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Cross-cultural adaptation and validation of the Japanese Knee Injury and Osteoarthritis Outcome Score (KOOS)

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Journal of Orthopaedic Science



In Japan, only few cross-culturally adapted, internationally used orthopaedic patient self-assessed outcome scores are available. In addition, the high incidence of knee osteoarthritis (OA) suggests the need for validated outcome measures such as the widely used Knee Injury and Osteoarthritis Outcome Score (KOOS) for Japanese populations. The purpose of this study was to provide a cross-culturally adapted and validated KOOS questionnaire for further use in national and international clinical projects involving Japanese patients.


The Japanese KOOS was developed according to the standard cross-cultural adaptation guidelines. For validation, the KOOS was tested on 58 patients diagnosed with OA. Reliability was tested using the intraclass correlation coefficient (ICC). Internal consistency or homogeneity was assessed using Cronbach’s alpha. Construct validity was evaluated by quantifying the correlation between the KOOS and the Japanese OKS and SF-36 questionnaires with Spearmann’s correlation coefficients.


No major difficulties were encountered during the translation and pre-testing stages. All five KOOS subscales showed adequate reproducibility with ICC values greater than 0.85, high internal consistency with Cronbach’s alpha values around 0.90, and high Spearmann’s coefficients over 0.50 signifying good correlation between the KOOS subscales and the OKS as well as the majority of the established subscales of the SF-36. No floor and ceiling effects were observed for the five subscales.


Our validated Japanese KOOS is a reliable and stable outcomes measure that provides a valuable basis for national and international clinical projects focusing on patient-based assessments in knee OA.

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  1. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25:3186–91.

    Article  PubMed  CAS  Google Scholar 

  2. Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol. 1993;46:1417–32.

    Article  PubMed  CAS  Google Scholar 

  3. Felson DT, Zhang Y, Hannan MT, Naimark A, Weissman BN, Aliabadi P, Levy D. The incidence and natural history of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum. 1995;38:1500–5.

    Article  PubMed  CAS  Google Scholar 

  4. Muraki S, Oka H, Akune T, Mabuchi A, En-yo Y, Yoshida M, Saika A, Suzuki T, Yoshida H, Ishibashi H, Yamamoto S, Nakamura K, Kawaguchi H, Yoshimura N. Prevalence of radiographic knee osteoarthritis and its association with knee pain in the elderly of Japanese population-based cohorts: the ROAD study. Osteoarthritis Cartilage. 2009;17:1137–43.

    Article  PubMed  CAS  Google Scholar 

  5. Hashimoto H, Hanyu T, Sledge CB, Lingard EA. Validation of a Japanese patient-derived outcome scale for assessing total knee arthroplasty: comparison with Western Ontario and McMaster Universities osteoarthritis index (WOMAC). J Orthop Sci. 2003;8:288–93.

    Article  PubMed  Google Scholar 

  6. Akai M, Doi T, Fujino K, Iwaya T, Kurosawa H, Nasu T. An outcome measure for Japanese people with knee osteoarthritis. J Rheumatol. 2005;32:1524–32.

    PubMed  Google Scholar 

  7. Kellgren JH, Jeffrey M, Ball J. Atlas of standard radiographs. Oxford: Blackwell Scientific; 1963.

    Google Scholar 

  8. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28:88–96.

    PubMed  CAS  Google Scholar 

  9. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–40.

    PubMed  CAS  Google Scholar 

  10. Roos EM, Lohmander LS. The Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis. Health Qual Life Outcomes. 2003;1:64.

    Article  PubMed  Google Scholar 

  11. Goncalves RS, Cabri J, Pinheiro JP, Ferreira PL. Cross-cultural adaptation and validation of the Portuguese version of the Knee injury and Osteoarthritis Outcome Score (KOOS). Osteoarthritis Cartilage. 2009;17:1156–62.

    Article  PubMed  CAS  Google Scholar 

  12. Ornetti P, Parratte S, Gossec L, Tavernier C, Argenson JN, Roos EM, Guillemin F, Maillefert JF. Cross-cultural adaptation and validation of the French version of the Knee injury and Osteoarthritis Outcome Score (KOOS) in knee osteoarthritis patients. Osteoarthritis Cartilage. 2007;18:522–9.

    Article  Google Scholar 

  13. Xie F, Li SC, Roos EM, Fong KY, Lo NN, Yeo SJ, Yang KY, Yeo W, Chong HC, Thumboo J. Cross-cultural adaptation and validation of Singapore English and Chinese versions of the Knee injury and Osteoarthritis Outcome Score (KOOS) in Asians with knee osteoarthritis in Singapore. Osteoarthritis Cartilage. 2006;14:1098–103.

    Article  PubMed  CAS  Google Scholar 

  14. Kessler S, Lang S, Puhl W, Stöve J. The Knee Injury and Osteoarthritis Outcome Score—a multifunctional questionnaire to measure outcome in knee arthroplasty. Z Orthop Ihre Grenzgeb. 2003;141:277–82.

    Article  PubMed  CAS  Google Scholar 

  15. de Groot IB, Favejee MM, Reijman M, Verhaar JA, Terwee CB. The Dutch version of the Knee Injury and Osteoarthritis Outcome Score: a validation study. Health Qual Life Outcomes. 2008;6:16.

    Article  PubMed  Google Scholar 

  16. Salavati M, Mazaheri M, Negahban H, Sohani SM, Ebrahimian MR, Ebrahimi I, Kazemnejad A, Salavati M. Validation of a Persian-version of Knee injury and Osteoarthritis Outcome Score (KOOS) in Iranians with knee injuries. Osteoarthritis Cartilage. 2008;16:1178–82.

    Article  PubMed  CAS  Google Scholar 

  17. Roos EM, Toksvig-Larsen S. Knee injury and Osteoarthritis Outcome Score (KOOS)—validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes. 2003;1:17.

    Article  PubMed  Google Scholar 

  18. Verkleij SP, Luijsterburg PA, Koes BW, Bohnen AM, Bierma-Zeinstra SM. Effectiveness of diclofenac versus acetaminophen in primary care patients with knee osteoarthritis: [NTR1485], DIPA-trial: design of a randomized clinical trial. BMC Musculoskelet Disord. 2010;11:7.

    Article  PubMed  Google Scholar 

  19. Birmingham TB, Giffin JR, Chesworth BM, Bryant DM, Litchfield RB, Willits K, Jenkyn TR, Fowler PJ. Medial opening wedge high tibial osteotomy: a prospective cohort study of gait, radiographic, and patient-reported outcomes. Arthritis Rheum. 2009;61:648–57.

    Article  PubMed  Google Scholar 

  20. Englund M, Lohmander LS. Patellofemoral osteoarthritis coexistent with tibiofemoral osteoarthritis in a meniscectomy population. Ann Rheum Dis. 2005;64:1721–6.

    Article  PubMed  CAS  Google Scholar 

  21. Dawson J, Fitzpatrick R, Murray D, Carr A. Questionnaire on the perceptions of patients about total knee replacement. J Bone Joint Surg Br. 1998;80:63–9.

    Article  PubMed  CAS  Google Scholar 

  22. Murray DW, Fitzpatrick R, Rogers K, Pandit H, Beard DJ, Carr AJ, Dawson J. The use of the Oxford hip and knee scores. J Bone Joint Surg Br. 2007;89:1010–4.

    PubMed  CAS  Google Scholar 

  23. Takeuchi R, Sawaguchi T, Nakamura N, Ishikawa H, Saito T, Goldhahn S. Cross-cultural adaptation and validation of the Oxford 12-item knee score in Japanese. Arch Orthop Trauma Surg. 2010;131:247–54.

    Article  PubMed  Google Scholar 

  24. Brazier JE, Harper R, Jones NM, O’Cathain A, Thomas KJ, Usherwood T, Westlake L. Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ. 1992;305:160–4.

    Article  PubMed  CAS  Google Scholar 

  25. Gross Portney L, Watkins MP. Foundations of clinical research—applications to practice. New Jersey: Prentice Hall Health; 2010.

    Google Scholar 

  26. Ware JEJ, Kosinski M, Dewey JE. How to score - version 2 of the SF-36 health survey (standard & acute forms). Rhode Island: QualityMetric Incorporated; 2001.

    Google Scholar 

  27. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, Bouter LM, De Vet HC. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60:34–42.

    Article  PubMed  Google Scholar 

  28. Japanese Ministry of Health, Labour and Welfare. Comprehensive survey of living conditions of the people on health and welfare. Accessed 17 Aug 2010.

  29. Edwards RR, Calahan C, Mensing G, Smith M, Haythornthwaite JA. Pain, catastrophizing, and depression in the rheumatic diseases. Nat Rev Rheumatol. 2011.

  30. Bellamy N, Sothern RB, Campbell J. Rhythmic variations in pain perception in osteoarthritis of the knee. J Rheumatol. 1990;17:364–72.

    PubMed  CAS  Google Scholar 

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The authors would like to acknowledge Toshinao Sawai and Naohiko Banno from Synthes K.K. for their administrative support, and Dr. Laurent Audigé from AO Clinical Investigation and Documentation for his statistical advice.

Conflict of interest

The work of the study was supported by the AO Foundation and Synthes Japan. The authors did not receive any benefits from any commercial party related directly or indirectly to the subject of this article.

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Correspondence to Sabine Goldhahn.

Additional information

The Japanese version of the KOOS will be published with a Japanese version of the abstract in the Journal of the Japanese Orthopaedic Association.

Electronic supplementary material

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Supplementary material (PDF 305 kb)



See Table 3

Table 3 Reliability data for the individual 42 items of the Japanese Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire

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Nakamura, N., Takeuchi, R., Sawaguchi, T. et al. Cross-cultural adaptation and validation of the Japanese Knee Injury and Osteoarthritis Outcome Score (KOOS). J Orthop Sci 16, 516–523 (2011).

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