The Journal of Bone and Joint Surgery (American) 83:1856-1864 (2001)
© 2001 The Journal of Bone and Joint Surgery, Inc.
Validity and Responsiveness of the Knee Society Clinical Rating System in Comparisonwith the SF-36 and WOMAC
Elizabeth A. Lingard, BPhty, MPhil, MPH,
Jeffrey N. Katz, MD, MS,
R. John Wright, MD,
Elizabeth A. Wright, PhD and
Clement B. Sledge, MD the Kinemax Outcomes Group
Elizabeth A. Lingard, BPhty, MPhil, MPH
Department of Trauma and Orthopaedic Surgery, The Medical School,
University of Newcastle upon Tyne NE2 4HH, England
Jeffrey N. Katz, MD, MS
Elizabeth A. Wright, PhD
Robert Brigham Multipurpose Arthritis and Musculoskeletal Diseases
Center, Brigham and Women’s Hospital, 75 Francis Street,
Boston, MA 02115
R. John Wright, MD
Clement B. Sledge, MD
Department of Orthopedic Research, Brigham and Women’s
Hospital, 75 Francis Street, Boston, MA 02115
The Kinemax Outcomes Group included participants from three countries.
In the United Kingdom, the participants included William Gillespie,
Colin Howie, Ian Annan, Alastair Gibson, and Judith Lane, Princess
Margaret Rose Hospital, Edinburgh; Ian Pinder, David Weir, Nigel
Brewster, and Karen Bettinson, Freeman Hospital, Newcastle upon
Tyne; Maurice Needhoff and Roz Jackson, King’s Mill Centre,
Mansfield; Tim Wilton and Peter Howard, Derbyshire Royal Infirmary,
Derby; Ian Forster, Paul Szyprt, Chris Moran, David Whitaker, Mike
Bullock, and Zena Hinchcliffe, Queen’s Medical Centre,
Nottingham; and Ian Learmonth, John Newman, Chris Ackroyd, George
Langkamer, Robert Spencer, Mark Shannon, Evert Smith, John Dixon,
and Sarah Whitehouse, Avon Orthopedic Centre, Bristol. In the United
States, the participants included Clement Sledge, Frederick Ewald,
Robert Poss, John Wright, Scott Martin, John Kwon, and Yvette Valderamma,
Brigham and Women’s Hospital, Boston; Steven Harwin and
Michael Lichardi, Beth Israel Medical Center, New York; Mark Mehlhoff,
Linda Weiler, and Tom Cahalan, Iowa Medical Clinic, Cedar Rapids;
and Richard Cronk and Allyson Sandago, Neuromuscular and Joint Center, Corvallis.
In Australia, the participants included Stephen Rackemann and Emma
McLaughlin, The Knee Centre, Gold Coast, and Peter Lewis, Robert
Bauze, Gordon Morrison, Tom Stevenson, and Jane Clasohm, Queen Elizabeth
Hospital, Adelaide.
In support of their research or preparation of this manuscript,
one or more of the authors received grants or outside funding from
Stryker/Howmedica, Rutherford, New Jersey, and Limerick,
Ireland, and National Institutes of Health Grant AR36308. In addition,
one or more of the authors received payments or other benefits or
a commitment or agreement to provide such benefits from a commercial
entity (Stryker/Howmedica). No commercial entity paid or
directed, or agreed to pay or direct, any benefits to any research
fund, foundation, educational institution, or other charitable or
nonprofit organization with which the authors are affiliated or associated.
Background: The aim of this study was to validate
the Knee Society Clinical Rating System (knee and function scores)
and to compare its responsiveness with that of the Western Ontario
and McMaster University Osteoarthritis Index (WOMAC) and the Medical
Outcomes Study Short Form-36 (SF-36).
Methods: Patients were recruited as part of a prospective
observational study of the outcomes of primary total knee arthroplasty
for the treatment of osteoarthritis in four centers in the United
States, six centers in the United Kingdom, and two centers in Australia.
Independent research assistants at each site collected the Knee
Society clinical data. The WOMAC, SF-36, patient satisfaction, and
demographic data were obtained with self-administered questionnaires.
Results: A total of 862 eligible patients were recruited,
and complete preoperative and twelve-month data were available for
697 (80.9%) of them. The mean age was seventy years (range,
thirty-eight to ninety years), and the majority of the patients
(58.9%) were women. Low correlations were found among the
items of both the knee and the function score at both assessment
times. The Knee Society pain and function scores had moderate-to-strong
correlations with the corresponding pain and function domains of
the WOMAC and SF-36 (r = 0.31 to 0.72). Measurement of
the standardized response mean showed the Knee Society knee score
to be more responsive (standardized response mean, 2.2) than the WOMAC
(standardized response means, 2.0 for pain and 1.4 for function)
and the SF-36 (standardized response means, 1.0 for bodily pain
and 1.1 for physical functioning). The Knee Society function score
was the least responsive measure (standardized response mean, 0.8).
Correlation of changes in scores at twelve months with patient reports
of satisfaction and improvement in health status showed the WOMAC
and SF-36 to be more responsive than the Knee Society scores.
Conclusions: There is a poor correlation among the
items of the Knee Society Clinical Rating System, but the rating
system has adequate convergent construct validity. The WOMAC and
SF-36 are more responsive measures of outcome of total knee arthroplasty.
As they are less labor-intensive for researchers to use and as use
of these instruments removes observer bias from the study design,
they are preferable for knee arthroplasty outcome studies.
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