Journal of Musculoskeletal Research, Vol. 18, No.

1 (2015) 1550003 (8 pages)

© World Scientific Publishing Company
DOI: 10.1142/S0218957715500037

VALIDITY OF THE RETROSPECTIVE APPLICATION

OF OXFORD HIP AND KNEE SCORES

Travis M. Falconer
,¶, Julie Headford†, Stephen Edmondston‡

and Piers J. Yates§


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Perth Orthopaedic & Sports Medicine Center

by GRAND VALLEY STATE UNIV on 09/16/16. For personal use only.

Sir Charles Gairdner Hospital

31 Outram Street, West Perth, WA 6008, Australia
†
Fremantle Hospital, Alma Street
Fremantle WA 6160, Australia
‡
University of Notre Dame, Western Australia
§
Fremantle Hospital, Kaleeya Hospital
St. John of God Hospital Murdoch
¶travisfalconer@me.com

Received 14 December 2014

Accepted 6 April 2015
Published 25 June 2015

ABSTRACT
The Oxford Hip Score (OHS) and Oxford Knee Score (OKS) are validated, reliable and reproducible
outcome measures, however their use retrospectively has not been examined. The aim of this pro-
spective cohort study was to examine the accuracy and reliability of patients’ ability to recall their OHS
and OKS in a retrospective manner. A total of 137 patients undergoing primary hip (40) or primary
knee (97) arthroplasty with a mean age of 70.8 years (range, 47–88) and a mean time to follow up of
27.2 months (range, 6–46) were included in the study. The mean retrospective OHS and OKS de-
creased compared to the pre-operative score (OHS ¼ 1:6  SD, p ¼ 0:36, OKS ¼ 4:7  SD, p < 0:001).
There was only a weak positive relationship between the actual pre-operative scores and the retro-
spective scores (OHS: r 2 ¼ 0:30, OKS: r 2 ¼ 0:19). Bland–Altman analysis demonstrated 95% limits of
agreement between scores of 19.9 to 23.1 for the OHS and 15.3 to 24.8 for the OKS. This study

¶ Correspondence to: Travis M. Falconer, Perth Orthopaedic & Sports Medicine, Center, Sir Charles Gairdner Hospital,
31 Outram Street, West Perth, WA 6008, Australia.

1550003-1
 T. M. Falconer et al.
shows that patients are poor at retrospectively recalling their pre-operative OHS and OKS and
therefore these scores should not be used in a retrospective manner.
Keywords: Retrospective; Hip; Knee; Oxford; Arthroplasty; Recall.
INTRODUCTION
Since their inception in the mid to late 90s, the
Oxford Hip Score (OHS) and Oxford Knee Score
(OKS) have become useful tools for the overall
clinical assessment of patients undergoing hip
and knee arthroplasty. These patient-centered
outcome measures have shifted the focus from
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morbidity and complication-based outcomes, to
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patient focused functional ability and satisfac-
tion-based scores as measures of successful sur-
gery.1 Quantifying functional and symptomatic
improvements with the use of such outcome
measures is a paramount for well-designed clin-
ical research.10
The OHS and OKS are reliable, internally valid
and simple assessments that have a high response
rate, and eliminate surgeon bias.4–6,8 Because
they are patient derived, quick and easy they can
be reliably performed via a postal questionnaire,
making them very time efficient and cost effective
for clinicians.8 They are also joint specific and
relatively eliminate the effect of patient co-mor-
bidities7,11 allowing a standardized comparison
across many applications.
These outcome measures are not only useful
when comparing the outcomes of arthroplasty
between patient groups, institutions and between
prostheses, but can also be highly useful when
scores are coupled pre and post operatively to
examine individual patients outcomes and elim-
inate other sources of bias.10 There are however,
many instances where the pre-operative score has
not been recorded. In such cases, if a pre-opera-
tive score was to be obtained, patients would
have to retrospectively recall their symptoms,
pain and functional status preceding their
arthroplasty. While a similar concept has been
4,5 explored for the Oxford Shoulder Score (OSS),10
to our knowledge there have been no studies
examining this application of OHS and OKS. This
study examines the reliability and accuracy of the
retrospective application of the OHS and OKS.
MATERIALS AND METHODS
All patients who underwent a joint replacement
at Fremantle Hospital Health Service (FHHS) are
pre-assessed medically and surgically. They are
evaluated using pre-operative outcomes score
relevant to the type of joint replacement that they
are having, at the time of their surgical consent
process approximately 1–2 weeks before surgery.
The medical records for all patients undergoing
primary hip or knee replacements by the De-
partment of Orthopaedics at the FHHS between
the May 2007 and August 2010 were examined.
Those that had successfully completed a pre-op-
erative OHS or an OKS and were having a pri-
mary arthroplasty were included.
Patients with documented cognitive impairment
and children under 16 years of age were excluded.
Approval from the Clinical Governance Unit at
the FHHS was obtained before taking consent
from participants.
Once these patients were identified, they were
invited to take part in the study by way of postal
mail. Each patient was sent an instructional letter,
consent form, the relevant OHS or OKS and an
SF-12 Health Outcomes Score. Patients who did
not respond after six weeks, were contacted by
phone to request their participation. Patients
were asked to complete the score as if it were the
1550003-2

day before their joint replacement. They would
have to remember their symptoms prior to their
hip or knee replacement as opposed to filling the
survey out based on current symptoms.
A power calculation was performed based
upon a similar previous study looking at the
retrospective use of the OSS.10 Wilson et al. as-
sumed that a clinically significant change was 5
points across the OSS. They calculated the mini-
mum number of participants to be 10, giving a
power of 90% to detect a five-point difference in
the OSS. In the present study, we are examining
two sets of data and have focused upon the level
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of agreement rather than the statistically signifi-
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cant differences between the pre-operative and
retrospective scores. The five-point difference is
important in the interpretation of differences
in OHS and OKS, as this has been defined
as the threshold of Minimal Clinical Important
Difference.8
Statistical Analysis
Statistical analysis was carried out using SPSS
13.0 (SPSS Inc.). The two sets of scores were ex-
amined for normality of distribution, and paired
t-tests used to test for significant differences be-
tween pre-operative and retrospective scores.
Bland–Altman analysis3 was used to define the
95% limits of agreement between pre-operative
Fig. 1
1550003-3
Retrospective Recall of OHS and OKS
and retrospective scores, and linear regression
analysis was used to examine the linear rela-
tionship between the two scores. To examine the
influence of time since surgery on recall accuracy,
each patient group was stratified with annual
increments and one factor analysis of variance
was used to test for the effect of time on recall
accuracy. For all analyses, the criterion for sta-
tistical significance was set at p < 0:05.
RESULTS
A total of 42 of 70 (60%) patients successfully
completed the retrospective OHS and 97 of 156
(62.2%) patients completed the OKS. This gave an
overall completion rate of 61.5% (139/226). The
mean time to follow-up was 26.1 months (range
9–46) for the hip group and 27.6 months (range 6–
46) for the knee group. The mean age of the
patients was 70.3 years (range 47–88) and 71.0
years (range 53–88) for the hip and knee groups,
respectively.
Frequency histograms showing the distribu-
tion of pre-operative and retrospective OHS and
OKS are shown in Figs. 1 and 2, and descriptive
statistics summarized in Table 1. The mean dif-
ference between the pre-op and retrospective
OHS was 1.6 points, which was not significantly
different ( p ¼ 0:36). There was also a decrease
of 4.7 points between the pre-operative (42.4)
 T. M. Falconer et al.
Fig. 2
Table 1 Summary of Pre-Operative and Retrospective OHS and OKS.
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Minimum
OHS Actual Pre-op 20
OHS Retrospective Estimate 14
OKS Actual Pre-op 13
OKS Retrospective Estimate 13
and retrospective (37.7) mean OKS scores (p ¼
< 0:001). This difference is consistent with the
MCID for the OHS and OKS proposed by Murray
et al.8 who proposed that clinically significant
differences in the OHS and OKS are likely to be
between 3 and 5. Table 1 displays the pre-oper-
ative and post-operative means and associated
standard deviations. It is important to note
that the post-operative standard deviations are
much larger than the actual pre-operative scores,
showing the considerable variability between the
two sets of scores in both the OHS and OKS.
When using regression analysis to determine
the strength of the relationship between the pre-
operative and retrospective scores for both
groups, the Pearson’s rank correlation coefficient
shows only a weakly positive relationship in both
the OHS (r 2 ¼ 0:30) and OKS (r 2 ¼ 0:19) as dis-
played in Fig. 3. This shows that the retrospective
estimates only explain 30% and 19% of the vari-
ance in the pre-operative actual scores for the
OHS and OKS, respectively, thus making it a
1550003-4
Maximum Mean Standard Dev.
57 42.6 9.2
55 41.0 11.1
57 42.4 7.8
57 37.7 10.2
poor predictor of the actual pre-operative score.
Adjusting for age, gender and health (SF-12,
mental and physical scores) did not improve the
model fit.
The level of agreement between the pre-oper-
ative and retrospective scores, which is arguably
the most important factor in this analysis is best
displayed using the Bland–Altman plot, first de-
scribed in 1986.2 This technique plots the mean
differences between scores against the mean of
the two scores, as shown in Fig. 4. While the
mean differences for both the OHS and OKS were
small (1.6 and 4.7, respectively), the 95% limits of
agreement are large in both cases (19.9 to 23.1
for the OHS, and 15.3 to 24.8 for the OKS). This
then suggests that while the level of agreement
across the group is good, the limits of agreement
are too large to permit accurate estimation of in-
dividual scores.
The data was also analyzed for the influence of
time, and patients grouped according to their
time between surgery and recall. The sub-groups

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Fig. 3
were 0–12 months, 13–24 months, 25–36 months
and 37–48 months for both the OHS and OKS as
shown in Figs. 5 and 6. This was done using one
factor ANOVA analysis comparing the means in
the subgroups over the four time periods. It is
important to note that the number of patients in
each time interval is not equal in both analyses,
and each OHS sub-group is small. There was no
significant difference between means across all 4
periods for both the OHS and OKS (p > 0:05).
When examining the OKS group closer, there was
a tendency for the spread of scores to be less in
the 0–12 month group, as indicated by a lower
standard deviation when comparing to the other
Fig. 4
1550003-5
Retrospective Recall of OHS and OKS
time periods, suggesting a more accurate recall
during the first year.
DISCUSSION
The OHS and OKS underwent extensive assess-
ment of validity, reliability and responsiveness in
many prospective trials as described by Wilson
et al.10 However, their retrospective use has not
yet been addressed in the literature. Knowing the
strengths and limitations of a scoring system is
integral to the overall applicability as well as the
validity and reliability.9 The simple, responsive
and patient centered nature of the OHS and OKS
 T. M. Falconer et al.
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Fig. 5

makes them ideal for retrospective application,
especially in the setting of trauma. Since they
require no clinician contact, no radiology mea-
surements and can be easily applied by mail, in-
vestigating the validity in this retrospective
manner is important for overall clinical practice.
Selection bias was minimized in this study by
including all patients who had undergone a pri-
mary hip or knee replacement over a three-year
period and had no documented cognitive im-
pairment. This allowed patients from a number of
different surgeons, using different approaches

Fig. 6

1550003-6

and different implants to be included. As the
participants were invited to take part by mail, it
could be assumed that only those who were
mentally capable of understanding the study
were included, with an overall response rate of
60.6%.
In the present study, we found no significant
influence of time since surgery on accuracy of
recall when comparing across different post-sur-
gical time increments. When comparing the four
time intervals, it is apparent that there is lower
variability in the difference between pre-opera-
tive and retrospective scores in the first 12
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months following surgery, which can likely be
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attributed to better recall. This conclusion is
supported Wilson et al.10 who examined retro-
spective recall of the OSS. With a recall period of
between 6 and 8 weeks they reported a strong
correlation between the two scores (r 2 ¼ 0:81).
Further, the limits of agreement for individual
scores was þ/8.8 points which is less than half
that recorded in the present study where the
mean time since surgery was 27 months. This
suggests that the most suitable time to perform
retrospective analysis of surgical outcome using
the OHS and OKS is within first 12 months after
surgery.
When examining the scores overall, it was in-
teresting to note that there was a trend in both
groups for patients to underestimate their pre-
operative scores. There was a statistically signif-
icant difference in the OKS group with a mean
decrease in mean of 4.7 points as compared to the
OHS group having a mean decrease of only 1.6
points. This is in contrast to the study examining
the OSS by Wilson et al.,10 who found that
patients tended to overestimate their pre-opera-
tive shoulder symptoms when asked to recall
them. While the mean difference for the OKS is
considered to be within the range to be consid-
ered clinically significant (3–5 points),8 spread of
scores about this mean is large, making this
1550003-7
Retrospective Recall of OHS and OKS
difference unreliable. Similarly, the Bland–Alt-
man analysis showed 95% limits of agreement of
about 20 points for both OHS and OKS. These
results suggest that while the OHS and OKS may
be used retrospectively to evaluate surgical out-
comes of groups of patients, this approach would
not be sufficiently accurate for estimation of the
pre-operative status of individual patients.
This is again reflected in the Bland–Altman
plots examining the level of agreement between
the two scores. While the mean differences are
low for both the OHS and OKS, the 95% confi-
dence limits are large, with ranges of 19.9–23.1
for the OHS, and 15.3–24.8 for the OKS.
Therefore, there is a 95% chance that an indivi-
duals’ retrospective estimate could be approxi-
mately 20 points higher or lower than their actual
pre-op score, displaying the inaccurate nature of
individuals’ ability to recall their symptoms. This
finding is also consistent with those made by
Wilson et al. when examining the OSS.10
Some imitations of this study should be con-
sidered in the interpretation of the results. While
the number of patients would provide sufficient
power to address the research question, the issue
of short-term recall could have been addressed
more specifically if the number of patients pro-
viding recall within the first year following sur-
gery was increased. The current level of pain and
physical function were not measured at the time
the recall questionnaire was administered. Con-
sequently, the association between current func-
tional status and recall accuracy could not be
examined. Finally this study examined the issue
of recall accuracy using only one type of outcome
questionnaire. Accuracy of recall may vary
according to the nature of the questionnaire and
inclusion of another function, or quality of life
questionnaire may have helped to address the
research objective more broadly.
These findings suggest that individuals are
unreliable at accurately recall their pre-operative
 T. M. Falconer et al.
symptoms by way of the OHS and OKS. Patients
tend to underestimate their pre-operative symp-
toms according to these outcome measures and
there is considerable variability between indivi-
duals’ ability to recall. While the overall mean
difference between the pre-operative and retro-
spective recalled scores is low, and there is a
tendency for patients to have more reliable recall
within the first 12 months, it is our recommen-
dation that the OHS and the OKS are not used as
retrospective tools.
We represent that this submission is original
work, and is not under consideration for publi-
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cation with any other journal.
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DISCLOSURE STATEMENT
There were no financial disclosures relating to
this study.
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