This systematic review and meta-analysis incorporated five studies encompassing a total of 584 patients undergoing total knee arthroplasty (TKA) to compare the clinical and radiographic outcomes of anterior referencing (AR) systems versus posterior referencing (PR) systems. Pooled outcomes of interest included the Knee Society Score (KSS), the Western Ontario and McMaster University (WOMAC) index, knee range of motion (ROM), posterior condylar offset (PCO), and the posterior condylar offset ratio (PCOR). The analysis revealed that AR systems may lead to improved knee ROM postoperatively, while PR systems could result in larger PCO and PCOR on postoperative imaging. However, no significant differences were observed in clinical outcomes between the AR and PR groups at the final follow-up.