Alignment after total knee arthroplasty (TKA) plays an important role with respect to patient satisfaction and implant survivorship. In patients undergoing ipsilateral TKA with prior total hip arthroplasty (THA), the femoral intramedullary (IM) guide cannot be fully inserted into the femoral canal because of the prior THA. The purpose of this study was to determine the effect of femoral component alignment using a shorter IM guide during TKA in patients with an ipsilateral THA. We identified 42 patients undergoing ipsilateral TKA with the use of a short IM guide in the setting of a prior THA. A matched cohort group was identified from our total joint registry that included 42 patients who underwent primary TKA. The surgical goal was to achieve 5 degrees of valgus on the femoral side and 0 degree on the tibial side with an overall postoperative tibial-femoral angle of 5 degrees of valgus. Patients were evaluated clinically using Knee Society pain scores (KSSs), function scores, and with radiography. Both the tibial-femoral limb alignment and the femoral component alignment were compared using Student's t -test. There were no significant differences between the two groups with respect to sex, age, body mass index (BMI), pre- and postoperative KSSs. There was a statistically significant difference between the two groups with respect to radiographic tibial-femoral limb alignment, 4.33 degrees of valgus in the short stem THA-TKA group versus 5.4 degrees of valgus in the TKA group (p < 0.04); however, this difference did not correlate to a difference in postoperative outcomes. An adequate tibial-femoral component alignment was achieved in patients undergoing ipsilateral TKA with prior THA using a shortened IM femoral guide.