Abstract
Psychological distress is common in individuals undergoing total joint arthroplasty (TJA). Understanding psychological phenotypes and their transitions from before to after surgery can inform risk stratification and targeted care. This study aimed to characterize psychological phenotypes, examine transitions, and compare patient outcomes across phenotypes. This retrospective study included 494 patients who underwent primary hip (43%) or knee (57%) arthroplasty at Duke University Health System (2018-2024). Latent transition analysis identified and examined transitions of psychological phenotypes preoperatively and postoperatively using the Optimal Screening for Prediction of Referral and Outcome Yellow Flag tool. Demographic characteristics, phenotype transitions, Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI), PROMIS Physical Function (PF), pain intensity, and high-impact chronic pain (HICP) were compared across phenotypes. The optimal model fit was a constrained model comprising five classes: class 1 (low self-efficacy with poor pain coping), class 2 (low distress), class 3 (poor pain coping), class 4 (high distress), and class 5 (low self-efficacy with acceptance). Most patients (n = 271, 55%) transitioned to a different phenotype. The probabilities for remaining in the same class ranged from 0.19 (poor pain coping) to 0.61 (low distress). The incidence of high distress was 6% within 12 months after TJA. High distress was associated with lower PROMIS-PF and higher PROMIS-PI scores, pain intensity, and prevalence of HICP (P < 0.001). Transitions were observed across all phenotypes, with some demonstrating greater stability and others showing more state-like variability. Identifying phenotypes with distinct trajectories and outcomes may support targeted screening and preoperative risk stratification.