Hours after the 2013 Super Bowl, Rob Gronkowski danced on stage at Encore, the kind of Vegas club you pray your friends never drag you to. As I watched the inevitable TMZ video—Gronk body-slammed a pal onstage—I was less interested in Gronk Gronking than in the black cast encasing his left forearm.
I am an infectious disease specialist at New York-Presbyterian Hospital in Manhattan (but have not treated Rob Gronkowski), and that cast raised a question that would be basic for people in my profession, but not for fans of the New England Patriots: Was there a metal plate in Gronkowski's surgically repaired forearm, as a result of his breaking it against the Indianapolis Colts on Nov. 18?
I couldn't help but worry. A large chunk of my days are spent caring for patients who develop infections after they have their knees or hips or forearms replaced or stabilized with metal rods, plates, or screws. These procedures—referred to as Open Reduction and Internal Fixation (ORIF)—are remarkable. The metal allows the fractured bones to heal properly and enables crippled patients to walk again or play catch with grandchildren. A young man quickly regains the ability to body-slam.
But the metal—the catchall medical phrase is "hardware"—predisposes even the healthiest patients to infection, and that's where I come in. The hardware itself, which for the forearm is often made of titanium or stainless steel, is sterile, handled with great caution, and is rarely the culprit. Rather, it's the bacteria that live harmlessly on our skin—primarily Staphylococcus and Streptococcus—that slip into the body during the initial surgical incision. To prevent this, antibiotics are given prior to surgery. Nevertheless, some bacteria manage to sneak under the skin and into the bone and hardware. Once that happens, the infections become very difficult to treat. Some patients at my hospital have had so many post-op infections that they know me by name. They've actually come to equate my face with infection. My parents are moderately proud.
In early April, several weeks after a third surgery to repair the injured left forearm, it was reported that Gronkowski developed swelling and discharge at the surgical site while visiting a friend in California. What happened at this moment in his post-operative course was critical to his recovery. If a patient appears to have a surgical site infection (marked by pain, redness, swelling, or discharge) as Gronkowski reportedly did, the medical team has two options. One is conservative management with antibiotics alone. For someone looking to return to a football field, this is obviously preferable, but often it doesn't work.
The other, more invasive option is to take the patient back to the OR to open up the surgical site, wash out and remove the questionable tissue, and send fluid to the microbiology lab to determine exactly which bacteria are causing the infection. The team may have tried conservative management, which ultimately failed, prompting the fourth surgery on May 21. (The Patriots have not confirmed many of the details that have been widely reported pertaining to Gronkowski's surgical procedures).
If the tissue or hardware looks infected—if surgeons can see pus or black, necrotic tissue—the orthopedist calls someone like me and asks for assistance. Before we have an answer from the microbiology lab, I invariably do two things: I start an intravenous antibiotic (usually something called Vancomycin to preemptively treat Staph infections, as they tend to be the most common and the most difficult to treat) and I ask the surgeons to remove the hardware. Sometimes they agree, other times they don't. Reasonable people will disagree. Surgeons will point out that the removal of hardware comes with its own set of risks, including nerve damage, re-fracture, and wound infection. I will counter with data showing how difficult it will be to truly eradicate the infection if the hardware is not removed. Medicine is often about trade-offs, and in many cases there is no perfect solution.
While we determine the best course of action, the bacteria can form something called a biofilm that is essentially a slime that covers the metal and is resistant to nearly all antibiotics. The only cure is removal of the infected hardware. In some cases this is possible. In others, as when the hardware is stabilizing the entire spine, it is not. As any physician will tell you, these infections are exceedingly difficult to treat. But it's important to remember that this is not a failure on the part of the surgeons, it's a failure of the antibiotics to completely eradicate an infectious slime.
Post-operative courses, like Gronk himself, are unpredictable. When I attempt to prognosticate for my post-op patients, I'll always involve the surgeons. I ask what they saw in the operating room (was pus oozing out of the joint or was the bone pristine?) and what they did about it (was the hardware removed? Were antibiotic beads inserted into the bone?). We don't know exactly what the surgeons saw when they last operated on Gronkowski's forearm or what they did about it. We also don't know what bacteria, if any, was found on the hardware that has been stabilizing his radius and ulna. These are critical pieces of information that will help determine the time frame of his recovery. It is impossible to say whether Gronkowski will be truly ready for this weekend's game against Cincinnati.
Whether we'll ever get access to such details is another matter entirely, but a better-informed fan would change the discourse surrounding player health. As people become more knowledgeable about the medical aspects of football, maybe questions shift from passive ones like, "When will Gronk be back?" to more forward-thinking, potentially invasive questions like, "Does he need hardware?"; "Who is his surgeon and what, exactly, did he or she say about the procedure?"; and "Will he need intravenous antibiotics?" Maybe the team physician becomes an integral part of the postgame press conference. Maybe players' already-meager rights to medical privacy erode even further.
No one anticipated that Gronkowski would be battling infection four-and-a-half months after he exited the Patriots' playoff game against the Texans cradling his left arm. But after four forearm operations—he underwent unrelated back surgery on June 16, his fifth procedure since November 2012—the man whom Sports Illustrated once dubbed "The Last Happy Man" has likely spent much of this offseason fighting off an outright miserable infection.
Matt McCarthy is an Infectious Disease Fellow at New York-Presbyterian Hospital