William M. Mihalko, MD, PhD, Khaled J. Saleh, MD, MSc, Kenneth A. Krackow, MD and Leo A. Whiteside, MD J Am Acad Orthop Surg, Vol 17, No 12, December 2009, Soft-tissue balancing during total knee arthroplasty is an important step in optimizing the mechanical balance of the knee joint. Soft-tissue contractures that result from varus coronal plane deformity can pose a difficult problem, and the surgeon should have a standard procedure for managing such situations in the operating room. Balance may be assessed intraoperatively with the use of spacer blocks, laminar spreaders, and tensioning devices as well as by placement of trial components. Techniques used to balance the varus knee during primary total knee arthroplasty include femoral component rotation, osteophyte resection, soft-tissue release, and bone resection. Flexion and extension gap balancing is crucial for long-term success and patient satisfaction.