Alabama QB and potential #1 draft pick Tua Tagavailoa suffered a devastating right hip posterior-dislocation fracture on November 16th against Mississippi State, in the waning minutes of the first half.

In this article – for which I consulted very closely with a trusted, sports minded orthopedic surgeon – I detailed the injury, the surgery, and Tua’s career outlook including potential risks and key challenges of rehab.

If you prefer video format, I have that covered as well:

Injury details

Anatomy

The hip joint – known as the femoroacetabular (FA) joint – is a “ball and socket joint” that consists of the head of the femur (upper leg bone) and socket of the hip (acetabulum). It’s a unique joint in that it combines both mobility – it has the second highest mobility of any joint in the body, second only to the shoulder joint – and strength – it’s the strongest, highest force-bearing joint in the body.

The injury

A posterior hip dislocation-fracture is when the femoral head (“the ball”) is forcibly ejected posteriorly (backwards) out of the acetabulum (“the hip socket”), with an associated fracture to the surrounding wall of the socket.

It’s an extremely serious, high force injury that’s typically only seen in young individuals due to motor vehicle or motorcycle accidents and falls from height. It’s an injury handled by trauma surgeons rather than sports orthopedic surgeons which speaks directly to just how serious this injury is for Tua.

The surgery

At the stadium

While still at the stadium, the medical staff “anatomically reduced” Tua’s hip, meaning the hip was set back into place. This takes stress off the neurovascular bundle (nerves and blood vessels) and reduces the risk of post traumatic arthritis. More on both in the Risks section.

Surgery plan of action

After the joint is reduced, the surgical course of action depends primarily on the extent of the posterior wall fracture.

Typically, if less than 20% of the posterior wall is fractured, the surgical team will perform an exam under anaesthesia (EUA) to stress the joint and check for hip stability. If the hip isn’t stable, you proceed with surgery.

If the posterior wall is greater than 20% fractured in the first place, immediate surgery is indicated.

Surgical procedure

The approach is called a “posterior approach” – the same as used for hip replacements – in which the surgeon enters into the joint from behind. The fractured posterior wall is typically repaired and stabilized by using a few “spring plates” over the fracture site and a “recon plate” that’s bent to act as a buttress.

It’s a very involved surgery and part of the reason why we have specialized 2+ year trauma surgery fellowships that focus on these types of injuries.

Return timeline

Considering the rare nature of this injury in sport, there’s not much definitive research out there on return to play timelines. What I was told is to expect at least six months before Tua’s back out on the field and it could be up to one year before he’s cleared to return.

That significant variance speaks to the severity of the injury, the huge demands on the hip joint during football, and multiple variables related to the potential risks and rehab.

Potential complications & risks

#1 – Post-Traumatic Arthritis

The greatest risk factor is known as “post traumatic arthritis”. The hip dislocation can result in damage to femoral head and acetabular cartilage and start a cascade of degeneration that leads to early onset arthritis.

#2 – Avascular Necrosis (AVN)

Avascular necrosis is when bone begins to die because its blood supply is impaired. With hip dislocations, there’s an inherent risk for AVN to develop in the femoral head which would then require a hip replacement. That’s what happened to Bo Jackson and essentially ended his career.

Numerous steps are taken to reduce AVN risk, particularly one during surgery in which – unlike a hip replacement – the shorter hip external rotator muscles are specifically re-attached at least 2cm away from their normal insertion (end point) on the femur (upper leg bone) to avoid damaging the blood supply to the femoral head.

#3 Heterotopic ossification (HO)

Heterotopic ossification is when bone tissue develops outside the normal skeleton and can lead to functional deficits such as a loss in hip range of motion. It’s a key consideration after traumatic lower body injuries and typically guarded against by administering certain medications or, in some cases, low level radiation is actually used.

#4 Nerve injury and foot drop

The research shows that roughly 13% of posterior wall hip fractures have an associated nerve injury, with a 2 to 10% rate of foot drop. The trauma surgeon can, arguably, mitigate against this by keeping a knee flexed and hip extended position during the surgery.

Rehab challenges

Physical

The high level of demands placed on the hip during football – especially for a mobile QB in Tua – in combination with the hip’s unique level of mobility and strength, can make rehab a slow, grind it out process.

You have to focus on maintaining hip mobility early and then methodically build up strength and function, particularly in the hip abductors and external rotators. It’s a frustrating process full of hills and valleys.

Mental

That frustration is why the mental challenge of rehab may be the largest hurdle for Tua to overcome in his journey back to the playing field. For example, the research shows that oftentimes the last hurdle to be cleared after a major injury is overcoming fear of movement or re-injury, known as kinesiophobia.

Additionally, the spectre and daily life of an extended rehab process that often finds you isolated and with the same one to two people every day can wear on athletes and affect their motivation, attitude, and recovery. 

For that reason, Tua viewing the injury and recovery through a “growth mindset” lens that paints it as a challenge rather than as a defeat will be critical for him. We’re seeing more and more tangible research showing how a positive, growth mindset can positively influence outcomes.

Former Tide QB Greg McElroy spoke directly on that in regards to Tua, stating:

“So much about overcoming an injury is about your attitude, and if there’s one thing I know about Tua, he’s going to have a remarkably positive attitude in the approach to the rehab and everything that’s going to go along with it.” 

Career Outlook

Look, there’s no denying that this is a brutal, extremely serious injury wrought with landmines of risk and highly variable timelines.

Fortunately, Tua does have access to the highest quality of medical care – from surgery through rehab to strength & conditioning – and by numerous accounts has a very positive mindset.

Each of these bodes well in his recovery and potentially getting back on the field at a high level but there’s simply a lot of uncertainty moving forward and this is truly a case of “only time will tell”.

That’s a wrap for this article. Thanks for watching. My goal is to provide you with in-depth, evidence based, narrative free analysis and you can always find me on IG and Twitter @3CBPerformance. Make sure to sub to the blog and YouTube channel for the latest updates. 3CB out.