Background: Osteoarthritis (OA) is a leading cause of disability, with isolated medial compartment knee OA being a common presentation. While total knee arthroplasty (TKA) remains the standard treatment for advanced knee OA, unicompartmental knee arthroplasty (UKA) has gained attention for its potential benefits for selected population, including faster recovery and improved patient satisfaction. Aim: We aimed to compared UKA and TKA in patients with anteromedial knee OA (AMOA), focusing on patient-reported outcomes (PROs), operative and postoperative outcomes. Methods: Eligible patients were randomized into one study group; UKA or TKA and followed for at least two years. Functional outcomes were evaluated using the Oxford Knee Score (OKS), Knee Society Score- Knee Score (KS-KS) and Functional Score (KS-FS)-, Forgotten Joint Score (FJS) and Range of Motion (ROM). Patient satisfaction was assessed at the final follow-up visit. Results: Forty-seven patients (53 knees) were included and randomized across study groups (UKA = 22, TKA = 31). Functional outcomes were comparable between the two groups, with no statistically significant differences in post-operative improvement of OKS (24.3 ± 10.1 vs. 21.3 ± 8.6; p = 0.21), KS-KS (39.5 ± 22.4 vs. 29.3 ± 14.4; p = 0.07), KS-FS (39.8 ± 26.9 vs. 31.8 ± 17.8; p = 0.23), and statistically significant differences in postoperative FJS (80 ± 20.1 vs. 68 ± 15.5; p = 0.024) and Postoperative ROM (132.0 ± 10.3 vs 125.0 ± 13.1; p = 0.035) . However, UKA patients reported significantly higher satisfaction rates (86.4% "Very Satisfied" vs. 61.3% in TKA). Additionally, UKA demonstrated operative advantages, including significantly shorter operative time, reduced blood loss, shorter hospital days and wound length, and fewer overall complications. Conclusion: UKA offers favorable functional outcomes compared to TKA, with faster recovery, lower blood loss, greater joint “forgottenness,” improved ROM, higher patient satisfaction, and fewer complications, making it a first choice for appropriately selected patients with AMOA.