Body Mass Index and Spinopelvic Alignment as Predictors of Incident Knee Osteoarthritis: An 8-Year Longitudinal Study from the TOEI Cohort of Older Japanese Women

<b>Background/Objectives</b>: Knee osteoarthritis (KOA) is multifactorial, and longitudinal evidence isolating early predictors remains limited. We investigated predictors of incident KOA in community-dwelling older adult Japanese women. <b>Methods</b>: We analyzed 191 knees from 105 women aged ≥50 years (baseline Kellgren-Lawrence (KL) grade 0-1) and followed them for 8 years. Incident KOA was defined as KL ≥ 2 at the 8-year follow-up. Baseline measures included body mass index (BMI), physical function (one-leg stance, functional reach), Geriatric Locomotive Function Scale (GLFS-25), EuroQol 5-Dimension (EQ-5D) questionnaire, standing lateral whole-spine radiographs (sagittal spinopelvic parameters), and standing full-length anteroposterior (AP) lower-limb radiographs (coronal alignment parameters). Incident KOA was defined as KL ≥ 2 at follow-up. Group comparisons, multivariable logistic regression, and receiver operating characteristic analyses were conducted. <b>Results</b>: Incident KOA occurred in 58/191 knees (mean participant age 69.3 ± 6.1 years). Compared with non-incident knees, incident knees had higher BMI (23.8 vs. 21.1 kg/m²), higher GLFS-25, greater pelvic tilt and pelvic incidence minus lumbar lordosis (PI-LL) mismatch (11.5° vs. 5.3°), and lower EQ-5D, medial proximal tibial angle, and joint line obliquity. BMI was the strongest single predictor (area under the curve [AUC] 0.753). PI-LL mismatch showed limited standalone discrimination (AUC 0.596) but improved discrimination when combined with BMI (AUC 0.803). <b>Conclusions</b>: BMI was the primary predictor of incident KOA in this cohort. PI-LL mismatch, while not strongly discriminative alone, acted as a complementary marker consistent with sagittal-alignment-related mechanical stress. Results suggest that early screening and prevention should prioritize weight management, using spinopelvic parameters to refine risk stratification.