The College Football Playoff and 2020 NFL Draft landscapes took unexpected turns this weekend when Alabama star quarterback Tua Tagovailoa suffered a devastating season-ending hip injury. The injury, a dislocated hip with a fracture to the posterior wall, occurred with 3:01 remaining before halftime of the Crimson Tide's game against Mississippi State. The quarterback rolled left and was tracked down by two Bulldogs defenders, who landed with all of their body weight on top of Tagovailoa.
Coach Nick Saban revealed after the game that it was intended to be Tagovailoa's final drive of the game -- Alabama was leading 35-7 at the time -- but he wanted to give him more exposure to two-minute offense scenarios.
In a statement after the game, Alabama team orthopedic surgeon Dr. Lyle Cain provided an early prognosis: "Tua Tagovailoa sustained a right hip dislocation that was immediately reduced at the stadium. He is undergoing further testing to determine the best course of treatment. He is expected to make a full recovery but will miss the remainder of the season."
This is a complex injury with some hurdles remaining for Tagovailoa before he can return to the field. As such, CBS Sports spoke with Dr. Louis Levitt, who serves as Vice President and Secretary for The Centers for Advanced Orthopaedics in Washington, D.C.
"The problem is we, as a lay public, don't really know the extent of his injury. The injury itself is one of the few true orthopedic emergencies; short of breaking a bone and having the bone stick out through the skin, which didn't happen -- that was the [Joe] Theismann injury -- for example," Levitt explained.
"This was the case where, when you dislocate the hip, that you have a limited period of time to get the hip back into the socket again because you compromise the blood flow to the ball of the ball and socket joint, hence the reason for the helicopter to get him to a reasonable trauma center so that they could get the hip reduced," Levitt continued.
"Once the hip is back in the socket, presumably, perfectly aligned in the socket -- and I say presumably because [that] we don't know -- sometimes when you pull the ball back into the socket, you entrap some bone fragments. Therefore, you can't leave it like that. You have to go in surgically and remove the bone fragments.
"Once the ball is back in the socket again, then you have to assess through varying tests to what extent is the socket damaged and what you would have to do to stabilize the socket. Often, the commonest form of this dislocation is to take out part of the socket when the ball dislocates."
Levitt said that this form of injury is uncommon and is generally associated with violent automobile accidents.
"It takes enormous force to dislocate a hip in a young player like this. This is usually automobile accidents driving the leg into the socket and then out of the socket. Often, you break the socket in this," Levitt said. "I would speculate that, more than likely, he will require surgical procedure to at least stabilize the socket: plates and screws in order to put the pieces back. It is all speculation because we really don't know the extent of the injury."
Tagovailoa will miss the remainder of the 2019 season and potentially the entirety of the 2020 season. Many are wondering whether he will ever play football -- at any level -- again.
"The recovery for this, even in a young healthy guy, is 6-12 months. I tend to err on the side of 12 months," Levitt said. "Let's say that everything goes perfectly and they are able to restore the anatomy, the bone heals and he can start his rehabilitation process. The second concern that you have in terms of months ahead is whether the blood supply to the ball was compromised. It is possible that the ball itself will die.
"Hence, we give you Bo Jackson's story as to why he ended up with avascular necrosis or AVN to his femoral head because he lost the blood supply. You can simply have a dislocation, get it back quickly and lose the blood supply. You can have no compromise to the blood supply, but when you go to repair the socket, you may have to actually pull down the ball or even dislocate the hip again as you repair the socket and that compromises an already challenged blood supply. It is sort of two phases. Can they anatomically reconstruct his hip, allow it to heal? And then, will he be subjected to some sort of deformity to the ball that leads him to severe arthritis and potentially hip replacement in the future like Bo Jackson?"
The injury occurred around 1:30 p.m. ET on Saturday. The events of the next week will be kept confidential but Levitt offered his expectations.
"I think [as of late Sunday morning] they are assessing him. They are probably running a CAT scan because that is the best way to look at the bone, and they are assessing the soft tissue injury. Then, they will determine -- most likely in a good trauma center, sooner than later -- [when] to go in and repair," Levitt said. "I would suspect it would be anywhere from 48 hours to a week. Not every trauma center has docs or orthopedics on board that are facile in doing this type of deep pelvic reconstruction. They may have to move him again. If he is at a place that is a Level 1 trauma center where they do pelvic work, it would not surprise me if he does not have surgery within 48-72 hours."
There may be neurological issues stemming from the injury as well.
"Then it is a matter of letting the wound heal, pray he doesn't get an infection; he is young and healthy, hopefully he would not. Then, it is the rehabilitation process," Levitt said.
"I spoke about one of the complications being he gets loss of the blood supply and the ball dies long-term -- long-term is within a year, that is not years, you will know that within a year. The other potential complication is that we don't know if he has any neurological injury. They will know that when they assess him. ... They will start the reconstruction and get him upright. They will not let him put any weight on it, but they will start him moving fairly early."
Some injuries leave athletes more susceptible to suffering a similar injury in the future. Levitt says that Tagovailoa will be no more vulnerable to a second dislocated hip than he was before Saturday's game.
"It is so rare. When you see all the major automobile accidents and sports injuries, it is really rare. The chances of him being back in the same situation again are so rare. Because he had the fracture the first time, if it heals with the plate and screws in place, it is actually a stronger socket in some respects, so I think his risks are not made greater because he had the fracture. This is really the case in high end athletes," Levitt said.
"Bo Jackson played professional baseball after having a hip replacement, and everybody thought that was the greatest thing since sliced bread. He probably set back hip replacements by about a decade because everybody thought they could go to the level of playing professional ball. I think Jackson's hip loosened after 3-4 years and he had to have a second hip replacement and never recovered from that.
"This is why you hope, the perfect scenario, the ball is back in the socket, there are no loose fragments in the socket, it is a single piece of the socket that can easily be put back. He doesn't get any complications and then, if all the Gods shine down on him, he then can probably get back to playing and retain his professional potential within a year."
If all goes accordingly with the surgery, the focus then shifts to the rehabilitation process.
"They are going to wait until the bone heals. What they are going to do, they are going to gently flex and extend his hip with minimal rotation on the hip. They may start that within 10 days of the surgery. They are probably not going to let him put full weight on this for at least 8-12 weeks. Then they will put him in a pool early once the wound heals to put him in a non-gravity environment and then land-based exercises really start to accelerate between 3-6 months. They are not going to let him do impact or pivoting sports for easily, I would guess, 4-6 months."
As a junior, Tagovailoa faces the choice to either return to Alabama for his senior season or depart early for the 2020 NFL Draft. The deadline to declare is Jan. 20, which would mean that that the Hawaii native would be roughly two months into a potentially year-long recovery process.
There are a lot of variables in play, but Levitt said he would most likely recommend Tagovailoa sit out the entirety of the 2020 season regardless of whether he is at the collegiate or professional level.
"He has a lot of obstacles in front of him. ... I would err on the side of this young fellow being conservative. I might keep him out," Levitt noted, citing how conservative the Washington Nationals were with the recovery timeline of star pitcher Stephen Strasburg.
Most high-level college athletes carry loss of value insurance as a safeguard for loss of potential earnings in the event of catastrophic injury. It is believed Tagovailoa carries such insurance.
Reasonably speaking, NFL teams will have a hard time selecting him where he had been projected -- top five picks of the 2020 NFL Draft -- based on the unknowns of his injury. It would neither be a surprise nor a poor decision if he elects to return for his senior season simply to sit out, heal and prepare to throw and workout ahead of the 2021 NFL Draft.
His brother, Taulia Tagovailoa, is a freshman quarterback at Alabama.
The elder Tagovailoa had already missed one game this season with an ankle injury, for which he underwent a tight-rope procedure. It was similar to the injury he suffered prior to the 2018 SEC Championship Game. He finished the year having completed 180-of-252 passes for 2,840 yards, 33 touchdowns and three interceptions.
Alabama turned to backup QB Mac Jones when Tagovailoa left the field. The Crimson Tide remain part of the College Football Playoff conversation with two games remaining, including an Iron Bowl showdown at Auburn in the final week. Jones has completed 45 of 65 passes for 566 yards, four touchdowns and an interception this season.