Multirater Agreement of the Causes of Anterior Cruciate Ligament Reconstruction Failure

Abstract

Background ACL reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. There is limited data regarding the agreement among orthopedic surgeons in terms of the etiology of primary ACL reconstruction failure and accuracy of graft tunnel placement. Purpose The purpose of this study is to test the hypothesis that experienced knee surgeons have a high level of inter-observer reliability in the agreement of the etiology of the primary ACL reconstruction failure, anatomical graft characteristics, tunnel placement. Methods Twenty cases of revision ACL reconstruction were randomly selected from the MARS database. Each case included the patient's history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. 10 MARS surgeons not involved with the primary surgery reviewed all 20 cases. Each surgeon completed a two-part questionnaire dealing with each surgeon's training and practice as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon's opinion as to the etiology of graft failure. Inter-rater agreement was determined for each question. Inter-rater agreement was determined for each question with the kappa coefficient and prevalence adjusted bias adjusted kappa (PABAK). Results The 10 reviewers were in practice an average of 14 years. All performed at least 25 ACL reconstructions per year and 9 were fellowship-trained in sports medicine. There was wide variability in agreement among knee experts as to the specific etiology of ACL graft failure. When specifically asked about technical error as the cause for failure, inter-observer agreement was only slight (prevalence adjusted bias adjusted kappa [PABAK]: 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK: 0.55), but only slight agreement whether a femoral tunnel was too anterior (PABAK: 0.24) and fair agreement whether it was too vertical (PABAK: 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK: 0.17). Conclusion This study suggests that more objective criteria are needed to accurately determine the etiology of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction.

Geometric Risk Factors Associated With Noncontact Anterior Cruciate Ligament Graft Rupture

“…Unfortunately, neither bone tunnel position data nor knee laxity data after surgery were available to us for this study. However, work by Matava et al 30 demonstrated that 10 orthopaedic surgeons reviewing 20 cases of revision ACLR were unable to agree whether the cause of graft failure was due to malpositioning of the graft or by other mechanisms. Therefore, even if we had intraoperative and/or radiographic data on bone tunnel location, it is unclear if we would have the ability to establish the cause of graft failure.…”

Posterior Wall Blowout in Anterior Cruciate Ligament Reconstruction

“…Improper surgical technique remains one of the most common sources of failure of primary ACL reconstructions. 1 , 10 , 28 , 30 , 38 , 42 Although careful surgical planning and knowledge of pertinent anatomical landmarks are key to prevent unexpected intraoperative complications, breach of the posterior or lateral cortex during reaming of the femoral tunnel remains one of the most challenging situations to properly address. Without thorough evaluation of the integrity of the femoral tunnel and posterior wall of the lateral femoral condyle, this complication can remain unrecognized and therefore place the graft at greater risk of failure due to loss of fixation or altered biomechanics.…”

“…Recent literature has demonstrated that tunnel malposition is a common cause of both intraoperative complications and graft failure after ACLR. 1 , 4 , 7 , 10 , 30 , 42 …”

Anterior Cruciate Ligament Remnant–Preserving Reconstruction Using a “Lasso-Loop” Knot Configuration

“…3 However, despite the numerous surgical techniques described, ACLR improves the patient's activity level and reduces, but does not eliminate, the risk of joint degeneration and the necessity for further surgery. 2,3 Restoration of normal ACL anatomy requires anatomic remodeling, fiber maturation, and ligamentization of the applied graft. Early ACL remnantesparing techniques support the theory of preserving the proprioceptive receptors, enhancing the revascularization process, and finally, achieving "cellular ligamentization."…”

“…1,2 In an effort to decelerate this degenerative process, arthroscopic anterior cruciate ligament reconstruction (ACLR) using tendon autografts has been one of the most popular surgical interventions worldwide. 3 However, despite the numerous surgical techniques described, ACLR improves the patient's activity level and reduces, but does not eliminate, the risk of joint degeneration and the necessity for further surgery. 2,3 Restoration of normal ACL anatomy requires anatomic remodeling, fiber maturation, and ligamentization of the applied graft.…”