IM nailing makes basketball player’s recovery a snap

Photo credit: University of Louisville

This month, players on the University of Louisville, KY, men’s basketball team will get back on the court for their first regular season game. And if he continues the progress he’s made since fracturing his leg last spring, Cardinals’ guard Kevin Ware could be right there with them. “He should be ready to go at it around late October,’’ Cardinals Coach Rick Pitino told as of press time.1 Mr. Pitino had said earlier this fall that he was “looking more like it’s going to be second semester for him to be 100 percent or close to it.”2

A university spokesperson said it was still undetermined how much Mr. Ware would be able to do on the court when he is able to return.

“We’re not going to rush things,” said Kenny Klein, the university’s senior associate athletic director for media relations. (Personal phone communication with the author, September 23, 2013.) Mr. Klein said Mr. Ware has no pain at this point, and he’s been concentrating on his academics in addition to his rehabilitation.

He’s been doing a lot of cardio work, mostly on a stationary bike, Mr. Klein said, and lifting weight on his right leg. Earlier this fall, about six months after his injury, a video reportedly taken by a teammate during practice and posted to YouTube showed Mr. Ware dunking the ball.3 Mr. Klein noted that Mr. Ware appreciates all the support he’s received from fans during what can be a grueling process.

Severity of injury

Dr. Roberts

This rapid recovery may come as somewhat of a surprise to anyone who was watching the game in which Mr. Ware was injured. Craig Roberts, MD, FACS, an orthopaedic surgeon and professor of surgery at the University of Louisville, had just come out of surgery and was in the physicians’ lounge on March 31, the day the Cardinals were playing the Duke Blue Devils in the Elite Eight in Indianapolis, IN. Roberts said that he saw the replay of Mr. Ware jumping up to block a three-point shot by a Duke player, but he was unable to really see the extent of the injury on the small TV. (Personal communication with the author, July 2013.) He later saw on a larger screen that Mr. Ware had come down awkwardly on his right leg, snapping his tibia and causing the bone to protrude through his skin.

The sight of the injury left coaches and players on both sides visibly shaken. A few of the Cardinals had tears in their eyes.

The compound tibial fracture, also called an open fracture, is an injury that is more typically associated with high-impact trauma, like a vehicle crash or a fall from a significant height, said Walter Virkus, MD, director of orthopaedic trauma services at Methodist Hospital in Indianapolis. (Personal communication with the author, July 2013.) Mr. Ware was taken to Methodist after he was injured with about six minutes left in the first half of the game. Dr. Virkus, who did not operate on Mr. Ware but is familiar with the case, estimated that he sees compound fractures on a weekly basis, but “it’s not something we regularly see in athletes.”

Dr. Roberts compared Mr. Ware’s leg position to a long tree branch or a pencil standing straight up and down that bends slightly off its axis. “Standing up, it’s strong, but if you angle it, it doesn’t take much to snap it,” he said. He’s seen similar injuries in football and soccer players, but many of them are closed, and the bone has no contact with the atmosphere.

How did it happen?

Dr. De Long

William De Long, Jr., MD, FACS, chief of orthopaedic surgery at St. Luke’s University Health Network, Bethlehem, PA, speculated that Mr. Ware’s injury was the result of an athlete trying to play through pain. “The catastrophe you saw on television was the product of a stress fracture that was occurring, and he ignored it,” Dr. De Long observed. (Personal communication with the author, September 27, 2013.)

Stress fractures occur when muscles become tired from overuse and can no longer absorb added shock. The muscle then transfers the shock to the bone, causing a tiny crack.4 Stress fractures in the feet and legs are common in sports like football, soccer, and basketball because of all the running involved, Dr. De Long said. They are called stress reactions at their onset and can be seen in magnetic resonance imaging tests but not a regular X ray. As a stress reaction evolves, the person will feel more pain as the bone starts to crack, Dr. De Long said, although surgeons are still working to understand what happens during that process.

Cells in the bones are constantly remodeling themselves, Dr. De Long said. Some cells, called osteoblasts, make bone, while others, called osteoclasts, break it down. In a stress fracture, Dr. De Long said, “the theory is that the kinetics of the take away is faster than the rebuild,” but a working model for that theory has yet to be developed.

Besides athletes, stress fractures occur very frequently in military recruits, who often go from not being active to a six-week boot camp where they are forced to exercise vigorously. Dr. De Long estimated that Mr. Ware could have been having leg pain for 60 to 90 days before his injury occurred.

Operation speeds recovery

Mr. Ware
University of Louisville

A surgical technique that didn’t fully take hold until the 1980s played a significant role in Mr. Ware’s rapid rebound, according to Dr. Roberts.

During the two-hour operation at Methodist, surgeons reset his tibia and cleaned out his open wound. Then they put a metal rod inside the bone cavity and secured it with an intramedullary (IM) nail, Dr. Roberts said. The IM nail is also called a Küntscher nail, named for Gerhard Küntscher, a German surgeon credited for developing the nailing technique for fractures of the long bones in the body. Dr. Roberts said Dr. Küntscher first used IM nails on soldiers who had fractured their femurs during World War II. It took a long time for the technique to get from Germany to the U.S., and has been growing in popularity over the last few decades as a treatment for compound fractures.

“This is a huge advance,” Dr. Roberts said of IM nailing, as opposed to a cast. “It really took well into the late ’70s and early ’80s [to arrive at a point] where people believed this was a good option.”

Dr. De Long said the technique was just starting to take off when he began his career in surgery. Before the nailing technique became popular, orthopaedic surgeons could insert a rod into a broken tibia, but they had no way of locking it in, he said. As a result, it would only work for a break in the middle of the bone that was straight across. Other people with broken leg bones filled hospital beds as physicians used the traction technique. They placed pins through patients’ bones and had weights to pull on them and hold them in position, Dr. De Long said. After up to six weeks, patients could return home in a cast to continue healing.

Dr. De Long said IM nailing is a better technique because the patient can put weight on the leg and start exercising sooner, and there is much less restriction of movement than with a cast, which can lead to muscle atrophy and loss of bone mass.

Photo credit: University of Louisville

Game on?

Despite the surgical advances used in his care and his strong recovery so far, Mr. Ware isn’t out of the woods just yet. According to Dr. Virkus, tibial fractures have a wide range of severity, and the healing depends on the health of the individual. Infection is the most common complication when the bone comes through the skin, and it can occur during the healing phase or after, Dr. Virkus said. The greater the damage to the bone, soft tissues, nerves, and blood vessels, the higher the risk of infection.5

In a couple of years, Dr. Roberts said, it may be possible to remove the rod. However, surgeons are more selective about performing that procedure today than they were 20 years ago. The benefits need to outweigh the risks for the elective surgery, and there is a chance that the bone will break again, Dr. Roberts said.

Privacy rules prevented him from going into too much detail about Mr. Ware’s specific case, but Dr. Roberts noted that Mr. Ware has a supportive family and access to top rehabilitation and physical therapy during his recovery. His treating physicians even determined it was safe enough for Mr. Ware to join his team in Atlanta, GA, eight days after his injury. It was there that he cut down the net after the Cardinals won the National Championship game. “If somebody’s going to come back quickly, it’ll be him,” Dr. Roberts said.


  1. Andy Katz.3-point shot: Champs ready to start again. Available at: Accessed September 27, 2013.
  2. Andy Katz. Louisville’s Kevin Ware Still Healing. Available at: Accessed September 12, 2013.
  3. Jeff Borzello. VIDEO: Kevin Ware is back to dunking already. Available at: Accessed September 17, 2013.
  4. American Academy of Orthopaedic Surgeons. Stress Fractures. Available at: Accessed September 27, 2013.
  5. American Academy of Orthopaedic Surgeons. Open Fractures. Available at: Accessed July 1, 2013.

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