Two hundred forty-four patients with varus knee osteoarthritis were randomized to receive (kinematic alignment total knee arthroplasty (KA-TKA) (n=126) or mechanical alignment total knee arthroplasty (MA-TKA) (n=118), all via a mini-subvastus approach using a cruciate retaining (CR) fixed-bearing prosthesis (no patellar resurfacing). The primary outcome of interest was patellar tracking (tilt and lateral shift) on standardized radiographs. Secondary outcomes included OKS, KSS, and the intraoperative rate of lateral retinacular release (LRR). Outcomes were assessed preoperatively and at 12 months. Overall, the results of the study revealed no between-group differences in patellar tilt/shift, but higher OKS and KSS and a markedly lower LRR rate with KA. In short, KA via a muscle-sparing approach achieved comparable patellar tracking with better early patient-reported/clinical scores and less need for soft-tissue release.