Total knee replacement (TKR) is an established procedure for advanced knee osteoarthritis, primarily indicated when pain and functional limitation significantly impair quality of life and activities of daily living. Surgical outcomes depend greatly on intraoperative technical decisions, particularly tibial cut and polyethylene thickness selection. This study explored the surgical preferences, intraoperative methods, and decision-making factors guiding proximal tibial resection and polyethylene selection among Nigerian orthopedic surgeons performing TKR. A descriptive cross-sectional survey of orthopedic surgeons with TKR experience was conducted using a structured questionnaire across four domains. Data were analyzed with descriptive statistics in SPSS v26. A total of 52 male surgeons participated, with 48.1% aged 41–50 years and 38.5% aged 51–60 years. Most had <10 years of arthroplasty experience (77%) and performed <50 TKRs annually (71%). Tibial resection was commonly guided by a combination of stylus and angel wing (69.2%), while polyethylene thickness was mainly determined by intraoperative gap assessment (69.3%). Key decision factors included flexion–extension gap balance (37.9% for tibial cut; 45.2% for polyethylene thickness) and joint line preservation (26.7% and 30.8%). The majority preferred polyethylene thickness of 10–12 mm (88.5%), with overstuffing indicated by polyethylene popping out on flexion (34.6%) or difficulty with insertion (31.5%). Nigerian orthopedic surgeons predominantly rely on conventional gap-balancing techniques and mid-range polyethylene thickness during TKR. The limited adoption of advanced technologies highlights the need for region-specific guidelines, enhanced training, and access to modern instrumentation to optimize surgical decision-making and long-term outcomes.