Clinical Rheumatology

, Volume 16, Issue 2, pp 185–198

Reliability and validity of clinical outcome measurements of osteoarthritis of the hip and knee — A review of the literature

  • Y. Sun
  • T. Sturmer
  • K. P. Gunther
  • H. Brenner


High reliability and validity of clinical rating schemes is crucial for their use as outcome measurements of treatment of hip and knee osteoarthritis. In this paper, we review the empirical evidence on the reliability and validity of commonly used clinical scores. Clinical scores and related reliability and validity studies were identified by systematic literature search. Scores were classified according to the type and joint. Reliability and validity studies were characterized according to design, population, number and qualification of observers, number of measurements, time interval between repeat measurements and results. Reliability and validity studies were reported for only 6 and 15 of the 45 identified clinical scores, respectively. Although comparisons are difficult due to differences in study design, relatively high reliability was reported for most measurements of pain, stiffness, and physical function, while results are less conclusive for clinical signs. Most validity studies focused on the correlation between various scores. Correlation was generally found to be high for overall numerical ratings, but scores often differed with respect to the interpretation of these ratings. Validity has been more comprehensively studied for Lequesne's scores, WOMAC, and ILAS, and these scores have shown satisfactory responsiveness to different treatment effects. Overall, knowledge on reliability and validity of clinical scores of hip and knee osteoarthritis is limited, underlining the need for further properly designed and conducted studies.

Key words

Osteoarthritis Clinical Assessment Outcome Measurement Reliability and Validity 


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  1. 1.
    Felson DT. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev 1988; 10: 1–28.PubMedGoogle Scholar
  2. 2.
    Guccione AA, Felson DT, Anderson JJ/ Defining arthritis and measuring functional status in elders: methodological issues in the study of disease and physical disability. Am J Public Health 1990; 80: 945–9.PubMedGoogle Scholar
  3. 3.
    McDowell I, Newell C. Measuring Health: A guide to rating scales and questionnaires. New York, Oxford University Press, 1987.Google Scholar
  4. 4.
    Altman DG. Practical statistics for medical research. London, Chapman & Hall, 1991.Google Scholar
  5. 5.
    Brown MB, Benedetti JK. Asymptotic standard errors and their sampling behavior for measures of association and correlation in the two-way contingency table. Technical Report No. 23, Health Sciences Computing Facility, University of California, Los Angeles, 1976.Google Scholar
  6. 6.
    Bartko JJ. The intraclass correlation coefficient as a measure of reliability. Psychol Rep 1996; 19: 3–11.Google Scholar
  7. 7.
    Fleiss JL. Statistical methods for rates and proportions. 2nd ed., New York, Wiley and Sons, 1981.Google Scholar
  8. 8.
    Goodman, LA, Kruskal WH. Measures of association for cross-classification. J Am Stat Assoc 1954; 49: 732–64.Google Scholar
  9. 9.
    Guyatt G, Walter S, Norman G. Measuring change over time: Assessing the usefulness of evaluative instruments. J Chron Dis 1987; 40(2): 171–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Gade HG. A contribution to the surgical treatment of osteoarthritis of the hip joint: a clinical study. Acta Chir Scand 1947; 120: 37–45.Google Scholar
  11. 11.
    Judet R, Judet J. Technique and results with acrylic femoral head prosthesis. J Bone Joint Surg 1952; 34-B: 173–80.Google Scholar
  12. 12.
    Merle d'Aubigné R, Postel M. Functional results of hip arthroplasty with acrylic prothesis. J Bone Joint Surg 1954; 36-A: 451–75.PubMedGoogle Scholar
  13. 13.
    Shepherd MM. Assessment of function after arthroplasty of the hip. J Bone Joint Surg 1954; 36-B: 354–63.Google Scholar
  14. 14.
    Stinchfield FE; Cooperman B, Shea CE. Replacement of the femoral head by Judet or Austin Moore prosthesis. J Bone Surg 1957; 39-A: 1043–58.PubMedGoogle Scholar
  15. 15.
    Larson CB. Rating scale for hip disabilities. Clin Orthop 1963; 31: 85–93.PubMedGoogle Scholar
  16. 16.
    Danielson LG. Incidence and prognosis of coxarthrosis. Acta Orthop Scand (Suppl) 1964; 66: 1–114.Google Scholar
  17. 17.
    Lanzansky MG. A method for grading hips. J Bone Surg 1967; 49-B: 644–51.Google Scholar
  18. 18.
    Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. J Bone Joint Surg 1969; 51-A: 737–55.Google Scholar
  19. 19.
    Wilson PD, Amstutz HC, Czerniecki A, Salvati EA, Mendes DG. Total hip replacement with fixation by acrylic cement. A preliminary study of 100 consecutive McKee-Farrar prosthetic replacements. J Bone Joint Surg 1972; 54-A: 207–36.Google Scholar
  20. 20.
    Anderson G. Hip assessment: A comparison of nine different methods. J Bone Joint Surg 1972; 54-B: 621–25.Google Scholar
  21. 21.
    Charnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg 1972; 54-B: 61–76.Google Scholar
  22. 22.
    McKee GK, Chen SC. The statistic of the McKee-Farrar method of total hip replacement. Clin Orthop 1974; 95-26–33.Google Scholar
  23. 23.
    Lequesne MG, Mery C. European guidelines for clinical trials of new antirheumatic drugs. Eular Bull 1980; 9: 171–5.Google Scholar
  24. 24.
    Dutton RO, Amstutz HC, Thomas BJ, Hedley AK. Tharies surface replacement for osteonecrosis of the femoral head. J Bone Joint Surg 1982; 64-A: 1225–37.Google Scholar
  25. 25.
    Pellici PM, Wilson PD, Sledge CB, Salvati EA, Ranawat CS, Poss R, Calaghan JJ. Long-term results of revision total hip replacement: a follow-up report. J Bone Joint Surg 1985; 67-A: 513–6.Google Scholar
  26. 26.
    Kavanagh BF, Fitzgerald RH. Clinical and roentgenographic assessment of total hip arthroplasty. Clin Orthop 1984; 193: 133–40.Google Scholar
  27. 27.
    Yano H, Sano S, Nagata Y, Tabuchi K, Okinaga S, Seki H, Suyama T. Modified rotational acetabular osteotomy (RAO) for advanced osteoarthritis of the hip joint in the middle-aged person. First report. Arch Orthop Trauma Surg 1990; 109: 121–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Potter TA, Weinfeld MS, Thomas WH. Arthroplasty of the knee in rheumatoid arthritis and osteoarthritis. As follow-up study after implantation of the McKeever and McIntosh prostheses. J Bone Joint Surg 1972; 54-A: 1–24.Google Scholar
  29. 29.
    Ranawat CS, Shine JJ. Doncondylar total knee arthroplasty. Clin Arthop 1973; 94: 185–95.Google Scholar
  30. 30.
    Larson RL. Rating sheet for knee function. In: Diseases of the Knee Joint. Eds.: Smili, I., Edingburg, Churchill Livingstone, 1974, 28–30.Google Scholar
  31. 31.
    Kettelkamp DB, Thompson C. Development of a knee scoring scale. Clin Orthop 1975; 107: 93–9.PubMedGoogle Scholar
  32. 32.
    Wilson FC, Venters GC. Results of knee replacement with the Walldius prosthesis. An interim report. Clin Orthop 1976; 120: 39–46.PubMedGoogle Scholar
  33. 33.
    Freeman MAR, Todd RC, Cundy AD. The presentation of the results of knee surgery. Clin Orthop 1977; 128: 222–7.PubMedGoogle Scholar
  34. 34.
    Lotke, PA, Ecker ML. Influence of positioning of prosthesis in total knee replacement. J Bone Joint Surg 1977; 59-A; 77–9.Google Scholar
  35. 35.
    Aichroth PM, Freeman MAR, Smillie IS, Souter WA. A knee function assessment chart. J Bone Joint Surg 1978; 60-B, 308–9.Google Scholar
  36. 36.
    Ewald FC. Rheumatoid arthritis. Part III. Surgery of the knee in rheumatoid arthritis. The American Academy of Orthopaedic Surgeons. Instr Course Lect 1979, 28: 285–98.Google Scholar
  37. 37.
    Goldberg VM, Heiple KG, Ratnoff OD, Kurczynski E, Arvan G. Total knee arthroplasty in classic hemophilia. J Bone Joint Surg 1981; 63-A: 695–701.Google Scholar
  38. 38.
    Hungerford DS, Kenna RV, Krackow KA. The porous-coated anatomic total knee. Orthop Clin North Am 1982; 13: 103–22.PubMedGoogle Scholar
  39. 39.
    Lequesne M. Clinical features, diagnostic criteria, functional assessments and radiological classifications of osteoarthritis. Rheumatol 1982; 7: 1–10.Google Scholar
  40. 40.
    Wang WN. Clinical observations of Blauth's total endoprosthesis of the knee joint. Arch Orthop Trauma Surg 1984; 103: 263–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Weber U, Hackenbroch MH, Zwingers Th. Ergebnisse In: Endoprothetik am Kniegelenk, Derzeitiger technischer und klinischer Stand. Arbeitstagung, Köln 1984. Eds.: Weber U, Hackenbroch MH. (in German) Stuttgart — New York, Thieme, 1985.Google Scholar
  42. 42.
    Matthews LS, Goldstein SA, Kolowich PA, Kaufer H. Spherocentric arthroplasty of the knee. A long-term and final follow-up evaluation. Clin Orthop 1986; 205: 58–66.PubMedGoogle Scholar
  43. 43.
    Merkel KD, Johnson EW. Supracondylar fracture of the femur after knee arthroplasty. J Bone Joint Surg 1986; 68-A: 29–43.Google Scholar
  44. 44.
    Mackinnon J, Young S, Baily RAJ. The St Georg Sledge for unicompartimental replacement of the knee. A prospective study of 115 cases. J Bone Joint Surg 1988; 70-B: 217–23.Google Scholar
  45. 45.
    Hernigou P, Goutallier D. GUEPAR unicopartmental lotus prosthesis for single compartment femorotibial arthrosis. A five to nine-year follow-up study. Clin Orthop 1988; 230: 186–95.PubMedGoogle Scholar
  46. 46.
    Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society Clinical Rating System. Presented at the 4th open Scientific Meeting of the Knee Society, Las Vegas, Nevada, February 12, 1989.Google Scholar
  47. 47.
    Baumgaertner MR, Cannon WD, Vittori JM, Schmidt ES; Maurer RC. Arthroscopic debridement of the arthitic knee. Clin Orthop 1990; 253: 197–202.PubMedGoogle Scholar
  48. 48.
    Raunest J, Löhnert J. Arthroscopic cartilage debridement by excimer laser in chondromalacia of the knee joint, a prospective randomized clinical study. Arch Orthop Trauma Surg 1990; 109: 155–9.CrossRefPubMedGoogle Scholar
  49. 49.
    Larson KR, Cracchiolo A, Dorey FJ, Finerman GAM. Total knee arthroplasty in patients after patellectomy. Clin Orthop 1991; 264: 243–54.PubMedGoogle Scholar
  50. 50.
    Hofmann AA, Murdock LE, Wyatt RWB, Alpert JP. Total knee arthroplasty Two to four-year experience using an asymmetric tibial tray and a deep trochleargrooved femoral component. Clin Orthop 1991; 269: 78–88.PubMedGoogle Scholar
  51. 51.
    Jones A, Hopkinson N, Pattrick M, Berman P, Doherty M. Evaluation of a method for clinically assessing osteoarthritis of the knee. Ann Rheum Dis 1991; 51: 243–45.Google Scholar
  52. 52.
    Bellamy N. Osteoarthritis — An evaluative index for clinical trials. Msc Thesis. McMaster University, Hamilton, Canada. 1982.Google Scholar
  53. 53.
    Öberg U, Öberg T. Validity and reliability of a new assessment of lower extremity dysfunction. Phys Ther 1994; 74: 861–71.PubMedGoogle Scholar
  54. 54.
    Shields RK, Leo KC, Miller B, Dostal WF, Barr R. An acute physical therapy clinical practice database of outcomes research. Phys Ther 1994; 74: 463–70.PubMedGoogle Scholar
  55. 55.
    Lequesne MG, Samson M. A functional index for hip disease. Reproducibility. Value for discriminating drug's efficacy. 15th International Congress of Rheumatology. Expansion Scientifique française, Paris, 1981: 778–9.Google Scholar
  56. 56.
    Lequesne MG. Indexes of severity for osteoarthritis of the hip and knee. Scand J Rheumatol (Suppl) 1987; 65: 85–9.Google Scholar
  57. 57.
    Lequesne MG, Samson M. Indices of severity in osteoarthritis for weight bearing joint. J Rheumatol (Suppl 27) 1991; 18: 16–8.Google Scholar
  58. 58.
    Bellamy N, Buchanan WW, Goldsmith H, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically-important patient relevant outcomes to anti-rheumatic drug therapy on patients with osteoarthritis of the hip or knee. J Rheumatol 1988; 15: 1833–40.PubMedGoogle Scholar
  59. 59.
    Shields RK, Enloe LJ, Evans RE, Smith KB, Steckel SD. Reliability, validity, and responsiveness of functional tests in patients with total joint replacement. Phys Ther 1995; 7(3): 169–79.Google Scholar
  60. 60.
    Bryant MJ, Kernohan WG, Nixon JR, Mollan RAB. A statistical analysis of hip scores. J Bone Joint Surg 1993; 75-B: 705–9.Google Scholar
  61. 61.
    Bellamy N, Buchannan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study WOMAC: a health status instrument for measuring clinically-important patient-relevant outcomes following total hip or knee arthroplasty in osteoarthritis. J Orthop Rheumatol 1988; 15: 95–108.Google Scholar
  62. 62.
    Bellamy N, Wells G, Campbell J. Relationship between severity and clinical importance of symptoms in osteoarthritis. Clin Rheumatol 1991; 10(2): 138–43.CrossRefPubMedGoogle Scholar
  63. 63.
    Bradburn NM. The structure of psychological well being. Chicago, Aldine Publishing, 1969.Google Scholar
  64. 64.
    Chambers LW. McMaster health index questionnaire (MHIQ). Hamilton, McMaster University, Department of Clinical Epidemiology and Biostatistics, 1980.Google Scholar
  65. 65.
    Dieppe P. Recommended methodology for assessing the progression of osteoarthritis of the hip and knee joints. Osteoath Cat 1995; 3: 72–6.Google Scholar

Copyright information

© Clinical Rheumatology 1997

Authors and Affiliations

  • Y. Sun
    • 2
  • T. Sturmer
    • 2
  • K. P. Gunther
    • 1
  • H. Brenner
    • 2
  1. 1.Department of OrthopaediesUniversity of UlmUlmGermany
  2. 2.Department of EpidemiologyUniversity of UlmUlmGermany

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