Editor’s Note: We’ve received messages for years asking for coverage of medical issues facing the NFL and fantasy football owners. ”The Dynasty Doctor” is a series we run on an as needed basis. If you have any questions in regards to concussions, ACL procedures, recovery times from specific injuries or anything else related to medical science, submit your question here and it may be featured in an upcoming article with our own resident M.D., Dr. Scott Peak. He’s a board certified neurologist, neuro-oncologist and is the Director of Neuro-Oncology in the Department of Neuroscience/Neurosurgery for a large health care system.

Recent reports on Rob Gronkowski have touched a nerve amongst fantasy football players, and concerns have been raised about his surgically-repaired left forearm. In this article, we will discuss chronic wound infections and our best estimate on how Gronkowski’s recent woes might impact his future for dynasty football.

Gronkowski first broke his left forearm on November 18, 2012, and missed the next five games recovering from it. In the playoff game against the Houston Texans, he re-broke his left forearm nearby the location of a plate used to repair the initial fracture. He has undergone a total of three surgeries to repair the fracture, and might need a fourth surgery that could further delay his recovery. It was recently reported that Gronkowski noticed swelling and leakage of fluid from his left forearm, and this is of particular concern given his history.

The original fracture, based on description, does not sound like a compound fracture, as this is when bone breaks through the skin and is visible to gross inspection. An example of a compound fracture is the recent injury suffered by Kevin Ware, a Louisville basketball player. Compound fractures are at greater risk of infection, as the open wound is exposed to bacteria that gain entry into the body, sticking to bone and soft tissue. If surgery is done quickly, risk of infection can be reduced.

If Gronkowski had a fracture that was apparent only on x-rays, that would make infection more likely to be a complication from surgery. Wound infections are a risk of any surgery, as skin serves as the first line of defense for the immune system, keeping bacteria from entering the body and wreaking havoc on our organ systems. When a surgeon makes an incision, even with sterile technique, there is a risk of infection in the wound. Possible reasons include fomites entering the wound in the operating room, instruments like rods needing to be exposed externally to help the bone heal, or bacteria on our skin moving into the wound after surgery, even if sutured appropriately.

Plates and screws are commonly used to help stabilize a fracture and promote proper union of bone. Plates are foreign bodies, and bacteria love to stick to them. Wound infections are hard to resolve once bacteria gain entry into a wound, especially when hardware is inside. This is a big reason why wound infections can be a long-term, persistent and hard to resolve problem. If bacteria gets into bone (called osteomyelitis), it becomes an even bigger problem. Bone tissue can become damaged and die from infection (called necrosis) and blood flow into necrotic tissue is not ideal. Bacteria can also get stuck into parts of bone that do not have optimal blood supply. It is an important point, as antibiotics need to be delivered to infected areas through blood vessels. If bacteria gain entry into parts of bone with poor blood flow, or hardware is not exposed internally to blood flow, antibiotics may not be delivered to the site of infection and thus will not eradicate offending organisms. If antibiotics cannot get to all points of the infection, the immune system must pick up the slack, but unless all bacteria are eradicated, they will continue to grow and seed the wound with organisms. This is the fundamental challenge in dealing with an infected wound. It is a long-term problem that hopefully responds to antibiotics, but sometimes several surgeries are needed to clean out the wound, culture the organism to find effective antibiotics, scrape out dead bone and remove hardware that could contaminate the wound.

Infections of bone can also impair proper union of bone, increasing risk of re-fracture and, worst case scenario, infect blood resulting in a life-threatening complication called sepsis. The reason why sepsis is such a serious problem is how the immune system reacts to infection, often releasing a variety of inflammatory chemicals to kill the organism, but this can lead to blood pressure falling to dangerously low levels, and ultimately multi-organ failure. In such cases, amputation has been used as an extreme measure and for chronic osteomyelitis this is necessary in 6 to 13% of cases, sometimes many years later1.

As it relates specifically to Rob Gronkowski, we will form an opinion based on available reports online, and do our best to estimate how this might impact his dynasty value moving forward. We do not have access to his medical chart, nor should we, but I believe we can create scenarios based on reports available online. It should noted, this is fluid process, and reports have only come from media outlets or Gronkowski’s agent. Updates from the medical team and Gronkowski are the only way to be certain. Nevertheless, the following scenarios may apply:

Scenario #1

There is no wound infection. I think this is unlikely, based on Gronkowski’s history of a wound infection and recent reports he experienced swelling and drainage of fluid from his arm. But, if he did not have a wound infection, that would be the best possible case.

Scenario #2

There is an infection in the soft tissue, but not on the plate(s) or in the bone. This is possible, but not as likely. Soft tissue has ample blood flow, so antibiotics should reach an infection in this location. I really doubt there would be resistance to antibiotics used to treat Gronkowski, as a simple sensitivity profile can establish which antibiotics will be effective for specific bacteria. Certainly, three months should be ample time for his wound to heal, so entry through the skin is hard to imagine.

Scenario #3

The infection has migrated to the hardware, including plates and screws used to stabilize the bone and promote union. If there is concern about the plate being infected with bacteria, the bone could very well be infected. This would probably be the worst possible scenario.

In the end, how Gronkowski recovers remains to be seen. Here are the good, bad and ugly points to take from his current predicament, relevant to dynasty owners:

The Good

On March 27, 2013, Gronkowski was quoted as saying he was “feeling a lot better”, and was hoping to gain clearance “in the next couple weeks”. This news seems encouraging, as it would suggest response to antibiotics and progress with healing of bone. Gronkowski is reportedly receiving care at Massachusetts General Hospital, the major hospital affiliated with Harvard University, so he is likely getting the best possible care from an elite group of physicians. Gronkowski has access to resources that will put him in the best possible position to recover from this issue, and that is certainly reason for optimism. He is also young and is in a better position to recover from this issue compared to an 80 year-old with multiple medical problems. Surgical debridement of chronically infected bone has success rates reported to be 90% or higher, depending on which techniques are used. It would be reasonable to conclude Harvard is using the best possible techniques, thus more cause for optimism with Gronkowski’s recovery1. There are sources reporting arrest of chronic bone infections in 80-90% of patients with proper treatment2.

The Bad

Gronkowski reportedly recently noticed swelling and discharge of fluid from his left forearm. This is not good news, and would at least suggest recurrence of infection. Any wound with a history of infection that is swollen and leaks fluid is recurrent infection until proven otherwise. Surgery is often necessary to prove whether an infection has returned, as imaging techniques, such as x-rays, CT and bone scans, are not specific-enough to be diagnostic. MRI can be helpful, with sensitivity and specificity of 90-100%, but still cannot determine the exact organism or sensitivity profile to antibiotics, and hardware present can obscure results1. Cultures are typically necessary, and these are best obtained by opening the wound for inspection. Dead bone may need to be scraped away, or bacteria can fester inside, grow larger, and become a nidus for further infection. Surgeons can debride the wound and clean out dead tissue, thus facilitating healing, allowing antibiotics to work better. Hardware must be removed or bacteria stuck to metal will re-infect the wound. Even with optimal treatment, recurrence rates of infection are 20-30% in two years, if bone is involved3.

The Ugly

The worst-case scenario for any patient with infection in bone would be amputation of the limb in question. The decision to perform an amputation rests solely on whether the limb can be salvaged, how capable a patient can withstand multiple operations and long-term treatment with antibiotics. Studies have shown 13% of patients with chronic bone infections, despite repeated operations and courses of antibiotics, ultimately required amputation to eradicate the infection permanently1. There is no way to predict whether this will be necessary for Gronkowski based on presently available information. Certainly, for his own welfare, we hope that is not the case. But, when evaluating chronic wound infections, it has to be discussed. It is challenging to identify which patients require amputation at diagnosis. A lot will depend on how severe Gronkowski’s infection has become and how he responds to future treatments. It would be a huge leap right now to think Gronkowski is anywhere near amputation, and it would be best to see how his fourth operation goes before drawing any conclusions in this regard.

Here are a few other tidbits of information that may be interesting:

1. One observational study of 2,847 patients showed rates of wound infection related to surgery are as follows3:

a.) Antibiotics given before surgery: 0.6%

b.) Antibiotics given during surgery: 1.4%

c.) Antibiotics given after surgery: 3.3%

2. Linezolid is a particularly effective oral antibiotic for chronic wound infections, and one study found remission of infection in 32 out of 51 patients (62%), duration of treatment 2 to 19 weeks and follow-up 3 to 50 months3. 17 patients (33%) required long-term treatment to prevent recurrence of infection, usually because hardware could not be removed. This data gives a sense for how long a patient might receive treatment for a chronic bone infection.

Given all the above, how should dynasty owners approach Rob Gronkowski? It depends on whether you own him or not, but three approaches seem reasonable:

If you own Gronkowski, and can get commensurate value for him, it would be understandable to trade him now. The reasons to trade him include risk of recurrence for this infection in the future, potential missed time from it, and risk for a serious complication like amputation. If you own Gronkowski, chances are you are probably getting low-ball offers as you read this article. I would NOT advocate trading Gronkowski far below his current value, which is an ADP of 13.5. Notably, success rates in treating chronic bone infections are over 90%, but it can become a chronic issue over several years. Chances are reasonably good that Gronkowski will return to the field at some point in the future, but he might need several months of antibiotics, more surgery and time to heal. If you do not own Gronkowski, I would NOT advocate trading for him at his previously high valuation. Too much risk right now for my taste for a player whose ADP is a late first round pick in dynasty start-up drafts. It would be interesting to take the risk and trade for him if owners are panicked and are willing to deal him for very low returns. If a Gronkowski owner sends you an offer to swap him for Jermaine Gresham, click accept then cross your fingers Harvard physicians can facilitate a full recovery. That is certainly a gambit I would be willing to make. I would not, however, trade Jimmy Graham for Gronk, or even slightly less valued players like Percy Harvin or Randall Cobb for him.

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