Background: Tibial implant's positioning in total knee arthroplasty (TKA) requires a compromise between implant's rotation and bone coverage. We hypothesized that morphometric tibial trays (MTTs) would improve implant positioning and clinical outcomes as compared with symmetrical tibial trays. Methods: Thirty-three patients were included prospectively accordingto the following criteria: age from 18 to 85 years, body mass index < 35 kg/m(2), and posterostabilized cemented TKA performed for primary arthritis. Patients were matched for age, gender, body mass index, and preoperative international knee society (IKS) scoring system and Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score, in a 1:1 fashion with patients from a prospectively collected database receiving a symmetrical tibial tray TKA. Tibial implant's rotation, bone coverage, and the percentage of patients with a posterior overhang (PO) >3 mm were assessed using computerized tomography. The IKS and the KOOS were compared at 3-year follow-up. Results: Bone coverage (90% vs 88%, P = .07) and rotation (mean difference 0.7 +/- 3 degrees; P = .69) were not different between the 2 groups. The percentage of patient with a PO was lower in the morphologic group (2/33 vs 14/33, P = .01, odds ratio = 10.3 [2.12-50.24]). Functional scores were superior in the morphometric group: IKS (mean difference 20 +/- 21 points; P = .0005), mainly due to a difference in the IKS pain subscore (mean difference 11 +/- 15 points; P = .0002). According to the multivariate analysis, an MTT had a positive, independent effect on IKS pain (P = .006) and KOOS pain subscores (P = .03) at the last follow-up. Conclusion: The use of an MTT in TKA did not modify the tibial implant position in the axial plane; however, it decreased implant's posterior overhang and improved functional scores. The clinical improvement was mainly found on pain scores.