Gap balancing versus measured resection in TKA—Brief comparison of the techniques

Accurate soft tissue tensioning, and appropriate component positioning are critical to the success of TKA. If a knee is not balanced correctly then patient outcomes are compromised. What evidence exists to support surgeons’ use of gap balancing or measured resection? Is one of these techniques superior to the other? The discussion around this question is quite controversial. In Part 1 of this article series we look at the debate surrounding these techniques and compare the two. Does one technique come out on top?



Globally, total knee arthroplasty (TKA) is being performed at a rapidly increasing rate [1]. There have been projections of 3.48 million annual procedures by 2030 in the US alone, which is growth of 673% from 2007 [1]. While a number of problems, such as osteo- and inflammatory arthritis, obesity, tumors, and congenital deformities [2], could prompt this procedure, especially in the elderly population, the reality is that TKA is increasingly performed on younger, active patients [1].

The success of TKA is dependent on many factors, but if soft tissue tensioning and component positioning are not accurately achieved then the resulting instability can cause early failure of the implant, pain in the joint, and even necessitate revision [3]. Gustkey et al. found that “balanced joints” were the “most significant contributing factor to improved postoperative outcomes” [4]. Sharkey et al. report that up to 35% of early TKA revisions in the US may be triggered by soft tissue imbalance [5].


Two techniques for balancing

Historically, there have been two balancing techniques used during TKA: gap balancing or measured resection [6]. These techniques are widely used around the globe, and have each been shown to successfully balance knees and deliver good TKA outcomes; but, each technique has its pros and cons. Part 2 of this article series looks at gap balancing, and Part 3 examines measured resection in more depth. In this article we present a side-by-side comparison of gap balancing and measured resection; what are the benefits and disadvantages of each? Are there indications that suggest the selection of one over the other? Is one technique superior to the other?

We interviewed Mathew Abdel, from the Mayo Clinic in Rochester, US, and Philipp von Roth from the Charité-University Hospital in Berlin, Germany, about gap balancing and measured resection. They offer their unique perspectives on these techniques and assert what they think is really happening in the OR when it comes to the use of gap balancing and measured resection.

Read the full article with your AO login

  • In discussion: gap balancing or measured resection?
  • Gap balancing: brief introduction, pros and cons
  • Measured resection: brief introduction, pros and cons
  • Comparing the two techniques
  • Conclusion
  • References

Part 2 | Evidence for/against gap balancing

Part 3 | Evidence for/against measured resection

Additional AO resources

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Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Matthew P Abdel MD

Mayo Clinic
Rochester, United States

Philipp von Roth MD

Charité—University Medicine Berlin
Berlin, Germany

This issue was created by Word+Vision Media Productions, Switzerland



  1. Kurtz SM, Ong KL, Lau E, et al. International survey of primary and revision total knee replacement. Int Orthop. 2011 Dec; 35(12):1783–1789.
  2. Martin GM, Crowley M. Total knee arthroplasty. Up to Date. Available at: Accessed January 3, 2018.
  3. Springer BD, Parratte S, Abdel MP. Measured resection versus gap balancing for total knee arthroplasty. Clin Orthop Relat Res. 2014 Jul;472(7):2016–2022.
  4. Gustke KA, Golladay GJ, Roche MW, et al. A new method for defining balance: promising short-term clinical outcomes of sensor-guided TKA. J Arthroplasty. 2014 May;29(5):955–960.
  5. Sharkey PF, Hozack WJ, Rothman RH, et al. Insall Award paper. Why are total knee arthroplasties failing today? Clin Orthop Relat Res. 2002;(404):7–13.
  6. Risitano S, Indelli PF. Is “symmetric” gap balancing still the gold standard in primary total knee arthroplasty? Ann Transl Med. 2017 Aug; 5(16):325.
  7. Daines BK, Dennis DA. Measured Resection and Gap Balancing Technique in TKR. In: Hirschmann M, Becker R (eds.) The Unhappy Total Knee Replacement. Springer, Cham; 2015:47–57.
  8. Rassiwala M. Navigation Assisted Total Knee Replacement. Slides 19, 20. Available at: Accessed: January 5, 2018.
  9. Katz MA, Beck TD, Silber JS, et al. Determining femoral rotational alignment in total knee arthroplasty: reliability of techniques. J Arthroplasty. 2001 Apr;16(3):301–305.
  10. Boldt JG, Stiehl JB, Munzinger U, et al. Femoral component rotation in mobile-bearing total knee arthroplasty. Knee. 2006 Aug;13(4):284–289.
  11. Lee DH, Park JH, Song DI, et al. Accuracy of soft tissue balancing in TKA: comparison between navigation-assisted gap balancing and conventional measured resection. Knee Surg Sports Traumatol Arthrosc. 2010 Mar;18(3):381–387.
  12. Dennis DA, Komistek RD, Kim RH, et al. Gap balancing versus measured resection technique for total knee arthroplasty. Clin Orthop Relat Res. 2010 Jan;468(1):102–107.
  13. Nakahara H, Okazaki K, Hamai S, et al. Does knee stability in the coronal plane in extension affect function and outcome after total knee arthroplasty? Knee Surg Sports Traumatol Arthrosc. 2015 Jun;23(6):1693–1698.
  14. Fujii H, Azuma Y, Doi K. Coronal Stability of the Knee After Total Knee Arthroplasty with Gap-balancing Technique. Orthopaedic Proceedings. 2012 94-B(SUPP XLI)5. Available at: Accessed January 13, 2018.
  15. Matsumoto T, Muratsu H, Kubo S, et al. Soft tissue balance using the tibia first gap technique with navigation system in cruciate-retaining total knee arthroplasty. Int Orthop. 2012 May;36(5):975–980.
  16. Springer BD, Parratte S, Abdel MP. Measured resection versus gap balancing for total knee arthroplasty. Clin Orthop Relat Res. 2014 Jul;472(7):2016–2022.
  17. Fehring TK. Rotational malalignment of the femoral component in total knee arthroplasty. Clin Orthop Relat Res. 2000 Nov;(380):72–79.
  18. Babazadeh S, Dowsey MM, Vasimalla MG, et al. Gap Balancing Sacrifices Joint-Line Maintenance to Improve Gap Symmetry: 5-Year Follow-Up of a Randomized Controlled Trial. J Arthroplasty. 2018 Jan;33(1):75–78.,
  19. Churchill JL, Khlopas A, Sultan AA, et al. Gap-Balancing versus Measured Resection Technique in Total Knee Arthroplasty: A Comparison Study. J Knee Surg. 2018 Jan;31(1):13–16.
  20. Yoon JR, Jeong HI, Oh KJ, et al. In vivo gap analysis in various knee flexion angles during navigation-assisted total knee arthroplasty. J Arthroplasty. 2013 Dec;28(10):1796–1800.
  21. Berger RA, Crossett LS, Jacobs JJ, et al. Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res. 1998 Nov;(356):144–153.
  22. Griffin FM, Math K, Scuderi GR, et al. Anatomy of the epicondyles of the distal femur: MRI analysis of normal knees. J Arthroplasty. 2000;15:354–359.
  23. Whiteside LA, Arima J. The anteroposterior axis for femoral rotational alignment in valgus total knee arthroplasty. Clin Orthop Relat Res. 1995;321:168–172.
  24. Talbot S. Femoral Rotation: Let’s Just Use the Posterior Condyles? July 13, 2017. Available at: Accessed: January 15, 2018.
  25. Moreland JR. Femoral Component Rotation. AAOS PowerPoint presentation. Available at: sa=t&rct=j&q=&esrc=s&source=web&cd=1& cad=rja&uact=8&ved=0ahUKEwjs7_Km_sbYAhWs64MKHT15D6cQFggxMAA& Femoral%2520Component%2520Rotation.ppt&usg=AOvVaw3_pJtdn3mwCiMzlwol3Vd9. Accessed January 7, 2018.
  26. Luyckx T, Peeters T, Vandenneucker H, et al. Is adapted measured resection superior to gap-balancing in determining femoral component rotation in total knee replacement? J Bone Joint Surg Br. 2012 Sep;94(9):1271–1276.
  27. Sheth NP, Husain A, Nelson CL. Surgical Techniques for Total Knee Arthroplasty: Measured Resection, Gap Balancing, and Hybrid. J Am Acad Orthop Surg. 2017 Jul;25(7):499–508.
  28. Hanada H, Whiteside LA, Steiger J, et al. Bone landmarks are more reliable than tensioned gaps in TKA component alignment. Clin Orthop Relat Res. 2007 Sep;462:137–142.
  29. Tigani D, Sabbioni G, Ben Ayad R, et al. Comparison between two computer-assisted total knee arthroplasty: gap-balancing versus measured resection technique. Knee Surg Sports Traumatol Arthrosc. 2010 Oct;18(10):1304–1310.
  30. Jerosch J, Peuker E, Philipps B, et al. Interindividual reproducibility in perioperative rotational alignment of femoral components in knee prosthetic surgery using the transepicondylar axis. Knee Surg Sports Traumatol Arthrosc. 2002 May;10(3):194–197.
  31. Schnurr C, Nessler J, König DP. Is referencing the posterior condyles sufficient to achieve a rectangular flexion gap in total knee arthroplasty? Int Orthop. 2009 Dec; 33(6):1561–1565.
  32. Dennis DA. Measured resection: an outdated technique in total knee arthroplasty. Orthopedics. 2008 Sep;31(9):940, 943-944.
  33. Babazadeh S, Dowsey MM, Stoney JD, et al. Gap balancing sacrifices joint-line maintenance to improve gap symmetry: a randomized controlled trial comparing gap balancing and measured resection. J Arthroplasty. 2014 May;29(5):950-954.
  34. Nikolaides AP, Kenanidis EI, Papavasiliou KA, et al. Measured resection versus gap balancing technique for femoral rotational alignment: a prospective study. J Orthop Surg (Hong Kong). 2014 Aug;22(2):158-162.
  35. Hommel H, Kunze D, Hommel P, et al. Small Improvements in Postoperative Outcome with Gap Balancing Technique Compared with Measured Resection in Total Knee Arthroplasty. Open Orthop J. 2017 Nov;10(11):1236-1244.
  36. Singh VK, Varkey R, Trehan R, et al. Functional outcome after computer-assisted total knee arthroplasty using measured resection versus gap balancing techniques: a randomised controlled study. J Orthop Surg (Hong Kong). 2012 Dec;20(3):344-347.
  37. Huang T, Long Y, George D, et al. Meta-analysis of gap balancing versus measured resection techniques in total knee arthroplasty. Bone Joint J. 2017 Feb;99-B(2):151-158.
  38. Moon YW, Kim HJ, Ahn HS, et al. Comparison of soft tissue balancing, femoral component rotation, and joint line change between the gap balancing and measured resection techniques in primary total knee arthroplasty: A meta-analysis. Medicine (Baltimore). 2016 Sep;95(39):e5006.