Promises and difficulties with the use of femoral intra-medullary lengthening nails to treat limb length discrepancies

Limb lengthening using external fixation may be associated with problems such as pin-track infections, poor patient acceptance, muscle transfixation, secondary axial deformity and re-fractures. Intramedullary lengthening nails have been designed to address these issues. We present our results for femoral limb lengthening in adults managed by intramedullary lengthening nails. A retrospective review was undertaken for 8 femoral lengthening procedures performed in adults using intra-medullary lengthening nails over a three-year period. The average age of our patients was 34 years; the average duration of follow-up was 26.5 months (range: 8 to 40 months). An Albizzia nail was used in 5 procedures, an Intra-medullary Skeletal Kinetic Distractor (ISKD nail) in 3 procedures. Target lengthening was achieved in 6 out of 8 femurs with an average of 38.77 mm (range: 0 to 70 mm) length gained. The distraction index (length gained per day) was 0.58 on average (range: 0-1.25) and the consolidation index average was 5039 (range: 0-79) days/cm. Premature consolidation was noted in 4 cases, runaway acute lengthening in one patient; prominent metalwork--noted in 4 patients--and a bent nail were frequent obstacles and meant multiple visits to theatre. Femoral lengthening with an intramedullary lengthening nail is a reasonable alternative to external fixators, thereby avoiding problems associated with callotasis using external fixation methods. It is however, important to counsel patients regarding possibilities of significant obstacles including failure and multiple visits to theatre during the process.     

A nail for progressive lengthening. An animal experiment with a 2-year follow-up]

The elongation nail was experimented on 10 pure-breed Romanov ewes aged 9 to 12 month-old. It was implanted in a randomly chosen femur, the other femur being used as a control. After a superior and lateral approach to the femur, drilling and initial distraction averaging 26 mm, the nail was inserted and locked at both ends. Lengthening began at D1 by alternate inward and outward rotation maneuvers exerted on the pelvic limb. One ewe presented an intraoperative hip dislocation, another one unlocked the upper lock, with secondary shortening. The other 8 ewes underwent successful lengthening without apparently suffering (63-mm gain, i.e. 37% at the end of lengthening). Two ewes died at 9 months and their femura presented with a space remaining to fill smaller than 3 mm. Five of the other 6 ewes were followed up for an average of 10 months after bone healing and nail removal, over a total follow-up of 2 years. The femur is modified all over its diaphysis and widened at the level of the regenerated tissue, where cortical bone is thinner but has a normal lamellar appearance. Bone marrow is replaced by trabecular bone filled with fatty marrow. The pathology study of the last of the 6 ewes followed up for 2 years showed a bridge between both sites of incipient regeneration, indicating bone healing. The final gain as compared to the non-operated side is 27%. Progressive lengthening can be performed with an internal fixator in animals. The clinical trial in progress with allow evaluating this technique and establishing its field of application.     

Tibial lengthening and concomitant foot deformity correction in 14 patients with permanent deformity after poliomyelitis

BACKGROUND: In neuromuscular diseases, limb lengthening and foot deformity correction are associated with a high risk of complications associated with distraction callus and joint contracture. We have found no published articles of tibial lengthening and concomitant foot deformity correction using the Ilizarov method or traditional methods. To compare result of gradual distraction with triple arthrodesis for foot deformity combined with tibial lengthening, we investigated healing index and complications of two methods. PATIENTS AND METHODS: We reviewed 14 patients with permanent deformity after poliomyelitis who underwent tibial lengthening and concomitant foot deformity correction using the Ilizarov external fixator. Tibial lengthening over an intramedullary nail was performed in 3 patients and lengthening without a nail was performed in 11 patients. RESULTS: The mean external fixation time was 6 (3.6-10) months without nail and 1.6 (1.5-1.7) months with nail, whereas the mean healing index was 1.8 (0.8-3.1) months/cm without nail and 2 (1.8-2.3) months/cm with nail. Concomitant foot treatments included triple arthrodesis in 7 patients, pantalar arthrodesis in 2 patients with flail ankle, and gradual foot frame distraction without bony foot procedures in 5 patients. Delayed consolidation and recurrent equinus contracture of the ankle requiring additional lengthening of the Achilles tendon were the most common bone and joint complications during tibial lengthening. INTERPRETATION: The gradual foot frame distraction method was associated with major complications, such as recurrent foot deformity, joint luxation, and arthritis. We therefore recommend triple arthrodesis as a concomitant procedure during tibial lengthening     

Tibial lengthening and concomitant foot deformity correction in 14 patients with permanent deformity after poliomyelitis

Background In neuromuscular diseases, limb lengthening and foot deformity correction are associated with a high risk of complications associated with distraction callus and joint contracture. We have found no published articles of tibial lengthening and concomitant foot deformity correction using the Ilizarov method or traditional methods. To compare result of gradual distraction with triple arthrodesis for foot deformity combined with tibial lengthening, we investigated healing index and complications of two methods.

Patients and methods We reviewed 14 patients with permanent deformity after poliomyelitis who underwent tibial lengthening and concomitant foot deformity correction using the Ilizarov external fixator. Tibial lengthening over an intramedullary nail was performed in 3 patients and lengthening without a nail was performed in 11 patients.

Results The mean external fixation time was 6 (3.6- 10) months without nail and 1.6 (1.5-1.7) months with nail, whereas the mean healing index was 1.8 (0.8-3.1) months/cm without nail and 2 (1.8-2.3) months/cm with nail. Concomitant foot treatments included triple arthrodesis in 7 patients, pantalar arthrodesis in 2 patients with fiail ankle, and gradual foot frame distraction without bony foot procedures in 5 patients. Delayed consolidation and recurrent equinus contracture of the ankle requiring additional lengthening of the Achilles tendon were the most common bone and joint complications during tibial lengthening.

Interpretation The gradual foot frame distraction method was associated with major complications, such as recurrent foot deformity, joint luxation, and arthritis. We therefore recommend triple arthrodesis as a concomitant procedure during tibial lengthening     

改良双侧胫肌延长术的疗效分析

目的 探讨改良双侧胫骨延长术的治疗效果。方法 1997年5月－2000年5月对32例患者行双侧胫骨延长达到增高目的,其中8例膝内翻。手术为颈骨结节下1．0cm处骨膜下横形截断胫骨,腓骨于外踝上10cm水平处横形截断,胫肌骨置入带锁髓内钉,近端上锁,小腿外置延长器,每日缓慢牵伸延长胫骨,达到预期延长目的后2周拆除延长器,同时带锁髓内钉远端上锁,延长段骨质完全愈合约1年后取出带锁髓内钉。结果 32例术后双侧胫骨延长3．5－12．0cm,平均8．5cm,延长时间为53－180天,平均128天,延长段骨痂生长时间为120－270天,平均180天,随访1－3年,患者在增高高度、步态及关节活动度等方面满意率达98％。结论 改良后的双侧胫肌延长术,胫骨骨折愈合时间缩短,并发症少,可同时矫正膝内、外翻畸形。     

应用Orthofix重建外固定架治疗骨缺损

目的 总结应用Orthofix重建外固定架分别利用骨运输术、一期清创 短缩肢体 截骨延长技术以及一期清创 短缩肢体 二期截骨延长技术治疗26例骨缺损的经验，探索肢体安全短缩的限度。方法 在患肢上安放Orthofix重建外固定架。对17例胫骨和2例股骨骨缺损5～22cm者行骨运输术。对5例胫骨干骨缺损小于5cm合并皮肤缺损及感染者和1例股骨干骨缺损4cm合并感染者行一期清创 短缩肢体 延长技术进行治疗。对2例胫骨缺损5cm和1例股骨干骨缺损4cm者合并感染的患者采用先一期清创 部分短缩肢体，术后继续短缩肢体，二期截骨延长恢复肢体的长度。截骨术后10～14d开始延长，每天4次，每天延长1mm。16例胫骨和2例股骨在远、近缺损端相遇后于骨缺损端行清创术和自体骨植骨术。结果 平均随访13个月。骨缺损均得以重建，患肢肢体长度完全恢复，骨折愈合，无感染复发。在5例使用一期清创 短缩 延长法的胫骨缺损和1例行一期短缩 延长法的股骨缺损患者中，3例胫骨和1例股骨短缩至4cm时出现血管危象，立即恢复1cm长度后肢体远端血运恢复。术后第3天开始继续短缩肢体，每天4mm，每天4次。1例术后出现腓总神经麻痹，术后2个月恢复。4例胫骨缺损患者诉膝部疼痛。3例胫骨缺损患者出现马蹄内翻足。2例胫骨缺损患者出现下胫腓分离。结论 应用Orthofix重建外固定架进行骨运输是治疗骨缺损的有效方法，谨慎使用短缩 延长技术。对于软组织有损伤的肢体一期短缩不应超过3cm，可以于术后第2天开始继续短缩，每天短缩4mm，每天4次，每次1mm。     

Tibial lengthening over an intramedullary nail

Background Long-term application of an external fixator to treat leg-length discrepancy and short stature often causes complications, such as pin-tract infection or loss of range of motion at the knee or ankle (or both). Prolonged fixator use also interferes with the activities of daily living. To minimize such problems, we have combined intramedullary nailing with external fixation. Using this technique, the external fixator can be removed more quickly after completing the lengthening. Methods We combined intramedullary nailing with lengthening in 13 tibias (8 patients) and then compared these cases with 17 standard tibial lengthenings (16 patients) using an external fixator alone. In both groups we excluded patients who had a history of previous bone infection, open fracture, immature bone, soft tissue compromise, antineoplastic chemotherapy, or bone deformity of a severity that required gradual deformity correction. We also excluded cases with lengthening of less than 3 cm. Results The mean external fixation index differed significantly between the two groups, but the consolidation index did not. Mean operating time for lengthening combined with intramedullary nail placement was approximately 60 min longer than for standard lengthening without nail placement; intraoperative blood loss was not greater in the nailing group. Complications related to the external fixator were far fewer in the combined intramedullary nailing and lengthening group compared with the control group, and callus formation was satisfactory for both groups. Conclusions A combination of intramedullary nailing and external fixation produces callus formation as good as that obtained by the standard Ilizarov method of lengthening. Furthermore, this combined procedure decreases the external fixation time and is associated with fewer complications.     

Limb lengthening with a fully implantable mechanical distraction intramedullary nail

AIM: The morbidity of fixator-assisted distraction osteogenesis should be reduced by intramedullary lengthening devices. The ISKD (intramedullary skeletal kinetic distractor) is a new, fully implantable mechanical lengthening nail. In a prospective cohort trial the possibilities and limitations of the device used on femur and tibia are examined. METHODS: 22 patients with a mean age of 25 (range: 16-46) years were treated with an ISKD for femoral (n = 16) and tibial (n = 6) lengthening. The average leg length discrepancy was 48 (range: 25-80) mm. The follow-up was 21 (range: 7-37) months. Clinical and radiological results and complications were evaluated. RESULTS: The results of femoral and tibial applications of the ISKD are different. At the tibia, in three patients a pseudarthrosis occurred and slow callus formation was observed twice. An equinus contracture became evident in 2 patients. At the femur, in one case the lengthening was not accomplished with the device. Five patients were manipulated under anaesthesia at least once to achieve the aim of distraction. Three of these patients received retrograde implantation of the ISKD. An infection or interlocking screw failure was not observed either at the femur or the tibia. CONCLUSION: The ISKD reduces fixator-associated problems but incorporates its own difficulties which are mainly based on the guidance of the device. Careful patient advice in monitoring the lengthening process is mandatory. At the femur 8 cm of lengthening can be achieved but the nail tends to "block". Proper reaming and osteotomy techniques are important. A lengthening of more than 1 mm/day is recommended to prevent early consolidation. At the tibia weak callus formation and soft tissue contractures occur, therefore not more than 4 cm lengthening should be planned, the distraction speed has to be reduced noticeable below 1 mm/day and the initial immobilisation should be for more than a week.     

Treatment of chronic osteitis of the tibia]

Since the beginning of May 1990, we have been using the original Ilisarov apparatus in our treatment of osteomyelitis. It has been used both statically and dynamically after corticotomy for segment transport and lengthening. So far we have treated 24 patients, of whom 13 had defect osteomyelitis, 9 had unstable infections and 2 had stable osteomyelitis with deformities. On average the bone defects measured 7.6 cm, and nine patients had soft tissue defects larger than 6 cm2. The Ilisarov apparatus performed a holding function in seven cases after defect grafting using autogeneic spongiosa. It was used in four cases for gradual compression, in seven cases for segment or fragment transport, in three cases for secondary lengthening and in three cases for correction. In all cases the infections were eliminated and stability was obtained. The duration of segment transport corresponded to the defect size, with a daily lengthening of approximately 1 mm. The fixation times ranged from 112 to 483 days (mean: 240 days). Apart from one special situation, no bone regeneration problems were observed. Some of the complications we encountered must be regarded as beginners' mistakes. We observed problems with segment transport (early corticotomy healing, deformity, non-union at the docking site) and problems with equipment, which has now been improved. For closure of the soft tissue defects it was sufficient to use mesh grafting. Its versatility and advantages as a stabilizing apparatus have made the Ilisarov fixator the instrument of our choice, especially in the treatment of circular infected defects larger than 3 cm.     

Repeated intramedullary stabilization following failed telescopic nail lengthening – An appropriate treatment strategy

Externally magnetic-controlled intramedullary telescopic nails for bone lengthening have recently gained popularity due to many advantages when compared to more traditional lengthening methods. Patients requiring lengthening often present with a clinical history of previous multiple surgeries increasing the risk for complications of further procedures. However, studies regarding the treatment of complications following implantation of these devices remain scarce in literature. Therefore, we report our experience with revision surgery after lengthening with a telescopic intramedullary lengthening nail. In 6 out of 20 cases (30%) of lower limb lengthening for leg length discrepancy revision surgery was necessary. Two revisions were necessary due to nail breakage while the other 4 cases required a secondary procedure for non-union. In all cases, revision surgery included standard intramedullary locking nailing with additional autologous bone grafting. The median interval between index and revision surgery was 11.5 months (range 2–15 months). Satisfying clinical results, the intended extend of lengthening and bony consolidation was observed in all 6 patients. We conclude that revision surgery using an intramedullary locking nail with autologous bone grafting after failed telescopic nail-based lengthening represents an useful salvage procedure in these cases.     

Post-retrieval functionality testing of PRECICE lengthening nails: The “Sleeper” nail concept

IntroductionPRECICE intramedullary magnetic lengthening nails, introduced in 2011, have changed the landscape of long bone limb lengthening. The implants have a stroke ranging from 5 to 8 cm, but it may be desirable to perform part of the lengthening at one treatment, allow bone healing, leave the implant in place, dormant, and then return one or more years later to re-lengthen with the same implant. We call this the “sleeper” nail concept. This strategy may be gentler for the joints and soft tissues. Would the nail mechanism still be functional one or more years later?MethodsWe tested 102 intact, consecutively explanted nails. Using a “fast magnet,” the male part was lengthened to 5 mm short of its maximum stroke capacity and retracted back to 35 mm (all nails start with the male part exposed 30 mm). The nails passed the test if the male part succeeded in lengthening to 5 mm short of the maximum stroke capacity and back to 35 mm (or only retract in case fully deployed at testing). During our testing, the nails were prevented from reaching their full capacity of lengthening/retraction to avoid jamming the gears. Failure was defined as the inability or partial ability to complete the process.ResultsEighty-six nails (84.3%) performed successfully according to our testing standard. When comparing successful and failed nails in terms of nail type, generation, diameter, length and in vivo interval, there was no statistical significance. Comparing both groups in terms of status at testing (fully deployed or not) showed statistical significance with 9 of the 16 failed nails fully deployed at testing (p < 0.001).ConclusionDormant PRECICE nails can be reactivated for further lengthening. The results imply that full deployment may damage the mechanism, making future re-use by retracting and then re-lengthening unsuccessful. The candidate nails for this purpose should not have any signs of clear damage (bending or breakage) and should not have been fully deployed. However, surgeons and patients should be aware of the need for possible nail exchange if the “sleeper” nail fails to wake up.Level of evidenceLevel IV case series analysis of retrieved surgical implants.     

Limb length discrepancy following titanium elastic nailing in paediatric femoral shaft fractures

The authors performed a prospective study to evaluate limb length discrepancy in children following titanium elastic nailing for femoral shaft fractures. Thirty-seven children (28 boys and 9 girls) were included in the study. The average time to radiological union in our study was 7.8 weeks (range: 5 to 14). Results after 3 years were evaluated for 29 children. Limb lengthening was noted in the first year in 15 children: at the time of nail removal, an average of 10.6 mm and at the end of one year 8.7 mm. After three years only nine were lengthened an average of 2.7 mm. An average of 12.6 mm shortening was seen in four patients at the time of nail removal, reduced to 12.1 mm at the end of one year. After three years three remained short, an average of 11.7 mm. No limb length discrepancy was seen in 10 patients. We conclude that limb length discrepancy is common following elastic nailing in paediatric femoral fractures, with lengthening being more frequent than shortening. Lengthening tends to decline with time at an average rate of around 1.5 mm per year.     

趾端骨软组织矫形术在顽固性嵌甲中的应用

目的探讨趾端骨、软组织矫形术治疗顽固性嵌甲的临床效果。方法1997年10月-2006年5月，收治顽固性晦趾嵌甲患者31例38趾，采用白行设计的趾端骨、软组织矫形术治疗。男23例27趾，女8例11趾。年龄12～28岁，平均17．5岁。病程2年1个月～14年，平均31．6个月。均经5～9次拔甲治疗。合并甲沟炎急性期14例18趾，甲沟炎慢性期17例20趾。选取同期收治足部疾病但晦趾完整38例患者作对照。测量患者甲沟深度及摄X线片，测量爪粗隆上翘比例r值。结果患者甲沟深度及r值分别为2．87±0．31mm及0．149±0、013，与对照组1、06±0.10mm及0．060±k0．019比较，差异均有统计学意义（P〈0．01）。术后30例37趾伤口I期愈合，1例1趾伤口延迟愈合。29例36趾获随访8～29个月，平均21个月。趾端外形良好，无复发或再次手术。结论（足母）趾末节趾骨爪粗隆上翘、甲沟肥大变深是（足母）嵌甲重要的解剖学病因，采用趾端骨软组织矫形术是根治顽固性嵌甲的一种有效手术方法。     

Implant failure after externally magnetic-controlled nail lengthening

The number of intramedullary procedures to treat leg length discrepancy (LLD) has risen in the past decade and this has led to increased complications such as nail breakage. The aim of this study was to reveal our experience with implant failure after externally magnetic-controlled telescopic bone lengthening. We observed nail-breakage in 4 out of 24 patients (16.7%) after 6 to 15 months (median 13.5 months) following lower limb lengthening for LLD due to non-union or insufficient bone healing. Three femora and one tibia were treated in one posttraumatic and three congenital cases. Three out of the four patients had an elevated Charleston Comorbidity Index (CCI). Revision surgery involved removal of the broken nail and implantation of a trauma nail. At final follow-up all patients showed subjective satisfaction, achievement of desired lengthening with complete bone healing. Based on our results no unequivocal risk factor including number of previous surgeries, comorbidities and age was identified. In cases of delayed bone formation, early revision surgery with an exchange to a trauma nail has to be considered to prevent breakage of the intramedullary telescopic device.     

Reconstructive procedures for segmental resection of bone in giant cell tumors around the knee

Background:

Segmental resection of bone in Giant Cell Tumor (GCT) around the knee, in indicated cases, leaves a gap which requires a complex reconstructive procedure. The present study analyzes various reconstructive procedures in terms of morbidity and various complications encountered.

Materials and Methods:

Thirteen cases (M-six and F-seven; lower end femur-six and upper end tibia -seven) of GCT around the knee, radiologically either Campanacci Grade II, Grade II with pathological fracture or Grade III were included. Mean age was 25.6 years (range 19-30 years).Resection arthrodesis with telescoping (shortening) over intramedullary nail (n=5), resection arthrodesis with an intercalary allograft threaded over a long intramedullary nail (n=3) and resection arthrodesis with intercalary fibular autograft and simultaneous limb lengthening (n=5) were the procedure performed.

Results:

Shortening was the major problem following resection arthrodesis with telescoping (shortening) over intramedullary nail. Only two patients agreed for subsequent limb lengthening. The rest continued to walk with shortening. Infection was the major problem in all cases of resection arthrodesis with an intercalary allograft threaded over a long intramedullary nail and required multiple drainage procedures. Fusion was achieved after two years in two patients. In the third patient the allograft sequestrated. The patient underwent sequestrectomy, telescoping of fragments and ilizarov fixator application with subsequent limb lengthening. The patient was finally given an ischial weight relieving orthosis, 54 months after the index procedure.After resection arthrodesis with intercalary autograft and simultaneous lengthening the resultant gap (∼15cm) was partially bridged by intercalary nonvascularized dual fibular strut graft (6-7cm) and additional corticocancellous bone graft from ipsilateral patella. Simultaneous limb lengthening with a distal tibial corticotomy was performed on an ilizarov fixator. The complications were superficial infection (n=5), stress fracture of fibula (n=2). The stress fracture fibula required DCP fixation and bone grafting. The usual time taken for union and limb length equalization was approximately one year.

Conclusion:

Resection arthrodesis with intercalary dual fibular autograft and cortico-cancellous bone grafting with simultaneous limb lengthening achieved limb length equalization with relatively short morbidity.     

Rotational stability of Seidel nail distal locking mechanism

The intramedullary distal locking mechanism in the Seidel nail uses interference fit, avoiding the need of a screw traversing soft tissue and the risk of neurovascular injury. However, there is concern for its rotational stability. This study was designed to test the rotational stability of the distal locking mechanism under the least stable conditions. A transverse osteotomy was performed 10 cm proximal to the trochlea in 10 cadaveric humeri, followed by insertion of a 9 mm diameter Seidel nail and distally locked. The proximal humeral segments were removed. Rotational test to failure was performed with a material testing machine. The initial medullary diameter and the amount of flange spread measured 9.95 mm and 11.28 mm, respectively. Most of the flanges were found to be incompletely deployed. Failure occurred by slippage of the flanges. The average failure torque and torsional stiffness of the nail bone construct tested were 0.262 N m and 0.070 N m/ degrees . The Seidel nail distal locking mechanism has low rotational stability on mechanical testing. However, the low failure torque tested in vitro does not always preclude successful fracture healing and a good clinical outcome. Whether the presence of rotational micro motion would be beneficial to bone healing would need further investigation.     

„Plate-assisted segmental bone transport“ mit Verlängerungsnagel und Platte

Background

Distraction osteogenesis represents an effective procedure for treatment of bone defects from various causes (e.g. trauma, malignancy, congenital and infection). In the past the available procedures were practically exclusively external.

Principles

In the plate-assisted segmental bone transport (PABST) procedure a commercially available motorized intramedullary lengthening nail is used for segment transport. The transport segment is transported along a bone plate, which is responsible for maintaining the position of the proximal and distal main fragments.

Surgical technique

In staged sequences, a plate spanning the defect is placed. A lengthening nail is inserted in an antegrade or retrograde direction and a vascularized transport segment is created with an osteotomy. Bone transport is initiated at 1.0 mm a day. The transport segment is pulled or pushed into place, depending on the location of the bone void. In due time, a docking procedure is performed and full weight bearing is allowed. Supplementary lengthening can be initiated at docking or in a separate procedure. In smaller defects the gap is closed immediately over the plate and the bone is lengthened by the nail in the opposite end of the defect.

Conclusion

The presented method is a valuable addition to the armamentarium for treatment of bone defects. The main advantages are the avoidance of external fixation (fixation wires, Schanz screws) and the creation of physiological bone substitute. Vital soft tissues are essential for a good outcome. With appropriate management (systematic debridement, local and systemic administration of antibiotics and free soft tissue flaps), this method can be a solution to even complex reconstructive problems.

     

Limb lengthening and deformities corrections with the femoral Albizzia nail

The albizzia femoral nail allows for lengthenings up to 10 cm. It can be used in achondroplastic patients. Multiplane corrections can be addressed with a special nail (3D-Albizzia) if multiple osteotomies are performed (e.g. for proximal and distal femoral varus). A derotation and a flexion/extension osteotomy can also be associated. IM nailing is suitable for patient with previous external fixators. Surgical planning should be careful. The operation is currently performed percutaneously, with a 1 to 2 cm skin incision for nail insertion, and a 6 mm incision for distal femoral dome osteotomies. CPM machine is applied in recovery room and rehabilitation resumes on day 1, allowing more than 120 degrees of knee flexion by day 1. Ratcheting for gradual lengthening is begun on day 5 at a rate of 1 mm/day. Muscle stretching and strengthening are maintained for one year. In bilateral cases, a preoperative strengthening program is set. A 120 degrees knee range of motion can be maintained all during lengthening. Intramedullary lengthening allows for maintaining muscle and soft tissue suppleness which protects from hyperpressure over joints and from long-term muscle waisting. The Albizzia is currently a good tool once the surgeon get used to its physiotherapy aspect. Previously reported general anaeshtesia for getting the ratcheting is barely needed, when the technique has been done percutaneously and when the full range of knee motion is recovered on day 1 and maintained thereafter.