1. The Elbow: Wrapping It Up Koco Eaton, M.D.

2. Tommy John’s Surgery - 1974 1974 surgery Has four 20 game win seasons after surgery, none before 1972 – Tommy John undergoes open arthrotomy for posterior osteophytes

3. Tommy John’s Surgery - 1974 Detachment of flexor mass Second surgery 3 months later for ulnar nerve palsy Ulnar nerve palsy delays rehab

4. Elbow Instability Conway et al, JBJS 1992 71 patients 21% ulnar nerve dysfunction 8 patients required revision surgery 5 patients with permanent partial ulnar nerve palsy

5. Elbow Instability Thompson, Jobe, Yocum & Pink, JSES 2001 83 athletes Muscle-splitting approach without transposition of the ulnar nerve 5% transient ulnar nerve symptoms One ulnar nerve palsy lasted 6 months, but resolved without a second operation

6. Elbow Instability Thompson et al. Better results if first procedure 82% success rate including all subjects 93% success if first elbow procedure Previous procedure usually olecranon decompression with removal of posterior osteophytes

7. Elbow Instability Hetchman et al, AJSM 1998 Suture anchors rather than drill holes Small series Cadaver study – anchors comparable to bone tunnels

8. Elbow Instability Rohrbough, Altchek & Hyman, AJSM 2002 Docking procedure Muscle-splitting approach 97% return to sports One tunnel in humerus

9. Elbow Instability Graft harvest Palmaris longus not always available Fourth toe extensor on opposite side of elbow Long, usually > 20 cm Low morbidity

10. Valgus Stress Radiograph

11. Epicondylar Drill Holes

13. Graft Placement

14. Anterior Tunnel

15. Ulnar Nerve Transposition

16. Conclusion We have come a long way in 30 years, but we still have further to go.