Hanley Ramirez, FLO (Left shoulder surgery—instability) [AGL: 94, ATD: +.065] (Explanation)
As the situation with Ramirez's shoulder progresses, we're finding out more about his options. In light of the mechanism of injury, we know the shoulder is unstable in at least the anterior direction. As with any injury, there is the option of not doing anything and continuing to rehabilitate the shoulder in the hope that it gets strong enough. Ramirez has already pursued that option, and the shoulder continued to be unstable, even on practice swings. That leaves us two surgical options that Ramirez is also considering: arthroscopic and open.
Arthroscopic procedures are minimally invasive and generally have a shorter recovery time. Small incisions are made in the shoulder to allow the instruments to be passed into the shoulder. Before addressing any repair of the capsule itself, the surgeon will take a look at the labrum, rotator cuff, and articular cartilage on the end of the humerus. If any of these is injured, repair of that structure will ensue.
Two of the most common injuries resulting from instability are a specific tear of the labrum called a Bankart lesion or a second lesion called a humeral avulsion of the glenohumeral ligaments, aka HAGL. The Bankart lesion occurs when the bottom front part of the labrum pulls away from the main ligament in the area. In order to repair the lesion, the torn labrum has to be anchored into the very edges of the bone. To repair the HAGL lesion, the ligaments must be reattached where they came off the humeral head or risk remaining unstable.
After all of the structures are evaluated and repaired inside the shoulder joint itself, attention turns to repairing the capsule itself. The inferior part of the capsule is then pinched and lifted up, tightening the bottom front of the capsule. The capsule is then sutured to permanently keep it in the tightened position before all the other subcutaneous tissue and skin is closed.
For the open reconstruction, a procedure called an arthrotomy occurs when the incision is made into the shoulder joint itself. All of the same structures are then evaluated in a manner similar to arthroscopy, except that they can be better visualized. After all the structures inside are addressed, the capsular repair begins. In open procedures, the capsule is split and left with flaps, which are then sutured in an overlapping fashion in order to tighten the capsule. The rest of the tissue is then closed and the incision is sutured shut.
Results of research studies are somewhat varied in terms of long-term redislocation rates, but generally an open procedure is still considered the gold standard despite its lengthier rehabilitation time. Improvements in arthroscopic techniques are closing this gap, especially in the hands of skilled surgeons. If Ramirez chooses surgery, he will miss anywhere from four to eight months, depending on what exactly needs to be repaired and what procedure he chooses.
Brennan Boesch, DET (Right thumb surgery—torn ligament) [AGL: 14(60DL), ATD: TBD(-.041DL)]
After trying repeatedly to play through a partial—and eventually a full—ulnar collateral ligament tear of the inside aspect of the thumb, Boesch will undergo surgery to repair the ligament. Most of the time, the ligament tears as its inserts into the bone of the thumb and therefore needs to be reattached distally. This can be done with anchors into the bone or by wrapping the sutures around a button placed on the bone. In the rare cases that the ligament tears in the middle of the ligament, the ends can be sutured together. Boesch will be placed in a cast for several weeks before starting slow rehabilitation. He should be ready for spring training, since most repairs of this ligament heal within three to four months.
Franklin Gutierrez, SEA (Left oblique strain) [AGL: 6(23DL), ATD: -.010(+.009DL)]
Gutierrez's season went from bad to worse on Sunday, when he couldn't finish an at-bat after straining his left oblique. It looks like it will at least be a moderate strain and very likely could end up costing him the rest of the season. It's unlikely that there is any direct correlation between his GI problems from earlier in the year and this oblique strain.
Mike Stanton, FLO (Right hamstring strain) [AGL: 4(27DL), ATD: -.018(-.005DL)]
Stanton has titanic power—you don't hit 474-foot home runs without it. In order to have that kind of power, you need to have strong legs and hips, but Stanton's legs have failed him a few times so far this year. In camp, he missed a few weeks with a right quad strain, and then he missed a few more days in April with left hamstring tightness. The Marlins are listing him as day-to-day and would be highly unlikely to put him on the disabled list unless it’s absolutely necessary.
Conor Jackson, BOS (Right knee contusion) [AGL: 1(40DL), ATD: -.011(-.019DL)]
Jackson left yesterday's game after running into the right field wall in his first start for the Red Sox in the outfield. Jackson has played the outfield before fairly regularly, so he wasn’t necessarily at increased risk due to switching defensive positions. Ligaments and cartilage in the knee can be damaged when running into a wall, but most contusions resolve within a few days and don’t hamper performance for too long.
Flesh Wounds: Pat Burrell's foot continues to bother him enough to limit his playing time. He will likely need off-season surgery in order to correct it… Nick Blackburn's transfer to the 60-day disabled list for forearm nerve entrapment has ended his season… Nate McLouth was also transferred to the 60-day disabled list while he recovers from sports hernia surgery that took place in early August… Jeff Karstens is still dealing with shoulder soreness and will likely have his next start pushed back… Ben Zobrist was out of the lineup for the last few days with neck stiffness… Felipe Paulino's low back tightness improved and allowed him to start yesterday. He may have wished that he’d waited at least one more day after being blasted for six runs in less than five innings… Yunel Escobar was forced from Saturday's game with a sprained left wrist. Toronto has said that Escobar will be day-to-day… Yadier Molina is day-to-day with a sore left calf… Jed Lowrie had to leave Saturday's game with tightness in the same shoulder that cost him two months of the season. He and the Red Sox both feel that it is fatigued more than anything else, and he should be able to return any day… Brian Duensing left Saturday's start with a right oblique strain. He is hoping that it's only a day-to-day issue, but that is unlikely… Alcides Escobar left Friday's game with a left ankle sprain. Like everyone else, he's day-to-day at this point… Jack Hannahan will miss several days with a minor calf strain… Roger Bernadina will miss several days with a laceration of his hand after sliding on Sunday… Jonathan Herrera caught his right index finger in a door, resulting in a fracture that could end his season. Not exactly the best way to go out…Josh Beckett will be given at least one extra day off before making his next start. He was forced to leave Monday's game with a sprained right ankle… Erik Bedard will skip his next start after feeling tightness behind his left knee again.