Under The Knife: Advances in surgery leaves past full of what-ifs

In Jane Leavy's book, The Last Boy, the author gives some details and investigates the 1953 knee surgery performed on Mantle, discussing how it affected his play over the rest of his career. The story has been covered before -- even contemporary accounts seem to agree -- but there are things we know. He had surgery in 1953, but did not end his season early or start the next season late. The procedures and rehab techniques don't approach those used today, so even in the best case, Mantle had six months to recover.

The techniques used had very poor results, according to Dr. Ralph Gambardella, head of the Kerlan-Jobe Orthopaedic Clinic in Los Angeles. "In the '50s, Dr. O'Donoghue reported on acute ACL repair in athletes. While his results were encouraging, we know the ACL repairs all failed and many people were made worse by getting a stiff knee. This is because many were splinted in knee flexion to allow the big incisions to heal, so many could not get their knees straight and walked with a limp and developed rapid onset of arthritis.

"Looking back on history, most athletes were actually 'better' by not undergoing surgery because if the surgery didn't kill you the rehab and casting the leg in flexion would still kill you. It was not until both surgical techniques and rehabilitation ideas improved that ACL surgery became consistently effective. That did not occur until the '80s."

It's easy to think of Mantle or any great athlete from the past as an exception, but it's possible that other athletes had similar results. We don't have a complete record of who had what (although I'm sure some readers have knowledge of major surgeries from the 50s, 60s and 70s that I'd love to hear about.) Mantle was one of the best players of all time, but not because he overcame a bad knee. It goes in the canon, just like "Sandy Koufax could have been saved by Tommy John surgery" and "How good would Addie Joss have been?" Leavy's book is well worth a read, if only as a reminder that in 50 years, we'll be thinking the same things about what we think of as advanced medicine now. Powered by Verve's Candelaria coffee (which I don't think has anything to do with the pitcher), on to the injuries:

The Cardinals look as if they will finish the season without Holliday. He hasn't picked up a bat in over a week, and while the Cards have stayed in the chase without him, the likelihood of catching the Braves is low enough (18 percent, per Coolstandings.com) that the Cardinals know better than to push things. The Cardinals haven't given much in the way of details about Holliday's injury, suffered while he was swinging in the on-deck circle, but tendon injuries tend to recur unless allowed to fully heal. Holliday isn't "shut down," but they're not pushing for him to come back. Given contract issues with Lance Berkman and the possibility of losing Albert Pujols this off-season, Holliday could well be the offense for the Cards in 2011.

Youkilis was out of the lineup again on Tuesday night, leaving Mike Aviles best available option for the Sox. Since Youkilis isn't on the DL, this is one of those things that will escape end of the year measures of days and dollars lost, but shouldn't. Even on a sabermetric basis, it's hard to get a real measure of the cost of this injury that's useful. It's easy enough to walk into the Cask 'N Flagon and say "Is Youk bettah than Aviles?" and you'll get a resounding response which can't be printed here.

While Youkilis was being the Greek God of sitting, Bedard joined him quickly. Bedard hit his pitch limit in just 2 2/3 innings (76) and left his team both behind and taxed. The bullpen has pitched a lot of innings in the last month. Just look at the last month of game logs and you'll see one -- one! -- game score over 55.

It's tough sometimes to tell the severity of any injury at this time of year. The slightest thing can keep a player out, both because of the expanded roster and, for some teams, the impending playoffs. Both of those are in play with Guillen, who's barely played this season due to various maladies. Jim Leyland has been flip-flopping between Ryan Rayburn and Ramon Santiago for much of the last month, looking for his best playoff lineup. At this stage, Guillen might not even make the playoff roster and will need to be healthy over the last week to even have a chance of making it. We'll see if that happens.

The Jays placed Escobar on the DL on Tuesday. This late, there's no apparent reason to do this with rosters expanded and there's some reasons that teams don't do this that are very technical. (Trust me, you don't want a discussion of Worker's Comp rules here.) Escobar was hit by a pitch on his elbow on Sept. 7, but there was no fracture. The problem has been vaguely described, but sources tell me that there's no visible discoloration or swelling at this stage. Escobar's injury is one that reminds us that reasonable protective devices aren't something we should legislate out of the game. Odder still, the Blue Jays have indicated that they expect Escobar to come off the DL and play when eligible early next week. I'll admit that I just don't get anything about this one.

I asked Dan Wade to look into HBPs. We've had twelve injuries this season, mostly hands, wrists, and fingers, though there were two injuries to the face (Marlon Byrd) and head (Corey Patterson.) As for what the HBP "leaders" are wearing?

2011 HBP Leaders

1. Carlos Quentin -- Sleeve2. Justin Upton -- Sleeve3. Danny Espinosa -- Small pad over the elbow, no bigger than a really baggy sleeve4. Sean Rodriguez -- Bare arms (like a boss)5. Kevin Youkilis -- Medium padding. No hard armor, but a definite protrusion from joint

Career HBP Leaders

1. Hughie Jennings -- 1890s, probably had an actual suit of armor.2. Craig Biggio -- definite hard armor. Big protrusion off the elbow3. Tommy Tucker -- also 1890s, when men were men.4. Don Baylor -- 1980s, can't find any image of him with anything more than sleeve5. Jason Kendall -- definite protection, looks to be hard-sided6. Ron Hunt -- 1960s, can't tell, but no photos to be found of him wearing one

Would it surprise you if I told you that the Cubs had lost over $50 million to pitcher injuries over the past seven seasons? And remember, that doesn't even include the peak lost seasons of Kerry Wood. Wood's return to the Cubs has gone about as expected as far as his production, but going out with an injury suffered while actually in the bullpen isn't how Wood wanted it to end. It's unclear whether Wood will be back with the team next season given all the front office upheaval, but one source told me that Wood has been a steadying influence and a clubhouse leader. "If there's one guy I bring back on that team, it's Wood," I was told. "He did more to save the focus of the team after [the Carlos Zambrano incident] than [Mike] Quade could. Wood will have his knee scoped, but should have plenty of time to be ready for spring training if the Cubs call. If they don't, Wood has made it clear he'll retire. If you'd told me in 1998 or even in 2003 that Wood would end his career with 86 wins, I would still be laughing. That stat, as much as the dollars lost, tells you about the true cost of not preventing pitcher injuries.

Remember all the talk about Stephen Strasburg being "rushed" back from Tommy John surgery? Parker didn't have the same focus since he injured his elbow at a much lower level and didn't have the same hype, but he came back this year after missing all of '10 and is now heading to the big league club. One of the amazing things about Tommy John surgery isn't that it can return pitchers to their previous levels of effectiveness, but that young pitchers that have the surgery don't seem to "lose a year" of development time. Parker progressed quickly through the D'backs system, but the team always seemed to be aiming at having him late in '11 for a chance at the '12 rotation, even back on draft day in '07. A native of northern Indiana, he's one of the top high school pitchers I've ever seen play live and features a 97 mph fastball. It's not likely that Parker will be on the playoff roster, but it's not impossible either.

Good luck, Derrick ... The Phillies don't seem terribly concerned about Hunter Pence's patellar tendinitis. They're sending him for an MRI, but anti-inflammatories tend to work pretty well with this ... The Yankees do not think Francisco Cervelli will be ready for the playoffs ... Troy Tulowitzki could be back as soon as Wednesday. His strained hip is making progress and he fought the idea of being shut down ... Vance Worley will shift to the pen after his Wednesday start so that he can give Charlie Manuel some idea how his arm will react to short rest. It also pauses his innings count, which is right in the Verducci Effect worry zone ... David Price is expected to make his scheduled Friday start. The Rays could shift to short rest for Price and others for the last "week" of the season ... Asdrubal Cabrera left Tuesday's game with back pain. The Indians will be very cautious with him over the last week ... Jeff Karstens will be shut down after his Tuesday start ... Jonathan Broxton had his elbow surgery to remove chips. He'll be ready in plenty of time for spring training and should have a normal off-season throwing program ... Aramis Ramirez left Tuesday's game with a quad strain. He could miss his last home game as a Cub ... Chase Headley was activated from the DL, but he's not ready to play yet and may not again this season ... Adam Jones was back in the lineup for the Orioles, but his thumb is "still an issue". He could be headed to off-season surgery ... Yonder Alonso injured his ankle on an inside-the-park homer. He'll be used as a pinch hitter, if necessary ... Chone Figgins won't make it back this season from his hip strain ... One more note on Mantle: I combed the Internet for pictures of his knee, since the shape and location of the scar could tell us more about the type of surgery he had. If anyone has one that shows this, please let me know by clicking the e-mail link at the top of this article.