Objective：In total knee arthroplasty (TKA), there is no consensus on whether external femoral arthroplasty is better than traditional intramedullary arthroplasty. The objective of this study was to compare the results of the two localization osteotomy techniques in terms of alignment of the lower limb, prosthesis Angle, postoperative blood loss, and operative time. Methods：China National Knowledge Network, Wanfang, Weipu, Chinese Biomedical Literature Database, PubMed, Embase, Cochrane Library and Web of Science were searched to collect all the comparative studies on the application of femoral extramedullary and intramedullary osteotomy in TKA. A meta-analysis was performed using Stata 15.0 software. Results：A total of 8 randomized controlled trials involving 804 patients were included. Results of the meta-analysis showed that: The postoperative blood loss in extramedullary group was less than that in intramedullary group [MD= -161.24, 95%CI (-233.93, -88.55), P < 0.001]. There was no significant difference in operation time between the two groups [MD= -0.74, 95%CI (-4.04, 2.57), P=0.665]. There was no significant difference in the coronal alignment of the lower limbs between extramedullary group and intramedullary group [RR=1.20, 95%CI (0.28, 5.21), P=0.809]. The coronal Angle of the extramedullary group was better than that of the intramedullary group [RR=0.184, 95%CI (0.07, 0.45), P < 0.001]. There was no significant difference in sagittal femoral component Angle [RR=0.66, 95%CI (0.17, 2.53), P=0.541]. Conclusion：In TKA, extramedullary femoral positioning is more accurate than intramedullary femoral positioning in the coronal Angle of the femoral component, with less postoperative blood loss. There was agreement between the two in terms of coronal alignment of the lower limbs, sagittal Angle of the femoral component, and operative time.