Published online: 11.10.

2019
THIEME
8 Original Article

Obesity Influences the Knee Injury and

Osteoarthritis Outcome Score
Peter Larsen1 Anne S. Engberg2 Isa Motahar3 Svend E. Ostgaard4 Rasmus Elsoe4

1 Department of Occupational Therapy and Physiotherapy, Aalborg Address for correspondence Rasmus Elsoe, MD, PhD, MPA,
University Hospital, Aalborg, Denmark Department of Orthopaedic Trauma Surgery, Aalborg University
2 Department of Abdominal Surgery, Aalborg University Hospital, Hospital, 18-22 Hobrovej, Aalborg DK-9000, Denmark
Aalborg, Denmark (e-mail: [email protected]).
3 Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
4 Department of Orthopaedic Surgery, Aalborg University Hospital,
Aalborg, Denmark

Joints 2019;7:8–12.

Abstract Purpose The primary aim of this study was to report the outcome of the Knee Injury
and Osteoarthritis Outcome Score (KOOS) in obese patients with a body mass index
(BMI) > 35.
Methods This is a prospective cohort study, including patients referred with the aim
of planning bariatric surgery between October 2015 and January 2017. The primary
outcome measurement was KOOS. An experienced radiologist obtained and evaluated
standard radiological osteoarthritis examinations of the knee joints.
Results The mean age was 43.1 years, and ages ranged from 24 to 69 years. The mean
BMI was 48.3, and BMI ranged from 35 to 66. Results show that obese patients reported
significantly worse in the KOOS subscales pain, activities of daily living, sport, and
quality of life (QOL) compared with a reference population, due to nonoverlapping 95%
confidence intervals. No significant differences between obese and superobese
patients were observed on the KOOS subscales (p > 0.08). The KOOS subscales showed
Keywords worse outcome with increasing severity of radiological knee osteoarthritis; however,
► KOOS score only significant differences were observed for the KOOS subscales sport and QOL
► joint pain (p < 0.05).
► patient-reported Conclusion Results imply that the KOOS scores vary significantly with obesity. When
outcomes utilizing KOOS outcome, considering obesity in the interpretation of outcome is highly
► obesity recommended.
► osteoarthritis Level of Evidence This is an observational, level III study.

Introduction betes, vascular diseases, sleep apnea, and reduced physical

function and quality of life (QOL).1,3
Worldwide, the prevalence of obesity is ever-increasing, and In an orthopaedic setting, obese patients with joint pain and
World Health Organization estimated that more than 650 reduced physical function represent a challenging patient
million adults are obese.1,2 group.1 The association between joint pain, osteoarthritis,
Obesity is associated with a variety of severe health and obesity is well established.1,3 Moreover, obesity is a
problems, including increased risk of chronic diseases such significant risk factor for both an increasing incidence of
as musculoskeletal pain, osteoarthritis, heart diseases, dia- osteoarthritis and progression of osteoarthritis.3

received DOI https://doi.org/ Copyright © 2019 Georg Thieme Verlag

May 16, 2018 10.1055/s-0039-1697612. KG Stuttgart · New York
accepted after revision ISSN 2282-4324.
August 7, 2019
published online
October 11, 2019
 Outcome of the KOOS in Obese Patients Larsen et al. 9

A wide range of different measurements has been used to The primary outcome measurements of this study were
capture musculoskeletal pain and physical function in the the joint-specific patient-reported questionnaires: KOOS.
obese patient.1,4–6 Both generic and joint-specific patient- Secondary outcome scores were Eq. 5D-5L index score and
reported measurements in combination with objective meas- Knee Society Score (KSS). An experienced radiologist
urements are commonly used.1,4–6 Most patient-reported obtained and evaluated standard radiological osteoarthritis
measurements used are not specifically designed to capture examinations of the knee joints.
the health status of obese patients, and the literature lacks The Danish Data Protection Agency (J. nr. 2008-58-0028 ID:
studies investigating the effect of obesity on the outcome of 2015-71) and the local ethics committee (J.nr: N-20150044)
patient-reported measurements.7 One such commonly used approved the study, which was performed in accordance with
score is the Knee Injury and Osteoarthritis Outcome Score the principles of the Helsinki Declaration. All participants gave
(KOOS).8 KOOS is a standardized and validated instrument written informed consent before inclusion. The reporting of
developed to evaluate knee and associated knee problems. the study complies with the Strengthening the Reporting of
Although the effect of obesity on osteoarthritis is well estab- Observational Studies in Epidemiology statement.9
lished, little is known about the effect of obesity on KOOS in
absence of osteoarthritis. To investigate the effect of obesity, Measurement Methods
KOOS scores from obese patients without a medical history of The KOOS8 is a standardized and validated instrument to
osteoarthritis are needed. Obesity is expected to constitute an evaluate knee and associated knee problems. The question-
important ceiling effect on KOOS outcome, and as a conse- naire includes five subscales: pain, activities of daily living
quence, this information is important for both clinicians and (ADL), symptoms, sport, and QOL. A total score of 100
patients when utilizing KOOS in the evaluation of treatment indicates no symptoms, and 0 indicates major symptoms.
and when informing patients on expected outcomes of Historically, KOOS reference data from a general population-
treatment. based sample in southern Sweden are available.10
The primary aim of this study was to report the outcome The KSS is a clinical reported outcome score developed to
of the KOOS in obese patients with a body mass index assess patients’ outcome after total knee arthroplasty.11 The
(BMI) > 35 and without a medical history of osteoarthritis. score combines subjective and objective assessment and
The hypothesis of the study was that obese patients separates the knee score (pain, stability, range of motion,
would report worse KOOS score compared with a reference etc.) from the functional score (ability to walk, go up, and
population even in the absence of radiological knee down stairs). The score range is from 0 to 100 points, with
osteoarthritis. higher scores indicating a better outcome.
Eq. 5D-5L is a standardized and validated instrument to
assess health outcome.12 It consists of five dimensions:
Methods
mobility, self-care, usual activities, pain/discomfort and
Study Design anxiety/depression, and a self-rated health scale on a
The study design was a prospective cohort design, including 20-cm vertical, visual analog scale with endpoints labeled
all patients referred to clinical examination and interview “the best health you can imagine” and “the worst health you
between October 2015 and January 2017 at Aalborg Uni- can imagine.” An Eq. 5D-5L index at 1.0 indicated full health,
versity Hospital, Denmark, with the aim of planning bariat- and 0.59 denoted death.
ric surgery preceded by written information. To be The radiological evaluation of osteoarthritis included
considered for bariatric surgery in Denmark, patients are standing anteroposterior and lateral views of both knees.
“superobese” with a BMI
50 with severely impaired QOL Tibiofemoral osteoarthritis was classified as described by
or “obese” with a BMI
35 and with at least one of the Kellgren and Lawrence (normal or with one of four increas-
following comorbidities: (1) type II diabetes, (2) serious ing levels of osteoarthritis).13
obesity-related hypertension, (3) sleep apnea, (4) polycystic
ovary syndrome, or (5) serious osteoarthritis in the hip or Data Analysis
knee. Moreover, other nonsurgical means of weight loss Normal distribution was checked visually by QQ plots.
were unsuccessful. Before surgery, patients must partici- Categorical data were expressed by frequencies. Continuous
pate in a 3-month presurgery program, including general data were expressed with mean and median, standard
information about bariatric surgery, education regarding deviations, and 95% confidence intervals (95% CI).
nutrition, and daily routines of physical activity. The study The Student’s t test was used for analysis of the effect of
excluded patients below 24 years and patients with mental obese (BMI: 35–49) and superobese patients (BMI > 50) and
disability or abuse of alcohol or drugs and a history of osteoarthritis on the KOOS subscales.
symptomatic knee osteoarthritis in their medical history. The results of the Kellgren and Lawrence classification
Patients were excluded from radiological examination if were divided into two categories of knee osteoarthritis for
they were pregnant. analysis. No radiological signs and grade I of osteoarthritis
Basic characteristics, including age, gender, BMI, smoking, were defined as “none or doubtful osteoarthritis,” and grades
diabetic, measurements of hip, waist, and shoulder circumfer- II, III, and IV were defined as “definite osteoarthritis.”
ence, education, and employment, were obtained. All patients A p-value of < 0.05 was considered significant. The statis-
were systematically examined at the outpatient clinic. tical analysis was performed using SPSS (version 22).

Joints Vol. 7 No. 1/2019

10 Outcome of the KOOS in Obese Patients Larsen et al.

Results Table 2 Values of the Knee Injury and Osteoarthritis Outcome

Score
Between October 2015 and January 2017, a total of 52
patients were included in this study. Fifteen percent of the KOOS
invited patients declined to participate. All included patients Pain
completed the KOOS score, and 45 patients (87%) completed Mean 80
the radiological examination.
SD 18.9
The mean age was 43.1 years, and the ages ranged from 24
to 69 years. The mean age for males was 45.2 (27–66) years Median 81.0
and for females 41.7 (24–69) years. The gender distribution 95% CI 74.7–85.3a
was 32 (61.5%) females and 20 (38.5%) males. The mean BMI 95% CI reference population 86.7–88.2
was 48.3, and the BMI ranged from 35 to 66. The mean BMI
Symptoms
for males was 48.3 (37–66) and for females 48.2 (35–59).
►Table 1 presents detailed baseline characteristics. Mean 81.7
The joint-specific, patient-reported KOOS score shows SD 20
that obese patients reported significant worse in the sub- Median 88
scales pain, ADL, sport, and QOL compared with the reference
95% CI 75.6–86.7
population, because of nonoverlapping 95% CI10 (►Table 2).
95% CI reference population 85.4–86.9
ADL
Table 1 Baseline characteristics Mean 80.4
SD 19.1
Age, mean (range), years 43.1 (24–69)
Median 85
Sex, n (%)
95% CI 75.1–85.8a
Male 20 (38.5)
95% CI reference population 86.5–88.1
Female 32 (61.5)
Sport
Height, mean (SD) 170.7 (10.1)
Mean 37.2
Weight mean (SD), kg 142.3 (25.0)
SD 30.9
BMI, mean (SD) 48.3 (6.4)
Median 38
Obese (BMI 35–50), n (%) 34 (65)
95% CI 28.6–45.8a
Superobese (BMI > 50), n (%) 18 (35)
95% CI reference population 72.5–75.1
Hip circumference, mean (SD) 132.9 (13.8)
QOL
Waist circumference, mean (SD) 139.3 (15.5)
Mean 62.8
Shoulder circumference, mean (SD) 156.3 (13.2)
SD 24.9
Smoking habits, n (%)
Median 56
Yes 13 (25)
95% CI 55.9–69.8a
No 39 (75)
95% CI reference population 77.4–79.6
Diabetic, n (%)
Abbreviations: ADL, activities of daily living; CI, confidence intervals;
Yes 16 (31) KOOS, Knee Injury and Osteoarthritis Outcome Score; QOL, quality of
No 36 (69) life; SD, standard deviation.
a
Significant difference.
Education, n (%)
Student 1 (2)
The effect of BMI (obese [BMI: 33–50] vs. superobese
Primary school 26 (50) patients [BMI > 50]) on the KOOS subscales showed that super-
Short-length education or craftsman 17 (32) obese patients reported worse KOOS scores on all the KOOS
Undergraduate education 7 (14) subscales; however, no significant differences between obese
and superobese patients were observed (p > 0.08) (►Table 3).
Graduate education or higher 1 (2)
The mean Eq. 5D-5L index score was 0.610 (95% CI: 0.558–
Work status, n (%) 0.662). The mean Eq. 5D-5L VAS score was 59.9 (95% CI: 54.1–
Employed 26 (50) 65.6). Compared with the Danish reference population, the
Subsidized employed 3 (6) obese population reported significantly worse Eq. 5d-5L index
score.14
Unemployed 23 (44)
The Kellgren and Lawrence scores grade 0 and I showed
Abbreviation: SD, standard deviation. none or doubtful osteoarthritis in 71% of the knees. Severe

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 Outcome of the KOOS in Obese Patients Larsen et al. 11

Table 3 Values of the Knee Injury and Osteoarthritis Outcome Discussion

Score divided into obese and superobese
This work reports the severity of knee complaints from an
Pain Symptoms ADL Sports QOL obese patient population without a medical history of knee
Obesea 77.2 78.8 78.9 36.2 58.5 osteoarthritis, measured with the commonly used joint-spe-
Superobeseb 85.4 85.7 83.3 39.2 70.9 cific patient-reported measurement KOOS. Findings suggest
that it is important to consider obesity in the interpretation of
p-Value 0.12 0.21 0.39 0.75 0.08
outcome of the KOOS measurement. An understanding of the
Abbreviations: ADL, activities of daily living; BMI, body mass index; QOL, expected values of the KOOS measurement in obese patients
quality of life. without a medical history of osteoarthritis is important when
a
Obese ¼ BMI 35–50. advising clinicians and patients on the expected outcome of
b
Superobese ¼ BMI > 50.
treatment under the influence of obesity.
In an orthopaedic setting, reference material, including
normative values, is widely used in the evaluation of the
osteoarthritis (Kellgren & Lawrence grades III and IV) was treatment effect following surgery and in the interpretation
observed in only six patients. of disability.15–17 Most joint-specific patient-reported meas-
►Table 4 presents the results of the primary outcome urements available are not developed specifically for the
KOOS and the secondary outcomes KSS divided into two evaluation of obese patients. Normative reference values
groups: none or doubtful radiological osteoarthritis and from the general population are available for some patient-
defined radiological signs of knee osteoarthritis. The scores reported measurements.10,14,18,19 General reference popula-
showed worse outcome with increasing severity of radiolog- tions are available for KOOS10,17 and Eq. 5D.14
ical knee osteoarthritis; however, only significant differ- The KOOS subscales pain, ADL, sport, and QOL and the Eq.
ences were observed for the KOOS subscales sport and QOL 5D index showed a significantly worse outcome for the
(p < 0.05). studied obese patient group compared with the general
reference populations. This indicated a significant influence
of obesity on these patient-reported measurements and that
Table 4 Outcome between severity of radiological osteoarthritis reference values from a general population are of limited
value, in an obese setting. Large-scale studies are needed to
Primary outcome KOOS fully understand the influence of obesity on joint-specific
n Mean Median patient-reported measurements.
Pain None or doubtful 32 82.6 83 Previous analyses of joint-specific patient-reported meas-
osteoarthritis urements such as KOOS, KSS, and general health question-
naires such as Eq. 5d have reported that outcomes vary along
Definite osteoarthritis 13 71.8 81
baseline characteristics such as age, gender, education, and
Symptoms None or doubtful 32 80.8 86
nationality.10,14,18 Based on findings from this study, consid-
osteoarthritis
ering weight and/or BMI is highly recommended in the
Definite osteoarthritis 13 78.2 82 interpretation of joint-specific patient-reported measure-
ADL None or doubtful 32 82.9 89 ments. However contradictory, this study found nonsignificant
osteoarthritis difference between obese and superobese patients on the
Definite osteoarthritis 13 74.2 82 KOOS score. This may be explained by the high BMI (35–66)
Sport None or doubtful 32 41.1 40 in the study population, representing a ceiling effect in several
osteoarthritis of the KOOS subscales (e.g., one cannot run with a BMI of either
Definite osteoarthritis 13 30.3 20 44 or 66). The development of adjusted joint-specific patient-
reported measurements designed to capture outcome from
QOL None or doubtful 32 66.7 63
obese patient groups may be of clinical interest in the future,
osteoarthritis
especially in an orthopaedic setting. These tools may assist in
Definite osteoarthritis 13 48.6 44
guiding both surgeon and patient expectations when consid-
Secondary outcome KSS ering the expected function level following knee joint surgery
n Mean Median such as total knee replacement.
KSS None or doubtful 32 72.3 74 The effect of radiological osteoarthritis in obese patients
osteoarthritis on the KOOS score showed worse joint-specific patient-
reported outcomes with increased radiological severity of
Definite osteoarthritis 13 59 59
osteoarthritis. This is comparable to other studies reporting
KSS None or doubtful 32 70.8 70
on nonobese patients.20 Changes in KOOS score between the
function osteoarthritis
two levels of osteoarthritis showed worse scores with
Definite osteoarthritis 13 70.4 70 increasing degrees of osteoarthritis but did not exceed the
Abbreviations: ADL, activities of daily living; KSS, Knee Society Score; minimal clinical important changes of 8 to 10 points.8
QOL, quality of life. However, these results should be interpreted with caution,

Joints Vol. 7 No. 1/2019

12 Outcome of the KOOS in Obese Patients Larsen et al.

as only a few patients in the study group presented with by high-field MRI and radiography. Osteoarthritis Cartilage 2012;
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needed to fully understand the influence of obesity.
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implying that no conclusions regarding causality can be made. broucke JP; STROBE Initiative. The Strengthening the Reporting of
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37(05):467–474
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15 Elsoe R, Larsen P, Shekhrajka N, Ferreira L, Ostgaard SEE, Rasmus-
outcome, considering obesity in the interpretation of out- sen S. The outcome after lateral tibial plateau fracture treated
come is highly recommended. with percutaneous screw fixation show a tendency towards
worse functional outcome compared with a reference population.
Funding Eur J Trauma Emerg Surg 2016;42(02):177–184
16 Larsen P, Elsoe R, Laessoe U, Graven-Nielsen T, Eriksen CB,
None.
Rasmussen S. Decreased QOL and muscle strength are persistent
1 year after intramedullary nailing of a tibial shaft fracture: a
Conflict of Interest prospective 1-year follow-up cohort study. Arch Orthop Trauma
None declared. Surg 2016;136(10):1395–1402
17 Larsen P, Lund H, Laessoe U, Graven-Nielsen T, Rasmussen S.
Restrictions in quality of life after intramedullary nailing of tibial
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