The 2011 Knee Society Knee Scoring System©
Contents
1. The 2011 Knee Society Knee Scoring System LICENCED USER MANUAL Created December 2012 In This Document Background scistivcseedectsncanssecuescveiceccedncuhasdeciceccsadetyssueeceeecetecsbuasecdenecessasbususilerecedscsbusteulGeccsatcs 2 Me thod of Validato Die seatittsxectubade ed cnitiuna ti DtW at aasileade tad psenacss aia iaai Sda wbelavabeansbeleaesuud 2 Components of the 2011 Knee Society Score scccidssdcvscdsdedeicansassveneddcansenadesoonecdenccnnees 2 Patient Demographics eeeeescee cece cece eece cece ee ee eee aaaaeaeee sete eaeaaaaaaeaeeeeeeesaaaaeaeeeeeeeeseceeaaaeaes 3 Objective VIS OO E nasisisi na AEA AEE ATELE AET 3 Patient Expectations and Satisfaction ccccsssssessececeeeesessseeaeeeceseesesssesaeeeeeeeesessssseseens 3 Functional AIG ON seunteandeaccndazcennvasycasatiaccevausenanedsacecauusunassutiesconrerndenanediueanittaysemnnaceasoumueseadla 4 Frequently Asked QUESTIONS ccceessssssececeeeeecsssesaeseeeceeeesesssaeaeeecuseeessssasaeeeceseeessessanaeens 4 BIDINOS REI DINY searen eea E e a Rara a ae E AE E S 9 2011 Knee Society Knee Scoring System Licensed User Manual 1 Background In 1989 The Knee Society Clinical Rating System was developed to rate both the knee prosthesis function and patients functional abilities after total knee arthroplasty TKA Insall While this scoring system became the most popular method of reporting outcomes after total and partial knee art2. have collected KS Scores and the Oxford Survey for many years preoperatively and at postoperative follow up What is the recommendation for how we would compare our data over time to the new KS evaluation 2011 Knee Society Knee Scoring System Licensed User Manual 8 A It is recommended that you continue your standard practice of collecting the data with the Oxford Survey and that you convert over to the New Knee Society Score This will allow you to assess whether the patients outcome has changed based on the Oxford Score and to establish a new baseline for future comparison based on the New Knee Society Score Bibliography Charnley J The long term results of low friction arthroplasty of the hip performed as a primary intervention Bone J oint Surg Br 1972 54 61 76 Insall N Dorr LD Scott RD Scott WN Rationale of the Knee Society Clinical Rating System Clin Othop Relat Res 1989 248 13 14 Scuderi GR Bourne RB Noble PC Benjamin J B Lonner J H The new Knee Society Knee Scoring system Clin Othop Relat Res 2012 470 3 19 Noble PC Scuderi GR Brekke AC Sikorskii A Benjamin J B Lonner J H Chadha P Daylamani DA Scott WN Bourne RB Development of a Knee Society Knee Scoring system Clin Othop Relat Res 2012 470 20 32 Benjamin J J ohnson R Porter S Knee scores change with length of follow up after total knee arthroplasty J Arthroplasty 2003 18 7 867 871 HHH If you have addition
3. if a patient indicates less than three 3 activities A If patients do lt 3 activities we suggest inserting a mean score for the missing items Q5 Reporting of outcomes is it to be reported as a two part score A No Outcomes are only scored using the patient reported responses Data derived from items on the objective clinician generated component of the questionnaire is collected for background information and to facilitate comparison of patient outcome with the old KSCR QG Scoring details Are the PROs to be combined or reported individually for each sub score A The new score consists of separate components Function Satisfaction and Expectation and so should be reported as three separate scores One for each component The subcomponents of the Objective score Alignment Instability Joint Motion Symptoms are separate parameters and so cannot be totaled to make a single score with statistical validity 2011 Knee Society Knee Scoring System Licensed User Manual 5 2 RANGE OF MOTION Measured by Goniometer Extension Passive Flexion hyperextension c Anatomic alignment Measured by goniometer Enter a positive number C Valgus L Neutral Q7 Continuous variables including range of motion and anatomic alignment have been dichotomized What if they were collected as continuous and the computer dichotomized them A This could be done as long as the final score is preserved The
4. reason for the dichotomized treatment of deformity i e acceptable alignment 25 25 points significant varus or valgus 15 25 pints is that both deviations are considered detraction from the ideal knee function and appearance and appear to impact the longevity of TKA Range of motion ROM has not been dichotomized and is still continuous however penalties are present for extensor lag and flexion contracture regardless of the total arc of motion Note Measuring ROM with a goniometer is notoriously difficult with high inter and intra observer variability This becomes a problem with differing ROM scores reported at different follow up times when in fact there has been no change Q8 In our experience it is not advisable to show the point values to the study subjects as it can influence their responses Can the point values be removed when we create forms with our own headers A Yes This is a suggestion that will be considered for future updates Q9 Many of the point values of the new AKS are similar to the old AKS however for pain symptoms there is a challenge Pain does not map easily A We recommend you use the patient generated score instead of the objective score We found the old pain score unpredictable and subject to marker inter observer bias The 2011 Knee Society Knee Scoring System Licensed User Manual 6 new pain score was derived from our studies which demonstrated the most important pain related quest
5. al questions that have not been addressed please email them to knee aaos org 2011 Knee Society Knee Scoring System Licensed User Manual 9
6. dard Activities has a maximum of 30 points and evaluates standard activities of daily living Patients can also respond if they never participate in the activities Patients responding I never do this receive zero points for that activity Advanced Activities has a maximum of 25 points and evaluates function in performing more vigorous activities ranging from climbing a ladder or step stool to running Patients can also respond if they never participate in the activities Patients responding I never do this receive zero points for that activity Discretionary Activities has a maximum of 15 points and allows patients to select the three activities that they consider most important to tem personally from a group of seventeen recreational and exercise activities Patients who do not participate in any of the discretionary activities will have a functional knee score that is limited to 85 points The discretionary activities do not need to be identical in the pre operative and post operative period n patients with severe functional disabilities the functional score may actually be a negative number In these cases the score will default to zero It has been documented that patient functional scores decrease with time after TKA due to multiple musculoskeletal and general medical conditions Benjamin Inclusion of both the Advanced and Discretionary Activities in the new scoring system will allow more accurate ident
7. hroplasty it was felt to not provide enough detail specifically in documenting the functional capabilities of more contemporary knee arthroplasty patients The original score was only physician derived leaving unresolved the poor correlation between objective physician assessed knee scores and patient derived satisfaction scores It became clear that an updated and validated Knee Society scoring system with improved responsiveness and reliability was needed With these issues in mind the new Knee Society Scoring System copyrighted in 2011 is a validated system that combines an objective physician derived component with a subjective patient derived component that evaluates pain relief functional abilities satisfaction and fulfillment of expectations Noble Scuderi This score prioritizes the patient perspective to better track patient expectations satisfaction and activity levels than was possible with its predecessor Method of Validation The new score was validated by a multi centered study over a several year period capturing regionally diverse patients and physicians with over 500 patients examined and surveyed both preoperatively and postoperatively Objective and subjective data were captured and compared to the KOOS and SF 12 scores for validation Using statisticians and epidemiologists each question in the functional score was analyzed to detect differential item functioning The new updated Knee Society Scoring System has been p
8. ification of activities that patients participate in prior to and after knee arthroplasty surgery Frequently Asked Questions Q1 Is there an instructional manual for the 2011 KSS A We do not have a scoring manual at this time but would refer our users to the CORR article available upon request A manual would be helpful to foster reporting consistency and it is something we are considering Q2 Please send the scoring algorithm and scoring instructions for the 2011 KSS A We do not have any particular instructions or algorithm Please clarify elaborate on your request 2011 Knee Society Knee Scoring System Licensed User Manual 4 Q3 Please provide guidance on scoring when there is missing data A It is not possible to provide a truly valid estimate of the score for any domain e g satisfaction function etc that is missing responses However to satisfy the criteria for unidimensionality of each subscale on the instrument we selected individual items that were themselves strongly correlated which gives robustness to the final estimates of function satisfaction and expectation In practice we recommend that clinicians or research investigators a contact the patient and ask them to answer the missing items or b to enter dummy values equal to the average of all of the other items in the same domain This practice is limited to instances where fewer than 50 of responses are missing preferably less than 25 Q4 What
9. in patients with greater than 125 of flexion and a stable painless knee as outlined below Alignment has a maximum of 25 points and is determined on a weight bearing AP radiograph measuring the femoral tibial Anatomic axis Instability allows a maximum of 25 points for a knee that is stable in the coronal and saggital axis Joint Motion allows one point for each 5 of joint motion Unlike the old scoring system that allowed a maximum of 25 points the new system allows greater than 25 points for patients with greater than 125 of motion There are deductions for flexion contracture and extension lag The presence of recurvatum is not specifically addressed however patients with recurvatum will have significant ligament laxity in other planes that is captured in the Instability category of the objective score Maximum allowable points 25 Symptoms category contains two 10 level scales ranging from none to severe for each patient to rate their pain with walking on level ground and on stairs inclines The patient starts with 10 points on each scale for a painless knee with deductions of up to 10 points deductions as indicated by the patient s response on each pain scale There is an additional question regarding how normal the knee feels to the patient Maximum allowable points 25 Patient Expectations and Satisfaction These elements are considered vital in the clinical and functional assess
10. ions Q10 Race and ethnicity are not per FDA guidance A This is correct As the Knee Score is used throughout the world and is affected by cultural factors we have developed a new classification system based on feedback from investigators from different centers worldwide Q11 Has the minimal clinically important difference been identified A We have not identified a minimally clinically important difference but plan to do so Q12 Please clarify if question 4 ROM has a point maximum A In designing the scoring system for the Objective Score the intent was to give bonus points for extra ROM without completely changing the scaling of the original KSS In theory a thin patient with normal ROM say 155 degrees would score 31 points for the ROM component and could hypothetically score more than 100 pints for the Objective Score as a whole In practice this expected to happen only rarely Q13 How do we relate the new 2011 KSS to the old score A The 2011 Knee Society Score consists of 4 separate sub scales 1 An Objective Knee Score seven items 100 points 2 A Patient Satisfaction Score five items 40 points 3 A Patient Expectation Score three items 15 points and 4 A Functional Activity Score 19 items 100 points Both the new and old scores attempt to quantify patient outcome after TKA and both have an Objective score with sub scales for Pain Alignment Stability and ROM 100 points plus a separa
11. ld be avoided wherever possible This practice can be minimized by patient ID s linked to a central data base However the New Score collects some demographic data that we believe is both important and relevant in providing much needed context to the interpretation of outcome scores Thus the new forms request information concerning Charnley Classification and ethnicity in addition to the data obtained in the past Q17 Ifthe user is not able to modify the form how do you identify the individual Can the user add the following information e Account Patient Name on Demographic Page e At east Account and orinitials and the Date on Subsequent Pages of the evaluation A Yes the patient s name name or identification number may be added to the form Q18 Please clarify the following conflict The KS forms that the patient completes the SYMPTOMS portion of the evaluation regarding pain with walking and pain with stairs but the article in CORR indicates that this is completed by the surgeon A The pain data is collected from the patient during the patient interview and recorded on the form in the Objective evaluation section We chose to leave the pain score in the objective section since this was its place in the old score and allowed for easy comparison Q19 For postoperative evaluations how do you evaluate the information if the patient changes the activities they list as most important Are all the activities considered of equal
12. ments of patients undergoing knee arthroplasty and feature prominently in the new KSS Patient Expectations is a three question fifteen point scale that is collected pre operatively and post operatively The pre operative questions reflect the patient s opinion on the extent to which the patient expects that the operation will improve their knee pain and their ability to perform their activities of daily living and recreational activities The post operative questions reflect the extent to which the outcome after the operation has met the patient s pre operative expectations with respect to pain and function Patient Satisfaction is a five question 40 point scale that is collected preoperatively and at each follow up visit 2011 Knee Society Knee Scoring System Licensed User Manual 3 Functional Score The functional score has been greatly expanded to include more detailed patient specific activities not only activities of daily living but also sports and recreational activities The individual items were derived from a comprehensive inventory of activities that were condensed and validated from a 120 item survey The final group of questions was validated at 18 arthroplasty centers and form the basis of this score The functional score is composed of four subgroups and has a maximum score of 100 Walking and Standing has a maximum value of 30 points with deductions for the use of walking aids and supports Stan
13. point value A We are interested in the extent to which knee symptoms and function impact the ability of each patient to do whatever activities they consider most important WE realize the identity of these activities may change with time However though the activities may change their contribution to the function score does not change Q20 Is the new Knee Society score meant to be used nstead of or in conjunction with other outcome measures i e the SF12 SF36 WOMAC Oxford activity ratings such as the UCLA A The new Knee Society Score can be used in conjunction with other outcome measures that you find useful Part of the validation process involved confirmation that it was generally consistent with other knee specific scores Other outcome instruments may provide more general insight into patient health and disability Q21 Is the evaluation form meant to be used as part of a combined Pre Op Packet and a Post Op Packet with the surgeon and patient information together A Yes it is important to have a pre operative and post operative score This permits comparison and evaluation of change in the individual components of the score Q22 What are the recommended intervals for postoperative evaluation A That is determined by the physician or the study protocol A common practice is to score the patient pre op and then post op at 3 months 6 months 1 year and then annually as needed Q23 At our institution we
14. roven to be broadly applicable across gender age activity level and implant type Given the diverse activity profiles of many contemporary patients the functional component of the score was expanded to include a patient specific survey which evaluates features such as standard activities of daily living as well as patient specific sports and recreational activities patient satisfaction and patient expectations Portions of the original Knee Society Scoring System have been integrated into the new version to try to maintain integrity of the prior version of the Knee Society score Components of the 2011 Knee Society Score The new Knee Society Score is composed of five components 1 Patient Demographics Objective Knee Score completed by the surgeon Patient Expectations completed by the patient Patient Satisfaction Score completed by the patient Functional Knee Score completed by the patient ae UWwN 2011 Knee Society Knee Scoring System Licensed User Manual 2 Patient Demographics This section is self explanatory and includes a detailed modification of the Charnley Functional Classification This should be included at each evaluation period since the functional classification can change with length of follow up Objective Knee Score The new score is not significantly different from the objective knee score of the original KSS Unlike the old scoring system the new objective score allows for more than 100 points
15. te score for Function 100 points The old and new Knee Society Scores differ primarily in the activities contributing to the Function Score the weightings of each activity and the fact that we have additional scales for Expectations and Patient Satisfaction Moreover the new score has been formally validated in a multi center trial using standard psychometric procedures The new score is not intended to be numerically related to the old score Q14 How do the components of pain ROM alignment and function correlate to the new 2011 KSS A The Objective components of the original and new Knee Society Scores are very similar The New Objective Score assesses the following domains e Pain with walking 30 points Pain with stairs 20 points e Alignment Standing Radiograph max deduction 10 points e Stability Medial Lateral 15 points Anterior Posterior 10 points e Joint Motion ROM 25 points adjusted for flexion contracture and extension lag Q15 Before the scoring tool consisted of the KSS and the Knee Society Function Score each worth 100 points With the New KSS tool do these continue to be separate or is it now combined A They continue to be separate Q16 Weare concerned for the repeated collection of post op demographic data can this form be omitted and or modified 2011 Knee Society Knee Scoring System Licensed User Manual 7 A We all agree that collection of redundant data is not necessary and shou
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