The New Knee Society Knee Scoring System

Abstract

In 1989, The Knee Society Clinical Rating System [3] was developed as a simple, but objective scoring system to rate the knee and patient’s functional abilities such as walking and stair climbing before and after TKA. Since the scoring system did not include assessment of radiographs, The Knee Society endorsed a method to evaluate radiographs [2]. The Knee Society Clinical Rating System has been the most popular method of tracking and reporting outcomes after total and partial knee arthroplasty worldwide. However, the reliability, responsiveness, and validity of the original score have been challenged. In addition, it became clear over time that there were ambiguities and deficiencies with the original Knee Society Clinical Rating System that challenged its utility and validity in our contemporary patients, who often have expectations, demands, and functional requirements that are different from those of prior generations of patients who underwent knee arthroplasty. The Knee Society therefore embarked on a complete review of the previous system. The project started more than 3 years ago and involved Knee Society members from 18 institutions in the United States and Canada; these individuals contributed more than 500 cases of both preoperative and postoperative TKA. The magnitude of this exhaustive project involved a multidisciplinary team of arthroplasty surgeons, epidemiologists, and statisticians. The prior objective knee score was amplified from the prior Knee Society score to incorporate current knee arthroplasty clinical parameters. The functional component of the new score was developed on the basis of comprehensive inventories of the activities and observations of 101 patients at five major knee arthroplasty centers who completed a 120-item survey, which was ultimately condensed down to the current assessment tool. This assessment tool was then included in the validation process at the 18 participating centers. The final scoring system was then approved by the Knee Society Scoring Committee. The new Knee Society Knee Scoring System is both physician and patient derived. It includes versions to be administered preoperatively (Appendix 1) and postoperatively (Appendix 2). It has an initial assessment of demographic details, including an expanded Charnley functional classification [1]. The objective knee score, completed by the surgeon, includes a VAS score of pain walking on level ground and on stairs or inclines, as well as an assessment of alignment, ligament stability, and ROM, along with deductions for flexion contracture or extensor lag. Patients then record their satisfaction, functional activities, and expectations. Given the diverse activity profiles of many contemporary patients, the functional component of the score was improved to include a patient-specific survey, which evaluates features such as standard activities of daily living, patient-specific sports and recreational activities, patient satisfaction, and patient expectations. Portions of the original Knee Society Clinical Rating System have been integrated into the new version to maintain the integrity of the prior version of the Knee Society score. The new Knee Society Knee Scoring System has been developed and validated, in part, to better characterize the expectations, satisfaction, and physical activities of the younger and more diverse population of current patients undergoing TKA. The new score provides sufficient flexibility and depth to capture the diverse lifestyles and activities of our current patients. The score was validated in a thoughtful and methodical fashion confirming internal reliability and analyzed for differential item functioning [4]. The new Knee Society Scoring System is broadly applicable across sex, age, activity level, and implant type. In conclusion, the new Knee Society Scoring System is a validated and responsive method for assessing objective and subjective outcomes after total and partial knee arthroplasty, without the ambiguities of the prior scoring system. As physicians, clinical practices, and health systems become increasingly more responsible for reporting patient outcomes, the clear value of this new scoring system will become apparent. The new scoring system is available through application on the Knee Society Web site (http://www.kneesociety.org).