Limb alignment is a critically important factor to consider in the management of the patient with knee arthritis. Abnormal alignment is associated with the accelerated progression of osteoarthritis and, if not addressed at the time of surgery, may contribute to early failure of knee replacement implants. The contribution of the hindfoot to overall limb alignment has received limited attention in the context of deformity correction in total knee arthroplasty (TKA). In this review, we present evidence supporting the inclusion of the hindfoot in the consideration of overall limb alignment for TKA and propose a management algorithm.