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Class III obesity (body mass index [BMI] ≥40 kg/mWe used the Osteoarthritis Policy model to assess long-term clinical benefits, costs, and cost-effectiveness of RYGB and LSG. We derived model inputs for efficacy, costs, and complications associated with these treatments from published data. Primary outcomes included quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs), all discounted at 3%/year. This analysis was conducted from a health care sector perspective. We performed sensitivity analyses to evaluate uncertainty in input parameters.The usual care + RYGB strategy increased the quality-adjusted life expectancy by 1.35 years and lifetime costs by $7,209, compared to usual care alone (ICER = $5,300/QALY). The usual care + LSG strategy yielded less benefit than usual care + RYGB and was dominated. Relative to usual care alone, both usual care + RYGB and usual care + LSG reduced opioid use from 13% to 4%, and increased TKR usage from 30% to 50% and 41%, respectively. For cohorts with BMI between 38 and 41 kg/mRYGB offers good value among knee OA patients with BMI ≥40 kg/m

Middle-aged subjects with meniscal tear treated with arthroscopic partial meniscectomy (APM) experience greater progression of damage to joint structures on imaging than subjects treated nonoperatively. It is unclear whether these changes are clinically relevant. The goal of this study was to assess whether worsening in magnetic resonance imaging (MRI)-assessed tissue damage over 18 months leads to subsequent worsening in knee pain over the subsequent 3.5 years.We used data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of APM versus physical therapy for subjects ages ≥45 years with knee pain, cartilage damage, and meniscal tear. We assessed whether change in cartilage surface area damage score (and other structural measures) from baseline to 18 months, assessed on MRI with the MRI Osteoarthritis Knee Score (MOAKS) system, was associated with change in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score (range 0-100; 100 = worst) from 18 to 60 months.The primary analysis included 168 subjects with complete MRI data at baseline and 18 months and KOOS data at 18 and 60 months. We did not observe clinically important associations between change in cartilage surface area score between baseline and 18 months and change in pain scores from 18 to 60 months. Pain scores in the worst tertile for cartilage surface area damage score progression worsened by 0.45 points more than in the best tertile (95% confidence interval -4.45, 5.35). Similarly, we did not observe clinically important associations between changes in bone marrow lesions, osteophytes, or synovitis and subsequent pain.We did not observe clinically important associations between early changes in cartilage damage and other structural measures and worsening in pain over the subsequent 3.5 years. Further follow-up is required to assess this association over a longer follow-up period.

Background: Surgeons are sometimes presented with patients with distal radius fractures who present in a delayed fashion or lose reduction after several weeks of attempted closed management. There are limited studies on delayed surgical treatment of distal radius fractures to assist providers in decision-making. Methods: We conducted a matched cohort study to compare radiographic outcomes and complications for patients with a distal radius fracture treated with delayed (3-5 weeks) or early (0-2 weeks) surgical fixation. Patients ages 18+ who underwent open reduction and internal fixation of distal radius fractures by a volar approach at 2 Level I trauma centers between 2003 and 2015 were eligible. We measured radiographic outcomes and reviewed medical records to determine operative approach and complications. Results: There were 25 cases and 50 controls matched for age (18-87), sex, and AO fracture type. The delayed group had surgery at a mean of 24.8 days from injury and the early group at 5.6 days. There was no statistically significant difference between the delayed and early cohorts in radiographic parameters on injury x-rays, in improvement in radiographic parameters on first postoperative x-rays, or in maintenance of radiographic parameters at union. Conclusion: We did not find significant differences in radiographic outcomes or complication rates between patients with delayed versus early surgical treatment for distal radius fracture. Providers treating patients with late presentation or late displacement have the option of surgical fixation beyond the first few weeks after injury. Level of Evidence: III (Retrospective matched cohort study)

To estimate the risk of magnetic resonance imaging (MRI)-based structural changes in knee osteoarthritis (OA) among individuals with meniscal tear and knee OA, using MRIs obtained at baseline and 18 and 60 months after randomization in a randomized controlled trial of arthroscopic partial meniscectomy (APM) versus physical therapy (PT).We used data from the Meniscal Tear in Osteoarthritis Research (METEOR) trial. MRIs were read using the MRI OA Knee Score (MOAKS). We used linear mixed-effects models to examine the association between treatment group and continuous MOAKS summary scores, and Poisson regression to assess categorical changes in knee joint structure. Analyses assessed changes in OA between baseline and month 18 and between months 18 and 60. We performed both intention-to-treat and as-treated analyses.The analytic sample included 302 participants. For both treatment groups, more OA changes were seen during the early interval than during the later interval. ITT analysis revealed that, between baseline and month 18, APM was significantly associated with an increased risk of having a worsening cartilage surface area score, involving both any worsening across all knee joint subregions (risk ratio [RR] 1.35 [95% confidence interval (95% CI) 1.14, 1.61]) and the number of subregions damaged (RR 1.44 [95% CI 1.13, 1.85]) having a worsening effusion-synovitis score (RR 2.62 [95% CI 1.32, 5.21]), and having ≥1 additional subregion with osteophytes (RR 1.24 [95% CI 1.02, 1.50]). Significant associations were detected between months 18 and 60 only for having any subregion with a worsening osteophyte score (RR 1.28 [95% CI 1.04, 1.58]).These findings suggest that the association between APM and MRI-based structural changes in knee OA is most apparent during the initial 18 months after surgery. The reason for attenuation of this association over longer follow-up merits further investigation.

To determine the optimal combination of imaging and biochemical biomarkers for use in the prediction of knee osteoarthritis (OA) progression.The present study was a nested case-control trial from the Foundation of the National Institutes of Health OA Biomarkers Consortium that assessed study participants with a Kellgren/Lawrence grade of 1-3 who had complete biomarker data available (n = 539 to 550). Cases were participants' knees that had radiographic and pain progression between 24 and 48 months compared to baseline. Radiographic progression only was assessed in secondary analyses. Biomarkers (baseline and 24-month changes) that had a P value of0.10 in univariate analysis were selected, including quantitative cartilage thickness and volume on magnetic resonance imaging (MRI), semiquantitative MRI markers, bone shape and area, quantitative meniscal volume, radiographic progression (trabecular bone texture [TBT]), and serum and/or urine biochemical markers. Multivariable logistic regression models were built using 3 different stepwise selection methods (complex models versus parsimonious models).Among baseline biomarkers, the number of locations affected by osteophytes (semiquantitative), quantitative central medial femoral and central lateral femoral cartilage thickness, patellar bone shape, and semiquantitative Hoffa-synovitis predicted OA progression in most models (C statistic 0.641-0.671). In most models, 24-month changes in semiquantitative MRI markers (effusion-synovitis, meniscal morphologic changes, and cartilage damage), quantitative central medial femoral cartilage thickness, quantitative medial tibial cartilage volume, quantitative lateral patellofemoral bone area, horizontal TBT (intercept term), and urine N-telopeptide of type I collagen predicted OA progression (C statistic 0.680-0.724). A different combination of imaging and biochemical biomarkers (baseline and 24-month change) predicted radiographic progression only, which had a higher C statistic of 0.716-0.832.The present study highlights the combination of biomarkers with potential prognostic utility in OA disease-modifying trials. Properly qualified, these biomarkers could be used to enrich future trials with participants likely to experience progression of knee OA.

Hypothesis: The purpose of this study was to identify potential differences using validated clinical outcome instruments between patients with and without diabetes mellitus (DM) after arthroscopic rotator cuff repair (RCR). Methods: Six-hundred eighty-four patients (32 with and 652 without DM) who underwent arthroscopic RCR were prospectively followed using the visual analog pain scale, Simple Shoulder Test, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons score, and Veterans RAND 12-item Health Survey (mental and physical component scores) preoperatively and at 3, 6, 12, and 24 months postoperatively. Results: Patients with DM experienced significantly more pain (P = .0172) and had lower Simple Shoulder Test (P = .0458) and American Shoulder and Elbow Surgeons (P = .0200) scores than patients without DM 6 months after surgery. Although differences between groups are seen at other postoperative time points, none are statistically significant.They also exhibited lower self-rated mental health status at 12 months (P = .0034) and 24 months (P = .0077), as well as lower self-rated physical health status at 12 months (P = .0223) and 24 months (P = .0077). Changes in scores from preoperatively to postoperatively were not different for patients with DM vs. without DM. Conclusion: Patients with DM experience significantly more pain, exhibit significantly poorer shoulder function, and report persistently diminished mental and physical health status compared with their counterparts without DM after undergoing arthroscopic RCR. Although these differences did not reach the minimal clinically important difference, orthopedic surgeons should be cognizant of DM as an outcome-modifying variable when selecting, counseling, and treating patients with rotator cuff tears. Glycemic control should be scrutinized and optimized during the perioperative medical evaluation and ultimately factored into the surgical risk profile and prognosis.

Class III obesity (BMI40kg/mUsing the Osteoarthritis Policy Model (OAPol) and data from published literature to derive model inputs for RYGB, LSG, LNSWL, and TKR, we assessed the long-term clinical benefits, costs, and cost-effectiveness of weight loss interventions for patients with Class III obesity considering TKR. We assessed the following strategies with a healthcare sector perspective: 1)no weight loss/no TKR, 2)immediate TKR, 3)LNSWL, 4)LSG, and 5)RYGB. Each weight loss strategy was followed by annual TKR reevaluation. Primary outcomes were cost, quality-adjusted life-expectancy (QALE), and incremental cost-effectiveness ratios (ICERs), discounted 3%/year. We conducted deterministic and probabilistic sensitivity analyses to examine the robustness of conclusions to input uncertainty.LSG increased QALE by 1.64 quality-adjusted life-years (QALYs) and lifetime medical costs by $17,347 compared to no intervention, leading to an ICER of $10,600/QALY. RYGB increased QALE by 0.22 and costs by $4,607 beyond LSG, resulting in an ICER of $20,500/QALY. Relative to immediate TKR, LSG and RYGB delayed and decreased TKR utilization. In the probabilistic sensitivity analysis, RYGB was cost-effective in 67% of iterations at a willingness-to-pay (WTP) threshold of $50,000/QALY.For patients with Class III obesity considering TKR, RYGB provides good value while immediate TKR without weight loss is not economically efficient.

Currently, no disease-modifying therapies are approved for osteoarthritis (OA) use. One obstacle to trial success in this field has been our existing endpoints’ limited validity and responsiveness. To overcome this impasse, the Foundation for the NIH OA Biomarkers Consortium is focused on investigating biomarkers for a prognostic context of use for subsequent qualification through regulatory agencies. This narrative review describes this activity and the work underway, focusing on the PROGRESS OA study.

Objective To examine impact of pre-existing and incident problematic musculoskeletal (MSK) areas after total knee replacement (TKR) on postoperative 60-month Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain/function scores. Methods Using data from a randomized controlled trial of subjects undergoing TKR for osteoarthritis, we assessed problematic MSK areas in six body regions before TKR and 12, 24, 36, and 48 months after TKR. We defined the following two variables: 1) density count (number of problematic MSK areas occurring after TKR; range 0-24) and 2) cumulative density count (problematic MSK areas both before and after TKR, categorized into four levels: no preoperative areas and density count of 0-1 [reference group]; no preoperative areas and density count of 2 or more; one or more preoperative areas and density count of 0-1; and one or more preoperative areas and density count of 2 or greater). We evaluated the associations between categorized 60-month WOMAC and cumulative density count by ordinal logistic regression. Results Among 230 subjects, 24% reported one or more preoperative problematic MSK area. After TKR, 75% reported a density count of 0 to 1; 25% reported a density count of 2 or more. Compared with the reference group, each cumulative density count category was associated with an increased odds of having a higher category of 60-month WOMAC pain score, as follows: 2.97 (95% confidence interval [CI], 1.48-5.98) for no preoperative problematic areas and density count of 2 or greater, 3.31 (95% CI, 1.64-6.66) for one or more preoperative problematic areas and density count of 0 to 1, and 2.85 (95% CI, 0.97-8.39) for one or more preoperative problematic areas and density count of 2 or greater. Similar associations were observed with 60-month WOMAC function score. Conclusion In TKR recipients, the presence of problematic musculoskeletal areas beyond the index knee-preoperatively and/or postoperatively-was associated with worse 60-month WOMAC pain/function score.

Background Postoperative behavior and allodynia evaluation in rodents are commonly used to confirm preclinical disease models. In contrast, we are investigating pain and functional recovery after traumatic fracture and surgical repair. We created a tibial fracture in the rat and repaired the fracture internally with plating. We hypothesized that histological bone healing would be strongly correlated with functional recovery. Methods Sixteen male Sprague-Dawley rats underwent a metaphyseal transverse osteotomy of the proximal tibia. The defect was repaired by abutting the bone surfaces and fixing them in place using a 5-hole Y-plate with 4 screws. Fracture healing was investigated quantitatively and qualitatively at 2, 4, 6, and 8 weeks using micro-CT imaging, X-ray, and histology. Functional recovery was assessed using video recording and analysis of gait, static weight bearing, hind paw reflex response, and toe spread. Results The micro-CT and histological results demonstrated complete fracture healing at 8 weeks. Specific gait analysis parameters: temporal symmetry, hindlimb duty factor imbalance, phase dispersion, and toe spread showed longitudinal changes commensurate with fracture healing. Conclusions We aim to use this model to evaluate the efficacy of locally administered non-opioid analgesics with long-term effects on healing and function. Our long-term goal is to assess the local efficacy of drug delivery devices in improving post-surgical pain and function. The correlation in this tibia fracture model between bone healing and functional outcomes suggests that post-operative recovery can be monitored, and treatments can be compared using these endpoint measurements.

Inflammation is a potential pain generator and treatment target in knee osteoarthritis (OA). Inflammation can be detected on MRI and by synovial fluid white blood cell count (SF WBC). However, the performance characteristics of SF WBC for the detection of synovitis have not been established.We identified records of patients seen at an academic center with a diagnosis code for knee OA, a procedural code for knee aspiration and laboratory order for SF WBC in the same encounter, as well as an MRI within 12 months of the aspiration. MRIs were read for effusion synovitis (E-S) using the MRI OA Knee Score (MOAKS). We dichotomized E-S as: 1) none or small, or 2) medium or large. We calculated the sensitivity and specificity of SF WBC, using MRI E-S (medium/large) as the gold standard. We used Youden's Index to identify the best cut-point.We included 75 patients. Mean age was 63 y.o. (SD 12) and 69% were female. The SF WBC was higher in the medium/large E-S group (median = 335, IQR =312) than in the none/small group (median = 194, IQR =272). The optimal cut-point was 242, yielding a sensitivity of 71% (95% CI 56-83%) and specificity of 63% (95 % CI 41-81%).The sensitivity and specificity of SF WBC in identifying E-S on MRI were limited. Further research is needed to better understand the association between MRI and SF measured E-S and to determine which measure more strongly relates to synovial histopathology and patient outcomes.

BACKGROUND The diagnosis of bone mineral density (BMD) abnormalities involves dual-energy x-ray absorptiometry (DXA), but few patients complete this after a fragility fracture. The assessment of BMD using Hounsfield unit (HU) measurements from computed tomography (CT) scans has been correlated with DXA results in previous studies. We aimed to evaluate the correlation between shoulder CT HU and DXA scores. METHODS Billing databases of 3 academic institutions were queried for patients who underwent both DXA and CT scan of the upper extremity within 1 year of each other. DXA T-scores for spine, hip, and femoral neck were recorded. BMD status was defined based on composite T-scores, using the lowest T-score in the spine, hip, or proximal femur. CT scans were measured for HU over 4 slices, recorded to create a bone column, then averaged. The patients' risks of major osteoporosis-related fracture and hip fracture were calculated using the Fracture Risk Assessment Tool. RESULTS In total, 300 patients were included. A positive correlation was found between composite T-scores and HU for glenoid and proximal humerus (0.36; 0.17). The proximal humerus HU was significantly associated with the BMD T-score for the hip (P = 0.01); the glenoid HU was significantly associated with BMD T-scores for the hip, spine, and femoral neck (P = 0.002; P = 0.001; P = 0.002). A 10-year risk of hip fracture >3% was associated with lower proximal humerus HU. CONCLUSIONS Our study is the first to discover significant correlations between HU at the glenoid and proximal humerus and risk factors as established by the Fracture Risk Assessment Tool scoring system. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Total knee replacement (TKR) is an effective and cost-effective strategy for treating end-stage knee osteoarthritis. Greater risk for complications among TKR recipients with a body mass index (BMI) of 40 kg/m2 or greater has raised concerns about the value of TKR in this population. Objective To assess the value of TKR in recipients with a BMI of 40 kg/m2 or greater using a cost-effectiveness analysis. Design Osteoarthritis Policy Model to assess long-term clinical benefits, costs, and cost-effectiveness of TKR in patients with a BMI of 40 kg/m2 or greater. Data sources Total knee replacement parameters from longitudinal studies and published literature, and costs from Medicare Physician Fee Schedules, the Healthcare Cost and Utilization Project, and published data. Target population Recipients of TKR with a BMI of 40 kg/m2 or greater in the United States. Time horizon Lifetime. Perspective Health care sector. Intervention Total knee replacement. Outcome measures Cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs), discounted at 3% annually. Results of base-case analysis Total knee replacement increased QALYs by 0.71 year and lifetime medical costs by $25 200 among patients aged 50 to 65 years with a BMI of 40 kg/m2 or greater, resulting in an ICER of $35 200. Total knee replacement in patients older than 65 years with a BMI of 40 kg/m2 or greater increased QALYs by 0.39 year and costs by $21 100, resulting in an ICER of $54 100. Results of sensitivity analysis In TKR recipients with a BMI of 40 kg/m2 or greater and diabetes and cardiovascular disease, ICERs were below $75 000 per QALY. Results were most sensitive to complication rates and preoperative pain levels. In the probabilistic sensitivity analysis, at a $55 000-per-QALY willingness-to-pay threshold, TKR had a 100% and 90% likelihood of being a cost-effective strategy for patients aged 50 to 65 years and patients older than 65 years, respectively. Limitation Data are derived from several sources. Conclusion From a cost-effectiveness perspective, TKR offers good value in patients with a BMI of 40 kg/m2 or greater, including those with multiple comorbidities. Primary funding source National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health.

Background and Hypothesis Smoking is a well-established risk factor for tendon healing. The purpose of this study was to evaluate the differences in patient-reported outcome measures between smokers and nonsmokers who have undergone arthroscopic rotator cuff repair. It was hypothesized that smokers would have worse self-reported outcomes at 1 and 2 years postoperatively. Methods A total of 560 consecutive patients who underwent arthroscopic rotator cuff repair were divided into 2 groups: group I (smokers) n = 25 and group II (nonsmokers) n = 535. All participants were administered preoperative and postoperative surveys consisting of the following outcome-measuring tools: (i) visual analog scale, (ii) Veterans Rand 12-Item Health Survey, (iii) American Shoulder and Elbow Surgeons shoulder score, (iv) standard preoperative form consisting of 4 questions regarding their expectations of recovery, (v) Single Assessment Numeric Evaluation shoulder score, and (vi) Simple Shoulder Test. Results At 1 and 2 years postoperative, nonsmokers reported statistically significant differences in Veterans Rand 12-Item Health Survey mental scores (56.2 vs. 51.9, P = .0162 and 56.3 vs. 49.5, P = .0004, respectively). American Shoulder and Elbow Surgeons Shoulder scores showed no differences until the 2-year mark, at which time nonsmokers reported higher scores than smokers (87.9 vs. 79.0, P = .0212). Single Assessment Numeric Evaluation scores also remained similar up until 2-year follow-up, at which time nonsmokers reported statistically significant improvement (80.0 vs. 68.5, P = .0339). Nonsmokers reported higher Simple Shoulder Test scores at baseline and at 2-year follow-up (43.3 vs. 37.0, P = .0417 and 83.7 vs. 68.1, P = .0046, respectively). Conclusion At 2 years postoperatively, nonsmokers had significantly higher patient-reported outcome measure scores than smokers. In elective surgery, smoking status should be considered as a risk factor for poorer patient-reported outcomes after arthroscopic rotator cuff repair. However, smokers continue to report a clinical benefit at 2 years postoperatively.

PURPOSE This study aimed to assess associations between exertional heat stroke (EHS) and sex, age, prior performance, and environmental conditions, and report on resources needed for EHS cases at the Boston Marathon. METHODS We analyzed participant characteristics, environmental data, and EHS medical encounters during the 2015-2019 Boston Marathon races. RESULTS Among 136,161 starters, there was an incidence of 3.7 EHS cases per 10,000 starters (95% confidence interval, 2.8-4.9), representing 0.5% of all medical encounters. There were significant associations between sex and age (P < 0.0001), sex and start wave (P < 0.0001), and age group and start wave (P < 0.0001). Sex was not significantly associated with increased EHS incidence; however, age younger than 30 yr and assignment to the first two start waves were. All cases occurred at races with average wet bulb globe temperatures of 17°C-20°C. There was a linear correlation between EHS incidence and greater increases in wet bulb globe temperature from start to peak (R2 = 0.7688). A majority of cases (37; 72.5%) were race finishers; nonfinishers all presented after mile 18. Most were triaged 3-4 h after starting, and all were treated with ice water immersion. Treatment times were prolonged (mean (SD), 78.1 (47.5) min; range, 15-190 min); 29.4% (15 cases) developed posttreatment hypothermia, and 35.3% (18 cases) were given intravenous fluids. Most (31 cases; 64.6%) were discharged directly, although 16 cases (33.3%) required hospital transport. There were no fatalities. CONCLUSIONS Younger and faster runners are at higher risk for EHS at the Boston Marathon. Greater increases in heat stress from start to peak during a marathon may exacerbate risk. EHS encounters comprise a small percentage of race-day medical encounters but require extensive resources and warrant risk mitigation efforts.

A joint contains many different tissues that can exhibit pathological changes, providing many potential targets for treatment. Researchers are increasingly suggesting that osteoarthritis (OA) comprises several phenotypes or subpopulations. Consequently, a treatment for OA that targets only one pathophysiologic abnormality is unlikely to be similarly efficacious in preventing or delaying the progression of all the different phenotypes of structural OA. Five structural phenotypes have been proposed, namely the inflammatory, meniscus-cartilage, subchondral bone, and atrophic and hypertrophic phenotypes. The inflammatory phenotype is characterized by marked synovitis and/or joint effusion, while the meniscus-cartilage phenotype exhibits severe meniscal and cartilage damage. Large bone marrow lesions characterize the subchondral bone phenotype. The hypertrophic and atrophic OA phenotype are defined based on the presence large osteophytes or absence of any osteophytes, respectively, in the presence of concomitant cartilage damage. Limitations of the concept of structural phenotyping are that they are not mutually exclusive and that more than one phenotype may be present. It must be acknowledged that a wide range of views exist on how best to operationalize the concept of structural OA phenotypes and that the concept of structural phenotypic characterization is still in its infancy. Structural phenotypic stratification, however, may result in more targeted trial populations with successful outcomes and practitioners need to be aware of the heterogeneity of the disease to personalize their treatment recommendations for an individual patient. Radiologists should be able to define a joint at risk for progression based on the predominant phenotype present at different disease stages.

Background Effective pain control balanced with maintaining physical function and minimizing medication side effects is essential to accelerated recovery after total knee arthroplasty (TKA). Multimodal pain management regimens combining oral medications as well as local analgesia have shown promise in facilitating these goals. Some regimens use anesthetics delivered via a local infiltration catheter while others use periarticular injections (PAIs). However, it is uncertain if an infiltration catheter provides additional pain relief or decreases opioid consumption when compared with conventional PAI alone. Methods Fifty patients undergoing TKA at one institution were randomized equally into 2 groups for a prospective trial. Group I received an intraarticular catheter (On-Q∗) in combination with injection of 30 ml of 0.5% bupivacaine the day after surgery before removal. Group II received no pain catheter. Both groups received a conventional intraoperative PAI and postoperative oral pain medication. Pain scores were measured with visual analog scale and opioid medication consumption in morphine milligram equivalents (mgs). Results There were no differences in pain scores or opioid consumption in the first 48-hours postoperatively (P = .05). Reported maximum pain scores were low in both groups; 3.33 in group I and 2.97 in group II. Although not statistically significant in this cohort, there was increased opioid consumption in the catheter group: 14.78 mg vs 12.76 mg. Conclusion An intraarticular pain catheter in conjunction with a multimodal approach with intraoperative PAI after TKA does not improve 48-hour pain scores or opioid consumption compared with PAI alone in this randomized controlled trial. Overall pain scores were very low.

Summary Objective To investigate whether baseline cartilage thickness and its longitudinal change are associated with incident widespread full-thickness cartilage loss (wsFTCL) in knee osteoarthritis, and whether there are optimal cut-off values for predicting wsFTCL. Methods Central medial tibial (cMT) and femoral (cMF) cartilage were assessed using quantitative magnetic resonance imaging data from the Osteoarthritis Initiative cohort (N = 600 knees). Cartilage thickness was measured at baseline and 12 months. wsFTCL was defined semi-quantitatively (scores 2 and 3 from the MRI Osteoarthritis Knee Score) and its incidence at 24 months recorded. Logistic regression was used to determine the odds of developing wsFTCL for baseline and for each 0.1 mm decrease in cartilage thickness. Cut-off values were investigated using the minimal-p method and area under the Receiver Operating Characteristic curves (AUC). Results Incident wsFTCL was observed in 66 (12%) and 73 (14%) knees in cMT and cMF, respectively. Lower baseline cMT and cMF cartilage thickness values were associated with wsFTCL (OR = 1.20; 95% CI: 1.11, 1.28 and OR = 1.15; 95% CI: 1.06 to 1.24, respectively). Optimal cut-off AUCs for the tibia and femur were 0.64 (0.57–0.70) and 0.63 (0.57–0.69), respectively. Longitudinal decrease in femoral, but not tibial, cartilage thickness was associated with incident wsFTCL (OR = 1.77; 95% CI: 1.30 to 2.40); optimal cut-off AUC 0.65 (95% CI: 0.58–0.72). Conclusion Lower baseline cMT and baseline/change (decrease) over 12 months in cMF cartilage thickness were associated with incident, location-specific, wsFTCL at 24 months. Optimal cut-off values were relatively low and of uncertain utility for predicting incident wsFTCL.

Objective The present study was undertaken to evaluate changes in knee magnetic resonance imaging (MRI) findings over the course of 18 months in subjects with osteoarthritic change and meniscal tear treated with arthroscopic partial meniscectomy (APM) or nonoperatively with physical therapy (PT). Methods We used 18-month follow-up data from the Meniscal Tear in Osteoarthritis Research Trial. MRI results were read with reference to the MRI Osteoarthritis Knee Score. We focused on 18-month change in bone marrow lesions (BMLs), cartilage thickness, cartilage surface area, osteophyte size, effusion-synovitis, and Hoffa-synovitis. We used multinomial logistic regression to assess associations between MRI-based changes in each feature and treatment type. Results A total of 351 subjects were randomized, and 225 had both baseline and 18-month MRI results. In both treatment groups, patients experienced substantial changes in several MRI-based markers. In 60% of the APM group, versus 33% of the PT group, cartilage surface area damage advanced in ≥2 subregions (adjusted odds ratio 4.2 [95% confidence interval 2.0-9.0). Patients who underwent APM also had greater advancement in scores for osteophytes and effusion-synovitis. We did not find significant associations between treatment type and change in cartilage thickness, BMLs, or Hoffa-synovitis. Conclusion This cohort of patients with meniscal tear and osteoarthritis showed marked advancement in MRI-based features over 18 months. Patients treated with APM showed more advancement in some features compared to those treated nonoperatively. The clinical relevance of these early findings is unknown and requires further study.

We examined the cost-effectiveness of treatment strategies for concomitant meniscal tear and knee osteoarthritis (OA) involving arthroscopic partial meniscectomy surgery and physical therapy (PT).We used the Osteoarthritis Policy Model, a validated Monte Carlo microsimulation, to compare three strategies, 1) PT-only, 2) immediate surgery, and 3) PT + optional surgery, for participants whose pain persists following initial PT. We modeled a cohort with baseline meniscal tear, OA, and demographics from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of arthroscopic partial meniscectomy versus PT. We estimated risks and costs of arthroscopic partial meniscectomy complications and accounted for heightened OA progression post surgery using published data. We estimated surgery use rates and treatment efficacies using MeTeOR data. We considered a 5-year time horizon, discounted costs, and quality-adjusted life-years (QALYs) 3% per year and conducted sensitivity analyses. We report incremental cost-effectiveness ratios.Relative to PT-only, PT + optional surgery added 0.0651 QALY and $2,010 over 5 years (incremental cost-effectiveness ratio = $30,900 per QALY). Relative to PT + optional surgery, immediate surgery added 0.0065 QALY and $3080 (incremental cost-effectiveness ratio = $473,800 per QALY). Incremental cost-effectiveness ratios were sensitive to optional surgery efficacy in the PT + optional surgery strategy. In the probabilistic sensitivity analysis, PT + optional surgery was cost-effective in 51% of simulations at willingness-to-pay thresholds of both $50,000 per QALY and $100,000 per QALY.First-line arthroscopic partial meniscectomy has a prohibitively high incremental cost-effectiveness ratio. Under base case assumptions, second-line arthroscopic partial meniscectomy offered to participants with persistent pain following initial PT is cost-effective at willingness-to-pay thresholds between $31,000 and $473,000 per QALY. Our analyses suggest that arthroscopic partial meniscectomy can be a high-value treatment option for patients with meniscal tear and OA when performed following an initial PT course and should remain a covered treatment option.

Background: Most patients experience sleep disturbances before rotator cuff repair, with these symptoms largely improving postoperatively. However, the relationship between the resolution or persistence of sleep disturbance and patient-reported outcomes after rotator cuff repair remains unknown. Purpose: To compare outcomes after rotator cuff repair between patients who reported a preoperative sleep disturbance and those who did not. Outcomes at various time points after surgery were also assessed in relation to the persistence or resolution of sleep disturbance. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing primary arthroscopic rotator cuff repair at a tertiary academic center were prospectively enrolled in a registry database. Patient characteristics were obtained preoperatively and validated patient-reported outcome measures (PROMs) were obtained pre- and postoperatively, including the visual analog scale for pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Veterans RAND 12-Item Health Survey Physical and Mental components. Sleep disturbance was evaluated via responses to Simple Shoulder Test question 2. Patients with and without sleep disturbance were compared before and after surgery. Results: In total, 293 patients were prospectively enrolled. A total of 262 (89.8%) patients reported a sleep disturbance preoperatively. Of these, 221 (84.4%) reported a resolution of sleep disturbance by 2 years postoperatively. After adjustment for age, workers’ compensation status, and Cofield tear size, patients with a preoperative sleep disturbance reported significantly worse baseline PROMs, apart from the Veterans RAND 12-Item Health Survey Mental component, before surgery. However, postoperatively, these patients had greater improvement in PROMs, and no significant remaining differences were seen at follow-up between patients with and without preoperative sleep disturbance. Among patients who reported a preoperative sleep disturbance, those whose symptoms resolved postoperatively had superior PROM scores as well as significantly greater improvements from preoperative baseline values compared with patients with persistent sleep disturbances after surgery. Conclusion: Patients with preoperative sleep disturbances reported worse baseline functional scores before rotator cuff repair compared with patients without sleep disturbance. These disturbances largely resolved after surgery, with postoperative outcomes comparable with those of patients who reported no preoperative sleep concerns. Patients whose sleep disturbances resolved postoperatively also reported superior PROM scores compared with patients whose sleep disturbances persisted postoperatively.

Background: Upper extremity (UE) fragility fractures are common and strong predictors of subsequent fractures. To investigate the relative importance of an UE fragility fracture in determining future fracture risk, we conducted a cross-sectional study to compare future fracture risk between patients presenting for osteoporosis evaluation after an UE fragility fracture and a similarly aged cohort of patients without an UE fracture. Methods: In all, 129 UE fracture patients seen in our bone health clinic (BHC) and 114 non-fracture UE fracture patients seen in an UE clinic completed clinic intake surveys assessing for fracture risk factors. Prefracture fracture risk (PFFR) and fracture risk assessment tool (FRAX) scores estimated the future fracture risks at the timepoint before and after the UE fragility fracture event, respectively. The primary study outcome was the 10-year risk of future fracture. Results: The 10-year probability of major osteoporotic and hip fractures were significantly higher among the BHC group when estimated with FRAX. When estimated with PFFR score, there was no difference in the 10-year probability of hip fracture between the groups. Prevalence of secondary osteoporosis and glucocorticoid use was higher in the BHC group, and prevalence of rheumatoid arthritis was higher in the UE clinic group. Conclusions This study underscores the importance of an UE fragility fracture in determining the risk of future fracture. A fragility fracture of the UE should be considered a sentinel event and physicians who evaluate these patients should recognize them as a high-risk group for future hip fracture.

To determine whether, and at which frequency, runners return to running after undergoing arthroscopic partial meniscectomy (APM).We identified patients who underwent surgery between August 2012 and December 2019 who were classified as runners (defined as running 2+ times per week according to Marx Activity Rating Scale Q1) and completed the 1-year follow-up to assess outcomes. Patients were followed using the Marx Activity Rating Scale, Knee Injury and Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-item Health Survey mental and physical components, and visual analog pain scale scores preoperatively and 1 and 2 years postoperatively. The association between baseline characteristics and return to running was assessed using the unpairedA total of 185 patients were included in this study. One year after APM, 41% of runners returned to running at the same frequency or more frequently than before. Further, 50% of runners returned to running at least twice weekly. Return to running according to those definitions was similar at 2 years (38% and 47%, respectively). At both 1 and 2 years, runners exhibited significant improvements in KOOS (Pain), KOOS (Function in Sport and Recreation), visual analog pain scale, and Veterans RAND 12-item Health Survey physical component scores. Lower body mass index (Roughly 1 in 2 runners return to their preoperative running frequency after undergoing APM. Obesity and lower baseline running frequency were significantly associated with inability to return to running.III, retrospective cohort study.

Rotator cuff tears have a wide variability in presentation, with some causing pain and reduced function but others remaining completely asymptomatic. Sleep disturbances are a primary driver for patients with rotator cuff tears to see a physician, and one of the main goals of rotator cuff repair (RCR) surgery is to restore normal sleep patterns in these patients. The primary purpose of this study aimed to determine the percentage of patients undergoing RCR who report preoperative sleep disturbances. Second, this study sought to identify at what postoperative follow-up intervals patients stopped reporting sleep disturbances and how the percentages change over time. It was hypothesized that the majority of patients undergoing arthroscopic RCR would report preoperative and initial postoperative sleep disturbances and that 75% of patients would report resolution of sleep disturbances by 1 year postoperatively.A total of 326 patients undergoing primary arthroscopic RCR were prospectively enrolled in this study. Validated patient-reported outcome measures were obtained preoperatively and postoperatively, including the visual analog pain scale score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, Simple Shoulder Test (SST) score, and Veterans RAND 12-Item Health Survey physical and mental component scores.According to question 2 of the SST, 291 patients (89%) reported preoperative sleep disturbances. Within the cohort of patients who reported resolution of sleep disturbances, 46% reported resolution by 3 months postoperatively; an additional 31%, by 6 months; a further 14%, by 12 months; and the final 8%, by 24 months. Age ≥ 65 years was significantly associated with increased reporting of resolution compared with age65 years. All patient-reported outcome measures, including the visual analog pain scale score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, SST score, and Veterans RAND 12-Item Health Survey (physical component) score, showed statistically significant improvements after surgery.Eighty-nine percent of patients reported preoperative sleep disturbances. Seventy-seven percent of patients reported resolution of sleep disturbances by 6 months postoperatively, and 81% of patients reported resolution of sleep disturbances by 2 years postoperatively.

Purpose The aim of this study was to determine factors associated with presentation of carpal tunnel syndrome for carpal tunnel release (CTR) in the advanced electrodiagnostic stages. Methods We identified 920 patients with preoperative electrodiagnostic studies (EDSs) who underwent CTR at a tertiary-care referral center from July 2008 to June 2013. Patients were divided into 2 groups: those in the advanced electrodiagnostic stage, defined as those with unrecordable nerve potentials on preoperative EDSs (group 1), and those with recordable nerve potentials on preoperative EDSs (group 2). Logistic regression was used to determine factors that were associated with presentation in the advanced stages of the disease. Results Multivariable regression analysis showed older age (odds ratio [OR] 1.05; 95% confidence interval [95% CI], 1.04–1.07), diabetes mellitus (OR, 1.72; 95% CI, 1.13–2.62), and hypertension (OR, 1.88; 95% CI, 1.25–2.84) to be associated with advanced presentation for CTR. Conclusions A 10-year increase in age results in a 1.6-times increase in the odds of advanced presentation. Diabetes mellitus or hypertension independently doubles the odds of advanced presentation. A subset of symptomatic patients with carpal tunnel syndrome may benefit from earlier referral for hand surgery evaluation and earlier CTR. Older patients with diabetes mellitus and hypertension are at increased risk for advanced presentation. Type of study/level of evidence Therapeutic II.

Background Acute physiologic compartment syndrome (ACS) is a disorder of increased intra-compartmental pressure leading to decreased tissue perfusion and muscle necrosis. Tissue ischemia can result in irreversible muscle and nerve injury and requires urgent fasciotomy. The aim of this study was to determine the factors associated with the presence of necrotic muscle in patients undergoing leg fasciotomy. Methods This is a retrospective cohort study of all patients undergoing fasciotomies for ACS of the leg at two level 1 trauma centers from 2000 to 2015. We found 1,028 patients who underwent leg fasciotomies. We excluded ACS at other sites than the leg, the index fasciotomy performed at an outside institution, prophylactic fasciotomy with no clinical signs of ACS, and patients with inadequate medical records. A total of 357 patients were included in the final analysis. We used bivariate analysis to assess which explanatory variables are associated with the main outcome measure, the presence of necrotic muscle at fasciotomy. We used multivariable regression analysis to determine association accounting for any confounding. Results Of 357 cases of ACS of the leg, 14.6% of patients presented with an open fracture and 21.3% of patients were multiply injured. Overall, 14.3% of cases had muscle necrosis at the time of fasciotomy. Fifty-nine percent of patients with necrotic muscle required more than 3 debridements. Open fracture was the only statistically significant predictor of muscle necrosis (OR=2.8). Crush injury (OR=3.1) and soft tissue injuries (OR=2.8) were at an increased odds of necrotic muscle, but only marginally significant. Conclusion ACS is a potentially limb threatening condition often associated with poor outcomes, particularly when the diagnosis is delayed. Patients with open fracture have a three-fold increase in odds of necrotic muscle at the time of fasciotomy.

Objective Most patients with rheumatoid arthritis (RA) strive to consolidate their treatment from methotrexate combinations. The objective of this analysis was to identify patients with RA most likely to achieve remission with tocilizumab (TCZ) monotherapy by developing and validating a prediction model and associated remission score. Methods We identified four TCZ monotherapy randomized controlled trials in RA and chose two for derivation and two for internal validation. Remission was defined as a Clinical Disease Activity Index score less than 2.8 at 24 weeks post randomization. We used logistic regression to assess the association between each predictor and remission. After selecting variables and assessing model performance in the derivation data set, we assessed model performance in the validation data set. The cohorts were combined to calculate a remission prediction score. Results The variables selected included younger age, male sex, lower baseline Clinical Disease Activity Index score, shorter RA disease duration, region of the world (Europe and South America [increased odds of remission] versus Asia and North America), no previous exposure to disease-modifying antirheumatic drugs and/or methotrexate, lower baseline Health Assessment Questionnaire Disability Index score, and baseline hematocrit. The area under the receiver operating characteristic curve was 0.739 in the derivation data set and 0.756 in the validation data set. Patients were categorized into three remission prediction categories based on the remission prediction score: 40% in the low (less than 10% probability of remission), 45% in the intermediate (10%-25% probability), and 15% in the moderate remission prediction category (greater than 25% probability). Conclusion We used easily accessible factors to develop a remission prediction score to predict RA remission at 24 weeks after initializing TCZ monotherapy. These results may provide guidance to clinicians tailoring treatment options based on clinical characteristics.

The majority of periprosthetic joint infections occur shortly after primary joint replacement (

Objective Azathioprine (AZA) and mycophenolate mofetil (MMF) are immunosuppressants frequently used in the treatment of moderate-to-severe systemic lupus erythematosus (SLE). We studied longitudinal patterns and predictors of adherence to AZA and MMF in a nationwide US SLE cohort. Methods In the Medicaid Analytic eXtract (2000-2010) database, we identified patients with SLE who initiated AZA or MMF (no use in the prior 6 months) with ≥12 months of continuous follow-up. We dichotomized adherence at 80%, with ≥24 of 30 days per month considered adherent. We used group-based trajectory models to estimate monthly adherence patterns and multivariable multinomial logistic regression to determine the association between demographic, SLE and utilization-related predictors, and the odds ratios (OR) of belonging to a nonadherent versus the adherent trajectory, separately for AZA and MMF. Results We identified 2,309 AZA initiators and 2,070 MMF initiators with SLE. Four-group trajectory models classified 17% of AZA and 21% of MMF initiators as adherent. AZA and MMF nonadherers followed similar trajectory patterns. African American race (OR 1.67 [95% confidence interval (95% CI) 1.20-2.31]) and Hispanic ethnicity (OR 1.58 [95% CI 1.06-2.35]) increased odds of AZA nonadherence; there were no significant associations between race/ethnicity and MMF nonadherence. Male sex and polypharmacy were associated with lower odds of nonadherence to both medications; lupus nephritis was associated with lower odds of nonadherence to MMF (OR 0.74 [95% CI 0.55-0.99]). Conclusion Adherence to AZA or MMF over the first year of use was rare. Race, sex, and lupus nephritis were modestly associated with adherence, but the magnitude, direction, and significance of predictors differed by medication, suggesting the complexity of predicting adherence behavior.

Objective We sought to evaluate the performance of Fitbit in estimating ActiGraph-derived moderate-to-vigorous physical activity (MVPA) and sedentary time in the knee osteoarthritis (OA) population. Methods We used data from two weeks of Fitbit and ActiGraph wear among knee OA subjects. In primary analyses, we used literature-based ActiGraph thresholds of 200 and 1924 counts/min (triaxial vector magnitude) for sedentary and MVPA time as the gold standard to which we compared three sets of Fitbit thresholds informed by literature and data (Youden index). We also considered personalized, stride length-based Fitbit thresholds. In sensitivity analyses, we used uniaxial, vertical axis-based as well as personalized, BMI-based ActiGraph thresholds. We calculated agreement, sensitivity, and specificity of Fitbit in classifying sedentary and MVPA time. Results In the primary analysis (vector magnitude thresholds), maximum agreement for sedentary and MVPA time was 67.0% from the Youden index-based and 91.1% from the stride length-based Fitbit thresholds. For sedentary time, the 20 strides/min threshold had the highest sensitivity (97.6%), and Youden-derived 1 stride/min had the highest specificity (51.6%). For MVPA, Youden-derived 14 strides/min yielded 72.8% sensitivity, and using stride length yielded 98.6% specificity. MVPA time ranged from 49-323 min/d, depending on threshold used, with literature-based and personalized thresholds leading to more conservative estimates of MVPA than Youden-derived thresholds. Conclusion Using Fitbit for MVPA and sedentary time assessment may lead to inaccurate estimates of both. Fitbit MVPA estimates were generally more conservative than ActiGraph estimates. Incorporating individuals' characteristics did not meaningfully improve Fitbit performance. Caution should be exercised when measuring activity using Fitbit.

Purpose To increase awareness of the need for coordinated medical care at 10-km races and to help direct future medical planning for these events. Methods We related medical encounter data from nineteen 10-km road races to runner, race, and environmental characteristics. We quantified the most commonly used resources and described the disposition of runners in these encounters. Results Across the 19 races and 90,265 finishers, there were 562 medical events for a cumulative incidence of 6.2 events per 1000 finishers (95% confidence interval, 5.7-6.8). Race size was associated with an increased incidence of medical events. Overall, the most common diagnosis was heat-related illness (1.6 per 1000 finishers), followed by musculoskeletal complaints (1.3 per 1000 finishers) and fluid-electrolyte imbalances (1.2 per 1000 finishers). For all diagnoses, runners with finishing times in the first performance quintile and in the fifth performance quintile had greater representation in the medical tent than mid-pack runners. Most runners were treated with supportive care, basic first aid, and oral rehydration. Ninety-four runners (1.0 per 1000 finishers) required ice water immersion for exertional heat stroke. There were low rates of hospital transport (0.2 per 1000 finishers), and no fatalities. Conclusions In 10-km road races, injury rates are low compared with longer races in similar weather conditions. Common medical issues can be managed with basic resources in the on-site medical tent. Green flag start race conditions may not predict race safety with regard to exertional heat stroke risk. There were no deaths in nearly 100,000 finishers.

Postoperative glucose levels after total joint arthroplasty are important to monitor as hyperglycemia has been linked to complications such as periprosthetic joint infection. The purposes of this study were to identify how postoperative glucose values vary during the perioperative period and determine the optimal time to check glucose levels to best evaluate for hyperglycemia.A retrospective study was conducted from September 2017 to September 2018 on 314 patients who underwent knee and hip arthroplasties. Blood glucose levels were collected immediately preoperatively, immediately postoperatively, at 5 PM on the day of surgery (DOS), at 9 PM on the DOS, and in the morning of postoperative day (POD) 1. The total number of hyperglycemic patients was assessed at 3 glucose thresholds: strict ≥ 126 mg/dL, intermediate ≥ 137 mg/dL, and lenient ≥ 180 mg/dL. Descriptive statistics were performed for each glucose time period, and adjusted comparisons were made between the mean glucose values and number of hyperglycemic patients at all time points.Mean (±95% confidence interval) glucose values were 105.7 ± 2.1 mg/dL preoperatively, 117.3 ± 2.5 mg/dL immediately postoperatively, 138.6 ± 4.3 mg/dL at 5 PM on the DOS, 142.9 ± 4.3 mg/dL at 9 PM on the DOS, and 116.7 ± 3.1 mg/dL in the morning of POD 1. Values measured at 5 PM and 9 PM were significantly higher than those measured at all other time points in both diabetics and nondiabetics (P.001 for all). For all 3 hyperglycemia thresholds, the highest number of hyperglycemic patients was observed at 9 PM on the DOS: strict = 205 (65.3%) patients, intermediate = 177 (56.4%) patients; and lenient = 90 (28.7%) patients.Most patients who underwent total joint arthroplasty are hyperglycemic postoperatively, and 9 PM on the night of surgery may be the most sensitive time for detecting hyperglycemia in both diabetic and nondiabetic patients, in contrast to traditional POD 1 levels.

Objective The Intensive Diet and Exercise for Arthritis (IDEA) trial showed that an intensive diet and exercise (D+E) program led to a mean 10.6-kg weight reduction and 51% pain reduction in patients with knee osteoarthritis (OA). The aim of the current study was to investigate the cost-effectiveness of adding this D+E program to treatment in overweight and obese (body mass index >27 kg/m2 ) patients with knee OA. Methods We used the Osteoarthritis Policy Model to estimate quality-adjusted life-years (QALYs) and lifetime costs for overweight and obese patients with knee OA, with and without the D+E program. We evaluated cost-effectiveness with the incremental cost-effectiveness ratio (ICER), a ratio of the differences in lifetime cost and QALYs between treatment strategies. We considered 3 cost-effectiveness thresholds: $50,000/QALY, $100,000/QALY, and $200,000/QALY. Analyses were conducted from health care sector and societal perspectives and used a lifetime horizon. Costs and QALYs were discounted at 3% per year. D+E characteristics were derived from the IDEA trial. Deterministic and probabilistic sensitivity analyses (PSAs) were used to evaluate parameter uncertainty and the effect of extending the duration of the D+E program. Results In the base case, D+E led to 0.054 QALYs gained per person and cost $1,845 from the health care sector perspective and $1,624 from the societal perspective. This resulted in ICERs of $34,100/QALY and $30,000/QALY. In the health care sector perspective PSA, D+E had 58% and 100% likelihoods of being cost-effective with thresholds of $50,000/QALY and $100,000/QALY, respectively. Conclusion Adding D+E to usual care for overweight and obese patients with knee OA is cost-effective and should be implemented in clinical practice.

Objective Up to 30% of patients experience persistent pain and functional limitations following total knee replacement (TKR). Rapid symptom relief in the early postoperative period may be linked to longer‐term outcome improvements. We sought to identify early improvement trajectories and to identify risk factors for suboptimal outcomes. Methods We used data from the Adding Value in Knee Arthroplasty (AViKA) Cohort study, a prospective longitudinal study of patients with knee osteoarthritis who underwent TKR. We assessed pain and function using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). We used group‐based trajectory modeling to identify distinct patterns of pain and function improvement over 6 months. We assessed the association between these early improvement trajectories and 24‐month outcomes, including pain, function, and satisfaction. Results We analyzed data from 107 subjects. Mean baseline WOMAC pain and function scores were 42 (SD 17) and 44 (SD 15), respectively (0‐100; 100 = worst). We identified two pain‐improvement trajectories (suboptimal vs optimal improvement) and two function‐improvement trajectories (suboptimal vs optimal improvement). Greater pain catastrophizing, worse mental health status, and use of a supportive device prior to TKR were associated with being in a suboptimal trajectory. Recipients of TKR in the suboptimal trajectories had higher pain, high functional disability, and lower satisfaction at 24 months post‐TKR. Conclusion Patients with slower improvement over the first 6 months post‐TKR had worse outcomes at 24 months, suggesting that this early postoperative period may represent a window during which interventions aimed at speeding recovery may improve long‐term TKR outcomes.