130 patients with end-stage knee osteoarthritis were randomized to receive either restricted kinematic alignment (rKA) total knee arthroplasty with a medial pivot (MP) design (n=65) or mechanical alignment (MA) with the same MP design (n=65). The primary outcome of interest was the Knee Society Score (KSS). Secondary outcomes included the Oxford knee score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and forgotten joint score (FJS). Outcomes were assessed preoperatively and at 1 year and 2 years postoperatively. Overall, the results revealed superior joint awareness scores (FJS) and KSS subscores for patient satisfaction and expectations in the rKA group compared to the MA group, particularly in varus coronal plane alignment of the knee (CPAK) phenotypes. The study suggests that rKA with MP TKA may offer enhanced satisfaction and functional outcomes compared to MA with MP TKA.