[Objective] To explore the factors related to anterior femoral cortical notching in total knee arthroplasty (TKA) with anterior referencing (AR) system. [Methods] A retrospective study was conducted on 86 consecutive patients (105 knees) who underwent TKA with AR for primary knee osteoarthritis in our hospital from October 2015 to December 2020. The patients were divided into notching group (the NT) and non-notching group (the NNT) according to whether anterior femoral cortical notching was seen on postoperative lateral X-ray of the knee. Univariate comparison and multivariate logistic regression analysis were performed to analyze the factors related to the anterior femoral cortical notching. [Results] Among 105 knees, 28 knees had anterior femoral cortical notching, accounting for 26.7%, while the re- maining 77 knee had non-notching of the femoral anterior cortex, accounting for 73.3%. Of the NT group, 13 knees (12.4%) were of grade I, 10 knees (9.5%) of grade II, 5 knees (4.8%) of grade III, and no grade IV according to Tayside classification. In term of univariate compari- son, there were no significant differences in age, BMI, gender, side, anterior condylar thickness, lateral distal femoral angle (LDFA) , mechan- ical axis deviation (MAD) , anterior cortical flexion angle, intercondylar fossa shape, anterior condylar osteophyte, opening point position, dis- tal femoral osteotomy, posterior condylar osteotomy, and condylar line identification between the two groups (P＞0.05) . However, the NT group had significantly greater posterior condylar thickness measured on the preoperative radiographs (P＜0.05) , in addition, the significant- ly higher ratio of smaller femoral component used intraoperatively than NNT group (P＜0.05) . In term of multivariate logistic regression analy- sis, the larger posterior condyle thickness measured on preoperative image (OR=1.124; P＜0.05) was a risk factor for anterior femoral cortical notching, whereas the larger femoral component selected during operation (OR=0.375; P＜0.05) was a protective factor for anterior femoral cortical notching. [Conclusion] In anterior referencing TKA, larger preoperative posterior condyle thickness is a risk factor for anterior corti- cal notching, while larger femoral prosthesis used intraoperatively is a protective factor for anterior cortical notching.