The debate between kinematic versus mechanical alignment total knee arthroplasty (TKA) has been ongoing, with no clear favourite. Kinematic alignment (KA) relies on attempting to restore patient anatomy, with a "personalized" approach to TKA, often relying on computer navigation, with or without other supplemental technologies such as three-dimensional printing. Mechanical alignment, on the other hand, relies on a standardized, reproducible technique, with soft tissue balancing to compensate for individual patient anatomy as required. In this study, the authors randomized 45 patients undergoing bilateral TKA to receive a KA knee on one side and an MA knee on the other. The more symptomatic knee was randomized to KA or MA, with the other knee being assigned the alternative. At two year follow-up, there were no significant differences in terms of Forgotten Joint Score, KOOS scores, Oxford Knee Scores, or range of motion. There were also no significant differences in terms of component position. When asked which knee they preferred, about half of patients had no preference. Overall, this study does not support the use of either technique, though given the simplicity and fewer resources generally required for MA TKA, this may be preferred.