couple days later, Medranda subbed in again, building up some minutes towards a future start. Again, the crowd gave him some loud love as he stepped across the white line. When asked if he heard the loud cheer he humbly responded. “It is amazing the love the fans have for me but it’s normal because this club is like a family and they love all of the players. We feel it and it is amazing. It gives us extra strength to go on the field and play harder.”

“I don’t have the words to tell them all of my love for what they show me,” Medranda added.

Thad Bell