Fifteen randomized controlled trials with patients undergoing total knee arthroplasty were included in this systematic review and meta-analysis comparing infrapatellar fat pad (IPFP) preservation versus excision. Pooled outcomes of interest included patellar tendon length (PTL), Insall-Salvati ratio (ISR), anterior knee pain, Knee Society Scores (KSS), and knee range of motion (ROM). IPFP excision resulted in greater PTL shortening (MD = 1.498 mm, p = 0.001) and reduced ISR scores at ≥6 months (MD = 0.050, p = 0.026). Preservation was associated with significantly less anterior knee pain (MD = -0.448, p = 0.039). These findings suggest that preserving the IPFP during TKA may help maintain patellar tendon integrity and reduce anterior knee pain without compromising overall knee function.