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INTRODUCTION

  1. Top of page
  2. INTRODUCTION
  3. HARRIS HIP SCORE (HHS)
  4. HIP DISABILITY AND OSTEOARTHRITIS OUTCOME SCORE (HOOS)
  5. OXFORD HIP SCORE (OHS)
  6. LEQUESNE INDEX OF SEVERITY FOR OSTEOARTHRITIS OF THE HIP (LISOH)
  7. AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS (AAOS) HIP AND KNEE QUESTIONNAIRE
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

Outcome measures included in this review are the Harris Hip Score, the Hip Disability and Osteoarthritis Outcome Score, the Oxford Hip Score, the Lequesne Index of Severity for Osteoarthritis of the Hip, and the American Academy of Orthopedic Surgeons Hip and Knee Questionnaire.

The outcome measures chosen are the most common ones in the literature concerning hip function and symptoms. Most of them are patient-reported. The selected measures meet the basic requirements for an outcome measurement, although there are shortcomings in a few of them.

HARRIS HIP SCORE (HHS)

  1. Top of page
  2. INTRODUCTION
  3. HARRIS HIP SCORE (HHS)
  4. HIP DISABILITY AND OSTEOARTHRITIS OUTCOME SCORE (HOOS)
  5. OXFORD HIP SCORE (OHS)
  6. LEQUESNE INDEX OF SEVERITY FOR OSTEOARTHRITIS OF THE HIP (LISOH)
  7. AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS (AAOS) HIP AND KNEE QUESTIONNAIRE
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

Description

Purpose.

The HHS was developed for the assessment of the results of hip surgery, and is intended to evaluate various hip disabilities and methods of treatment (1) in an adult population. The original version was published 1969.

Content.

The domains covered are pain, function, absence of deformity, and range of motion. The pain domain measures pain severity and its effect on activities and need for pain medication.

The function domain consists of daily activities (stair use, using public transportation, sitting, and managing shoes and socks) and gait (limp, support needed, and walking distance). Deformity takes into account hip flexion, adduction, internal rotation, and extremity length discrepancy. Range of motion measures hip flexion, abduction, external and internal rotation, and adduction.

Number of items.

There are 10 items.

Response options/scale.

The score has a maximum of 100 points (best possible outcome) covering pain (1 item, 0–44 points), function (7 items, 0–47 points), absence of deformity (1 item, 4 points), and range of motion (2 items, 5 points).

Recall period for items.

Not described.

Examples of use.

Total hip replacement (THR) (1–4), femoral neck fractures (5), and osteoarthritis (6).

Practical Application

How to obtain.

Available in the original article (1), URL: http://www.orthopaedicscore.com/ and URL: http://www.ncbi.nlm.nih.gov/pubmed/5783851.

Method of administration.

The HHS is a clinician-based outcome measure administered by a qualified health care professional, such as a physician or a physical therapist.

Scoring.

Each item has a unique numerical scale, which corresponds to descriptive response options. The number of response options varies by item, as does the number of points assigned to each response option. The range of motion item consists of 6 motions that are graded based on the arc of motion possible. Each range of motion gradation is assigned an index factor and a maximum possible value, which are used to calculate arc of motion points. These points are added and multiplied by 0.05 to receive the total points for range of motion. The total score is calculated by summing the scores for the 4 domains.

Score interpretation.

The HHS score gives a maximum of 100 points. Pain receives 44 points, function 47 points, range of motion 5 points, and deformity 4 points. Function is subdivided into activities of daily living (14 points) and gait (33 points).

The higher the HHS, the less dysfunction. A total score of <70 is considered a poor result; 70–80 is considered fair, 80–90 is good, and 90–100 is an excellent result (1). No normative values are available.

Respondent burden.

Takes 5 minutes to complete.

Administrative burden.

No formal training is necessary. Data calculating can be performed automatically during data processing using computer-based algorithms.

Translations/adaptations.

The HHS has been used in many different countries (Sweden, The Netherlands, Denmark, etc.), but there are no validated versions in other languages available.

Psychometric Information

Method of development.

Thirty-eight (31 men) individuals who had undergone THR operations due to traumatic arthritis were the first patients who were evaluated with the HHS. The items were generated based on the opinion by experts that pain and functional capacity are the 2 basic considerations. They were the indications for surgery and hence received the heaviest weighting: 91 of 100 points (1).

Acceptability.

Wamper et al (7) report unacceptable ceiling effects in 31 of 59 studies. Pooled data across the studies included (n = 6,667 patients) suggested ceiling effects of 20% (95% confidence interval 18–22).

Reliability.

Cronbach's alpha coefficient showed high internal consistency reliability except for deformity, which could not be calculated.

The test–retest interval was 3 to 4 weeks. The total score reliability was excellent for physicians (r = 0.94) and physiotherapists (r = 0.95). The physiotherapist and the orthopedic surgeon showed excellent test–retest reliability in the domains of pain (r = 0.93 and r = 0.98, respectively) and function (r = 0.95 and r = 0.93, respectively). The calculations were done with Pearson's and Spearman's correlation coefficients (8).

The interrater correlations were good to excellent (0.74–1.0) for the domain scores in Söderman's study, as well as in study by Kirmit et al (8, 9).

Validity.

The HHS content validity has been tested by directly comparing HHS, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form 36 (SF-36). No major differences between the scores were seen (8). The HHS construct validity was tested by comparing the pain and function domains in HHS, WOMAC, Nottingham Health Profile (NHP), and SF-36. The HHS domains pain and function correlated (Spearman's rho) better with similar domains in WOMAC, NHP, and SF-36 than with different domains (4). In another study, the same result was obtained when comparing HHS, WOMAC, and SF-36 (8). Correlations (Kendall's tau) between HHS and SF-36 have been shown to be strong in the physical domains (3) and weak in the mental domains. A strong correlation (Spearman's rho) has been found between HHS and NHP (2).

Ability to detect change.

HHS responsiveness has been determined in a study of 335 THRs. The effect size between preoperative and 6-months postoperative was excellent for pain (2.80) and function (1.72), but weak in the 2-years followup, i.e., pain (0.15) and function (0.18) (10). When comparing the HHS, Barthel Index, and EuroQol 5-domain (EQ-5D) in patients with femoral neck fractures 4 and 12 months after surgery, the standardized response mean was 0.75 for HHS, 0.40 for Barthel Index, and 0.46 for EQ-5D (5).

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths.

The HHS is widely used throughout the world for evaluating outcome after THR (11). The indication for THR is particularly pain and impaired physical function, which are the 2 dominating domains in HHS. The HHS has also been proven appropriate to measure outcome after interventions such as physical therapy (6) and femoral neck fractures (5).

Caveats and cautions.

There are unacceptable ceiling effects that severely limit its validity (7).

Clinical usability.

The psychometric evaluation does not support interpretation of scores to make decisions for individuals. The administrative burden does not limit clinical use nor the respondent burden since HHS is not self-administered.

Research usability.

For short-time followup studies it seems to be useful (5, 10) if you are aware of the problem with the ceiling effects.

HIP DISABILITY AND OSTEOARTHRITIS OUTCOME SCORE (HOOS)

  1. Top of page
  2. INTRODUCTION
  3. HARRIS HIP SCORE (HHS)
  4. HIP DISABILITY AND OSTEOARTHRITIS OUTCOME SCORE (HOOS)
  5. OXFORD HIP SCORE (OHS)
  6. LEQUESNE INDEX OF SEVERITY FOR OSTEOARTHRITIS OF THE HIP (LISOH)
  7. AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS (AAOS) HIP AND KNEE QUESTIONNAIRE
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

Description

Purpose.

HOOS was developed as an instrument to assess the patients' opinion about their hip and associated problems, and is intended to be used in an adult population with hip disability with or without osteoarthritis (OA).

HOOS has been validated in 2 slightly different versions, LK 1.1 and LK 2.0 (12, 13). The LK 2.0 version is available on line at www.koos.nu. HOOS includes Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) LK 3.0 (14) in its complete and original format (with permission), and WOMAC scores can be calculated. In 2008, a 5-item measure of physical function, the HOOS-PS, was published derived from the HOOS questionnaire by item-response theory to elicit patients' opinions about difficulties experienced due to hip problems (15).

Content.

HOOS consists of 5 subscales: pain, other symptoms, function in activities of daily living (ADL), and function in sport and recreation (Sport/Rec), and hip-related quality of life (QOL).

Number of items.

In total, 40 items: 10 items for pain, 5 items for other symptoms (3 for symptoms and 2 for stiffness), 17 items for function in ADL, 4 items for function in Sport/Rec, and 4 items for hip-related QOL.

Response options/scale.

Standardized answer options are given (5 Likert boxes) and each question is scored from 0 to 4. Scores are summarized for each subscale and transformed to a 0–100 scale (0 indicating extreme problems and 100 indicating no problems).

Recall period for items.

The last week is taken into consideration when answering the questions.

Endorsements.

The HOOS-PS was the result of an Osteoarthritis Research Society International (OARSI) and Outcome Measures in Rheumatology (OMERACT) initiative (15).

Examples of use.

The HOOS has been used in subjects with hip disability with or without hip osteoarthritis (12), and in patients with hip OA pre- and postoperative total hip replacement (THR) (13, 15).

Practical Application

How to obtain.

The HOOS can be obtained for no cost at: www.koos.nu.

Method of administration.

The questionnaire is patient reported.

Scoring.

The user's guide includes a manual scoring sheet and an Excel file ready to download at the web site (www.koos.nu). There are instructions for handling missing values in the user's guide. Computer scoring is not necessary but is recommended since it increases the usefulness in the clinic.

Score interpretation.

Each subscale has a score of 0–100, where 0 indicates extreme problems and 100 indicates no problems. The results can be plotted as an outcome profile, the HOOS profile. (The HOOS-PS was used in an OARSI-OMERACT–supported study of pain and functional disability and its correspondence to total joint replacement. Neither pain nor functional disability alone could discriminate between patients who were or were not eligible for a total joint replacement according to the orthopedic surgeon [16].)

Respondent burden.

The HOOS questionnaire takes ∼10–15 minutes to complete.

Administrative burden.

No administration burden; time to score by hand takes 10–15 minutes. No training is necessary. Computer scoring by using the Excel file only takes 2 or 3 minutes (entering of data).

Translations/adaptations.

Available in Swedish (13), Dutch (17), and French (18) all with published validation studies. Available in Danish, English, German, Korean, and Lithuanian, according to the web site. Also available in versions for knee injury and knee OA (Knee injury and Osteoarthritis Outcome Score), for a variety of foot- and ankle-related problems (Foot and Ankle Outcome Score), and for assessing problems from the lower extremity in patients with inflammatory arthritis (Rheumatoid and Arthritis Outcome Score). All information is available at the web site, www.koos.nu.

Psychometric Information

Method of development.

Items in the HOOS questionnaire were generated through literature search, through interviews with more than 100 patients with hip disability, with and without hip OA (12), and by questioning 90 patients undergoing THR (13).

Acceptability.

Missing data are reported to range from 0.9–2.6% in the different validations studies (13, 18). A total score could be calculated for 99% of the subjects in the Swedish validation study and for all subjects in the French study.

Floor effects are more common in the subscale Sport/Rec, where worst possible scores have been reported to range from 4.1–17.8% in subjects eligible for THR and subjects with hip OA (13, 17, 18). Reports of ceiling effects have only been reported in the Swedish validation study 6 months after THR where 19% of the subjects reported a best possible score in the pain subscale, 10% in the symptoms subscale, 5% in the ADL subscale, and 9% in the Sport/Rec and the QOL subscale (13).

Reliability.

HOOS has been used in patients ages 42–89 years, including subjects with hip OA treated by medication only, subjects eligible for THR and postoperatively (12, 13, 17, 18). The internal consistency ranged from 0.82 to 0.98 (Cronbach's alpha coefficient) in the different studies (12, 17, 18), with the highest value in the ADL subscale (0.94–0.98), which might indicate a redundancy of items. HOOS has high test–retest reproducibility, with the intraclass correlation coefficient ranging from 0.75 to 0.97 in the validation studies (12, 17, 18).

The standard error of measurement published in the Dutch study ranged from 3.71 (QOL subscale) to 6.94 (pain subscale) for subjects with hip OA, and from 4.78 (ADL subscale) to 10.07 (Sport/Rec subscale) for subjects who had undergone THR (17).

Validity.

HOOS content validity was performed by asking patients to rate item importance in the 2 Swedish validation studies (12, 13) resulting in slightly different questionnaires where the LK 2.0 version has been translated into Dutch and French. HOOS construct validity has been tested by comparing it with the Short Form 36, the Oxford Hip Score, the Lequesne Index, and the visual analog scale for pain, and predetermined hypotheses were confirmed (13, 17, 18).

Ability to detect change.

HOOS responsiveness has been determined in 1 Swedish and in 1 French study (n = 90 and n = 30, respectively) after THR (13, 18). The standardized response mean ranged from 1.29–3.24 (13, 18). Younger patients (age <66 years) showed larger responsiveness in all subscales compared with older subjects (13).

In the French sample, the effect size ranged from 1.97 (QOL subscale) to 3.24 (pain subscale) (18). The smallest detectable difference of the HOOS ranged from 9.6 for the ADL subscale to 16.2 for the QOL subscale (18).

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths.

The HOOS is an extension of the WOMAC and is suggested to be valuable for younger and more active people due to added subscales. The HOOS has been included in 2 systematic reviews concerning psychometric evaluations of questionnaires assessing hip OA and yielded positive findings (19, 20). The HOOS needs further psychometric testing in different cultures and in different groups of patients with hip disabilities.

Clinical usability.

The HOOS can be used to follow patients with hip OA over time in the clinic, whatever the severity. Using the Excel file at the web site to calculate scores makes it fast and easy to administer.

Research usability.

HOOS is suitable to use in research as a disease-specific questionnaire.

OXFORD HIP SCORE (OHS)

  1. Top of page
  2. INTRODUCTION
  3. HARRIS HIP SCORE (HHS)
  4. HIP DISABILITY AND OSTEOARTHRITIS OUTCOME SCORE (HOOS)
  5. OXFORD HIP SCORE (OHS)
  6. LEQUESNE INDEX OF SEVERITY FOR OSTEOARTHRITIS OF THE HIP (LISOH)
  7. AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS (AAOS) HIP AND KNEE QUESTIONNAIRE
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

Description

Purpose.

To assess outcome after total hip replacement (THR) by measuring patients' perceptions in adjunction to surgery. The original version from 1996 (21) was updated in 2007 introducing a new scoring system (22).

Content.

OHS assesses pain (6 items) and function (6 items) of the hip in relation to daily activities such as walking, dressing, sleeping, etc.

Number of items.

12 items with 5 categories of response; no subscales.

Response options/scale.

The original scoring from 1996 ranged from 1–5 (best to worst) with a total score of 12–60 (least difficulties to most difficulties) (21).

A new scoring was suggested in 2007 and supported by the original authors: 0–4 (worst to best) with overall scores ranging from 0–48 where 48 represents the best score (22).

Recall period for items.

During the past 4 weeks.

Examples of use.

Designed for assessment of joint replacement and has been used in several countries in large registry studies (23–28). Has also been validated and used in revision hip replacement (29, 30).

Practical Application

How to obtain.

Information concerning the Oxford Orthopaedic scores can be found at http://phi.uhce.ox.ac.uk/ox_scores.php and the new scoring system can be found at http://phi.uhce.ox.ac.uk/pdf/OxfordScores/hip_score_guide.pdf. Free to use.

Method of administration.

Self-administered; also used in postal surveys (24, 31).

Scoring.

According to the updated version, “Each of the 12 questions is scored in the same way with the score decreasing as the reported symptoms increase (i.e., become worse)” (22). Scores range from 0 to 4 (worst to best); see http://phi.uhce.ox.ac.uk/pdf/OxfordScores/hip_score_guide.pdf.

Computer scoring is not necessary. A maximum of 2 missing values can be accepted and replaced by mean value. Overall scores should not be calculated if more than 2 items are left unanswered. If 2 answers are indicated for 1 question, the worst response should be used for calculation of scores.

Score interpretation.

According to the updated version, scores range from 0 to 48 (worst to best) (22). Cut off points based on large international data are under progress (22). Categories for the OHS based on data from the Harris Hip Score (HHS) and translated to the 0–48 scoring has suggested cut off scores: >41 as excellent, 34–41 as good, 27–33 as fair, and <27 as poor (32). Based on the original scoring system (12–60, best to worst) (21), <19 was excellent, 19–26 was good, 27–33 was fair, and >33 was poor (32).

According to the above classification by Kalairajah et al (32), the OHS at 6 months is a useful predictor of early revision after THR. A poor score was associated with a revision risk within 2 years of 7.6% for THR compared with risks of 0.7% for a good/excellent score (26). No normative values are available.

Respondent burden.

The OHS takes between 2–15 minutes to complete (33).

Based on patient interviews, there were issues raised concerning item clarity and double-barreled questions (33, 34).

Administrative burden.

The OHS is a patient-reported questionnaire. Time to score is short, just sum items up. No training to score is necessary.

Translations/adaptations.

Dutch (35), Japanese (27), German (36), and French (37) versions have been developed and evaluated. The OHS is widely used in many countries even though published validation studies are lacking. The Oxford Orthopaedic Scores also include a similar questionnaire for assessing outcome after knee replacement surgery (the Oxford Knee Score) together with questionnaires assessing shoulder surgery and shoulder instability.

Psychometric Information

Method of development.

Questions were based on patient interviews where hip OA patients were asked to report their experience and problems. Patients were involved in face and content validity of the questionnaire (21). The OHS includes only 1 scale. OHS underwent item-response theory testing in 2004 by Fitzpatrick et al, and there was an overall good item fit of the data to the Rasch model (38).

Acceptability.

Ninety percent of 6,174 questionnaires had no missing items. Most problems referred to item 6 (distance walked before severe pain). Older patients and patients with more severe medical problems were less likely to complete the questionnaire fully compared with younger and healthier patients (31). Ceiling effects (13.5%) were present in postoperatively collected data, but there were very low levels of floor effects (39, 40).

Reliability.

Internal consistency was measured in patients pre- and postsurgery; Cronbach's alpha varied between 0.84–0.93 (3, 6, 12, and 24 months) (21, 31, 35). Reproducibility was measured by the coefficient of repeatability according to the method of Bland and Altman, and found to be acceptable (21, 35).

Validity.

Developing the OHS, patients were asked to comment on and to include hip-related problems not addressed by the questionnaire for content validity (21). No hypotheses prior to analysis were provided measuring construct validity. Higher correlations to measures of pain and function than to psychological measures have been established (21, 29, 32, 39, 40). High correlation (rs = 0.7, P < 0.001) was found between OHS and the HHS in THR patients (32).

Ability to detect change.

OHS had greater responsiveness compared with generic measures (Short Form 36 and EuroQol 5-domain) and the disease-specific measures, the Western Ontario and McMaster Universities Osteoarthritis Index and the Arthritis Impact Measurement Scales. Effect size of the OHS varied between 2.38–3.1 at 6–24 months after THR (21, 29, 31, 35, 39–41) and was 1.84 at 6 months after revision surgery (41). According to Murray et al, the minimum clinically important difference can be expected to be between 3–5 points concerning joint replacement, but work is in progress (22).

A similar concept to the Patient Acceptable Symptom State was performed by Arden et al, relating the OHS to patient satisfaction with surgery after 12 and 24 months (42). The authors found that scores of 38 and 33 were associated with patient satisfaction at 12 and 24 months, respectively. However, the threshold varied according to preoperative scores and to body mass index limiting the clinical use of the threshold value.

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths.

The OHS assesses pain and function outcomes in patients undergoing hip replacement. It has shown acceptable to excellent psychometric properties and has been reported to be a useful predictor of early revision after THR.

Caveats and cautions.

Like many of these questionnaires, the OHS has a few double-barreled questions that can be a problem to the patient. Questions have also been raised about the lack of items concerning activities requiring a large angle of hip flexion, as well as aids and medication; this information has to be addressed by other means.

Clinical usability.

The questionnaire is easy to use due to self-administered distribution, and it only takes a few minutes to complete. A single administration will not provide much information on an individual, but repeated administrations might give some information

Research usability.

The OHS was developed to supplement other generic outcome measures in systematic studies of hip replacement surgery with long-time followup; it is also feasible for surveys by post. Due to its shortness, the OHS questionnaire yields a high response rate and is therefore preferred for larger studies (24).

LEQUESNE INDEX OF SEVERITY FOR OSTEOARTHRITIS OF THE HIP (LISOH)

  1. Top of page
  2. INTRODUCTION
  3. HARRIS HIP SCORE (HHS)
  4. HIP DISABILITY AND OSTEOARTHRITIS OUTCOME SCORE (HOOS)
  5. OXFORD HIP SCORE (OHS)
  6. LEQUESNE INDEX OF SEVERITY FOR OSTEOARTHRITIS OF THE HIP (LISOH)
  7. AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS (AAOS) HIP AND KNEE QUESTIONNAIRE
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

Description

Purpose.

The LISOH was developed to evaluate the severity of hip osteoarthritis (OA) in drug trials in an adult French population, the long-term treatment effects for hip OA, and as a help in decision making regarding the need for hip replacement (43). The index covers OA-specific symptoms and physical functional disability (43–45). Developed in France in the early 1980s as an interview format to use in clinical drug trials, the instrument is available currently in several versions: interview based (43), self-administered (46), and in modified versions due to changed scoring and wording (45).

Content.

A composite measure aggregating symptoms and function, which are not graded separately, where pain is analyzed by 5 items, maximum distance walked by 2 items, and activities of daily living (ADL) by 4 items.

Number of items.

There are 11 items; the score ranges from 0 (no pain or no disability) to 24 (maximum pain or maximum disability) and is scored as the sum of all questions.

Recall period for items.

Not specified.

Examples of use.

To assess the severity of hip OA (47), the effectiveness of pharmacologic interventions (44), and to help with indications for surgery (46, 48).

Practical Application

Method of administration.

Patient-, interviewer-, or clinician-completed.

Scoring.

The score ranges from 0–8 for each part (pain or discomfort, maximum distance walked, and ADL) resulting in a total score ranging from 0 to 24. The index was modified in 1991 when a question for sexual activity was included if appropriate, resulting in a maximum score of 28.

Score interpretation.

Score 0–24 points (lower score indicates less dysfunction) where 0 = no handicap, 1–4 = mild handicap, 5–7 = moderate handicap, 8–10 = severe handicap, 11–13 = very severe handicap, and ≥14 = extremely severe handicap. A score over 11-12 points after appropriate treatment is suggested to indicate surgery (45). A sore >10 indicated a relative risk of 2.59 for total hip arthroplasty (48). The questions are suggested to score disabilities connected with a single hip. There are no indications of how to score in case of bilateral hip OA, complicating interpretation (47).

Respondent burden.

Takes 2–5 minutes to complete (47, 49, 50).

Administrative burden.

Some training may be needed for use of the interview-based questionnaire to reach interobserver reproducibility (43). Scoring takes only a few minutes (49).

Translations/adaptations.

Validated for hip OA, it is available in French (original), English (47), German (46), Turkish (51), and Korean (52) but used in many languages where a published cultural adaptation is hard to find. Several cultural adaptations and validations have also been performed for the version used in knee OA.

Psychometric Information

Method of development.

Developed in the early 1980s by specialists. Rasch analysis has been applied later in validity studies and has questioned the psychometric properties of the questionnaire (47).

Acceptability.

Two of 10 patients needed some explanation to fill out the questionnaire in a French study using the Lequesne Index of Severity for Osteoarthritis of the Knee (49). In a postal survey, the constituent item response rate was 71% for the LISOH, which was lower than for the Short Form 36 (SF-36; 76–96%), but higher than the SF-36 total score (58%) (47).

Reliability.

Satisfactory internal consistency for the composite score (alpha 0.83–0.84) has been presented (46, 47, 52). However, internal consistency was lower for the pain section compared with the function section (Cronbach's alpha 0.63 versus 0.84) (46). Recommendations are to only use the LISOH for group comparisons. Factor analysis did not show unidimensionality of the scale (47). Satisfactory test–retest reliability was found for the composite score, intraclass correlation coefficient 0.94 (46). For interrater reliability, the interview-based questionnaire had a mean deviation of 0.55 points when rated by 2 observers (43).

Validity.

Doubtful construct validity (20, 46, 47). Also, the convergent validity of the questionnaire has been questioned (47).

Ability to detect change.

Information concerning responsiveness is lacking. Active drug treatment has shown an effect size of 1.3–1.8 (45).

Critical Appraisal of Overall Value to the Rheumatology Community

Caveats and cautions.

Problems raised are due to lack of validity, and the LISOH cannot be recommended for use as the single measure, neither in the clinic nor in research.

Clinical usability.

Psychometric evaluations do not support the interpretation of scores on an individual level.

Research usability.

Suggestions of more appropriate questionnaires for evaluation of pain and physical disability have been published in the last 10 years.

AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS (AAOS) HIP AND KNEE QUESTIONNAIRE

  1. Top of page
  2. INTRODUCTION
  3. HARRIS HIP SCORE (HHS)
  4. HIP DISABILITY AND OSTEOARTHRITIS OUTCOME SCORE (HOOS)
  5. OXFORD HIP SCORE (OHS)
  6. LEQUESNE INDEX OF SEVERITY FOR OSTEOARTHRITIS OF THE HIP (LISOH)
  7. AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS (AAOS) HIP AND KNEE QUESTIONNAIRE
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

Description

Purpose.

The hip and knee core scale assesses hip and knee conditions and treatment improvements. The hip and knee questionnaire belongs to a series of lower extremity questionnaires initiated and developed by the AAOS. Intended for use in patients age ≥18 years. The original version was published in 2004 (53).

Content.

The questionnaire covers stiffness, swelling, and pain in conjunction to functioning (walking on flat surfaces, going up or down stairs, lying in bed at night, ability to get around, and difficulties with taking on and off socks/stockings).

Number of items.

7 items, no subscales. If both hips are involved, the questions should be answered for the worse side.

Response options/scale.

Likert scales with 5–7 response options (best to worse). Five response options for swelling and stiffness. Seven response options for pain and function, including 1 option for “could not do for other reasons,” 7 options for getting around, and 6 response options for taking on and off socks/stockings.

Recall period for items.

During the past week.

Examples of use.

To measure functional impairment in patients treated for slipped capital femoral epiphysis (54).

Practical Application

How to obtain.

Questionnaires and scoring instructions can be found at the AAOS web site: www.aaos.org/research/outcomes/outcomes_lower.asp.

Method of administration.

Patient-administered questionnaire.

Scoring.

Scoring includes both standardized and normative scores. Scoring instructions and a scoring worksheet can be obtained at the AAOS web site. Computer scoring is not necessary, but it speeds up the scoring process. Scores cannot be calculated if more than half of the items are missing.

Score interpretation.

Standardized scores ranges from 0–100 (most disability to least disability). Standardized scores can then be transformed to normative scores using the mean and SD from the general healthy population. A patient scoring >50 on the normative scale will be above the general healthy population's average and a scoring <50 is under the general healthy population's average (55).

Respondent burden.

The questionnaire takes only a few minutes to complete.

Administrative burden.

Takes only a few seconds to score if the scoring sheet is used. If scored by hand, it takes ∼15 minutes to score.

Translations/adaptations.

There are versions for the lower extremity, for global sports/knee, and for the foot and ankle (53).

Psychometric Information

Method of development.

In 1994, a consensus meeting was held and domains relevant for the lower extremity instruments were identified by group technique. The groups included clinicians and health-service researchers with an expertise in the field (53). The items in the scale were reduced from 28 to 7 due to factor analysis showing a considerable overlap with the Short Form 36 (SF-36) physical function scale (53).

Acceptability.

Not studied.

Reliability.

Internal consistency for patients with hip/knee diagnosis (n = 43) resulted in a Cronbach's alpha of 0.80. Test–retest was performed on 40 subjects and analyzed with the Pearson's correlation coefficient (r = 0.91) (53).

Validity.

Face and content validity were determined by the item selection process. Construct validity of the hip/knee scale was performed by analyzing data from 43 patients in the hip/knee group, yielding correlations of 0.95 with the lower extremity core scale, 0.70 with the unweighted mean of the SF-36 physical health score, 0.73 and 0.69 with physician assessment of function and pain, respectively. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was assessed for criterion validity, a global score for the WOMAC was calculated, and the correlation with the hip/knee core score was 0.89 (53).

Ability to detect change.

Differences between change scores were not calculated for the hip/knee core scale, but they were for the lower extremity core scale after 24 months. Change scores on the lower extremity questionnaire were correlated with a patient-physician–generated score regarding the perception of improvement during the last year (r = 0.53).

In a regression analysis with the transition score generated from patient-physician perception of improvement as dependant variable, the lower extremity core scale accounted for 40% of the variance, which was the highest among the tested outcome measures (53).

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths.

The AAOS lower extremity questionnaires went through a psychometric evaluation reported by Johanson et al in 2004 (53); this is, however, the only one performed and published. The authors conclude that the measures combined with the SF-36 will provide useful information concerning orthopedic outcome in patients with lower extremity diagnoses. The usefulness of the questionnaire will need to be studied further.

Clinical usability.

Developed for use in the clinic as well as in research. The transformation of standardized scores to normative scores can be useful also in the clinic. Further testing of the instrument is warranted.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. INTRODUCTION
  3. HARRIS HIP SCORE (HHS)
  4. HIP DISABILITY AND OSTEOARTHRITIS OUTCOME SCORE (HOOS)
  5. OXFORD HIP SCORE (OHS)
  6. LEQUESNE INDEX OF SEVERITY FOR OSTEOARTHRITIS OF THE HIP (LISOH)
  7. AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS (AAOS) HIP AND KNEE QUESTIONNAIRE
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES

Both authors were involved in drafting the article or revising it critically for important intellectual content, and both authors approved the final version to be published.

REFERENCES

  1. Top of page
  2. INTRODUCTION
  3. HARRIS HIP SCORE (HHS)
  4. HIP DISABILITY AND OSTEOARTHRITIS OUTCOME SCORE (HOOS)
  5. OXFORD HIP SCORE (OHS)
  6. LEQUESNE INDEX OF SEVERITY FOR OSTEOARTHRITIS OF THE HIP (LISOH)
  7. AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS (AAOS) HIP AND KNEE QUESTIONNAIRE
  8. AUTHOR CONTRIBUTIONS
  9. REFERENCES
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