Component malalignment has long been implicated in poor implant survival in Total Knee Arthroplasty (TKA). Malalignment can occur in orientation of bony cuts, and in component cementation/implantation. Several systems exist to aid bony cut alignment (navigation, shape matching), but final implantation technique is common to all TKA. Correction of errors in bony cut alignment at cementation/implantation by surgeons has been described. Changes in alignment at this stage are likely to result in asymmetrical cement penetration, which is implicated in early failure. This study reviewed a consecutive series of 150 primary cemented TKAs using an imageless navigation system (aiming for neutral overall limb alignment). Deviation at implantation was calculated by comparing limb alignment recorded using the trial components with limb alignment recorded with the final implanted components, prior to closure. 136 patients (91%) had a final overall limb alignment within 2° of neutral. Three patients (2%) had a final overall limb alignment greater than 3° from neutral. Deviation occurring at implantation is shown in Figure 1 with deviations distributed around zero (mode 0, median 0.3, range −2 to +4,)