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. 2025 Aug 21;6(8):983–990. doi: 10.1302/2633-1462.68.BJO-2025-0105.R1

Improvement in six of the 12 Oxford Knee Score questions is independently associated with patient satisfaction following knee arthroplasty

Eliott Sophie Martinson 1,✉, Nick D Clement 1, Gillian Leitch 1, Chloe E H Scott 1
PMCID: PMC12368461  PMID: 40836658

Abstract

Aims

The Oxford Knee Score (OKS) is an established and validated outcome measure of knee arthroplasty (KA), but it is not clear how responses to each of the 12 questions relate to satisfaction. The aim was to assess which of 12 OKS questions were associated with patient satisfaction after KA.

Methods

This single-centre retrospective cohort study was conducted over an eight-year period from January 2014 to December 2021. A total of 3,361 patients completed preoperative and six months postoperative OKS. The mean age was 69.9 years (34 to 94, SD 9.3), and 1,792 were female (55.0%). Patient satisfaction with their KA was assessed at six months, which was categorized into satisfied (satisfied, very satisfied) and dissatisfied (neutral, dissatisfied, very dissatisfied).

Results

All 12 questions demonstrated significant improvements postoperatively (p < 0.001), with moderate (q2/3/7) to large (q1/4/5/6/8/9/10/11/12) effect sizes. There were 2,704 patients (82.9%) who were satisfied with their KA at six months. Satisfied patients had significantly greater improvements (p < 0.001) in each of the OKS questions, with the greatest differences found in questions 6 (limping; mean difference (MD) 1.41 (95% CI 1.29 to 1.53)) and 1 (pain; MD 1.32 (95% CI 1.22 to 1.42)). Preoperative responses to each of the OKS questions demonstrated poor discriminatory ability to predict patient satisfaction (area under the curve < 0.70). Improvement in questions 1 (pain; odds ratio (OR) 1.72 (95% CI 1.51 to 1.96), p < 0.001), 6 (limping; OR 1.28 (95% CI 1.16 to 1.41), p < 0.001), 7 (kneeling; OR 1.20 (95% CI 1.06 to 1.35), p = 0.003), 8 (night pain; OR 1.11 (95% CI 1.01 to 1.23), p = 0.038), 9 (working; OR 1.21 (95% CI 1.05 to 1.39), p = 0.015), and 12 (stairs; OR 1.42 (95% CI 1.25 to 1.63), p < 0.001) were independently associated with satisfaction.

Conclusion

Improvements in six of the 12 OKS questions were independently associated with patient satisfaction; these could be prioritized as areas to be addressed following KA, and modification of related patient expectations may improve satisfaction with surgery.

Cite this article: Bone Jt Open 2025;6(8):983–990.

Keywords: Oxford knee score, Knee arthroplasty, Satisfaction, Change, Question, Symptoms, knee arthroplasty (KA), retrospective cohort study, t-tests, patient-reported outcome measures (PROMs), knee, Knee injury and Osteoarthritis Outcome Score, chi-squared test, arthroplasty, logistic regression analysis

Introduction

The move from a volume-driven healthcare system to a value-based system that focuses on improving patient outcomes and delivering cost-effective interventions relies on patient-reported outcome measures (PROMs).1 PROMs are now the standard of care following arthroplasty, and are routinely collected following knee arthroplasty (KA) by numerous registries.2 The Oxford Knee Score (OKS)3,4 is a validated assessment tool and is the PROM of choice for the NHS in England and Wales.5 Despite some limitations,6 it remains the leading tool to assess the outcome of KA with no obvious superior measure.7 Despite each of the 12 OKS questions being equally weighted, the observed improvement postoperatively varies according to the question asked.8

Despite KA being an effective procedure, between 10% and 34% of patients have unfavourable outcomes in relation to pain relief from surgery, and satisfaction rates range from 80% to 100%.9,10 Postoperative PROMs and change in score relative to baseline are associated with patient satisfaction following KA.10-12 When employing a PROM, such as the OKS, a summative score may hide benefits from KA, according to each of the questions being asked. The OKS has previously been split into pain and functional sub-scores to better understand the effect of these following KA,12-15 and worse preoperative pain scores have been shown to influence postoperative satisfaction.12 Specific responses to individual OKS questions (pain, limping, giving way) have more specifically been shown to be associated with the risk of revision.16 It is recognized that the mean improvement in each of the 12 questions following KA varies greatly and suggests an unequal response to surgery.8 To the authors’ knowledge, no previous study has assessed whether the individual responses preoperatively, or improvement postoperatively, are independently associated with patient satisfaction. This would help to inform discussions about the goals of KA, patient expectations, and their expected satisfaction; an approach like this aligns with shared decision-making.17

The aims of the study were to assess which of 12 OKS questions were associated with patient satisfaction after KA.

Methods

This study was classed as a service evaluation and did not meet the criteria requiring ethical approval. Ethical approval was obtained for data collection and analysis (Scotland B REC, number 20/SS/0125 A), and was conducted in accordance with the Declaration of Helsinki and the guidelines for good clinical practice.18,19 This single-centre retrospective cohort study was conducted over an eight-year period from January 2014 to December 2021. The study centre has an established arthroplasty register that prospectively records patient demographics and routine pre- and postoperative PROMs. Patients undergoing primary KA for arthritis and who completed a pre- and postoperative OKS were included. Patients undergoing revision were excluded.

The OKS was administered preoperatively and at six months postoperatively via a postal questionnaire. Patients who did not return the questionnaire, or had missing responses to specific questions, were routinely contacted via telephone to complete the OKS. This has been shown to be a valid way to collect the OKS.20 The responses to each of the OKS questions were scored from 0 to 4.3,4 A summative score of 48 is the best possible score (least symptomatic) and 0 is the worst possible score (most symptomatic).

Patients were asked at six months how satisfied they were with their KA, with responses available on a five-point Likert scale of very satisfied, satisfied, neutral, dissatisfied, or very dissatisfied. Patients with responses of satisfied or very satisfied were defined as satisfied, and those with responses of neutral, dissatisfied, or very dissatisfied were categorized as dissatisfied.12

Patient characteristics

During the study period, 3,261 patients completed 12 questions of their pre- and postoperative OKS at six months. There were 501 who had completed the preoperative questionnaire but were lost to follow-up. There were differences in age (p = 0.871, independent-samples t-test), sex (p = 0.999, chi-squared test), and preoperative OKS (p = 0.511, independent-samples t-test) between those lost to follow-up and the study cohort. There were 1,792 females (55.0%) and the overall mean age was 69.9 years (34 to 94, SD 9.3).

Statistical analysis

Statistical analysis was performed using Statistical Package for Social Sciences version 17.0 (SPSS, USA). Simple descriptive analysis was undertaken according to mean and SD for pre- and postoperative responses for each question. Effect size (mean change/SD) was also calculated for each question, and effect sizes of 0.2, 0.5, and 0.8 were considered ‘small’, ‘medium’, and ‘large’ effect, respectively.21 Paired and independent-samples t-tests were used to compare parametric continuous variables within and between groups, respectively. A chi-squared test was used to compare categorical variables between groups. Receiver operating characteristic curve analysis was used to assess the predictive value of responses to preoperative and improvement postoperatively at six months for patient satisfaction. This is reported as an area under the curve (AUC), where 0.5 equates to no discrimination, 0.5 to 0.7 has poor discrimination, 0.7 to 0.8 has acceptable discrimination, 0.8 to 0.9 has excellent discrimination, and more than 0.9 has outstanding discrimination.22 Logistic regression analysis was used to identify independent variables (OKS questions) associated with patient satisfaction with their KA six months following surgery. A p-value of < 0.05 was defined as significant in the regression model. However, a p-value of < 0.010 was defined as significant for unadjusted analysis to account for multiple testing.

Results

The mean preoperative OKS for the total cohort was 20.9 (SD 7.7), which improved to 34.5 (SD 9.4) six months postoperatively, which was significant (mean difference (MD) 13.9, 95% CI 13.3 to 13.9, p < 0.001, paired t-test). All 12 questions demonstrated significant (p < 0.001, paired t-test) improvements postoperatively and a moderate to large effect sizes (Table I), with question 6 demonstrating the greatest improvement (MD 1.87, 95% CI 1.82 to 1.92) and question 1 having the largest effect size (1.44).

Table I.

Mean pre- and postoperative scores and change in score with associated effect size for each of the 12 Oxford Knee Score questions.

Question Preoperative Postoperative Change
(95% CI)		 Effect size p-value*
Q1: Pain 0.70 (0.65) 2.25 (1.14) 1.74 (1.70 to 1.78) 1.44† < 0.001
Q2: Washing 2.98 (0.95) 3.47 (0.79) 0.49 (0.46 to 0.52) 0.51 < 0.001
Q3: Transport 2.18 (0.81) 2.87 (0.88) 0.69 (0.66 to 0.73) 0.69 < 0.001
Q4: Walking 2.19 (1.11) 3.27 (1.05) 1.08 (1.03 to 1.12) 0.81 < 0.001
Q5: Standing 1.79 (0.83) 2.95 (0.89) 1.16 (1.12 to 1.20) 1.11 < 0.001
Q6: Limping 1.10 (1.07) 2.97 (1.11) 1.87 (1.82 to 1.92) 1.33† < 0.001
Q7: Kneeling 0.95 (0.91) 1.47 (1.23) 0.51 (0.47 to 0.55) 0.44† < 0.001
Q8: Night pain 1.32 (1.14) 2.56 (1.28) 1.24 (1.19 to 1.29) 0.87† < 0.001
Q9: Working 1.54 (0.90) 2.99 (1.01) 1.45 (1.41 to 1.49) 1.28† < 0.001
Q10: Stability 2.08 (1.13) 3.41 (0.86) 1.33 (1.29 to 1.37) 1.08 < 0.001
Q11: Shopping 2.07 (1.20) 3.1 (1.19) 1.04 (1.00 to 1.08) 0.87 < 0.001
Q12: Stairs 1.97 (0.91) 2.97 (1.01) 1.00 (0.96 to 1.04) 0.92† < 0.001
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*

Paired t-test.

†

Independently associated with patient satisfaction with their knee arthroplasty at six months.

There were 557 patients (17.1%) who were not satisfied with their KA at six months. There were no differences in sex (odds ratio (OR) 1.11 (95% CI 0.93 to 1.32), p = 0.249, chi-squared test), age (MD 0.8 (95% CI -0.1 to 1.6), p = 0.073, independent-samples t-test), or BMI (MD 0.1 (95% CI -0.4 to 0.7), p = 0.596, independent-samples t-test) between satisfied and dissatisfied patients. Satisfied patients had a significantly (p < 0.001, independent-samples t-test) greater improvement in each of the OKS questions postoperatively relative to their preoperative baseline (Table II). The greatest differences were observed in questions 6 (limping; MD 1.41 (95% CI 1.29 to 1.53)) and 1 (pain; MD 1.32 (95% CI 1.22 to 1.42)).

Table II.

Mean for each of the 12 Oxford Knee Score questions according to group.

Question Dissatisfied Satisfied Difference (95% CI) p-value*
Q1: Pain 0.65 (0.91) 1.97 (1.14) 1.32 (1.22 to 1.42) < 0.001
Q2: Washing 0.02 (0.94) 0.58 (0.93) 0.56 (0.48 to 0.65) < 0.001
Q3: Transport 0.02 (0.91) 0.83 (0.96) 0.81 (0.72 to 0.90) < 0.001
Q4: Walking 0.41 (1.30) 1.21 (1.30) 0.80 (0.68 to 0.92) < 0.001
Q5: Standing 0.36 (0.97) 1.32 (0.99) 0.96 (0.87 to 1.05) < 0.001
Q6: Limping 0.70 (1.37) 2.11 (1.29) 1.41 (1.29 to 1.53) < 0.001
Q7: Kneeling -0.18 (0.89) 0.65 (1.18) 0.84 (0.73 to 0.94) < 0.001
Q8: Night pain 0.25 (1.22) 1.44 (1.37) 1.19 (1.07 to 1.31) < 0.001
Q9: Working 0.53 (1.02) 1.64 (1.06) 1.11 (1.01 to 1.20) < 0.001
Q10: Stability 0.68 (1.46) 1.46 (1.17) 0.78 (0.67 to 0.89) < 0.001
Q11: Shopping 0.28 (1.11) 1.19 (1.15) 0.91 (0.81 to 1.02) < 0.001
Q12: Stairs 0.15 (1.03) 1.17 (1.00) 1.03 (0.93 to 1.12) < 0.001
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*

Independent-samples t-test.

Preoperative responses to each of the OKS questions demonstrated poor discriminatory ability to predict patient satisfaction following surgery, with AUCs of less than 0.70 (Table III and Figure 1), whereas postoperative improvements in questions 3 (transport), 5 (standing), 6 (limping), 7 (kneeling), 8 (night pain), 9 (working), 11 (shopping), and 12 (stairs) were acceptable, and question 1 (pain) was an excellent discriminator of patient satisfaction following surgery, with an AUC of more than 0.70 (Table III and Figure 2).

Table III.

Area under the receiver operating characteristic curves for each of the Oxford Knee Score (OKS) questions preoperatively and change at six months postoperatively as predictors of patient satisfaction with their knee arthroplasty.

Question Preoperative OKS Change in OKS
AUC (95% CI) p-value AUC (95% CI) p-value
Q1: Pain 0.526 (0.501 to 0.551) 0.044 0.808 (0.79 0 to 0.827) < 0.001
Q2: Washing 0.552 (0.526 to 0.578) < 0.001 0.658 (0.633 to 0.683) < 0.001
Q3: Transport 0.540 (0.515 to 0.565) 0.002 0.722 (0.699 to 0.745) < 0.001
Q4: Walking 0.538 (0.513 to 0.564) 0.003 0.677 (0.653 to 0.702) < 0.001
Q5: Standing 0.523 (0.498 to 0.549) 0.070 0.747 (0.726 to 0.769) < 0.001
Q6: Limping 0.490 (0.464 to 0.515) 0.420 0.769 (0.748 to 0.790) < 0.001
Q7: Kneeling 0.539 (0.514 to 0.563) 0.003 0.705 (0.684 to 0.726) < 0.001
Q8: Night pain 0.553 (0.528 to 0.578) < 0.001 0.737 (0.715 to 0.758) < 0.001
Q9: Working 0.547 (0.521 to 0.572) < 0.001 0.768 (0.747 to 0.788) < 0.001
Q10: Stability 0.537 (0.511 to 0.563) 0.004 0.666 (0.640 to 0.691) < 0.001
Q11: Shopping 0.543 (0.518 to 0.568) 0.001 0.710 (0.687 to 0.734) < 0.001
Q12: Stairs 0.525 (0.499 to 0.550) 0.059 0.757 (0.735 to 0.779) < 0.001
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AUC, area under the curve.

Fig. 1.

Figure showing a receiver operating characteristic curve evaluating how well individual preoperative Oxford Knee Score questions predict patient satisfaction six months after knee arthroplasty. A receiver operating characteristic curve used to assess the predictive value of each question from the preoperative Oxford Knee Score in determining patient satisfaction six months after undergoing knee arthroplasty. The curve plots sensitivity against 1-specificity for each question, illustrating how effectively each item discriminates between satisfied and unsatisfied patients. The shape and position of the curve indicate the overall accuracy of the predictors, with curves closer to the top-left corner representing better performance.

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Receiver operator characteristic curve for patient satisfaction with their knee arthroplasty at six months using each of the preoperative Oxford Knee Score (OKS) questions as predictors.

Fig. 2.

Figure showing a receiver operating characteristic curve evaluating how changes in Oxford Knee Score questions from before to six months after surgery predict patient satisfaction with knee arthroplasty. A receiver operating characteristic curve used to assess the predictive accuracy of changes in responses to Oxford Knee Score questions from the preoperative baseline to six months post-knee arthroplasty. The curve plots sensitivity against 1-specificity for each question, illustrating how well the change in each item predicts patient satisfaction. The shape and proximity of the curve to the top-left corner reflect the strength of each question as a predictor, with higher curves indicating better discrimination between satisfied and unsatisfied patients.

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Receiver operator characteristic curve for patient satisfaction with their knee arthroplasty at six months using change from baseline preoperative to six months postoperative Oxford Knee Score (OKS) questions as predictors.

Direct logistic regression analysis was undertaken to assess the impact of change in each of the 12 OKS questions at six months on the likelihood that patients would be satisfied with their KA. The model contained improvement in each of 12 OKS questions and was statistically significant (chi-squared test = 858.0, p < 0.001), indicating the ability to distinguish between satisfied and dissatisfied patients. Age and sex, when included in the model, were not significantly associated with patient satisfaction and were excluded from further analysis. The model as a whole explained between 23% (Cox and Snell R squared) and 39% (Nagelkerke R squared) of the variance in the pain status and correctly classified 95.4% (n = 2,578/2,701) of the satisfied patients. Hosmer and Lemeshow test was not significant (p = 0.097) and supports the goodness of fit of the model. Improvement in questions 1 (pain; OR 1.72, 95% CI 1.51 to 1.96, p < 0.001), 6 (limping; OR 1.28, 95% CI 1.16 to 1.41, p < 0.001), 7 (kneeling; OR 1.20, 95% CI 1.06 to 1.35, p = 0.003), 8 (night pain; OR 1.11, 95% CI 1.01 to 1.23, p = 0.038), 9 (working; OR 1.21, 95% CI 1.05 to 1.39, p = 0.015), and 12 (stairs; OR 1.42, 95% CI 1.25 to 1.63, p < 0.001) were all independently associated with patient satisfaction with their KA at six months (Table IV).

Table IV.

Direct logistic regression analysis for change in each of the 12 Oxford Knee Score questions at six months following knee arthroplasty on the likelihood that patients would be satisfied with their knee.

Question Odds ratio (95% CI) p-value
Q1: Pain 1.72 (1.51 to 1.96) < 0.001
Q2: Washing 1.07 (0.94 to 1.23) 0.295
Q3: Transport 1.15 (1.00 to 1.33) 0.051
Q4: Walking 1.04 (0.94 to 1.14) 0.467
Q5: Standing 1.13 (0.98 to 1.30) 0.104
Q6: Limping 1.28 (1.16 to 1.41) < 0.001
Q7: Kneeling 1.20 (1.06 to 1.35) 0.003
Q8: Night pain 1.11 (1.01 to 1.23) 0.038
Q9: Working 1.21 (1.05 to 1.39) 0.015
Q10: Stability 1.00 (0.90 to 1.11) 0.974
Q11: Shopping 1.01 (0.89 to 1.14) 0.914
Q12: Stairs 1.43 (1.25 to 1.63) < 0.001
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Discussion

This study has shown that improvement in six of 12 OKS questions was independently associated with patient satisfaction with their KA at six months, with improvements in pain and stair descent having the greatest effect on satisfaction. Of these six questions, five (pain, limping, night pain, working, stairs) had large effect sizes and one (kneeling) had moderate effect sizes, suggesting less of an improvement in kneeling following KA. Preoperative responses to each of the OKS questions were not associated with postoperative patient satisfaction, whereas improvements in eight of the OKS questions were acceptable discriminators of patient satisfaction following surgery, and question 1 in relation to pain was the only excellent discriminator.

There were several limitations of this retrospective study that should be acknowledged. The cohort was reported as a combined single group, and the responses to the individual questions may be different according to patient demographics such as age and sex, for example.23 However, when age and sex were included in the regression model, they were significant factors and the model remained unchanged. The study did not include additional patient variables such as the presence of comorbidities, which has been demonstrated to be associated with lower rates of postoperative patient satisfaction with their arthroplasty.24-27 Furthermore, surgical variables such as patella resurfacing,28 implant design,29 implant alignment,30 or health-related quality of life measures such as the EuroQol five-dimension questionnaire (EQ-5D)31 were not adjusted for in the model, and therefore the findings may not be independent of such variables. This may in part account for the fact that the OKS questions only predicted 22% to 35% of the variation in the model, with the remainder being due to other variables. However, the model correctly classified 95% of those patients who were satisfied. The intended aim of the study was to identify which of the 12 individual OKS questions were associated with patient satisfaction with their KA, which is why the authors chose to only include the questions in the model. Finally, the study did not include radiological assessment of either the preoperative severity of the arthritis or the joint alignment postoperatively, both of which have been shown to influence joint-specific function.32,33 While this study identifies which OKS questions are associated with patient satisfaction following KA, it has not explored the development or validation of a tool to assess knee score. We acknowledge that the development of this would be a future step and application of this study.

The OKS is a commonly employed tool in assessing the improvement of joint-specific symptoms following KA, and a mean improvement of approximately 15 points is observed following KA.34 There is a well-established association between improvement in the mean OKS and postoperative patient satisfaction,11,15 but it is not clear how each of the 12 OKS questions relates to patient satisfaction. Moreover, the clinically important improvement in the OKS has been defined as a mean improvement of seven points or more,35 but the contribution of the 12 individual questions to achieve this value has not been explored. The improvement in each of the 12 OKS questions varies from 0.7 (washing) to 2.2 (limping) points after KA, suggesting that patients experience different improvements in their symptoms according to the 12 questions following KA, despite having equal weighting.8 Previously, authors have divided the OKS into pain and functional components, and have shown that improvements in these two subdivisions are related to different patient variables.36 Scott et al12 identified that patient satisfaction was not independently related to improvement in the functional sub-score of the OKS (questions 2, 3, 6, 7, 10, 11, and 12) but was related to the pain sub-score (questions 1, 4, 5, 8, and 9). In contrast, the current study found that questions from both the pain (questions 1, 8, and 9) and functional (6, 7, and 12) sub-scores of the OKS were independently associated with patient satisfaction. However, the current study assessed the independence of each of the 12 OKS questions, and therefore suggests that the three pain and three functional questions assess different aspects of the individual’s outcome and satisfaction with their KA.

The rate of satisfaction ranges from 80% to 100%,9,10 with multiple pre- and postoperative factors influencing this.10 Previous authors have investigated whether the preoperative OKS is associated with postoperative satisfaction and demonstrated no significant predictive association.37,38 This finding is consistent with the current study, which found the individual responses to each of the 12 OKS questions to be poor discriminators of postoperative patient satisfaction with their KA. Pronk et al39 is one of the few studies to demonstrate that preoperative function, using the Knee injury and Osteoarthritis Outcome Score,40 was predictive of patient satisfaction, but despite being statistically significant it was not a reliable predictor (< 7%). Improvement in the OKS postoperatively is associated with patient satisfaction,11 and has been used to define the minimal clinically important difference.35,41 The current study found that improvement in question 1 of the OKS, relating to usual pain in the knee, was the most reliable discriminator of patient satisfaction with an AUC of 81%. Judge et al42 assessed the improvement in the total OKS at six months and demonstrated an AUC of 80% for predicting patient satisfaction with their KA. This suggests that improvement in a single question in the OKS postoperatively is more predictive than when all 12 OKS are employed. This may be due to some of the OKS questions (2, 4, and 10) being poor discriminators of patient satisfaction, and this reduces the predictive ability of total OKS.

The current study demonstrated that questions 1 (usual pain), 6 (limping), 7 (kneeling), 8 (night pain), 9 (interferes with work), and 12 (stair descent) were independently associated with patient satisfaction. Question 6 in relation to kneeling improved less (moderate effect size) compared to questions 1, 6, 9, and 12 that showed large effect sizes. This suggests that KA addressed kneeling to a lesser degree. Potentially addressing symptoms related to kneeling through modification of patient expectations of their KA may improve patient satisfaction with KA.43 Focused physiotherapy to address this area postoperatively may also help to improve satisfaction.44 In the knowledge that six of the 12 OKS questions are independently related to patient satisfaction, there may be scope to consider reducing the OKS to a shorter version including these six questions, which seem to be important to patients and their satisfaction. The Knee injury and Osteoarthritis Outcome score has been reduced from 42 questions to seven to assess ‘knee health’, which has been validated to assess the outcome of KA.45 This may help to improve the efficiency of administration and reduce patient questionnaire burden.

In conclusion, improvements in six of the 12 OKS questions were independently associated with patient satisfaction, and these could be prioritized as areas to be addressed following KA; modification of related patient expectations may improve satisfaction with surgery.

Take home message

- Improvements in six of the 12 Oxford Knee Score questions were independently associated with patient satisfaction.

- These could be prioritized as areas to be addressed following knee arthroplasty, and modification of related patient expectations may improve satisfaction with surgery.

Author contributions

E. S. Martinson: Conceptualization, Project administration, Writing – original draft, Writing – review & editing

N. D. Clement: Conceptualization, Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review & editing

G. Leitch: Data curation, Project administration, Writing – review & editing

C. E. H. Scott: Conceptualization, Supervision, Writing – review & editing

Funding statement

The author(s) received no financial or material support for the research, authorship, and/or publication of this article.

ICMJE COI statement

C. E. H. Scott is the PI on an institutional grant from Stryker, and reports consultings fees from Stryker, Smith & Nephew, and Osstec, and payments for teaching on courses from Stryker, all of which are unrelated to this study. C. E. H. Scott is a member of advisory boards for Osstec and Smith & Nephew, the data safety monitoring board of the PASHION Study, and the editorial board of The Bone & Joint Journal. C. E. H. Scott is also Editor-in-Chief of Bone & Joint Research. N. D. Clement is a member of the editorial boards of Bone & Joint Research and The Bone & Joint Journal.

Data sharing

The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.

© 2025 Martinson et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/

Contributor Information

Eliott Sophie Martinson, Email: eliott.martinson2@nhs.scot.

Nick D. Clement, Email: nickclement@doctors.org.uk.

Gillian Leitch, Email: gillian.leitch@nhs.scot.

Chloe E. H. Scott, Email: chloeehscott@yahoo.co.uk.

Data Availability

The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.

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