The influence of intramedullary (IM) and extramedullary (EM) femoral cutting guides on survivorship of total knee arthroplasty was studied in 6726 total knee arthroplasty guided by either an IM (4993 knees) or EM (1733 knees) system. Fifteen-year survivorship of the 2 cohorts showed no statistically significant difference (EM 97.9% vs IM 98.5%; P = .2500, log rank). Medial bone collapse comprised the highest proportion of all failure modes for both groups (0.35% vs 0.40%, respectively, P = .6731, Cox regression). Mean tibiofemoral (overall) anatomical alignment was statistically more accurate in the IM group (IM 4.6° [± 2.2°] valgus vs EM 5.1° [± 3.1°] valgus; P < .0001). The mean tibial alignment was 90.5° (± 3.0) and 90.3° (± 2.2) (P = .0077). The EM group had a significantly larger tibial component alignment variance (SD(2)) than the IM group. No statistical difference in postoperative Knee Society scores, pain, or stair-climbing abilities was found. The choice of either alignment system should be determined by the patient's anatomy; however, the overall alignment is not as precise using the extramedullary system.
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