Background: Personalized alignment in total knee arthroplasty (TKA) has demonstrated good functional outcomes for knees with varus alignment. However, limited research has explicitly addressed optimal alignment strategies for valgus knees. The aims of the current study were to assess the impact of the postoperative knee alignment and of the degree of correction of knee alignment on functional outcomes and satisfaction in a population with preoperative valgus and to evaluate the complication and revision rates based on postoperative alignment. Methods: This retrospective study included primary posterior-stabilized TKA with a preoperative hip-knee-ankle (HKA) angle of ≥180°, with a minimum follow-up of 32 months. There were 460 knees included, divided into 3 groups: (1) preoperative neutral alignment (180° to 183°) (n = 162), (2) preoperative mild valgus (184° to 190°) (n = 204), and (3) preoperative severe valgus (>190°) (n = 94). A standardized surgical technique was employed with a goal of achieving neutral postoperative alignment. Data on radiographs, Knee Society Scores (KSS), range of motion, satisfaction, complications, and revisions were collected at the last follow-up. Results: The mean follow-up was 74.3 ± 12.4 months. In the preoperative mild valgus group, 10.8% of patients had postoperative varus, 81.4% had postoperative neutral alignment, and 7.8% had postoperative valgus. In the preoperative severe valgus group, 4.3% had postoperative varus, 83.0% had postoperative neutral alignment, and 12.8% had postoperative valgus. In the preoperative mild valgus group, patients with postoperative neutral alignment had significantly higher satisfaction (p = 0.0004) and KSS function score (p = 0.031) than patients with postoperative valgus alignment. In the preoperative severe valgus group, patients with postoperative valgus alignment had significantly higher satisfaction (p = 0.035) and greater improvement of the KSS knee score (p = 0.014) than patients with postoperative neutral alignment. Functional outcomes were not impacted by the degree of HKA angle correction. There were significantly fewer complications (p = 0.022) and revisions (p = 0.007) in the preoperative mild valgus group when patients had a postoperative neutral alignment compared with a postoperative valgus alignment. Conclusions: For preoperative mild valgus, correction to neutral alignment achieved better outcomes and fewer complications than leaving residual valgus. For preoperative severe valgus, retaining residual valgus postoperatively ensured satisfactory functional outcomes without increased complications. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.