Lateral Ulnar Collateral Ligament Reconstruction With Positive Pivot Shift Test

Posterolateral rotatory instability of the elbow (PLRI) results from incompetence of the lateral ulnar collateral ligament (LUCL), part of the lateral elbow ligamentous complex. A pivot shift test is a sensitive and specific intraoperative maneuver to assess for PLRI. While several LUCL repair and reconstruction techniques have been described, ligament reconstruction remains the gold standard treatment.

LUCL reconstruction is indicated for active patients with symptomatic PLRI whose conservative treatment has failed. Patients classically present with pain and mechanical symptoms, often during active elbow extension, supination, and valgus loading, or with maneuvers such as pushing up from a chair. While the pivot shift test has poor sensitivity in awake patients, it is useful as an examination under anesthesia. This case involves a patient with PLRI and a positive pivot shift test under anesthesia.

We present a video-based technique guide of LUCL allograft reconstruction utilizing a docking technique at the humerus with transosseous ulnar tunnels. The patient was positioned supine with the arm on a hand table. The lateral elbow was approached through a Kocher interval. A semi-tendinosis allograft was passed through transosseous ulnar tunnels at the supinator crest, docked into the humerus at the isometric point, and secured over a bone bridge. A postreconstruction pivot shift test confirmed stability of the elbow.

LUCL reconstruction with ulnar tunnels reliably improves pain and restores elbow stability. In this case, the pivot-shift test was eliminated after graft fixation, and the patient's symptoms resolved postoperatively. This technique restores native LUCL biomechanics and durable elbow stability.

LUCL reconstruction with ulnar transosseous tunnels is a reproducible technique for addressing posterolateral rotatory instability. The pivot-shift test is a valuable intraoperative tool for assessing PLRI. This case and video may serve as a useful tool for orthopaedic surgeons implementing biomechanically sound allograft reconstruction of the LUCL via transosseous tunnels.

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