Knee osteoarthritis in the intact- and amputation-side knees of UK military personnel and veterans with traumatic unilateral transtibial limb loss 8- and 11-years post-injury: the ADVANCE cohort
File(s)
Article in press
Author(s)
Type
Journal Article
Abstract
Objective
To compare knee osteoarthritis (OA) in people with unilateral transtibial (UTT) limb loss (LL) between (1) intact- and amputation-side knees and (2) ∼8- and ∼11-years post-LL and to report knee OA in the reference population.
Design
Inception cohort.
Setting
UK military.
Participants
Volunteers with UTT LL (n=36) and matched controls (n=36).
Interventions
Not applicable.
Main Outcome Measures
Kellgren-Lawrence (KL; 0-4 [none–severe]) score and Knee Injury and Osteoarthritis Outcome Score (100-0 [no problems–severe problems]) for pain and symptoms.
Results
At baseline, ∼8 years after LL, the mean age was 32.9±4.2-years. Participants used dynamic–passive prosthetic limbs for daily activities and exercise. At baseline, KL was not different between intact- and amputation-side knees (P=.220). At follow-up, KL was worse on the amputation side than intact-side knee (P=.021). Rank-biserial correlation indicated that, for a randomly chosen pair, the amputation-side knee was 67% more likely to have a higher KL score than the intact-side knee. On both the intact- and amputation-side knees, KL was not different between baseline and follow-up (P=.706 and .138). Knee Injury and Osteoarthritis Outcome Score pain and symptoms were not different between intact- and amputation-side knees at baseline (pain: median, 100.0 vs 100.0; P=.253; symptoms: median, 90.0 vs 86.5; P=.573) or follow-up (pain: median, 94.4 vs 97.2; P=.291; symptoms: median, 90.0 vs 90.0; P=.247). Knee Injury and Osteoarthritis Outcome Score Pain (P=.619 and .557) and Symptoms (P=.664 and .580) were not different between baseline and follow-up for the intact- and amputation-side knees.
Conclusions
For the first time, we have compared OA of the intact- and amputation-side knee of people with UTT LL. Contrary to current opinion, radiographic OA was worse on the amputation-side knee 11 years post-LL. Modern military populations may be unique in their access to rehabilitation and prosthetic technology, resulting in different patterns of OA. Clinical care should focus on the intact- and amputation-side knee of people with UTT LL.
To compare knee osteoarthritis (OA) in people with unilateral transtibial (UTT) limb loss (LL) between (1) intact- and amputation-side knees and (2) ∼8- and ∼11-years post-LL and to report knee OA in the reference population.
Design
Inception cohort.
Setting
UK military.
Participants
Volunteers with UTT LL (n=36) and matched controls (n=36).
Interventions
Not applicable.
Main Outcome Measures
Kellgren-Lawrence (KL; 0-4 [none–severe]) score and Knee Injury and Osteoarthritis Outcome Score (100-0 [no problems–severe problems]) for pain and symptoms.
Results
At baseline, ∼8 years after LL, the mean age was 32.9±4.2-years. Participants used dynamic–passive prosthetic limbs for daily activities and exercise. At baseline, KL was not different between intact- and amputation-side knees (P=.220). At follow-up, KL was worse on the amputation side than intact-side knee (P=.021). Rank-biserial correlation indicated that, for a randomly chosen pair, the amputation-side knee was 67% more likely to have a higher KL score than the intact-side knee. On both the intact- and amputation-side knees, KL was not different between baseline and follow-up (P=.706 and .138). Knee Injury and Osteoarthritis Outcome Score pain and symptoms were not different between intact- and amputation-side knees at baseline (pain: median, 100.0 vs 100.0; P=.253; symptoms: median, 90.0 vs 86.5; P=.573) or follow-up (pain: median, 94.4 vs 97.2; P=.291; symptoms: median, 90.0 vs 90.0; P=.247). Knee Injury and Osteoarthritis Outcome Score Pain (P=.619 and .557) and Symptoms (P=.664 and .580) were not different between baseline and follow-up for the intact- and amputation-side knees.
Conclusions
For the first time, we have compared OA of the intact- and amputation-side knee of people with UTT LL. Contrary to current opinion, radiographic OA was worse on the amputation-side knee 11 years post-LL. Modern military populations may be unique in their access to rehabilitation and prosthetic technology, resulting in different patterns of OA. Clinical care should focus on the intact- and amputation-side knee of people with UTT LL.
Date Issued
2026-03-12
Date Acceptance
2026-02-27
Citation
Archives of Physical Medicine and Rehabilitation, 2026
ISSN
0003-9993
Publisher
Elsevier
Journal / Book Title
Archives of Physical Medicine and Rehabilitation
Copyright Statement
© 2026 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
License URL
Identifier
10.1016/j.apmr.2026.02.497
Publication Status
Published online
Date Publish Online
2026-03-12