title: Multirater agreement of the causes of anterior cruciate ligament reconstruction failure: a radiographic and video analysis of the MARS cohort.
abstract: BACKGROUND
  Anterior cruciate ligament (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. Limited data are available regarding the agreement among orthopaedic surgeons regarding the causes of primary ACL reconstruction failure and accuracy of graft tunnel placement.
  
  
  OBJECTIVE
  Experienced knee surgeons have a high level of interobserver reliability in the agreement about the causes of primary ACL reconstruction failure, anatomic graft characteristics, and tunnel placement.
  
  
  METHODS
  Cohort study (diagnosis); Level of evidence, 3.
  
  
  METHODS
  Twenty cases of revision ACL reconstruction were randomly selected from the Multicenter ACL Revision Study (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. All 20 cases were reviewed by 10 MARS surgeons not involved with the primary surgery. Each surgeon completed a 2-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 causes of graft failure. Interrater agreement was determined for each question with the kappa coefficient and the prevalence-adjusted, bias-adjusted kappa (PABAK).
  
  
  RESULTS
  The 10 reviewers have been in practice an average of 14 years and have 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 causes of ACL graft failure. When participants were specifically asked about technical error as the cause for failure, interobserver agreement was only slight (PABAK = 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK = 0.55) but only slight agreement on whether a femoral tunnel was too anterior (PABAK = 0.24) and fair agreement on whether it was too vertical (PABAK = 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK = 0.17).
  
  
  CONCLUSIONS
  This study suggests that more objective criteria are needed to accurately determine the causes of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction.
authors.affiliation: Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, Missouri, USA matavam@wudosis.wustl.edu.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Matava
authors.affiliation: University of Connecticut Health Center, Farmington, Connecticut, USA.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Arciero
authors.affiliation: Orthopaedic Institute, Sioux Falls, South Dakota, USA.
authors.forename: Keith M
authors.initials: KM
authors.lastname: Baumgarten
authors.affiliation: Vanderbilt University, Nashville, Tennessee, USA.
authors.forename: James L
authors.initials: JL
authors.lastname: Carey
authors.affiliation: University of Connecticut Health Center, Farmington, Connecticut, USA.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: DeBerardino
authors.affiliation: University of California-Los Angeles, Los Angeles, California, USA.
authors.forename: Sharon L
authors.initials: SL
authors.lastname: Hame
authors.affiliation: Hospital for Special Surgery, New York, New York, USA.
authors.forename: Jo A
authors.initials: JA
authors.lastname: Hannafin
authors.affiliation: University of Michigan Medical School, Ann Arbor, Michigan, USA.
authors.forename: Bruce S
authors.initials: BS
authors.lastname: Miller
authors.affiliation: Connecticut Children's Medical Center, Farmington, Connecticut, USA.
authors.forename: Carl W
authors.initials: CW
authors.lastname: Nissen
authors.affiliation: University of North Carolina, Chapel Hill, North Carolina, USA.
authors.forename: Timothy N
authors.initials: TN
authors.lastname: Taft
authors.affiliation: University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
authors.forename: Brian R
authors.initials: BR
authors.lastname: Wolf
authors.affiliation: Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, Missouri, USA.
authors.forename: Rick W
authors.initials: RW
authors.lastname: Wright
mesh_terms: D016118:Anterior Cruciate Ligament / Q000000981:diagnostic imaging / Q000601:surgery*; D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods*; D015331:Cohort Studies; D016208:Databases, Factual; D005269:Femur / Q000601:surgery; D006801:Humans; D007719:Knee Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D015588:Observer Variation; D011859:Radiography; D015203:Reproducibility of Results; D011795:Surveys and Questionnaires; D013977:Tibia / Q000601:surgery; D019737:Transplants; D017211:Treatment Failure
keywords: anterior cruciate ligament; interobserver reliability; revision; tunnel placement