Well, I've been asked to share with you some thoughts about the technique that we describe, the 3LT technique to reconstruct scapholonate instability. I'll do it in a way of the typical 10 most frequently asked questions. I think that I have not 10, but many more frequently asked questions about this technique. I'll start by, why should we call it 3LT and not Modified Brunelli? And this is very pertinent, because in the literature, it's quoted as a Modified Brunelli, but I believe that Giorgio Brunelli was a genius surgeon who devised a way to stabilize the scaphoid using a strip of FCR, but his stabilization is purely in the sagittal plane, and this is completely different from what we are doing, that we are trying to reconstruct the dorsal scaphoid with a link, so they are so dissimilar, the techniques, that I don't think that it's fair to say that the 3LT technique is a Modified Brunelli, and besides, if you ask Giorgio Brunelli, he will say, he will tell you that the technique that we are defending is the wrong Brunelli, so he deserves to maintain his name to his technique, and we change our technique into the 3-ligament tenodesis. The second question is, when is the 3LT technique indicated? I think it's very clear that you should use that when the defect is non-repairable, but above all, it needs to be easily reducible, and the cartilage needs to be normal. The third question, is there any important contraindication? Yes, there is. You should never use the technique, you should never use a soft tissue reconstruction in scapho-lunate dissociation, if the deformity is not reducible, and also, if the lunate is unstable, because they look alike, but they are not the same. These two scapho-lunate dissociations, they look alike, but they are not the same. The lunate on the left is stable, meaning that the long radial lunate ligament is intact, but the other one is not, and if the lunate is unstable, and you try to recreate the scapho-lunate link, it will fail, so remember, lunate needs to be stable. You cannot build stability on the scaphoid if the lunate is unstable. You cannot build a house over the sand of a beach. You need something stable to be upon. Four questions, how we do it, step by step, I'll be quick. You first need to reduce the scaphoid, usually we use a K-wire, a cannulated drill to create that tunnel, then we pass on to the FCR, slip across that tunnel, then there you are with the tendon on the back, then we are using the dorsal radial tracheal ligament, a slit as an anchor point for the tendon to be reattached onto itself, but before tightening the construct, we reduce the scapho-lunate arrangement, and we use K-wires to neutralize the reduction, and this is how it looks like. What results may we expect if the indication is right, and I insist, if the indication is right, well, as far as pain is concerned, we very seldom obtain a completely painless wrist. There's always some occasional discomfort in these patients. Motion is okay. Stiff strength is 83%, and this is one case to show that not only the angle, but also the kinematics of the scaphoid are obtained. Of course, I must declare that this is the best case that I can show. What happens when the indication is not correct, well, you all know that. We may get a stiff, painful osteoarthritic wrist if the indication was incorrect, and this case was incorrect because we believed on the reducibility of this case, but it was not reducible. Are there any worthwhile modification? Yes, we have been working because we are never happy with our results. We have been working on the idea of, instead of using the FCR, the FCR is a scaphoid dynamic stabilizer. If instead of using the FCR, you use the ECRL in this fashion, it has a better mechanical advantage in the reduction of the flexion of the scaphoid, and if you use the ECRL in this way, the tendon obtains a much better supination of the scaphoid, so it closes the gap much better using the ECRL rather than the FCR. This is a case to show you, the pre-op and the post-op using ECRL instead of FCR. Are we proud of having introduced the 3LT technique? I must tell you, I am very proud of my daughter, but I am not that happy, I am not that proud of 3LT. I don't think that 3LT is great. Why? If the 3LT was so great, there wouldn't be so many modifications published. If the 3LT technique was so great, our results should have been reproducible, and they have not been fully reproduced, mostly because of the indication. You see the lunate? It's translocated. It's not a good indication. If the 3LT technique was so great, the indications wouldn't be so restrictive. We should be able to use it more extensively, in more indications, and this is not the case. And finally, what's going to happen to the tendon graft? Are we naïve as to believe that the tendon will be a ligament forever? Well, I am not naïve, and I know that the tendon graft will not become a real ligament unless its fibers get re-innervated by the posterior interosseous nerve somehow. And this is very unlikely, so I am very pessimistic about the long-term results of this technique. However, will a tendon graft be ever re-innervated? Up to this point, I would say no, but there is some hope, some evidence of regeneration of nerve elements in autografts, as they are now starting to see with ACL reconstructions using tendon grafts. So there's hope, and I don't want to be terribly pessimistic, but not terribly optimistic either. Thank you.

3LT technique

scapholunate instability

Modified Brunelli technique

indications

contraindications