What is a balanced knee replacement?

For multifactorial reasons an estimated 20% of patients remain unsatisfied after total knee arthroplasty (TKA).Appropriate tension of the soft tissue envelope encompassing the knee is important in total knee arthroplasty and soft tissue imbalance contributes to several of the foremost reasons for revision TKA, including instability, stiffness and aseptic loosening.There is debate in the literature surrounding the optimum way to achieve balancing of a total knee arthroplasty and there is also a lack of an accepted definition of what a balanced knee replacement is.It may be intuitive to use the native knee as a model for balancing; however, there are many difficulties with translating this into a successful prosthesis.One of the foundations of TKA, as described by Insall, was that although the native knee has more weight transmitted through the medial compartment this was to be avoided in a TKA as it would lead to uneven wear and early failure. There is a focus on achieving symmetrical tension and pressure and subsequent 'balance' in TKA, but the evidence from cadaveric studies is that the native knee is not symmetrically balanced.As we are currently trying to design an implant that is not based on its anatomical counterpart, is it possible to create a truly balanced prosthesis or to even to define what that balance is? The authors have reviewed the current evidence surrounding TKA balancing and its relationship with the native knee. Cite this article: EFORT Open Rev 2018;3:614-619. DOI: 10.1302/2058-5241.3.180008.