Since the initiation of modern total knee arthroplasty (TKA) in the 1970s, the surgical technique has continued to evolve. It became evident that the desired surgery needed to produce a reproducible result that mimicked the normal anatomy and kinematics of the knee. TKA needed to have an anatomic goal, which would need to be thoroughly defined from which the desired surgical plan would be established. Restoration of a neutral mechanical axis has been a long-standing principle of total knee arthroplasty (TKA). This alignment is based upon the precept that post-operative alignment following TKA should be within 30 of a neutral mechanical axis or “coronal safe zone.” Recently, there has been some debate over the acceptable mechanical alignment and alternative alignment techniques have emerged offering innovative solutions tailored to the unique anatomical and biomechanical characteristics of each patient. These approaches leverage advanced technologies to enhance precision and personalization. Among the prominent individualized techniques are kinematic alignment, unrestricted kinematic alignment, restricted kinematic alignment, inverse kinematic alignment, and functional alignment. These strategies aim to replicate natural knee kinematics and improve patient-reported outcomes by preserving or reconstructing the individual’s native joint alignment. Despite their promise, these techniques come with unique challenge. As TKA evolves, the balance between achieving natural knee kinematics and maintaining durable implant performance remains at the forefront.