9/1/21 - Kenta Maeda had Tommy John Surgery

[nicksaviking]

13 hours ago, KirbyDome89 said:

Agreed on the first paragraph. Agreed that quality > quantity. 

I'd imagine a roster tear down starts with moving Buxton, and I think that's a mistake. It might be a couple years until they're competitive with the major league quality players they have; I don't see how they can redo the roster and we only endure a couple of bad seasons. 

I get the angst over panic moves. I'm almost more concerned about handing this FO another 3-5 year window as we cross our collective fingers on pitching prospects. 

In regards to Buxton, an extension for him would assumedly carry into the next contention period. I still want that.

I don't know that if there's a tear down, this FO needs to be in charge though. But my thoughts on starting over aren't necessarily trading a bunch of guys; there's not a ton left to trade anyway. I just don't want them "going for it" next year by desperately giving ugly contracts to a bunch of #3-4 starting pitchers and saying "We tried!" Next to no chance that works.

I'd rather do one long term deal for a good starter with upside, try hard to find a trade partner and give the young guys a long look next year. Then re-evaluate at next trade deadline. 

 

[Hosken Bombo Disco]

Reposting what Mike Sixel posted earlier. If nothing else it’s a good place to start to educate one’s self on elbow surgeries in general 

https://fansided.com/2017/01/30/baseballs-next-miracle-surgery/

 

[Brock Beauchamp]

1 hour ago, nicksaviking said:

But my thoughts on starting over aren't necessarily trading a bunch of guys; there's not a ton left to trade anyway.

I'm not really sure how you reached that conclusion. The value of Polanco is through the roof. Arraez has four seasons of control remaining and is posting another incredible season. Kepler still has significant value because of that contract. Hell, even Sanó looks like he might have a little value again. Of course, Buxton is still here.

Cleaning house on this team and trading anyone with value would return an enormous prospect haul.

And if a team has that much quality to trade, they probably shouldn't need to tear it down and rebuild. All of those players, excluding Buxton, have 2+ seasons of remaining control.

[nicksaviking]

32 minutes ago, Brock Beauchamp said:

I'm not really sure how you reached that conclusion. The value of Polanco is through the roof. Arraez has four seasons of control remaining and is posting another incredible season. Kepler still has significant value because of that contract. Hell, even Sanó looks like he might have a little value again. Of course, Buxton is still here.

Cleaning house on this team and trading anyone with value would return an enormous prospect haul.

And if a team has that much quality to trade, they probably shouldn't need to tear it down and rebuild. All of those players, excluding Buxton, have 2+ seasons of remaining control.

I figured Sano and Kepler are probably moveable, but I probably disagree on how much value they actually have to this team or another organization. Kepler has been a pretty underwhelming offensive player for a couple years now. I figure you can get a comparable free agent corner OF for less than the 8-10M per year he is under contract for. His inconsistency and continued inability to get on base are starting to look an awful lot like Eddie Rosario. Maybe I'm the low-man on him though. I suppose whether or not Atlanta picks up Joc Pederson's 10M option this offseason might help demonstrate what kind of value Kepler still has.

I also kind of thought Sano and Donaldson's contract might have negative value at this point. Maybe I'm wrong.

 

 

[Brock Beauchamp]

9 minutes ago, nicksaviking said:

I figured Sano and Kepler are probably moveable, but I probably disagree on how much value they actually have to this team or another organization. Kepler has been a pretty underwhelming offensive player for a couple years now. I figure you can get a comparable free agent corner OF for less than the 8-10M per year he is under contract for. His inconsistency and continued inability to get on base are starting to look an awful lot like Eddie Rosario. Maybe I'm the low-man on him though. I suppose whether or not Atlanta picks up Joc Pederson's 10M option this offseason might help demonstrate what kind of value Kepler still has.

I also kind of thought Sano and Donaldson's contract might have negative value at this point. Maybe I'm wrong.

Donaldson likely still have negative value simply because he's so old at this point and decline is inevitable. There's no reason for another team to take a risk on him because of the dollars involved.

Sanó's contract is reasonable, dropping down to just $9.25m next season. His OPS+ is back up to 110 and overall, he's posting another "league average starter" season. How valuable is that? Not a ton but he could return *something* for a team that needs big RH power, maybe a team that plays in a stadium where RH power plays up.

I don't think you're entirely wrong about Rosario v. Kepler, but Max can still play center (I wish the Twins would do so) while Eddie can barely be an effective corner OFer. It's interesting, though, as Kepler's defensive metrics have declined quite a bit this season. He's at the age where that will happen but it's hard to tell whether that's a statistical anomaly or real decline. Either is very possible.

None of those players will bring back huge hauls but they're competent enough, young enough, and paid the right dollars to make them worth something to the right team.

[nicksaviking]

Yeah, anyway for most of the vets on the team, I'd be more inclined to move them based on when you need to start getting MLB at bats for the prospects and not on the return they'll bring back. But that's based on the belief that the return would be pretty modest.

If Polanco, Arraez or Taylor Rogers hold significant value, then of course I'd move them based on the return. Or keep them if they'll help for years to come.

[Brock Beauchamp]

12 minutes ago, nicksaviking said:

Yeah, anyway for most of the vets on the team, I'd be more inclined to move them based on when you need to start getting MLB at bats for the prospects and not on the return they'll bring back. But that's based on the belief that the return would be pretty modest.

If Polanco, Arraez or Taylor Rogers hold significant value, then of course I'd move them based on the return. Or keep them if they'll help for years to come.

My belief is that the front office has assembled a roster with far too many "non-positional" players, or guys who all play at the corners, often not very well. I believe they need to move at least two of these players and replace them with better up-the-middle solutions, or at least more versatile solutions:

- Sanó
- Kepler
- Larnach
- Arraez
- Kirilloff

Five guys to play essentially three positions (LF, RF, 1B). That's not great because I didn't even mention the guy who will likely soak up a bunch of DH time next season, Donaldson, or the guy everyone is waiting to see replace Donaldson, Miranda. That's too many players who contribute offensively and do damage defensively (to varying degrees, obviously... Kirilloff is likely a good 1B, Kepler is a good RF).

And these are the guys who just need to go already:

- Rooker (I'm least confident in releasing him but god, he's a butcher in the field)
- Refsnyder
- Cave
- Astudillo

I just listed nine effing guys, not a single one of which that can play outside of a corner position and most of them are bad at the corners, too.

No wonder this team is a trash fire.

[MN_ExPat]

20 minutes ago, Brock Beauchamp said:

My belief is that the front office has assembled a roster with far too many "non-positional" players, or guys who all play at the corners, often not very well. I believe they need to move at least two of these players and replace them with better up-the-middle solutions, or at least more versatile solutions:

- Sanó
- Kepler
- Larnach
- Arraez
- Kirilloff

Five guys to play essentially three positions (LF, RF, 1B). That's not great because I didn't even mention the guy who will likely soak up a bunch of DH time next season, Donaldson, or the guy everyone is waiting to see replace Donaldson, Miranda. That's too many players who contribute offensively and do damage defensively (to varying degrees, obviously... Kirilloff is likely a good 1B, Kepler is a good RF).

And these are the guys who just need to go already:

- Rooker (I'm least confident in releasing him but god, he's a butcher in the field)
- Refsnyder
- Cave
- Astudillo

I just listed nine effing guys, not a single one of which that can play outside of a corner position and most of them are bad at the corners, too.

No wonder this team is a trash fire.

Can't say I agree with you on the vast majority of this and I would probably be willing to commit to a cage match on La Tortuga ?, but I do understand where you are coming from (I think ).

[Dodecahedron]

4 hours ago, Brock Beauchamp said:

I just listed nine effing guys, not a single one of which that can play outside of a corner position and most of them are bad at the corners, too.

No wonder this team is a trash fire.

Yep.  Trying to fit Sano into a Twins lineup has caused ripple effects across the roster since day one.  Just getting rid of him would solve so many problems, or they can just make him a dang DH already.

[Brock Beauchamp]

1 hour ago, Dodecahedron said:

Yep.  Trying to fit Sano into a Twins lineup has caused ripple effects across the roster since day one.  Just getting rid of him would solve so many problems, or they can just make him a dang DH already.

I consider having 3-4 left-handed corner outfielders on the same roster a larger problem, though. The complete lack of good right-handed OF options has been a problem for half a decade now. 

[Major League Ready]

On 9/3/2021 at 6:39 PM, Brock Beauchamp said:

I consider having 3-4 left-handed corner outfielders on the same roster a larger problem, though. The complete lack of good right-handed OF options has been a problem for half a decade now. 

The roster construction you mention here and earlier sure seems to contribute to the inconsistency of this team and a horrible record against LHP.  Too many slow guys who are below average defenders and can't run the bases.  I would guess this particular problem is why the continue to give Rooker an opportunity.  Not that he solves the below average defender portion of this problem.

IMO, a good way to start this retool is to move Donaldson this off-season and bring up Miranda.  We don't need him blocking Miranda and we don't need his $21.75M contract on the books in 2023 or the $8M buyout in 2024 because I seriously doubt he is going to be worth the $16M option.  Let's do what we need to next year to retool this roster and bring up the myriad of SP prospects who should be ready and use that money to bring back Jose Berrios or someone like him in 2023.

Arraez and Polanco are redundant in my view.  Trade one of them this off-season for a SS that is near ready or a stud pitching prospect if you can get one.  Finding a RH outfielder and a long-term SS would make a big difference on this roster.  Finding a SS to pair with Miranda would bode well for the next several years.  Polanco or Arraez at 2B and one of several options will work at 1B.  Sign Buxton and put Kirilloff in the OF.  We have plenty of 1B.  Add the RH OFer that started this tangent and you have a very good roster of position players.  I should add we have a bunch of guys in the minors + Gordon that look to be good utility players.

[Heezy1323]

On 9/2/2021 at 4:23 PM, Squirrel said:

@Heezy1323 ... if you are out and about, reading TD ... your input would be appreciated and invaluable!

Ok- I'll give it a shot. Hopefully there's something valuable I can share.

I did not see the STrib article (my bad, would've liked to read it), but I have been aware of the internal brace concept being utilized with UCL reconstructions for a short time.

Feel free to review my prior blog post about UCL injuries.

Nomenclature is important here. Recall that UCL repair means that the athlete's own ulnar collateral ligament (UCL) is repaired back to bone. This repair is often protected with an especially strong suture called an 'internal brace'.

The internal brace has been around for a number of years. It has been (and is currently) used in a number of other places in the body to protect various ligament or tendon repairs. It began (if I recall correctly) being used to help protect the repair of ligaments at the outside part of the ankle when patients required surgery for chronic ankle instability. With it's success there, it has gradually been expanded to other parts of the body. By way of example, I have used it in basically every one of my ACL reconstructions for the past 2.5 years to protect the healing graft during recovery (somewhere around 150 ACL's). I have also used it to help protect PCL, MCL, patellar tendon and posterolateral corner surgeries in the knee, among others.

When the UCL is repaired, the idea is that the tissue of the UCL is healthy/strong enough that it can successfully withstand the forces of pitching once it has become firmly healed back to the bone. The injury in these cases is to the area where the ligament meets the bone, not within the ligament itself. The purpose of the internal brace in this case is to 'protect' the repair. Specifically, when a patient moves the elbow after surgery (even if they aren't doing something demanding such as throwing), there is microscopic movement at the interface between the healing ligament and the bone. In theory, if there is excessive stress at this junction, the healing will be less robust and therefore the ligament less able to withstand substantial forces of throwing later on in the rehab process. By using an internal brace, the idea (as I understand it), is that the relatively small forces of day to day movements of the elbow are now shared between the healing ligament and the internal brace suture. Therefore, this stress is less likely to cause a negative effect on the healing progress of the ligament back to the bone. Hopefully (the idea goes) this results in more strong and robust amount of healing of the ligament when compared to a repair done without an internal brace.

(Feel free to review my previous blog post about UCL repair vs. reconstruction here.)

That leads us to this particular case with Kenta of a UCL reconstruction performed with an internal brace. This is similar, but not identical to the situation discussed above. Recall that the term 'reconstruction' is used when tissue (almost always a TENDON) from somewhere else (either the patient themselves or in some cases a donor/cadaver) is used to make a NEW ligament. There are numerous reasons why this option might be chosen rather than a repair, but most commonly it is because there is an accumulation of damage to the native ligament that makes it unlikely to be strong enough itself to stand up to the necessary stresses once healed. Indeed, most UCL repairs are performed on young athletes who don't have the same cumulative amount of damage as MLB pitchers. 

As a result of this, there is an additional variable in these cases of reconstruction. Namely, in addition to successful healing, the TENDON also requires time to 'turn into' a LIGAMENT. This is primarily why the recovery from UCL repair surgery is typically so much shorter than UCL reconstruction --> in a UCL repair the ligament is already a ligament. So it doesn't require time to undergo this transition from tendon tissue to ligament tissue (called ligamentization).

(I know this is getting tedious- and I apologize. Hang with me here...)

So the use of the internal brace with UCL reconstruction has a slightly different goal than with primary repair (again, as I understand it). Obviously, when you use a tendon to replace a ligament, you have to remove that tendon from the body completely for a short time in order to reimplant it. As a result, the tendon is completely removed from its normal blood supply. Once implanted, the body has to reestablish blood supply to this tendon in its new location in order to keep it alive. This takes some time to accomplish. There have been animal studies done that have shown that the strength of the newly implanted tendon in situations such as this actually goes down for the first few weeks after surgery, then starts to increase again. As a result, there is a period of time after surgery when this graft is vulnerable to 'stretching out' which could compromise the ultimate strength of the graft. The internal brace seeks to avoid this problem by protecting or 'bracing' the graft during this period of time so that it doesn't stretch out and is able to heal in more strongly and at the appropriate tension. 

How much difference in 'looseness' (what we would call laxity) is too much? Well, during my fellowship with Dr. Andrews we did a study that showed that when placed under stress, the injured elbow opened up on average only 0.3mm (that's a third of a millimeter!) more than their opposite, uninjured elbow. So it appears that it doesn't take much difference in laxity to cause a problem in a thrower's elbow.

There is a mountain of data supporting the use of an internal brace with UCL repair. There is very little data available that I am able to find regarding the use of an internal brace with UCL reconstruction. I found one biomechanical paper that showed that the use of an internal brace with UCL reconstruction allowed the biomechanics of the elbow to more closely replicate a normal elbow than when UCL reconstruction was done without internal brace (this was a cadaver study). I was not able to find any clinical data reporting on the success rate of UCL reconstructions done with internal brace compared to those done without. My guess is that this data is coming, just not published yet.

Logically, it makes a lot of sense to me that the use of an internal brace in conjunction with a UCL reconstruction would improve the success rate, but medicine doesn't always follow logic. I'll be interested to see the results in the future. 

Also, I don't know exactly which reconstruction technique Dr. Meister uses, which could potentially have some influence on results as well.

One reservation I have about the idea that this internal brace shortens the return to play timeline is that despite the fact that this internal brace likely results in a 'tighter' ligament once healing is complete, the internal brace probably does not do anything to speed up the transition of the tendon tissue into ligament tissue that occurs over time. Perhaps we can be a bit more aggressive with the rehab when an internal brace is present, without as much concern for the new ligament 'stretching out'. But ultimately, the new ligament has to be (very) strong in order to withstand the extreme forces of pitching, especially at the MLB level. Time will tell if this new modification to UCL reconstruction technique will allow for a quicker return to play. I hope it does- 18 months is a darn long time.

If you've managed to read this far- thank you. This is pretty dense stuff (sorry...)

 

 

[Squirrel]

wow! much appreciated! Always nice to have such expertise close at hand. Thank you!

[Dodecahedron]

On 9/4/2021 at 1:37 PM, Heezy1323 said:

Ok- I'll give it a shot. Hopefully there's something valuable I can share.

Very cool information.  The question I would ask if in Maeda's situation, as a layman, is how much would that ligament tighten if it is braced.  It can be more painful to stretch out a ligament than one can imagine.  It sounds like bracing it restricts its ability to stretch, at least until the person is ready to begin full rehab.

I have a genetic condition where my radius is too long, preventing full arm extension, and my patella ligaments are wired up differently.  I have no clue how much this would affect the ability to pitch, but I can say my father made it into the little league world series tournament as a pitcher.  Maybe someday someone with this condition will rise through the ranks and we will see what he (or she) can do.  

My daughter also has this condition, and as a parent I worry about her tearing up her knees in particular.  One of her patella is only about the size of a quarter -- the connecting ligaments are larger than the patella itself.  Some of her cousins had "corrective" surgery for their elbows and knees, but the body is an interesting beast.  Since their bodies have DNA programmed to have these joints be constructed in a certain way, eventually both the knees and elbows reverted to their old structure.  If my daughter ever tears up her knee and someone tries to do surgery, they could make it worse.  We are making sure she wears a brace when doing any sort of workout.  

[bean5302]

On 9/4/2021 at 1:37 PM, Heezy1323 said:

...The purpose of the internal brace in this case is to 'protect' the repair. Specifically, when a patient moves the elbow after surgery (even if they aren't doing something demanding such as throwing), there is microscopic movement at the interface between the healing ligament and the bone. In theory, if there is excessive stress at this junction, the healing will be less robust and therefore the ligament less able to withstand substantial forces of throwing later on in the rehab process...

I get the feeling the tape suture brace in UCL repair (when the existing ligament is reused) is designed to prevent something kind of like "bad ice" on a lake? A pattern of freeze/thaw/freeze which creates a weak, easily broken ice where in the surgical case, it's heal/tear/heal which could create a weak connection of the ligament?

From a mechanics standpoint, using the tape suture brace in UCL replacement wouldn't actually reduce the stress on the tendon during stretching. Since the goal is to stretch the elbow "x" number of degrees rather than to bear a static load, adding a brace just increases the resistence to the elbow stretching. This would mean an equal, greater force is applied by the muscles to move the elbow which completely offsets the tape suture brace's tension. Ultimately, in this scenario, the exact same force and stretch is applied to the tendon as without the brace, but the stretching process is accelerated. This would mean the tendon would be permanently loosened/stretched. I suppose the intent of this procedure is to allow the brace to function as a supplementary ligament for the stretched tendon to offset the loss in its tension on the joint?

[Heezy1323]

35 minutes ago, bean5302 said:

I get the feeling the tape suture brace in UCL repair (when the existing ligament is reused) is designed to prevent something kind of like "bad ice" on a lake? A pattern of freeze/thaw/freeze which creates a weak, easily broken ice where in the surgical case, it's heal/tear/heal which could create a weak connection of the ligament?

From a mechanics standpoint, using the tape suture brace in UCL replacement wouldn't actually reduce the stress on the tendon during stretching. Since the goal is to stretch the elbow "x" number of degrees rather than to bear a static load, adding a brace just increases the resistence to the elbow stretching. This would mean an equal, greater force is applied by the muscles to move the elbow which completely offsets the tape suture brace's tension. Ultimately, in this scenario, the exact same force and stretch is applied to the tendon as without the brace, but the stretching process is accelerated. This would mean the tendon would be permanently loosened/stretched. I suppose the intent of this procedure is to allow the brace to function as a supplementary ligament for the stretched tendon to offset the loss in its tension on the joint?

Agreed on the good ice/bad ice analogy.

Not sure I follow the second paragraph. The purpose of the internal brace is to avoid stretching of the graft (by resisting tension/reducing stress) during it's initial period of relative weakness after implantation, and perhaps some degree of protection of the graft going forward by acting as a sort of 'rebar.' This allows the graft to heal in at a more desirable (i.e. tighter) tension, rather than becoming loosened, as it might without the internal brace in place. 

 

 

 

[bean5302]

11 minutes ago, Heezy1323 said:

Agreed on the good ice/bad ice analogy.

Not sure I follow the second paragraph. The purpose of the internal brace is to avoid stretching of the graft (by resisting tension/reducing stress) during it's initial period of relative weakness after implantation, and perhaps some degree of protection of the graft going forward by acting as a sort of 'rebar.' This allows the graft to heal in at a more desirable (i.e. tighter) tension, rather than becoming loosened, as it might without the internal brace in place. 

 

 

 

I understand now. I was misunderstanding the timeline of how quickly a tendon could be stretched and converted to a ligament. I was thinking that was the long process moreso than the attachment process. Sorry about that!

[MN_ExPat]

On 9/4/2021 at 2:37 PM, Heezy1323 said:

Ok- I'll give it a shot. Hopefully there's something valuable I can share...

Thanks much Heezy.  Love these explanations and discussions about what goes on with the science of injuries.  I've always geeked out about the little details and how they fit into the larger picture.

For example I didn't get the option of watching my Meniscus surgery on my knee, but would have loved to see it (your write up on that type of injury and the procedures involved is still on of my favorites ).