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Purpose The purpose of this study is to determine whether the lexion irst balancing technique, developed in an attempt to solve the dissatisfaction due to instability in total knee arthroplasties, leads to better restoration of joint line height and medial posterior condylar ofset. This might result in better knee lexion, compared to the classic extension irst gap balancing technique. The secondary objective is to show non-inferiority of the lexion irst balancing technique in terms of clinical outcomes as measured by the Patient Reported Outcome Measurements. Methods A cohort of 40 patients (46 knee replacements) operated using the lexion irst balancing technique was retrospectively analyzed and compared with a cohort of 51 patients (52 knee replacements) operated using the classic gap balancing technique. Radiographic analysis of the coronal alignment, joint line height and posterior condylar ofset was performed. Clinical and functional outcome data were analyzed pre-and postoperatively and compared between both groups. The two sample t test, Mann-Whitney U test, Chi-square test and a linear mixed model were used for performing statistical analyses, after normality analyses were executed. Results Radiologic evaluation showed a decrease in posterior condylar ofset using the classic gap balancing technique (p = 0.040) versus no change using the lexion irst balancing technique (p = n.s.). No statistically signiicant diferences were noted for joint line height and coronal alignment. Using the lexion irst balancer technique leads to a greater postoperative range of motion with deeper lexion (p = 0.002) and a better Knee injury and Osteoarthritis Outcome Score (KOOS) (p = 0.025). ConclusionThe Flexion First Balancing technique is a valid and safe technique for TKA, resulting in better preservation of PCO with consequently greater postoperative lexion and better KOOS scores. Level of evidence III.

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The traditional use of the Trethowan bone lever when providing superior retraction in open shoulder surgeries can result in obstructed views, limited light exposure, and ergonomic strain on assistants. We describe a simple modification of the ring handle spike that addresses these issues, allowing for maximal exposure and improved ergonomics. The curvature of a bent ring handle spike provides superior retraction without obstructing the surgeon's view and keeps the assistant's hand away from the operative field. This modification of the bone lever offers a simple and effective solution to a common problem, enabling adequate visibility to perform shoulder surgery safely and ergonomically.