Paul George suffered a gruesome injury on Friday, fracturing both the tibia and fibula of his right leg. George's leg collided with the stanchion below the basket and snapped the bones, necessitating immediate surgery to correct the issue. The Indiana Pacers star now faces months of rehabilitation and years of questions. It is very unlikely that he will be able to play in the upcoming 2014-15 NBA season.
George was taken to the hospital in Las Vegas, where Dr. Riley Williams, the team doctor for both USA Basketball and the Brooklyn Nets, performed a procedure called an open reduction, internal fixation (ORIF). The procedure is very common and involves inserting a rod or plate over the fracture(s) and then pinning or screwing it into place.
The key to this procedure is alignment. The surgeon needs to make sure that the bones are lined up properly to allow for clean healing. Given the violent nature of the fractures, it was unlikely to be a "clean break," leaving a lot of splintering at the ends. The surgeons may have had to clean up some of this before fixating the bones. They would have also had to check for circulatory and nerve damage.
I spoke with Dr. Bert Mandelbaum, one of the top orthopedic physicians in sports medicine, about George's injury:
"The treatment for these displaced tibia and fibula fractures is usually immediate intramedullary rodding of the tibia. The surgeon places a titanium rod down the center of the tibia and then further fixes it with small screws [that] go in between the rod and the bone above and below the fracture site.
"It could take anywhere from six to 12 months to return to fully competitive basketball after such a fracture. He first requires a period of six weeks of being on crutches. Then the athlete gradually progresses to rehabilitation, physical therapy and cross training. Once the fracture healing is strong, the athlete will return for progressions to practice and games. Once completed, most athletes can perform at pre-injury levels."
The bone itself is usually the least of the worries, but Dr. Terry Trammell, the longtime surgeon for Indy Car, has seen plenty of violent lower leg fractures. He told The Indianapolis Star's Curt Cavin that tibia fractures can be very slow to heal. It will be months before George is fully weight-bearing, let alone starting basketball activities.
It is unknown how long George will need to remain fixated, but it's possible that he will need surgery at some point in the future to remove the hardware. There are several techniques for an ORIF, and depending on those options and the healing, that determination can be made in the future. It will affect George's availability and the timeline for his return, to be sure.
Beyond the fractures, the reports have been good. Marc J. Spears of Yahoo Sports tweeted on Saturday morning that there was "no ancillary damage." While this is an overgeneralization, to be sure, it is nonetheless some good news. There was obvious ancillary damage, to the skin if nothing else, which opens up the immediate possibility of infection. That's easily addressed and hopefully will not be an issue.
Inside the leg, the worry would be about ligaments and tendons, muscle that could have been damaged as the bones broke through, and for damage to the internal structure of the leg itself, often referred to as compartments. It will be nearly impossible to tell how any damage, even minor, to this area could affect George's game.
I spoke with Ralph Reiff, the head of St. Vincent Sports Performance in Indianapolis, about what George faces in rehab, and Reiff focused on the alignment. "We won't know the effect on the joints for six to eight months, when he gets really weight-bearing. In a traumatic situation like this, it's going to be impossible to tell what the effect is on soft tissue function for quite a while."
One noted issue with the injury is the placement of the stanchion, as noted here by ESPN.com's Brian Windhorst. While it is noticeably closer to the baseline at the Thomas & Mack Center than it is at most NBA arenas, it's not clear that it is the sole cause of the injury.
If George had landed with his foot on the floor, it is possible that the force could have been transferred to the knee and led to a serious injury there. He also could have escaped without injury. We'll just never know, though stanchion placement will surely be an issue going forward.
For Mike Krzyzewski, this had to be a horrible case of deja vu. Krzyzewski was on the court for the last memorably gruesome basketball injury, that of Kevin Ware during the Louisville-Duke game in 2013. That game took place in Indianapolis, and many of the same men who treated Ware will likely be involved in George's rehab.
Reiff was in charge of the venue when Ware was injured, and he noted that George received excellent care. "I could see they reacted quickly, and that doesn't just happen. I could see the hand signals the athletic trainer was using and how quickly he stabilized the leg."
While Ware and other gruesome injuries to athletes like Tyrone Prothro, Anderson Silva and Tim Krumrie will come to mind, there's really no good comparable for George. Jeff Stotts, one of the top NBA injury researchers, was unable to find a direct comp for George's fracture in his extensive database.
That George was so quickly handled on the court and moved to surgery is a testament to the athletic trainers and doctors on site. That he has a chance to come back and play again is a testament to what modern orthopedics and sports medicine can do. How well he comes back will be all about Paul George.