Translation and Validation of the German New Knee Society Scoring System
Authors: Kayaalp Mahmut Enes , Keller Thomas , Fitz Wolfgang , Scuderi Giles R. , Becker Roland 
Published: November 2018

Abstract

Background
In 2011 the Knee Society Score (KSS) was revised to include patient expectations, satisfaction, and physical activities as patient-reported outcomes. Since the new KSS has become a widely used method to evaluate patient status after TKA, we sought to translate and validate it for German-speaking populations.

Questions/purposes
After translation of the new KSS into German using established guidelines, we sought to test the new German version for (1) validity; (2) responsiveness; and (3) reliability.

Methods
The new KSS form was translated and adapted according to the available guidelines. The final version was used to validate the German version of the new KSS (GNKSS) in 133 patients undergoing TKA, of which 100 patients were included in the study as per inclusion criteria. Patients completed the GNKSS form along with the German WOMAC and the German SF-36 scores preoperatively and at the 2-year postoperative followup. Construct validity was tested by comparing domain scores of the GNKSS with domain scores of the German WOMAC and the SF-36. Responsiveness was evaluated by comparing pre- and postoperative scores in all questionnaires in all patients using standardized response means. To evaluate reliability, every second patient (n = 50) in the whole group was asked to complete the GNKSS form a second time 1 week after their 2-year followup; 39 patients responded. This sample group was considered representative after testing the difference among age, sex, body mass index, operation side, preoperative or postoperative GNKSS, and WOMAC scores with the original group. Intraclass correlation coefficients (ICCs) were used to assess reliability and Cronbach’s α was an indicator of internal consistency of each domain score.

Results
Construct validity was excellent pre- and postoperatively between the GNKSS and the WOMAC for domains including symptoms, satisfaction, total functional score, and total score and activity subdomains, except the expectation domain and advanced and discretionary subdomains of the GNKSS and the stiffness domain of WOMAC. The expectation domain showed either no significant correlation or only weak correlations with the domains of WOMAC pre- as well as postoperatively (r ranging between -0.19 and -0.34). Correlation of the function section of the GNKSS as well as the physical function and role-physical domains of the SF-36 pre- and postoperatively were moderate to strong, respectively, with statistically significant (p < 0.001) r values of 0.49 and 0.48 preoperatively and 0.73 and 0.65 postoperatively. Correlation of the symptom section of the GNKSS and bodily pain domain of the SF-36 was also strong pre- and postoperatively. Regarding responsiveness, all domains of the GNKSS showed large changes except the expectation domain. The symptom and functional sections of the GNKSS showed higher responsiveness than the corresponding pain and function domains of the WOMAC and bodily pain and physical function domains of the SF-36. Also, the total score changes were larger for the GNKSS compared with the WOMAC. No floor or ceiling effect was observed. Reliability was excellent with ICCs of 0.83 to 0.97 as an indicator of test-retest reliability and Cronbach’s α values of 0.78 to 0.85 preoperatively and 0.92 to 0.94 postoperatively as an indicator of internal consistency for all domains and subdomains.

Conclusions
The GNKSS is a valid, responsive, reliable, and consistent outcome measurement tool that may be used to evaluate the outcome of TKA.

Level of Evidence
Level II, diagnostic study.