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In mechanically aligned (MA) total knee arthroplasty (TKA), the grand piano sign helps surgeons to further ensure the proper external rotation of the femoral component. The goal of this study was to determine the sex-related differences in the shape of the anterior resection surface using 3D magnetic resonance imaging (MRI) models. MRI scans were performed on 267 consecutive patients (202 women and 65 men) with osteoarthritis who underwent TKA in order to reconstruct a 3D model. Virtual anterior condylar resection was performed based on the surgical transepicondylar axis (sTEA), Whiteside's line (WSL), and flexion-extension axis (FEA). On the anterior resection surface, both lateral length (LatL) and medial length (MedL) were measured, and the ratio between the two (MedL/LatL) was calculated. The mediolateral width of the distal femur (ML) and anterior resection surface (M'L') were measured, and the ratio between the M'L' and ML (M'L'/ML) was calculated. Both the lateral deviation (LD) and the ratio between LD and ML (LD/ML) were also determined. Morphological classification of the anterior resection surface was conducted based on the presence of a definite medial peak. When based on the sTEA or WSL, the MedL/LatL of female subjects was significantly greater than that of male subjects ( p &lt; 0.001 and p &lt; 0.05, respectively). The MedL/LatL of the FEA was consistently larger than that obtained using the sTEA or WSL. Among female subjects, the MedL/LatL of the sTEA was significantly greater than that of the WSL, although this was not the case in either the total study population or the male subjects alone. When based on the sTEA, the M'L'/ML was statistically greater in the female subjects ( p &lt; 0.01). The LD was greater in the male subjects ( p &lt; 0.01), but there was no difference between the male and female subjects when comparing the LD/ML ( p = 0.93). The proportion of double- and single-peak types was not significantly different between the sexes ( p = 0.196). Surgeons should be aware that the shape of the anterior resection surface may differ depending on the sex of the patient. The results of this study provide more consistent surgical outcomes as well as fundamental anatomical data for designing suitable prostheses applicable to the Korean population.

Gender-Based Quantitative Analysis of the Grand Piano Sign in Mechanically Aligned Total Knee Arthroplasty in Asians