Alex Smith recovery timetable keeps getting longer 

Redskins quarterback Alex Smith is carted off the field after
suffering a leg injury Nov. 18.
(John McDonnell / The Washington Post)
ProFootballDoc 
Sports Medical Analyst

The news on Alex Smith continues to worsen.

I’m not ready to say he won't return to football, but it is time to revise the initial thought that the Redskins quarterback should reliably be ready for the start of the 2019 season.

Infection was always the worry with an open fracture (where the sharp end of the bone sticks thru the skin). His initial emergency surgery was more to prevent infection than to fix the fracture.

With good quick treatment like Smith undoubtedly had, the risk of infection is well under five percent. But it has happened here.

The early news of infection was concerning. The word of multiple debridement surgeries to clean up necrotic (dead) tissue and help cure the infection are normal and hand in hand with intravenous antibiotics and that in and of itself didn't mean a longer timeline for recovery, even if it was a difficult infection like MRSA.

However, a patient typically goes home within two days of such surgery, and Smith is in the hospital three weeks after his Nov. 18 injury.

Now, the latest news of the need to remove the plates and screws ratchets up the worry and delays the recovery timeline.

Expect to hear word next that Smith has an external fixator (a system of pins/wires with rods, like an erector set similar to the look of scaffold on the outside of a building) applied to his leg. This is necessary as the plates/screws holding the fracture were removed. A cast would not work due to the need to access the wound. The apparatus looks archaic and scary but is necessary in these situations.

The original implants needed to be removed, as once metal is contaminated, it makes it very hard to cure the infection without its removal.

It will be multiple weeks before more definitive fracture fixation can finally be done.

Smith is headed for several more surgeries.

The next worry is coverage of the fracture.

Multiple debridement surgeries means the loss of skin and tissue. The question is will he have enough to cover the underlying bone.

By video, the fracture is likely more distal (towards the ankle). One can feel your own lower leg and see that it is mostly skin and bone around the ankle, as opposed to higher up where the bone is harder to feel and more easily covered by muscle.

At a minimum, Smith will need two more surgeries. One will be to close the wound and the other to remove the fixture and fix the fracture.

He could have many more if there is enough damage or loss of skin.

If he needs a skin graft, that cannot be applied directly to the bone. One needs to transfer or move muscle.

If this happens, the situation escalates more and Smith’s career would be in jeopardy. A transfer of the calf muscle would affect strength. A free flap where muscle was transferred from another area of his body would lead to a long recovery. (This type of procedure is what is used in distal third tibia which is where I suspect the fracture and wound issue are.)

At this point, the start of ’19 is in jeopardy, as the bone healing clock likely won’t start until a minimum of six weeks from now, adding to the original 6-9 month recovery timeline.

Let’s hope we don't hear about a grafting procedure, as that could signal the end of his career.

Dr. David Chao wrote: