Gap balancing versus measured resection in TKA—Evidence for/against measured resection

Measured resection is a total knee arthroplasty (TKA) technique that relies on bony landmarks to set component placement and adapts the soft tissues to the chosen implant position. It is an effective method and commonly used by surgeons around the globe. In Part 3 of this article series we look at measured resection and explore the benefits and shortcomings of this technique.



Establishing acceptable component positioning and soft tissue tensioning are two important aspects of TKA that influence patient outcomes [1, 2, 3]. If these considerations are not adequately addressed then patients can experience pain and implant malfunction or wear [4]. Studies have shown that between 8 and 19% of patients report being dissatisfied with their TKA for various reasons, including pain and unmet expectations [5, 6]. A few problems that could result from malrotation and/or incorrect soft tissue tensioning are: patellofemoral instability [7], anterior knee pain [8], arthrofibrosis [9], and flexion gap instability [10].

Measured resection is one technique commonly used by surgeons during TKA to attain correct alignment and soft tissue tension, and ideally deliver a pain-free knee that allows patients a return to daily activities [11]. It has been suggested that North American surgeons predominantly use measured resection versus gap balancing, while the use of the techniques is likely more variable within Europe [12]. Part 1 of this article series explains why surgeons would prefer one technique over the other.


Measured resection philosophy

Measured resection is characterized by the use of bony landmarks to determine femoral component rotation [7, 13, 14]. With this technique, and in contrast to gap balancing, bone cuts are made before soft tissue tensioning takes place. Generally, three bony landmarks are referenced [12, 15]. These are the: transepicondylar axis (TEA) (surgical and anatomical); anteroposterior axis (AP) or ‘Whiteside’s line’; and posterior condylar axis (PCA). These axes should not be used singularly, but in combination [11] as unique variations in anatomy and/or deformity can skew femoral component placement [8]. Additionally, surgeons may have difficulty accurately identifying these landmarks during TKA [8]. Figure 1 shows these landmarks.


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  • Transepicondylar axis (TEA)
  • Anterioposterior axis (AP)
  • Posterior condylar axis (PCA)
  • A note about intraoperative identification of axes
  • The pros of measured resection
  • The cons of measured resection
  • Conclusion
  • References

Part 1 | Brief comparison of the techniques

Part 2 | Evidence for/against gap balancing

Additional AO resources

Access videos, tools, and other assets to learn more about this topic.

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. 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.
  2. Merican AM, Ghosh KM, Iranpour F, et al. The effect of femoral component rotation on the kinematics of the tibiofemoral and patellofemoral joints after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2011 Sep; 19(9):1479–1487.
  3. Harvey RA, Hossain M. Femoral Component Rotation in Attune TKR, Balanced Technique and Measured Resection Instrumentation. Available at:
    in%20ATTUNE%20TKR%20Balan....pdf. Accessed January 7, 2018.
  4. Poilvache PL, Insall JN, Scuderi GR, et al. Rotational landmarks and sizing of the distal femur in total knee arthroplasty. Clin Orthop Relat Res. 1996 Oct; (331):35–46.
  5. Robertsson O, Dunbar M, Pehrsson T, et al. Patient satisfaction after knee arthroplasty: a report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acta Orthop Scand. 2000 Jun;71(3):262–267.
  6. Bourne RB, Chesworth BM, Davis AM, et al. Patient Satisfaction after Total Knee Arthroplasty: Who is Satisfied and Who is Not? Clin Orthop Relat Res. 2010 Jan; 468(1): 57–63.
  7. erger RA, Crossett LS, Jacobs JJ, et al. Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res. 1998 Nov;(356):144–153.
  8. Daines BK, Dennis DA. Gap balancing vs. measured resection technique in total knee arthroplasty. Clin Orthop Surg. 2014 Mar;6(1):1–8.
  9. Boldt JG, Stiehl JB, Munzinger U, et al. Femoral component rotation in mobile-bearing total knee arthroplasty. Knee. 2006 Aug;13(4):284–289.
  10. Romero J, Stähelin T, Binkert C, et al. The clinical consequences of flexion gap asymmetry in total knee arthroplasty. J Arthroplasty. 2007 Feb;22(2):235–240.
  11. Moreland JR. Femoral Component Rotation. AAOS PowerPoint presentation. Available at:
    &usg=AOvVaw3_pJtdn3mwCiMzlwol3Vd9. Accessed January 7, 2018.
  12. 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.
  13. 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.
  14. Whiteside LA, Arima J. The anteroposterior axis for femoral rotational alignment in valgus total knee arthroplasty. Clin Orthop Relat Res. 1995;321:168–172.
  15. 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.
  16. Olcott CW, Scott RD. A comparison of 4 intraoperative methods to determine femoral component rotation during total knee arthroplasty. J Arthroplasty. 2000 Jan;15(1):22–26.
  17. Insall JN, Scuderi GR, Komistek RD, et al. Correlation between condylar lift-off and femoral component alignment. Clin Orthop Relat Res. 2002 Oct;(403):143–152.
  18. Miller MC, Berger RA, Petrella AJ, et al. Optimizing femoral component rotation in total knee arthroplasty. Clin Orthop Relat Res. 2001 Nov;(392):38–45.
  19. 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.
  20. Kinzel V, Ledger M, Shakespeare D. Can the epicondylar axis be defined accurately in total knee arthroplasty? Knee. 2005 Aug;12(4):293–296.
  21. Yau WP, Chiu KY, Tang WM. How precise is the determination of rotational alignment of the femoral prosthesis in total knee arthroplasty: an in vivo study. J Arthroplasty. 2007 Oct;22(7):1042–1048.
  22. Siston RA, Patel JJ, Goodman SB, et al. The variability of femoral rotational alignment in total knee arthroplasty. J Bone Joint Surg Am. 2005 Oct;87(10):2276–2280.
  23. Jenny JY, Boeri C. Low reproducibility of the intra-operative measurement of the transepicondylar axis during total knee replacement. Acta Orthop Scand. 2004 Feb;75(1):74–77.
  24. von Roth P. Die ewige Debatte. Die ewige Debatte gap balancing vs. measured resection –gibt es einen Sieger? [The eternal debate gap balancing vs. measured resection is there a winner?] PowerPoint presentation.
  25. Talbot S, Dimitriou P, Radic R, et al. The sulcus line of the trochlear groove is more accurate than Whiteside’s Line in determining femoral component rotation. Knee Surg Sports Traumatol Arthrosc. 2015; 23(11): 3306–3316.
  26. Hyung-Min J, Dong San J, Jun H, et al. Comparison of alternate references for femoral rotation in female patients undergoing total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2402–2406.
  27. 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.
  28. Arima J, Whiteside LA, McCarthy DS, et al. Femoral rotational alignment, based on the anteroposterior axis, in total knee arthroplasty in a valgus knee. A technical note. J Bone Joint Surg Am. 1995 Sep;77(9):1331–1334.
  29. Wheeless CR. Rotational Alignment of Femoral AP Cutting Guide. Wheeless’ Textbook of Orthopaedics, presented by Duke Orthopaedics. Available at: Accessed January 12, 2018.
  30. Castelli CC, Falvo DA, lapicca ML, et al. Rotational alignment of the femoral component in total knee arthroplasty. Ann Transl Med. 2016 Jan; 4(1): 4.
  31. Nagamine R, Miura H, Inoue Y, et al. Reliability of the anteroposterior axis and the posterior condylar axis for determining rotational alignment of the femoral component in total knee arthroplasty. J Orthop Sci. 1998;3:194–198.
  32. 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.
  33. Orthopedics This Week. Measured Resection Trumps Gap Balancing in TKA. August 20, 2015. Available at: Accessed January 13, 2017.
  34. Shao H, Chen C, Scholl D, et al. Tibial shaft anatomy differs between Caucasians and East Asian individuals. Knee Surg Sports Traumatol Arthrosc. 2017 Sep 22. doi: 10.1007/s00167-017-4724-2.
  35. 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.
  36. 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.
  37. 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.