Rob Gronkowski's forearm injury, re-injury and subsequent infection serve as a reminder of one painful truth in medicine: Sometimes things don't go according to plan.
According to Ron Borges and Karen Guregian of the Boston Herald, Gronkowski will undergo surgery on his forearm for a fourth time to remove the metal plate originally implanted within his arm. He will do so due to concern over a lingering infection first reported in February.
Other reports refrain from calling the need for surgery definitive. Rather, sources told USA Today's Mike Garafolo that Gronkowski only "might require" the operation. However, ESPNBoston.com reports surgery is "very likely."
As always, exact medical details are unavailable to the public. However, by piecing together the available information, some conclusions can be drawn. From there, it becomes possible to project how this story might one day end.
The possibilities range from Gronkowski being 100 percent ready well before the 2013 season to him being forced to miss some time. Most likely, it will still be the former, though recent developments haven't done anything to solidify that prediction.
To start off, here's a brief review of Gronkowski's injury timeline:
2. Jan. 13, 2013: Following several weeks of recovery, Gronkowski breaks his forearm a second time during a game against the Houston Texans and again has surgery to revise and repair the plate and fracture.
3. Feb. 25, 2013: Gronkowski undergoes a third operation on his forearm, this time to clean out a post-surgical infection likely stemming from the second surgery.
4. April 7, 2013: Reports surface of Gronkowski possibly needing to go under the knife for a fourth time.
With that in mind, let's break down what might be in store next for the star New England Patriots tight end in the weeks and months to come.
Possibility No. 1: Gronkowski Receives Continued Medical Treatment for a Persistent Soft-Tissue Infection (Relative Likelihood: Low)
The Boston Herald report states that doctors are unsure if Gronkowski's infection is resolved.
It may be. However, evidence presented by the aforementioned ESPNBoston.com column suggests otherwise:
Gronkowski was in California visiting friends recently, and when he woke up in the morning, his arm was swollen and he noticed some discharge. After he called the Patriots, the club quickly arranged for his cross-country return to Boston to address the issue.
Swelling and discharge are two tell-tale signs of infection, so it seems like one still exists. If that is the case, the probability that the infection is confined to soft tissues—such as the skin or underlying connective tissue—is low.
In fact, it's essentially nonexistent.
Antibiotics usually clear up soft-tissue infections without much difficulty. Additionally, soft-tissue infections generally appear relatively soon following surgery.
In other words, the full six weeks between Gronkowski's second and third surgery suggest the initial infection represented something more than a simple skin or wound infection. The most recent developments further strengthen that conclusion.
Possibility No. 2: Doctors Remove the Metal Plate, Find No Signs of Infection and Replace it Immediately (Relative Likelihood: Medium to High)
As mentioned, swelling, discharge and a known previous infection make the diagnosis of some sort of persistent disease likely the correct one.
Even if that is not the case, if Gronkowski's original infection involved the bone or metal plate, it's very possible—probable even—that doctors planned to remove and replace the plate all along once as much of the infection as possible cleared with antibiotic therapy. The public is just now hearing about it.
Nevertheless, it needs to be re-emphasized that the above statements represent only educated speculation. The infection may not have involved the metal plate or bone at all, and the timing of the events is only what the team released, not necessarily what actually happened.
All of that said, one obvious question remains: Why replace the plate without any obvious infection? The reasoning behind doing so is multifactorial.
By implanting a metal device into a fracture site—necessary to ensure proper healing of the bone—surgeons disrupt a bone's normal structure and blood supply. As a result, the body's immune response has difficulty reaching the locations where metal meets bone, allowing for any bacteria introduced to the sites to grow and multiply without any interference from the body's protective mechanisms.
If infecting bacteria create a so-called "biofilm" on a metal device—a protective protein barrier sitting on top of a layer of bacteria, separating them from antibiotics and the body's immune system—they can become extremely resistant to treatment. Antibiotics can deter their spread, but the infection source itself can persist and must be removed.
In short, even though there may be no obvious signs of infection, the risk of leaving a potential infection source implanted within Gronkowski's arm is too high to not intervene.
Possibility No. 3: An Infection Persists in Gronkowski's Forearm Bone, Metal Plate or Both (Relative Likelihood: High)
The most troubling scenario is one in which Gronkowski's original infection continues to rage within his forearm and has extended to the bone—a process called osteomyelitis. If the worst comes to pass, osteomyelitis can become chronic and lead to permanent bone destruction.
Osteomyelitis is notoriously difficult to treat because growing bacteria damage the already poor blood supply of bone. If the osteomyelitis is due to a particularly nasty or antibiotic-resistant bacteria, matters become even more complicated. An abscess—where the body walls off an infection, thereby preventing antibiotics or the immune system from reaching it—can also linger indefinitely until it is surgically drained.
If surgeons do indeed decide to operate on Gronkowski's forearm for a fourth time and are greeted by pus and dead or dying tissue, they would need to remove the metal implant that may serve as an infection source and clean out the infected area. They would then start further antibiotic treatment to clear the infection once and for all. After all that, Gronkowski would then probably need to undergo a fifth surgery to reinstall a new supportive metal plate.
And yes, that new metal plate also carries with it a chance to become infected in its own right.
Unfortunately, if Gronkowski's twice-fractured forearm is not yet fully healed, the plate is a necessary evil. Without metal reinforcement of proper alignment, the bone could reattach itself in a non-anatomic way—or even not at all.
Dr. Andrew Blecher, a sports medicine specialist at the Southern California Orthopedic Institute, weighed in on what the most recent developments could mean for the 23-year-old Gronkowski. In short, it could get ugly:
"If Gronkowski still needs metal hardware because the bone isn't healed, the current hardware needs to be removed. The remaining infection must then be treated until it clears. Then, a new open-reduction internal-fixation (ORIF) needs to be done for the bone to heal. Recovery could be three months."
The ORIF procedure Dr. Blecher refers to is the name of the surgery performed to realign a broken bone and secure it with metal devices.
Nevertheless, another ORIF—Gronkowski's third in total—cannot be performed until there are no signs of infection. If the infection is osteomyelitis, that might not be for some time still. Dr. Blecher continued:
"Other factors also include how advanced the osteo(myelitis) is and (what bacteria is causing it). Antibiotic treatment could be anywhere from two to six weeks before going back for a revision ORIF. The revision could be even more difficult depending on how much bone destruction there was. Could be another eight to 12 weeks after that before he sees a practice field."
Dr. Blecher also mentioned that there are too many variables at this point to accurately predict when Gronkowski returns to play. However, the worst-case scenario is quite concerning.
Five months later, it appears the saga of Gronkowski's forearm is far from over. Though the possibility of the star tight end missing part of the 2013 season may not yet be likely, it is still very real. Even with the best surgeons practicing the best medicine—as is certainly the case with Gronkowski—complications are possible.
For now, we should assume that the projected additional 10-week recovery time following Gronk's next—and hopefully final—ORIF stems from his doctors' desire to be conservative rather than aggressive in their management of the oft-injured superstar. Yet given the way the story continues to unfold, nothing is a given.
Dave Siebert is a medical writer for Bleacher Report who will join the University of Washington as a Family Medicine resident physician in June. Medical information is based on his own knowledge except where otherwise cited, and quotes were obtained firsthand unless otherwise noted.