This article has an erratum: [https://doi.org/10.1051/sicotj/2019023]
Volume 5, 2019
|Number of page(s)||13|
|Published online||08 March 2019|
Arabic translation and validation of three knee scores, Lysholm Knee Score (LKS), Oxford Knee Score (OKS), and International Knee Documentation Committee Subjective Knee Form (IKDC)
Faculty of Medicine, Assiut University, Assiut, Egypt
2 Department of Orthopedics and Truamatology, Assiut University Hospitals, Assiut, Egypt
* Corresponding author: email@example.com
Accepted: 14 November 2018
Aim of the work: Translation and validation of three commonly used knee scores to Arabic language: the Lysholm Knee Score (LKS), the Oxford Knee Score (OKS), and IKDC Subjective Knee Form.
Methods: Our work focused on translation and validation of the LKS, OKS and IKDC. Construct validity was assessed by comparing the LKS, OKS, and IKDC Subjective Knee Form and previous Arabic translated version of Knee injury and Osteoarthritis Outcome Score (KOOS). Test−retest reliability, internal consistency, and construct validity were assessed, using Intraclass Correlation Coefficient (ICC), Cronbach's alpha, and Pearson correlation coefficient (r).
Results: Reliability was excellent for the Arabic IKDC subjective form (0.95), while the Arabic LKS and the Arabic OKS were good: 0.8 and 0.85, respectively. The Cronbach's ά was excellent for the Arabic LKS and Arabic OKS: 0.9 and 0.90, respectively, while the Arabic IKDC subjective form was good (0.89). Construct validity was high for the Arabic LKS and the Arabic OKS: 0.7 and 0.913, respectively, while the Arabic IKDC was moderate (0.4) in cases of ACL and meniscus injuries and mild (0.18) in cases of osteoarthritis.
Conclusion: Arabic LKS and Arabic OKS were reliable and valid scores for patients complaining of ligamentous injuries, meniscus injuries, and osteoarthritis to be used for Arabic-speaking people, while the Arabic IKDC had excellent reliability and mild validity in cases of osteoarthritis and moderate validity in cases of ACL and meniscus injuries.
Key words: Lysholm Knee Score / Oxford Knee Score / International Knee Documentation Committee Subjective Knee Form / Knee injury and Osteoarthritis Outcome Score / translation / validation.
© The Authors, published by EDP Sciences, 2019
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Until now no valid translation of the LKS, OKS, and IKDC scores into Arabic language has been developed.
Cross-cultural adaptation protocols are necessary to adjust the health-related evaluation with languages to achieve excellent equality with the original form [7–10]. This operation indicates not only to the translation but also to the adaptation across the cultures, and adoption manners of different life [1,3,4].
The aim of our work was to translate and validate three of commonly used knee scores to Arabic version: LKS, OKS, and IKDC.
Translation of the original knee outcome score (English) into Arabic by two English translators.
Review of translations and synthesis of the first project (version 0.1).
Return to translation from Arabic to English for version 0.1 by two English translators.
Review of both the backward and forward translations. Formulation of the second version in Arabic (version 0.2) by a specialized language translator specializing in medical questionnaires and by a third translator.
Writing of version 1.0. after a few culture-related differences necessitated the use of some modifications to the original questions in order to suite the Arabic life style.
Patients in this study completed version 1.0 of these knee scores and statistical analysis of data was done upon this version 1.0. Patients were informed that their questions from these scores would be used for this study and informed consents were obtained. The patients were given Arabic version copy of the three knee outcome scores.
To establish reliability and construct validity, the scores were applied 15 days preoperative, 1 day preoperative, and 6 month post-operative and then compared with the KOOS that was previously translated and validated into Arabic language [1,5].
From March 2016 to November 2017, 100 patients with knee problems were recorded from the Assiut University Hospital, Egypt after pilot group. Our candidate inclusion criteria were ligamentous injuries, meniscus injuries, and osteoarthritis based on clinical and radiological findings by their orthopedic surgeon(s), age range was between 18 and 70 and the mean age was 38.7.
The patients were from Egypt and Arabic-speaking language with good education in order to understand and answer the questionnaire. Our candidate exclusion criteria were the refusal of patients to participate in the study and patients unable to read these scores.
The Lysholm Knee Scale (LKS) is divided into eight sections that assess instability (25 marks), pain (25 marks), catching (15 marks), stair climbing (10 marks), swelling (10 marks), need for support (5 marks), squatting (5 marks), and limping (5 marks).
Each response question has been assigned a random scale on an increasing scale. The total score is the sum of each response to the eight questions and may range from 0 to 100. Higher results of the score indicate a better result with fewer symptoms ([12–14], Appendix).
The IKDC Subjective Knee Form was divided into three sections: (1) symptoms including swelling, pain, stiffness, giving way, and locking, (2) sports , (3) current knee function and knee function after knee injury (not included in the total score) . Number of items of IKDC, 18 (7 items for symptoms, 1 item for sport activity, 9 items for daily activities, and 1 item for current knee function) (Appendix).
The KOOS consists of 42 items with five sections:
Symptoms (S), pain (P), sport, activities of daily living (ADL), and recreation (Sport/Rec), and quality of life related to the knee (QoL). The Likert scale was used from five points from 0 (no problem) to 4 (severe problems) to record each section and the scores from each unit were individually changed to 0 = 100 scale (0 = extreme knee problems, 100 = no knee problem) [5,10,19].
It refers to the proportion of the patient who did not respond to any question according to the previous visit to surgery. The feasibility study was analyzed in 100 questionnaires completed on the first visit [1,20]. It was represented using the Bland−Altman plot.
The reliability of the retest was applied to the current study of the 100 patients who answered the initial translated version of three knee scores after 15 days of initial visit. The reliability was assessed by Intra class Correlation Coefficient (ICC). It was considered acceptable, if it was equal to or greater than 0.7 [1,5].
It refers to a function of number of subscales and covariation. Random error due to item selection modeled in this estimate of reliability of the instruments based on internal consistency is Cronbach's ά [1,21,22]. It is calculated using a two-way fixed effects model, which measures the agreement between items.
Cronbach's ά is usually considered acceptable if the value is 0.70 or above [1,5]. Internal consistency was analyzed in the 100 questionnaires completed in the first visit. If the value of Cronbach's ά was 0.7, it is considered fair, if it was 0.8, it is considered good, and if it was 0.9, it is considered excellent [1,21,23].
It is a tool that measures the property being investigated. This was measured by comparing the results obtained in 100 completion surveys in 15 days preoperative, 1 day preoperative, and 6 months postoperative in both scales (three knee scores and KOOS) [1–3,12,13,20,22].
Construct validity was assessed through Pearson correlation coefficient (r) and it addressed the ability of whether the questionnaire measured what it was intended to measure  using the Spearman's rho [1,5]. Pearson correlations: r < 0.30 = low; 0.30 < r < 0.60 = moderate; r > 0.60 = high [1,5,22].
Of the 100 hundred included in the study, 55 cases (55%) were males while 45 cases were females (45%).
Fifty cases underwent knee arthroscopy: 30 cases for ACL reconstruction and 20 cases for arthroscopic partial menisectomy, while the remaining 50 cases complain of OA and underwent TKR (30 cases) and HTO (20 cases) (Figure 1).
Distribution of surgical procedure.
The patient's age ranges between 18 and 70, and the mean age = 38.7 years.
Differential age for various types of disease.
A-LKS: One hundred patients were studied for feasibility, of which 98 (98%) filled out the entire questionnaire, while 2 (2%) left question number 5 (locking) without answering.
A-OKS: One hundred patients were studied for feasibility, of which 95 (95%) filled out the entire questionnaire, while 5 (5%) left either question number 4 (How long can you walk before the pain from the knee becomes severe?) (with or without crutches) or question number 7 (Could you kneel down and get up afterward?) without answering.
A-IKDC subjective form: One hundred patients were studied for feasibility, of which 97 (97%) filled out the entire questionnaire, while 3 (3%) left either item number 6 (In past 4 weeks, or since injury, did knee catch?) or item number 7 (What is the level of activity that you can do without giving a clear knee way?) without answering.
ICC was excellent for the A-IKDC subjective form (0.95), while the A-LKS and A-OKS were good − (0.8) and (0.85), respectively.
Cronbach's ά was excellent for the A-LKS (0.9) and the A-OKS (0.90), while it was good for the A-IKDC subjective form (0.89).
A-LKS: Showed high construct validity against the KOOS (0.7).
A-OKS: Showed high construct validity against the KOOS (0.913).
A-IKDC: Showed moderate construct validity against the KOOS (0.58). The samples of the patients were divided into two groups:
ACL and meniscus injuries: The construct validity was moderate (0.4).
Osteoarthritis: The construct validity was mild (0.18).
Orthopedic scoring evaluation is an important tool in the evaluation of treatment effectiveness in orthopedic surgery. Ideally any score should be reliable, valid, and practical.
Although the LKS, OKS, and IKDC scores are adopted and validated in many languages, there is no Arabic adoption and validation for these scores. In this study, we translated and adopted these scoring systems into the Arabic language for patients undergoing knee surgery (ACL reconstruction, menisectomy, HTO, and TKR).
In this study, a few culture-related differences necessitated the use of some modifications to the original questions in order to suit the Arabic life style. In the LKS, question 8 was modified by adding the inquiry about squatting during praying and eating on the ground, which is quite common among Arab population as well as farming. In the IKDC score, question 9 is modified by adding the inquiry about squatting in a manner similar to question 8 in the LKS. In the IKDC score, the low-demand sport in question 8 is defined as walking and bicycling rather than golf and bowling.
In other studies, during cross-cultural adaptation of the LKS into Chinese language [1,4], most patients found difficulty to understand the terms in the questionnaire, for example, “catching” and “instability”; therefore, the meaning of these terms was attached in simple language beside it the final version of the Chinese LKS during the pre-evaluation period. This was similar to cross-cultural adaptation of the IKDC subjective form into Korean language [4,24]. Authors have held a committee of experts several times on the cultural equivalence of cultural and linguistic aspects during intercultural adaptation as “giving way,” and “squatting” are common terms in English language. In contrast to the Korean language, these words were not found. Thus, the authors discussed some expressions that are composed of several words and can be easily understood among Koreans without changing the original meaning. In addition, Koreans are familiar with the metric system, so miles were converted to meters . In contrast to the Portuguese LKS , questionnaire was easy to understand, especially that it was applied on individuals with good educational level, so there were no difficulties in reading it. Also, during the cross-cultural adaptation of the OKS into Finnish language , all participants deemed the questionnaire to be straightforward and easy to complete.
The results of the A-LKS and A-OKS were very good, no difficult questions, a few confusing items, and very low percentage of lost data for the items. These facts confirm that there are no translation problems, which is a reliable and valid measure for patients in Arabic-speaking countries with a variety of knee problems . This is in contrast to the A-IKDC which had mild to moderate validity.
Reliability was good for the A-LKS (0.8) and A-OKS (0.85), while it was excellent for the A-IKDC subjective form (0.95). This is similar to the Greek IKDC (0.095) in patients with knee-related injuries , the Portuguese LKS (0.9) in patients complaining of ACL injuries , the Swedish OKS (0.94) in patients complaining of osteoarthritis , and the Chinese LKS (0.935) in patients complaining of ACL injuries . It was good for the Finnish OKS (0.81) in patients complaining of osteoarthritis .This shows that the Arabic translation of LKS, OKS, and IKDC is reliable and this means that there is no difference between the test–retest values.
The internal consistency was accepted for all of the three scores. In this study, Cronbach᾿s ά for the A-LKS and A-OKS was excellent: 0.9 and 0.90, respectively. The internal consistency for the A-IKDC subjective form was good (0.89). This is similar to the Portuguese LKS (Cronbach's ά = 0.9) , the Turkish OKS (Cronbach's α: 0.90) in patients complaining of osteoarthritis , the Swedish OKS (Cronbach's ά = 0.93) , and the Greek IKDC (Cronbach's α = 0.87) . In contrast, the Korean IKDC (K-IKDC) was excellent (Cronbach's α = 0.91) . This indicates that there is a strong relationship regarding the data collected in the first visit.
The construct validity of the A-LKS showed high construct validity against the KOOS (0.7) similar to the construct validity of the Chinese LKS in patients complaining of ACL injuries against the IKDC and WOMAC (r = 0.837) ; the A-OKS also showed high construct validity against the KOOS (0.913) similar to the correlation between the Finnish OKS and the RAND-36 questionnaire and KOOS (r = 0.913) . In contrast to the construct validity for the Turkish OKS against the WOMAC, SF-36 scores showed a significant correlation (r < 0.05) .
The A-IKDC subjective form showed mild construct validity against the KOOS (r = 0.18) in cases of osteoarthritis. It showed a moderate construct validity against the KOOS (r = 0.4) in the cases of ACL and meniscus injuries. The explanation for this result might be that the IKDC is mainly planned for sports injuries rather than osteoarthritis. This is confirmed by the low pre-operative and post-operative scores, as the IKDC is most useful to evaluate patients presented with ACL injury . The construct validity of A-IKDC in cases of ACL and meniscus injuries is only moderate. The explanation for this result might be that the IKDC has many questions and with some repetitions that confuse the patients. This is similar to the correlation between the Greek IKDC and the SF-36 (r = 0.60) in patients with knee-related injuries .
The limitation in our study was the lack of comparison to other Arabic versions of knee questionnaires besides the KOOS that would have allowed us to better assess the construct validity.
The A-LKS and A-OKS are reliable and valid scores for patients suffering from ligamentous injuries, meniscus injuries, and osteoarthritis. While the A-IKDC has excellent reliability and mild validity in cases of osteoarthritis and moderate validity in cases of ACL and meniscus injuries. These scores are a good outcome tool for use in Arabic-speaking countries.
The authors declare that they have no conflicts of interest in relation to this article.
Special thanks to all staff members of arthroplasty unit for their help and support to complete this work and Dr. Mysara Bayoumy helping us in the preparation of this manuscript.
- Huang C-C, Chen W-S, Tsai M-W, Wang WTJ (2017) Comparing the Chinese versions of two knee-specific questionnaires (IKDC and KOOS): reliability, validity, and responsiveness. Health Qual Life Outcomes 15, 238. [CrossRef] [PubMed] [Google Scholar]
- Talbot S, Hooper G, Stokes A, Zordan R (2010) Use of a new high-activity arthroplasty score to assess function of young patients with total hip or knee arthroplasty. J Arthroplasty 25(2), 268–273. [PubMed] [Google Scholar]
- Collins NJ (2011) Measures of knee function. Arthritis Care Res 63(11), 208–228. [Google Scholar]
- Wang W, Liu L, Chang X, Jia ZY, Zhao JZ, Xu WD (2016) Cross-cultural translation of the Lysholm knee score in Chinese and its validation in patients with anterior cruciate ligament injury. Musculoskelet Disord 19(17), 436. [CrossRef] [Google Scholar]
- Almangoush A, Herrington L, Attia I, Jones R, Aldawoudy A, Abdul Aziz A, Waley A (2013) Cross-cultural adaptation, reliability, internal consistency and validation of the Arabic version of the Knee injury and Osteoarthritis Outcome Score (KOOS) for Egyptian people with knee injuries. Osteoarthritis Cartilage 21(12), 1855–1864. [CrossRef] [PubMed] [Google Scholar]
- Seijas R, Sallent A, Ruiz-Ibán M, Ares O, Marín-Peña O, Cuéllar R, Muriel A (2014) Validation of the Spanish version of the hip outcome score: a multicenter study. Health Qual Life Outcomes 12, 70. [CrossRef] [PubMed] [Google Scholar]
- Guillemin F (1995) Cross-cultural adaptation and validation of health status measures. Scand J Rheumatol 24(2), 61–63. [CrossRef] [PubMed] [Google Scholar]
- Guillemin F, Bombardier C, Beaton D (1993) Cross-cultural adaptation of health-related quality of life measures: literatures review and proposed guidelines. J Clin Epidemiol 46 (12), 1417–1432. [CrossRef] [PubMed] [Google Scholar]
- Beaton DE, Bombardier C, Guillemin F, Ferraz MB (2000) Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 25(24), 3186–3191. [CrossRef] [PubMed] [Google Scholar]
- Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, et al. (2005) Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) measures: report of the ISPOR task force for translation and cultural adaptation. Value Health 8(2), 94–104. [CrossRef] [PubMed] [Google Scholar]
- Pfeiffer E (1975) A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 23(10), 433–441. [PubMed] [Google Scholar]
- Smith HJ, Richardson JB, Tennant A (2009) Modification and validation of the Lysholm Knee Scale to assess articular cartilage damage. Osteoarthritis Cartilage 17 (1), 53–58. [CrossRef] [PubMed] [Google Scholar]
- Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR (2009) The reliability, validity and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee. Am J Sports Med 37(5), 890–897. [Google Scholar]
- Celik D, Coşkunsu D, Kılıçoğlu Ö (2013) Translation and cultural adaptation of the Turkish Lysholm Knee Scale: ease of use, validity, and reliability. Clin Orthop Relat Res 471(8), 2602–2610. [CrossRef] [PubMed] [Google Scholar]
- Roos EM (1998) A user's guide to Knee injury and Osteoarthritis Outcome Score KOOS. J Orthop Sports Phys Ther 78(2), 88–96. [Google Scholar]
- Dawson J, Fitzpatrick R, Murray D, Carr A (1998) Perceptions of patients about total knee replacement. J Bone Joint Surg Br 80(1), 63–69. [CrossRef] [PubMed] [Google Scholar]
- Khanna G, Singh JA, Pomeroy DL, Gioe TJ (2011) Comparison of patient-reported and clinician-assessed outcomes following total knee arthroplasty. J Bone Joint Surg 93(20), 117. [Google Scholar]
- Higgins, LD, Taylor MK, Park D, Ghodadra N, Marchant M, Pietrobon R, Cook C (2007) Reliability and validity of the International Knee Documentation Committee (IKDC) Subjective Knee Form. Joint Bone Spine 74(6), 594–599. [CrossRef] [PubMed] [Google Scholar]
- Roos EM, Toksvig-Larsen S (2003) Knee injury and Osteoarthritis Outcome Score (KOOS) − validation and comparison to the WOMAC in total knee replacement. J Orthop Sports Phys Ther 28(2), 88–96. [Google Scholar]
- Ruiz-Iban MA, Seijas R, Sallent A, Cuéllar R (2015) The international Hip Outcome Tool-33 (iHOT-33): multicenter validation and translation to Spanish version. Health Qual Life Outcome 13(1), 1. [CrossRef] [Google Scholar]
- Cronbach LJ (1951) Coefficient alpha and the internal structure of tests. Psychometrika 16(3), 297–334. [Google Scholar]
- Streiner DL, Norman GR (2003) Health measurement scales: a practical guide to their development and use. Aust N Z J Public Health 40 (3), 294–295. [Google Scholar]
- Mobasheri A (2018) Osteoarthritis: from basic and translational approaches to clinical practice. Musculoskelet Disord 13(1), 12–18. [Google Scholar]
- Kim JG, Ha JK, Lee JY, Seo SS, Choi CH, Lee MC (2013) Translation and validation of the Korean version of the International Knee Documentation Committee Subjective Knee Form, Knee Surg Relat Res 25(3), 106–111. [CrossRef] [PubMed] [Google Scholar]
- Peccin MS, Ciconelli R, Cohen M (2006) Specific questionnaires for knee symptoms − The Lysholm Knee Scoring Scale − translation and validation into Portoguese. Acta Orthop Bras 14 (5), 268–272. [CrossRef] [Google Scholar]
- Reito A, Järvistö A (2017) Translation and validation of the 12-item Oxford knee score for use in Finland. Musculoskelet Disord 18 (1), 1. [CrossRef] [Google Scholar]
- Koumantakis GA, Tsoligkas K, Drosos GI (2016) Cross-cultural adaptation and validation of the International Knee Documentation Committee Subjective Knee Form in Greek version. J Orthop Traumatol 17 (2), 123–129. [Google Scholar]
- Dunbar MJ, Robertsson O, Ryd L, Lidgren L (2000) Translation and validation of Swedish version of OKS. Acta Orthop Scand 71 (3), 268–274. [CrossRef] [PubMed] [Google Scholar]
- Tuğay BU, Tuğay N, Güney H, Kınıkl Gİ, Yüksel İ, Atilla B (2013) Translation and validation of Korean version of OKS. Clin Orthop Relat Res 471(2), 600–605. [CrossRef] [PubMed] [Google Scholar]
- Van Meer BL, et al. (2013) Knee injury and Osteoarthritis Outcome Score or International Knee Documentation Committee Subjective Knee Form which questionnaire is most useful to monitor patients with an anterior cruciate ligament rupture in the short term? Arthroscopy 29(4), 701–715. [CrossRef] [PubMed] [Google Scholar]
Cite this article as: Ahmed KM, Said HG, Ramadan EKA, El-Radi MA & El-Assal MA (2019) Arabic translation and validation of three knee scores, Lysholm Knee Score (LKS), Oxford Knee Score (OKS), and International Knee Documentation Committee Subjective Knee Form (IKDC). SICOT-J, 5, 6.
Current usage metrics show cumulative count of Article Views (full-text article views including HTML views, PDF and ePub downloads, according to the available data) and Abstracts Views on Vision4Press platform.
Data correspond to usage on the plateform after 2015. The current usage metrics is available 48-96 hours after online publication and is updated daily on week days.
Initial download of the metrics may take a while.