Objective:To analyze the factors influencing the occurrence of anterior knee pain after total knee arthroplasty?without patellar resurfacing.Methods:A retrospective analysis was conducted on 2,200 patients who underwent TKA without patellar resurfacing at the First Affiliated Hospital of Nanjing Medical University, between September 2020 and May 2025. According to the inclusion and exclusion criteria, 2,027 patients (766 males and 1,261 females) were finally included, with a mean age of 68.05±5.64 years (range, 47-86 years), and a mean body mass index (BMI) of 26.52±3.59 kg/m2 (range, 15.09~40.01 kg/m2). Based on the presence of postoperative anterior knee pain, patients were divided into?a non-AKP group (1,886 cases) and an AKP group (141 cases).Preoperative and postoperative radiographic parameters were measured and compared between the groups, including patellar tilt angle, patellar shift, patellar morphology (Wiberg classification), patellar thickness, patellar height, hip-knee-ankle (HKA) angle, and patellofemoral overstuffing. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for anterior knee pain.Results:All patients were followed up for more than 6 months. There were no statistically significant differences in gender, age, or BMI between the two groups (P > 0.05).There were statistically significant differences between the two groups in the preoperative patellar tilt angle, preoperative patellar shift, preoperative patellar morphology, postoperative patellar tilt angle, postoperative patellar shift, postoperative patellar morphology, and patellofemoral overstuffing (P < 0.05). The preoperative patellar thickness, ?preoperative patellar height, preoperative HKA angle, postoperative patellar thickness,?postoperative patellar height, and postoperative HKA angle showed no significant differences between the two groups (P > 0.05).Multivariate analysis identified?postoperative patellar tilt angle, postoperative patellar shift, patellofemoral overstuffing, and patellar height?as independent risk factors?(P < 0.05).?Mediation analysis demonstrated that?patellar morphology had no direct effect on anterior knee pain, and its influence?was completely mediated by?patellar tilt angle and patellar shift.Conclusion:Increased postoperative patellar tilt angle, increased postoperative patellar shift, postoperative patella baja, and patellofemoral overstuffing are independent risk factors for anterior knee pain after TKA without patellar resurfacing. Mediation analysis further revealed that the effect of patellar morphology on anterior knee pain was entirely mediated by patellar tilt angle and patellar shift.