The　size　and　axial　alignment　of　prostheses,　when　planned　during　total　knee　replacement　(TKA)　are　critical　for　recovery　of　knee　function　and　improvement　of　knee　pain　symptoms.　This　research　aims　to　study　the　effect　of　artificial　intelligence　(AI)-based　preoperative　three　dimensional　(3D)　planning　technology　on　prosthesis　size　and　axial　alignment　planning　in　TKA,　and　to　compare　its　advantages　with　two　dimensional　(2D)　X-ray　template　measurement　technology.　A　total　of　60　patients　with　knee　osteoarthritis　(KOA)　who　underwent　TKA　for　the　first　time　were　included　in　the　AI　(n　=　30)　and　2D　(n　=　30)　groups.　The　preoperative　and　postoperative　prosthesis　size,　femoral　valgus　correction　angle　(VCA)　and　hip-knee-ankle　angle　(HKA)　were　recorded　and　compared　between　the　two　groups.　The　results　of　the　University　of　Western　Ontario　and　McMaster　University　Osteoarthritis　Index　(WOMAC)　and　the　American　Knee　Association　Score　(AKS)　were　evaluated　before　surgery,　3　months,　6　months,　and　12　months　after　surgery.　The　accuracy　of　prosthesis　size,　VCA　and　HKA　prediction　in　AI　group　was　significantly　higher　than　that　in　2D　group　(P　＜　0.05).　The　WOMAC　and　AKS　scores　in　AI　group　at　3　months,　6　months　and　12　months　after　surgery　were　better　than　those　in　2D　group　(P　＜　0.05).　Both　groups　showed　significant　improvement　in　WOMAC　and　AKS　scores　at　12　months　follow-up.　AI-based　preoperative　3D　planning　technique　has　more　reliable　planning　effect　for　prosthesis　size　and　axial　alignment　in　TKA.