One hundred thirteen patients (120 knees) with knee osteoarthritis were randomized to receive robotic-assisted total knee arthroplasty with individualized femoral sagittal alignment (n=61 knees) or default femoral sagittal alignment (n=59 knees). The primary outcome of interest was prosthetic sagittal alignment, specifically the distribution of the distal femoral sagittal anteverted angle (DFSAA). Secondary outcomes included restoration of sagittal anatomy (anterior femoral offset and posterior condylar offset) and short-term clinical outcomes such as the Hospital for Special Surgery (HSS) Knee Score. Outcomes were assessed over three months. Overall, the results revealed that individualized alignment significantly reduced femoral prosthesis extension and significantly improved alignment within the optimal flexion range. Additionally, it better preserved anatomical features like anterior and posterior offsets. While short-term improvements in HSS scores were observed, these changes did not meet the minimal clinically important difference. The findings suggest that individualized alignment improves alignment and anatomical restoration but has limited early clinical benefits.