Racial disparities in pain and total knee arthroplasty across knee osteoarthritis phenotypes.

Introduction: Knee osteoarthritis is heterogeneous in radiographic severity, pain, and multimorbidity, and racial disparities in pain and knee replacement are documented. We derived knee osteoarthritis phenotypes from electronic health record and radiograph data and assessed their associations with race and incident total knee arthroplasty. Methods: We conducted a retrospective cohort study in the Emory Knee Radiograph dataset of adults aged ≥40 years with knee osteoarthritis (n = 33,553). Among participants with pain scores within ±90 days of the index radiograph (n = 20,030), we applied k-means clustering to features including age, radiographic severity, pain measures, and comorbidity indicators to define phenotypes. Among participants without pre-index strict total knee arthroplasty, we used Cox proportional hazards models to evaluate time to incident post-index strict total knee arthroplasty, with follow-up censored at last observed contact and capped at the procedure-code ascertainment horizon. Results: Clustering identified three phenotypes: structural/metabolic disease characterized by radiographic severity and multimorbidity; younger trauma-associated mild disease; and pain-dominant disease with pain disproportionate to radiographic severity. Black individuals were overrepresented in the pain-dominant phenotype and underrepresented in the structural/metabolic phenotype, whereas White individuals showed the opposite pattern. In time-to-event models, higher radiographic severity and male sex were associated with faster time to total knee arthroplasty, whereas the younger trauma-associated and pain-dominant phenotypes were associated with lower hazard of total knee arthroplasty than the structural/metabolic phenotype. These findings were preserved in known-race-only and categorical Kellgren-Lawrence grade sensitivity analyses. Discussion: Routinely available electronic health record and radiographic data can identify clinically meaningful knee osteoarthritis phenotypes that differ by race and are independently associated with subsequent total knee arthroplasty. These findings support further validation of phenotype-aware approaches to studying disparities and guiding osteoarthritis care.