Advertisement

Cross-Cultural Adaptation and Validation of the Arabic Version of the Harris Hip Score

Open AccessPublished:November 04, 2022DOI:https://doi.org/10.1016/j.artd.2022.07.006

      Abstract

      Background

      The Harris Hip Score (HHS) questionnaire has been translated and validated into many languages including Italian, Portuguese, and Turkish but not Arabic. The goal of this study was to translate HHS into the Arabic language with cross-cultural adaptation to include and benefit Arabic speaking communities as it is the most widely used instrument for disease-specific hip joint evaluation and measurement of total hip arthroplasty outcome.

      Methods

      This questionnaire was translated following a clear and user-friendly guideline protocol. The Cronbach’s alpha was used to assess the reliability and internal consistency of the items of HHS. Additionally, the constructive validity of HHS was evaluated against the 36-Item Short Form Survey (SF-36).

      Results

      A total of 100 participants were included in this study, of which 30 participants were re-evaluated for reliability testing. Cronbach’s alpha of the total score of Arabic HHS is 0.528, and after the standardization, it changed to 0.742 which is within the recommended range (0.7-0.9). Lastly, the correlation between HHS and SF-36 was r = 0.71 (P < .001) which represents a strong correlation between the Arabic HHS and SF-36.

      Conclusions

      Based on the results, we believe that the Arabic HHS can be used by clinicians, researchers, and patients to evaluate and report hip pathologies and total hip arthroplasty treatment efficacy.

      Keywords

      Introduction

      Hip pathology can cause significant disability and negatively impacts function, quality of life, and working capacity [
      • Thorborg K.
      • Roos E.M.
      • Bartels E.M.
      • Petersen J.
      • Hölmich P.
      Validity, reliability and responsiveness of patient-reported outcome questionnaires when assessing hip and groin disability: a systematic review.
      ,
      • Van Der Waal J.M.
      • Bot S.D.M.
      • Terwee C.B.
      • Van Der Windt D.A.W.M.
      • Bouter L.M.
      • Dekker J.
      The course and prognosis of hip complaints in general practice.
      ]. The prevalence of hip pathology is not uncommon, as it can affect up to 12.8% of the population aged 25 years and older [
      • Picavet H.S.J.
      • Schouten JSA G.
      Musculoskeletal pain in The Netherlands: prevalences, consequences and risk groups, the DMC(3)-study.
      ]. Osteoarthritis (OA) is 1 of the most common hip pathologies and is characterized mainly by joint pain and stiffness that interferes with a patient’s function and quality of life [
      • Conaghan P.G.
      Osteoarthritis: National clinical guideline for care and management in adults (NICE).
      ,
      • Neogi T.
      The epidemiology and impact of pain in osteoarthritis.
      ]. It is estimated that around 27 million people in the United States have been diagnosed with OA, while 25% of people older than 55 years are suffering from OA in the United Kingdom [
      • Lawrence R.C.
      • Felson D.T.
      • Helmick C.G.
      • et al.
      Estimates of the prevalence of arthritis and other rheumatic conditions in the United States.
      ,
      • Zhang W.
      • Doherty M.
      EULAR recommendations for knee and hip osteoarthritis: a critique of the methodology.
      ,
      • Cross M.
      • Smith E.
      • Hoy D.
      • et al.
      The global burden of hip and knee osteoarthritis: Estimates from the Global Burden of Disease 2010 study.
      ]. Moreover, hip and knee OA was ranked as the 11th highest contributing factor to global disability [
      • Cross M.
      • Smith E.
      • Hoy D.
      • et al.
      The global burden of hip and knee osteoarthritis: Estimates from the Global Burden of Disease 2010 study.
      ].
      In the 1960s, due to the highly disabling nature of hip pathologies, total hip arthroplasty (THA) was introduced as an effective option in the management of severely damaged hip joints [
      • Bederman S.S.
      • Rosen C.D.
      • Bhatia N.N.
      • Kiester P.D.
      • Gupta R.
      Drivers of surgery for the degenerative hip, knee, and spine: a systematic review.
      ,
      • Yoon P.W.
      • Lee Y.K.
      • Ahn J.
      • et al.
      Epidemiology of hip replacements in Korea from 2007 to 2011.
      ]. This procedure significantly improves joint function by greatly decreasing or eliminating joint pain. The successful long-term results of THA are well documented, especially in elderly patients with hip OA, and the number of performed THA surgeries is increasing worldwide [
      • Learmonth I.D.
      • Young C.
      • Rorabeck C.
      The operation of the century: total hip replacement.
      ,
      • Wells V.M.
      • Hearn T.C.
      • McCaul K.A.
      • Anderton S.M.
      • Wigg A.E.R.
      • Graves S.E.
      Changing incidence of primary total hip arthroplasty and total knee arthroplasty for primary osteoarthritis.
      ,
      • Kurtz S.
      • Mowat F.
      • Ong K.
      • Chan N.
      • Lau E.
      • Halpern M.
      Prevalence of primary and arthroplasty in the United States from 1990 through 2002.
      ]. Currently in the United States, about 7 million individuals have had a THA. Most of these individuals suffered primarily from hip OA followed by hip avascular necrosis, with a higher prevalence among females than males [
      • Kremers H.M.
      • Larson D.R.
      • Crowson C.S.
      • et al.
      Prevalence of total hip and knee replacement in the United States.
      ,
      • Liu S.S.
      • González Della Valle A.
      • Besculides M.C.
      • Gaber L.K.
      • Memtsoudis S.G.
      Trends in mortality, complications, and demographics for primary hip arthroplasty in the United States.
      ,
      • Hamdi A.
      • Bakhsh D.
      • Al-Sayyad M.
      Indications of total hip arthroplasty at a tertiary hospital in Jeddah.
      ].
      Many questionnaires have been employed to evaluate both the impact of a patient’s hip joint disease on their function and the efficacy of its treatment [
      • Bryant M.J.
      • Kernohan W.G.
      • Nixon J.R.
      • Mollan R.A.B.
      A statistical analysis of hip scores.
      ]. Two types of scales are used to follow the patient's condition [
      • Hoeksma H.L.
      • Vanden Ende C.H.M.
      • K Ronday H.
      • Heering A.
      • Breedveld F.C.
      • Dekker J.
      Comparison of the responsiveness of the harris hip.
      ]. The first type is a generic health status scale which measures the patient’s quality of life, such as the SF-36 questionnaire. The other type are disease-specific questionnaires such as Hip disability and Osteoarthritis Outcome Score (HOOS), Intermittent and Constant Osteoarthritis Pain, and Harris Hip Score (HHS) [
      • Söderman P.
      • Malchau H.
      Is the Harris hip score system useful to study the outcome of total hip replacement?.
      ,
      • Hays R.D.
      • Sherbourne C.D.
      • Mazel R.M.
      The rand 36-item health survey 1.0.
      ,
      • Nilsdotter A.K.
      • Lohmander L.S.
      • Klässbo M.
      • Roos E.M.
      Hip disability and osteoarthritis outcome score (HOOS) - validity and responsiveness in total hip replacement.
      ,
      • Maillefert J.F.
      • Kloppenburg M.
      • Fernandes L.
      • et al.
      Multi-language translation and cross-cultural adaptation of the OARSI/OMERACT measure of intermittent and constant osteoarthritis pain (ICOAP).
      ,
      • HARRIS W.H.
      Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty an End-result study using A New method of result evaluation.
      ]. Multiple studies have shown increased utility in reporting outcomes with disease-specific scales over generic health questionnaires for patients who have undergone THA [
      • Hoeksma H.L.
      • Vanden Ende C.H.M.
      • K Ronday H.
      • Heering A.
      • Breedveld F.C.
      • Dekker J.
      Comparison of the responsiveness of the harris hip.
      ].
      Many disease-specific questionnaires were created in order to evaluate specific symptoms and signs of the disease [
      • Bryant M.J.
      • Kernohan W.G.
      • Nixon J.R.
      • Mollan R.A.B.
      A statistical analysis of hip scores.
      ]. The Intermittent and Constant Osteoarthritis Pain instrument was developed to differentiate between intermittent and constant pain among patients with hip OA [
      • Maillefert J.F.
      • Kloppenburg M.
      • Fernandes L.
      • et al.
      Multi-language translation and cross-cultural adaptation of the OARSI/OMERACT measure of intermittent and constant osteoarthritis pain (ICOAP).
      ]. The HOOS scale was used to measure the function of daily living, quality of life, and function in sport and recreation [
      • Nilsdotter A.K.
      • Lohmander L.S.
      • Klässbo M.
      • Roos E.M.
      Hip disability and osteoarthritis outcome score (HOOS) - validity and responsiveness in total hip replacement.
      ]. These disease-specific questionnaires have been translated from English and culturally adapted to many languages including Arabic [
      • Torad A.
      • Abd W.H.
      • Kader E.
      • Saleh M.S.
      • Torad M.M.
      Validity and reliability of the Arabic version OF KOOS-physical function short.
      ,
      • Alageel M.
      • Al Turki A.
      • Alhandi A.
      • Alohali R.
      • Alsalem R.
      • Aleissa S.
      Cross-cultural adaptation and validation of the Arabic version of the intermittent and constant osteoarthritis pain questionnaire.
      ]. They have demonstrated validity in reflecting patient opinions about their condition [
      • Torad A.
      • Abd W.H.
      • Kader E.
      • Saleh M.S.
      • Torad M.M.
      Validity and reliability of the Arabic version OF KOOS-physical function short.
      ,
      • Alageel M.
      • Al Turki A.
      • Alhandi A.
      • Alohali R.
      • Alsalem R.
      • Aleissa S.
      Cross-cultural adaptation and validation of the Arabic version of the intermittent and constant osteoarthritis pain questionnaire.
      ]. However, no questionnaire has shown superior measurement properties over the others [
      • HARRIS W.H.
      Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty an End-result study using A New method of result evaluation.
      ].
      The HHS questionnaire has been translated and validated into many languages including Italian, Portuguese, and Turkish but not Arabic. The goal of this study was to translate the HHS questionnaire into Arabic with cross-cultural adaptation to include and benefit Arabic speaking communities as it is the most widely used instrument for disease-specific hip joint evaluation and measurement of THA outcome [
      • HARRIS W.H.
      Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty an End-result study using A New method of result evaluation.
      ,
      • Mahomed N.N.
      • Arndt D.C.
      • McGrory B.J.
      • Harris W.H.
      The Harris hip score: comparison of patient self-report with surgeon assessment.
      ]. It has demonstrated excellent responsiveness when compared to generic health scales such as 36-Item Short Form Survey (SF-36) [
      • Mahomed N.N.
      • Arndt D.C.
      • McGrory B.J.
      • Harris W.H.
      The Harris hip score: comparison of patient self-report with surgeon assessment.
      ,
      • Hoeksma H.L.
      • Van Den Ende C.H.M.
      • Ronday H.K.
      • Heering A.
      • Breedveld F.C.
      • Dekker J.
      Comparison of the responsiveness of the Harris Hip Score with generic measures for hip function in osteoarthritis of the hip.
      ]. Developing an Arabic version of the HHS questionnaire available will improve cultural accessibility, patient care, clinical practice, and future research.

      Material and methods

      Our study was conducted in the Orthopedic Out-Patient Clinics at King Saud University Medical City during the period from January 2020 to March 2020. Inclusion criteria were all adults aged 18 years and above; who spoke, read, and wrote Arabic; and with hip pathology including arthritis, fracture, or impingement syndrome among patients seen in our orthopedic clinic.
      Our study was conducted in 2 stages. The first stage was translation of the questionnaire to Arabic, followed by translation back to English, while the second stage included data collection for reliability and cross-cultural adaptivity.
      The questionnaire was translated to Arabic language by 2 independent translators who were fluent in both Arabic and English and experienced in the cultural differences between communities speaking both languages [
      • Sousa V.D.
      • Rojjanasrirat W.
      Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline.
      ]. The first translator (T1) had a background in medical terminology, experience in clinical orthopedics, and knowledgeable about the construct of the instrument. The second translator (T2) did not have a medical background and no previous experience with the construct of the instrument. Translation from the first translator was labeled as TL1, while that of the second translator was labeled as TL2. The translated versions (TL1 and TL2) and the original version of the HHS were compared by another 2 independent reviewers (R1 and R2), who are bilingual and bicultural, and no significant difference between the 2 translated versions (TL1 and TL2) was observed. Following consensus among both reviewers, a final Arabic translation version was adapted and labeled PI-TL. The questionnaire was then translated back from the final Arabic version (PI-TL) to English by another 2 independent translators (T3 and T4) who are fluent in both the English and Arabic languages and labeled (TL3 and TL4). Both translators (T3 and T4) have extensive knowledge of both cultures and have experience in translating medical literature. Finally, both reviewers (R1 and R2) compared the 2 back-translation versions (TL3 and TL4) to each other and then both versions (TL3 and TL4) to the original questionnaire and found no discrepancies. Following consensus between both reviewers (R1 and R2), a final Arabic version of HHS was produced.
      We then conducted a pilot study of 30 participants in order to determine if there was any difficulty in understanding the contents of the questionnaire.
      The second part of the study involved patient completion of an electronic version of the Arabic HHS questionnaire at 2 different appointments (3 weeks apart) to determine the reliability of the questionnaire. First, participants completed the Arabic version of HHS alone. Then, 2 weeks later, participants completed the Arabic versions of HHS and the validated Arabic SF-36 questionnaires in order to determine construct validity [
      • Osta N El
      • Kanso F.
      • Saad R.
      • Khabbaz L.R.
      • Fakhouri J.
      • El Osta L.
      Validation of the Arabic version of the sf-36, generic questionnaire of quality of life related to health among the elderly in Lebanon.
      ].

      Ethical consideration

      Approval was obtained from the Institutional Review Board in the Department of Family and Community Medicine in the College of Medicine, King Saud University. Each participant approved verbally after they were informed of the study purpose and the right to withdraw at any time without any obligation toward the study team. Participants’ anonymity was assured by not collecting identifying data. There were no incentives or rewards given to participants.

      Statistical analysis

      Data were analyzed using Statistical Package for Social Studies (SPSS 22; IBM Corp., New York, NY). Continuous variables were expressed as mean ± standard deviation, and categorical variables were expressed as percentages.
      Pearson Correlation coefficient was used to assess the correlation between HHS and SF-36. The Cronbach’s alpha was used to assess reliability and internal consistency of the items in the Harris Hip questionnaire. A P value <.05 was considered statistically significant. The correlation between the Arabic HHS and SF-36 was determined by using Pearson’s correlation coefficient The following guidelines were used to interpret the correlation coefficients (r): mild correlation (r < 0.3), moderate correlation (0.3 < r < 0.6), strong correlation (r > 0.6) [
      • Akoglu H.
      User’s guide to correlation coefficients.
      ].

      Results

      A total of 100 participants were included in this study, of which 30 participants were re-evaluated for reliability testing. The participants filled in all the sections of the HHS and the SF-36 questionnaires.
      Based on the participant’s feedback, the “duration time” was the preferred term instead of “blocks” for defining the walking distance. Otherwise, all the questions were clear and understandable.
      As shown in Table 1, reliability was assessed by using Cronbach’s alpha, which was found to be 0.528 for the current study.
      Table 1Measure of reliability.
      Reliability statistics
      Cronbach’s alpha0.528
      Cronbach’s alpha based on standardized scores0.742
      Cronbach’s alpha was determined following alternating removal of each item of the scale; the results are summarized in Table 2.
      Table 2Reliability for the items of the HHS questionnaire.
      ItemScale mean if item deletedScale variance if item deletedCorrected item-total correlationCronbach's alpha if item deleted
      Pain35.43126.290.330.728
      Distance walked64.17267.660.660.378
      Activities—shoes, socks68.61337.680.530.492
      Public transportation71.18366.77−0.070.539
      Support62.92304.550.410.460
      Limp63.36298.070.500.440
      Stairs69.09338.520.490.495
      Sitting67.94359.480.040.537
      Presence of deformity71.70365.690.000.512
       Total degrees of flexion70.93354.810.300.521
       Total degrees of abduction71.70365.690.000.512
       Total degrees of external rotation71.70365.690.000.512
       Total degrees of adduction71.70365.690.000.512
      Test and retest values for 30 participants of all the questions are shown in Tables 3a and 3b, the overall value of test and retest was 0.7 which is acceptable with no difference for all HHS items with P values < .001 (Table 3b).
      Table 3aCorrelation between items of Harris Hip Score (test-retest).
      TestRetest
      PainDistance walkedActivities- shoes, socksPublic transporationssupportLimbstairs
      Pain
       r0.572
      Correlation is significant at the 0.01 level (2-tailed).
      P value.001
      Distance walked
       r0.594
      Correlation is significant at the 0.01 level (2-tailed).
      P value.001
      Activities- shoes, socks
       r0.545
      Correlation is significant at the 0.01 level (2-tailed).
      P value.002
      Public transportations
       r0.202
      P value.284
      Support
       r0.868
      Correlation is significant at the 0.01 level (2-tailed).
      P value.001
      Limb
       r0.575
      Correlation is significant at the 0.01 level (2-tailed).
      P value.001
      Stairs
       r0.665
      Correlation is significant at the 0.01 level (2-tailed).
      P value<.001
      r, person correlation coefficient.
      a Correlation is significant at the 0.01 level (2-tailed).
      Table 3bCorrelation between items of Harris Hip Score (test-retest).
      TestRetest
      SittingPresence of deformityTotal degree of flexionTotal degree of abductionTotal degree of external rotationTotal degree of adductionOverall
      Sitting
       r0.163
      P value.389
      Presence of deformity
       r1.00
      Correlation is significant at the 0.01 level (2-tailed).
      P value<.001
      Total degree of flexion
       r0.514
      Correlation is significant at the 0.01 level (2-tailed).
      P value.004
      Total degree of abduction
       r1.00
      Correlation is significant at the 0.01 level (2-tailed).
      P value<.001
      Total degree of external rotation
       r1.00
      Correlation is significant at the 0.01 level (2-tailed).
      P value<.001
      Total degree of adduction
       r1.00
      Correlation is significant at the 0.01 level (2-tailed).
      P value<.001
      overall
       r0.7
      P value<.001
      r, person correlation coefficient.
      a Correlation is significant at the 0.01 level (2-tailed).
      Finally, the correlation between HHS and SF-36 was examined using criterion validity, and the result was r = 0.528 (P < .001). Therefore, based on the criterion validity, there is strong correlation between the Arabic HHS and SF-36 score (Table 4).
      Table 4Correlation between HHS and SF-36.
      ItemSF-36
      Physical functionRole limitation due to physical healthRole limitation due to emotional problemsEnergy fatigueEmotional well-beingSocial functionPainGeneral healthHealth changeOverall
      HHS
       r.569
      Correlation is significant at the 0.01 level (2-tailed).
      .597
      Correlation is significant at the 0.01 level (2-tailed).
      .551
      Correlation is significant at the 0.01 level (2-tailed).
      .530
      Correlation is significant at the 0.01 level (2-tailed).
      0.300.630
      Correlation is significant at the 0.01 level (2-tailed).
      .628
      Correlation is significant at the 0.01 level (2-tailed).
      0.286.389
      Correlation is significant at the 0.05 level (2-tailed).
      0.705
      Correlation is significant at the 0.01 level (2-tailed).
      P value.001<.001.002.003.107<.001<.001.125.034<.001
      Overall HHS with overall SF-36. r = 0.705. P value less than .001.
      a Correlation is significant at the 0.01 level (2-tailed).
      b Correlation is significant at the 0.05 level (2-tailed).

      Discussion

      There are approximately 20 questionnaires currently employed to assess patients' perception of hip joint diseases and their treatment, including the HHS [
      • Bryant M.J.
      • Kernohan W.G.
      • Nixon J.R.
      • Mollan R.A.B.
      A statistical analysis of hip scores.
      ]. HHS is a validated method to measure the outcome of femoral neck fracture, OA, and THA [
      • Hoeksma H.L.
      • Vanden Ende C.H.M.
      • K Ronday H.
      • Heering A.
      • Breedveld F.C.
      • Dekker J.
      Comparison of the responsiveness of the harris hip.
      ]. This measure has demonstrated its superiority to generic health scales such as the SF-36 as a more representative method for patients with THA [
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the harris hip score and the SF-36: Five years after total hip arthroplasty.
      ]. However, comparison of the HHS to other disease-specific scores did not show that any measure was significantly superior to the others [
      • HARRIS W.H.
      Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty an End-result study using A New method of result evaluation.
      ].
      The HHS was chosen to be translated because it is 1 of the most widely used scores for disease-specific measure for hip joint evaluation [
      • HARRIS W.H.
      Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty an End-result study using A New method of result evaluation.
      ,
      • Wilson P.D.
      • Amstutz H.C.
      • Czerniecki A.
      • Salvati E.A.
      • Mendes D.G.
      Total hip replacement with fixation by acrylic cement. A preliminary study of 100 consecutive McKee-Farrar prosthetic replacements.
      ]. It was developed and published in 1969 by William Harris as a physician assessment tool to evaluate THA [
      • HARRIS W.H.
      Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty an End-result study using A New method of result evaluation.
      ]. However, it has also proved to be a reliable measurement tool if completed by the patients [
      • Mahomed N.N.
      • Arndt D.C.
      • McGrory B.J.
      • Harris W.H.
      The Harris hip score: comparison of patient self-report with surgeon assessment.
      ,
      • Mannion A.F.
      • Kämpfen S.
      • Munzinger U.
      • Kramers-de Quervain I.
      The role of patient expectations in predicting outcome after total knee arthroplasty.
      ]. Many authors have employed this tool to evaluate patients with hip conditions such as femoral neck fracture or OA, as well as the success of surgical interventions such as THA, and have found that it is a representative measure of their condition and treatment [
      • Söderman P.
      • Malchau H.
      Is the Harris hip score system useful to study the outcome of total hip replacement?.
      ,
      • Frihagen F.
      • Grotle M.
      • Madsen J.E.
      • Wyller T.B.
      • Mowinckel P.
      • Nordsletten L.
      Outcome after femoral neck fractures: a comparison of harris hip score, eq-5d and barthel index.
      ,
      • Singh J.A.
      • Schleck C.
      • Harmsen S.
      • Lewallen D.
      Clinically important improvement thresholds for Harris Hip Score and its ability to predict revision risk after primary total hip arthroplasty.
      ]. HHS covers both pain and functional disability, which are also the 2 main factors leading to THA for patients with hip OA. As such, HHS has become the most widely used measurement tool for THA outcome worldwide [
      • HARRIS W.H.
      Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty an End-result study using A New method of result evaluation.
      ,
      • Mahomed N.N.
      • Arndt D.C.
      • McGrory B.J.
      • Harris W.H.
      The Harris hip score: comparison of patient self-report with surgeon assessment.
      ]. Therefore, many scholars aim to study patients with THA by using HHS in order to compare their results to studies in the literature. HHS has the advantage of assessing the clinical improvement among patients with hip OA before and after THA, and additionally, it can predict the risk for primary THA revision [
      • Singh J.A.
      • Schleck C.
      • Harmsen S.
      • Lewallen D.
      Clinically important improvement thresholds for Harris Hip Score and its ability to predict revision risk after primary total hip arthroplasty.
      ].
      The HHS is composed of 10 items with a maximum score of 100 points, covering 4 major domains: pain (1 item, 0-44 points), function (7 items 0-47 points), absence of deformity (1 item, 4 points), and range of motion (2 items, 5 points). The results are categorized as excellent, fair, or poor depending on the final score [
      • HARRIS W.H.
      Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty an End-result study using A New method of result evaluation.
      ].
      The translators faced no difficulties in the translation nor the cultural adaptation of the items and possible responses into the Arabic language for the HHS. The forward and backward translation of the HHS led to the development of a comprehensible Arabic HHS. This result is similar to what was reported for the Turkish, Portuguese, and Italian adaptation studies [
      • Dettoni F.
      • Pellegrino P.
      • La Russa M.R.
      • et al.
      Validation and cross cultural adaptation of the Italian version of the harris hip score.
      ,
      • Çelik D.
      • Can C.
      • Aslan Y.
      • Ceylan H.H.
      • Bilsel K.
      • Ozdincler A.R.
      Translation, Cross-cultural adaptation, and validation of the Turkish version of the harris hip score.
      ,
      • Guimarães R.P.
      • Alves D.P.L.
      • Silva G.B.
      • et al.
      Translation and cultural adaptation of the Harris Hip score into Portuguese.
      ]. Moreover, the participants did not report any difficulties in answering and understanding the Arabic HHS, again similar to the other adaptation studies [
      • Dettoni F.
      • Pellegrino P.
      • La Russa M.R.
      • et al.
      Validation and cross cultural adaptation of the Italian version of the harris hip score.
      ,
      • Çelik D.
      • Can C.
      • Aslan Y.
      • Ceylan H.H.
      • Bilsel K.
      • Ozdincler A.R.
      Translation, Cross-cultural adaptation, and validation of the Turkish version of the harris hip score.
      ,
      • Guimarães R.P.
      • Alves D.P.L.
      • Silva G.B.
      • et al.
      Translation and cultural adaptation of the Harris Hip score into Portuguese.
      ].
      The reliability of the Arabic HHS was evaluated by using Cronbach’s alpha and test-retest reliability. Cronbach’s alpha of the total score of the Arabic HHS is 0.528 which is considered moderate correlation. Other studies have higher reliability within the range (0.7-0.9). Furthermore, the Cronbach’s alpha reported in the Turkish and Italian translations were 0.7 and 0.816, respectively. The reason behind this difference is the low reliability that is seen in the pain scale, which was 0.33 [
      • Dettoni F.
      • Pellegrino P.
      • La Russa M.R.
      • et al.
      Validation and cross cultural adaptation of the Italian version of the harris hip score.
      ,
      • Çelik D.
      • Can C.
      • Aslan Y.
      • Ceylan H.H.
      • Bilsel K.
      • Ozdincler A.R.
      Translation, Cross-cultural adaptation, and validation of the Turkish version of the harris hip score.
      ,
      • Guimarães R.P.
      • Alves D.P.L.
      • Silva G.B.
      • et al.
      Translation and cultural adaptation of the Harris Hip score into Portuguese.
      ].
      Test-rest value was 0.7, which is considered acceptable reliability, while the Italian and Turkish results were 0.975 and 0.91, respectively. We think that the Turkish study has excellent reliability since the time interval for the reliability testing was short (1 week only). In the current study, the time interval was 3 weeks, which is the recommended period [
      • Söderman P.
      • Malchau H.
      Is the Harris hip score system useful to study the outcome of total hip replacement?.
      ,
      • Dettoni F.
      • Pellegrino P.
      • La Russa M.R.
      • et al.
      Validation and cross cultural adaptation of the Italian version of the harris hip score.
      ,
      • Çelik D.
      • Can C.
      • Aslan Y.
      • Ceylan H.H.
      • Bilsel K.
      • Ozdincler A.R.
      Translation, Cross-cultural adaptation, and validation of the Turkish version of the harris hip score.
      ].
      The constructive validity of the Arabic HHS and SF-36 was identified by finding the correlation between the 2 scales. The correlation was r = 0.71 (P < .001), which represents strong correlation between Arabic HHS and SF-36. When looking to the correlation of Harris questionnaire with the subdivision of SF-36, we found a strong correlation between the Arabic Harris questionnaire with SF-36 physical role functioning, SF-36 pain, and SF-36 social functioning with PCC of 0.6, 0.628, and 0.63, respectively. Compared to the Turkish study, they found a strong correlation of Turkish Harris with SF-36 pain subscales with a PCC of 0.7 while a moderate correlation with SF-36 social functioning and SF-36 physical role functioning with a PCC of 0.53 and 0.46, respectively. Additionally, a moderate correlation was seen between the Arabic HHS and SF-36 physical function and SF-36 role limitation due to emotional problems with a PCC of 0.57 and 0.55, respectively. The Turkish study found a strong correlation with SF-36 physical function with a PCC of 0.72 while a mild correlation was identified with SF-36 role limitation due to emotional problems with a PCC of 0.37 [
      • Çelik D.
      • Can C.
      • Aslan Y.
      • Ceylan H.H.
      • Bilsel K.
      • Ozdincler A.R.
      Translation, Cross-cultural adaptation, and validation of the Turkish version of the harris hip score.
      ].

      Limitations

      In the literature, constructive validity of HHS was done with generic health status scales like SF-36. Based on the literature, constructive validity of Arabic HHS is done with a generic health status scale (SF-36) only. Further studies are needed to assess the constructive validity with disease-specific scales like the HOOS.

      Conclusions

      In this study, we translated and adapted the HHS questionnaire into Arabic with cross-cultural considerations specific to Arabic communities while maintaining its psychometric properties. Its translation reliability and validity were thoroughly tested via forward and backward translation and found to be statistically similar to those of other translated versions of the HHS. This disease-specific questionnaire can effectively capture how the patient feels about their condition. Therefore, we believe that the Arabic HHS can be used by clinicians, researchers, and patients to evaluate and report hip pathologies and THA treatment efficacy. Having this version of the HHS questionnaire available will make a great additional tool for improving care and accessibility for Arabic-speaking patients as well as improve representation of this patient demographic in future research contributions.

      Conflicts of interest

      The authors declare there are no conflicts of interest.
      For full disclosure statements refer to https://doi.org/10.1016/j.artd.2022.07.006.

      Acknowledgments

      The authors would like to acknowledge and thank all the participants in this study.

      Appendix ASupplementary data

      References

        • Thorborg K.
        • Roos E.M.
        • Bartels E.M.
        • Petersen J.
        • Hölmich P.
        Validity, reliability and responsiveness of patient-reported outcome questionnaires when assessing hip and groin disability: a systematic review.
        Br J Sports Med. 2010; 44: 1186-1196
        • Van Der Waal J.M.
        • Bot S.D.M.
        • Terwee C.B.
        • Van Der Windt D.A.W.M.
        • Bouter L.M.
        • Dekker J.
        The course and prognosis of hip complaints in general practice.
        Ann Behav Med. 2006; 31: 297-308
        • Picavet H.S.J.
        • Schouten JSA G.
        Musculoskeletal pain in The Netherlands: prevalences, consequences and risk groups, the DMC(3)-study.
        Pain. 2003; 102: 167-178
        • Conaghan P.G.
        Osteoarthritis: National clinical guideline for care and management in adults (NICE).
        Consultant. 2008; 336: 502-503
        • Neogi T.
        The epidemiology and impact of pain in osteoarthritis.
        Osteoarthr Cartil. 2013; 21: 1145-1153
        • Lawrence R.C.
        • Felson D.T.
        • Helmick C.G.
        • et al.
        Estimates of the prevalence of arthritis and other rheumatic conditions in the United States.
        Part Arthritis Rheum. 2008; 58: 26-35
        • Zhang W.
        • Doherty M.
        EULAR recommendations for knee and hip osteoarthritis: a critique of the methodology.
        Br J Sports Med. 2006; 40: 664-669
        • Cross M.
        • Smith E.
        • Hoy D.
        • et al.
        The global burden of hip and knee osteoarthritis: Estimates from the Global Burden of Disease 2010 study.
        Ann Rheum Dis. 2014; 73: 1323-1330
        • Bederman S.S.
        • Rosen C.D.
        • Bhatia N.N.
        • Kiester P.D.
        • Gupta R.
        Drivers of surgery for the degenerative hip, knee, and spine: a systematic review.
        Clin Orthop Relat Res. 2012; 470: 1090-1105
        • Yoon P.W.
        • Lee Y.K.
        • Ahn J.
        • et al.
        Epidemiology of hip replacements in Korea from 2007 to 2011.
        J Korean Med Sci. 2014; 29: 852-858
        • Learmonth I.D.
        • Young C.
        • Rorabeck C.
        The operation of the century: total hip replacement.
        Lancet. 2007; 370: 1508-1519
        • Wells V.M.
        • Hearn T.C.
        • McCaul K.A.
        • Anderton S.M.
        • Wigg A.E.R.
        • Graves S.E.
        Changing incidence of primary total hip arthroplasty and total knee arthroplasty for primary osteoarthritis.
        J Arthroplasty. 2002; 17: 267-273
        • Kurtz S.
        • Mowat F.
        • Ong K.
        • Chan N.
        • Lau E.
        • Halpern M.
        Prevalence of primary and arthroplasty in the United States from 1990 through 2002.
        J Bone Joint Surg Am. 2005; 87: 1487-1498
        • Kremers H.M.
        • Larson D.R.
        • Crowson C.S.
        • et al.
        Prevalence of total hip and knee replacement in the United States.
        J Bone Joint Surg Am. 2014; 97: 1386-1397
        • Liu S.S.
        • González Della Valle A.
        • Besculides M.C.
        • Gaber L.K.
        • Memtsoudis S.G.
        Trends in mortality, complications, and demographics for primary hip arthroplasty in the United States.
        Int Orthop. 2009; 33: 643-651
        • Hamdi A.
        • Bakhsh D.
        • Al-Sayyad M.
        Indications of total hip arthroplasty at a tertiary hospital in Jeddah.
        Saudi Surg J. 2017; 1: 5-106
        • Bryant M.J.
        • Kernohan W.G.
        • Nixon J.R.
        • Mollan R.A.B.
        A statistical analysis of hip scores.
        J Bone Jt Surg - Ser B. 1993; 75: 705-709
        • Hoeksma H.L.
        • Vanden Ende C.H.M.
        • K Ronday H.
        • Heering A.
        • Breedveld F.C.
        • Dekker J.
        Comparison of the responsiveness of the harris hip.
        Ann Rheum Dis. 2003; 62: 935-939
        • Söderman P.
        • Malchau H.
        Is the Harris hip score system useful to study the outcome of total hip replacement?.
        Clin Orthop Relat Res. 2001; 384: 189-197
        • Hays R.D.
        • Sherbourne C.D.
        • Mazel R.M.
        The rand 36-item health survey 1.0.
        Health Econ. 1993; 2: 217-227
        • Nilsdotter A.K.
        • Lohmander L.S.
        • Klässbo M.
        • Roos E.M.
        Hip disability and osteoarthritis outcome score (HOOS) - validity and responsiveness in total hip replacement.
        BMC Musculoskelet Disord. 2003; 4: 1-8
        • Maillefert J.F.
        • Kloppenburg M.
        • Fernandes L.
        • et al.
        Multi-language translation and cross-cultural adaptation of the OARSI/OMERACT measure of intermittent and constant osteoarthritis pain (ICOAP).
        Osteoarthr Cartil. 2009; 17: 1293-1296
        • HARRIS W.H.
        Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty an End-result study using A New method of result evaluation.
        J Bone Joint Surg Am. 1969; 51: 737-755
        • Torad A.
        • Abd W.H.
        • Kader E.
        • Saleh M.S.
        • Torad M.M.
        Validity and reliability of the Arabic version OF KOOS-physical function short.
        Int J Recent Adv Multidis Res. 2015; 2: 599-604
        • Alageel M.
        • Al Turki A.
        • Alhandi A.
        • Alohali R.
        • Alsalem R.
        • Aleissa S.
        Cross-cultural adaptation and validation of the Arabic version of the intermittent and constant osteoarthritis pain questionnaire.
        Sport Med Int Open. 2020; 4: E8-E12
        • Mahomed N.N.
        • Arndt D.C.
        • McGrory B.J.
        • Harris W.H.
        The Harris hip score: comparison of patient self-report with surgeon assessment.
        J Arthroplasty. 2001; 16: 575-580
        • Hoeksma H.L.
        • Van Den Ende C.H.M.
        • Ronday H.K.
        • Heering A.
        • Breedveld F.C.
        • Dekker J.
        Comparison of the responsiveness of the Harris Hip Score with generic measures for hip function in osteoarthritis of the hip.
        Ann Rheum Dis. 2003; 62: 935-938
        • Sousa V.D.
        • Rojjanasrirat W.
        Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline.
        J Eval Clin Pract. 2011; 17: 268-274
        • Osta N El
        • Kanso F.
        • Saad R.
        • Khabbaz L.R.
        • Fakhouri J.
        • El Osta L.
        Validation of the Arabic version of the sf-36, generic questionnaire of quality of life related to health among the elderly in Lebanon.
        East Mediterr Health J. 2019; 25: 706-714
        • Akoglu H.
        User’s guide to correlation coefficients.
        Turk J Emerg Med. 2018; 18: 91-93
        • Shi H.Y.
        • Mau L.W.
        • Chang J.K.
        • Wang J.W.
        • Chiu H.C.
        Responsiveness of the harris hip score and the SF-36: Five years after total hip arthroplasty.
        Qual Life Res. 2009; 18: 1053-1060
        • Wilson P.D.
        • Amstutz H.C.
        • Czerniecki A.
        • Salvati E.A.
        • Mendes D.G.
        Total hip replacement with fixation by acrylic cement. A preliminary study of 100 consecutive McKee-Farrar prosthetic replacements.
        J Bone Joint Surg Am. 1972; 54: 207-221
        • Mannion A.F.
        • Kämpfen S.
        • Munzinger U.
        • Kramers-de Quervain I.
        The role of patient expectations in predicting outcome after total knee arthroplasty.
        Arthritis Res Ther. 2009; 11: 1-3
        • Frihagen F.
        • Grotle M.
        • Madsen J.E.
        • Wyller T.B.
        • Mowinckel P.
        • Nordsletten L.
        Outcome after femoral neck fractures: a comparison of harris hip score, eq-5d and barthel index.
        Injury. 2008; 39: 1147-1156
        • Singh J.A.
        • Schleck C.
        • Harmsen S.
        • Lewallen D.
        Clinically important improvement thresholds for Harris Hip Score and its ability to predict revision risk after primary total hip arthroplasty.
        BMC Musculoskelet Disord. 2016; 17: 1-8https://doi.org/10.1186/s12891-016-1106-8
        • Dettoni F.
        • Pellegrino P.
        • La Russa M.R.
        • et al.
        Validation and cross cultural adaptation of the Italian version of the harris hip score.
        HIP Int. 2015; 25: 91-97
        • Çelik D.
        • Can C.
        • Aslan Y.
        • Ceylan H.H.
        • Bilsel K.
        • Ozdincler A.R.
        Translation, Cross-cultural adaptation, and validation of the Turkish version of the harris hip score.
        HIP Int. 2014; 24: 473-479
        • Guimarães R.P.
        • Alves D.P.L.
        • Silva G.B.
        • et al.
        Translation and cultural adaptation of the Harris Hip score into Portuguese.
        Acta Ortop Bras. 2010; 18: 142-147