Ninety-six patients with knee osteoarthritis (OA) scheduled for a primary total knee arthroplasty (TKA) were randomized to receive osteotomy using a gap balancing technique (n=48) or measured resection technique (n=48) for femoral component alignment. The outcomes of interest included the clinical outcomes of pain severity on the visual analogue scale (VAS), the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, knee range of motion, the Oxford Knee Score (OKS), and the American Knee Society Score (KSS), as well as intraoperative outcomes (i.e., operative time, osteotomy volume, and external rotation angle). Clinical outcomes were assessed at 1, 3, 6 and 12 months post-operation. Results revealed all clinical outcomes, except OKS scores at 12 months, were significantly in favour of the gap balancing group compared to the measured resection group, at all time-points (p<0.05 for all). Operative time was shorter in the gap balancing group (p<0.001); however, osteotomy volume of the medial posterior femoral condyle was lower in the measured resection group (p<0.001). The rate of adverse events was significantly lower in the gap balancing group (p<0.05).