Introduction

Anterior cruciate ligament (ACL) tears are orthopedic injuries frequently associated with sports and, as a result, have been extensively described and studied.1-3 The objectives of ACL reconstruction (ACLR) are to restore knee joint stability, prevent secondary injuries, and improve functional outcomes.2,4 New technological advancements and progress in ACLR research have provided knee surgeons with multiple options in terms of graft types, fixation devices, and surgical techniques to achieve these clinical outcomes.2,4

The goal of ACLR is to reproduce the original anatomy of the ACL, which was traditionally accomplished through arthrotomy. However, the introduction of minimally invasive surgical techniques led to arthroscopic ACLR.4,5 In the past, arthroscopic ACL reconstruction was done using a two-incision technique that involved drilling the femoral bone tunnel from the outside to the inside.4,5 A single-incision technique was then adopted, in which the same tunnel is drilled from the inside out through the tibial tunnel. While both techniques are effective, unfortunately neither reproduces the native anatomy of the ACL.5

Anatomical ACL reconstruction has been defined as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites.2,4,6 Depending on the individual’s anatomy, different surgical approaches are available to achieve anatomical reconstruction, as well as various graft diameters and perforation angles.2,4,6

Since the concept of anatomical reconstruction was introduced, many authors have reported the performance of anatomical ACL reconstruction (AACLR).6-8 However, according to a systematic review conducted in 2016 by Desai et al.,9 studies often provide few details on the AACLR technique, which also presents significant variations. This situation prompted the creation of the Anatomic Anterior Cruciate Ligament Anatomic Reconstruction Scoring Checklist (AARSC),9 which was developed by Van Eck et al.10 in order to define the surgical methods and procedures necessary to increase the likelihood of achieving an anatomical ACL reconstruction.

While there are several AACLR techniques, the AARSC allows for a critical and objective assessment of the surgical procedure performed to establish whether or not the described surgical technique can be considered an AACLR. This Checklist comprises 17 items developed and validated by means of a survey methodology and an expert panel, concluding that the increased use of these items in the technique enhances the anatomical accuracy of the reconstruction.10 The final version of the original AARSC (English) was validated in terms of inter-rater reliability, construct validity, and internal consistency.10

Although it was published more than a decade ago (2013), and based on a literature review, the AARSC has not been validated in other languages, and studies on its use have been published mainly by its creators.9,11-18 In light of the above, and given the academic usefulness of this Checklist in the critical evaluation of scientific publications on ACLR techniques, the objective of this study was to validate the Colombian Spanish version of the AARSC in terms of inter-rater reliability, construct validity, and internal consistency as a tool for assessing ACLR surgical techniques described in the literature.

Methodology

Study type

Validation study of the AARSC in Colombian Spanish. The study was conducted in two phases: translation and adaptation of the Checklist into Colombian Spanish, and validation of the instrument (inter-rater reliability, construct validity, and internal consistency).

Phase 1. Translation and adaptation into Colombian Spanish

A native Spanish speaker, who is an orthopedic surgeon specializing in knee surgery and has a high level of proficiency in English, translated the original version of the AARSC10 from English into Spanish. Then, another native Spanish speaker, also an orthopedic surgeon specialized in knee surgery and with a high level of proficiency in English as a second language, translated it back into English (back-translation). Both versions (Spanish translation and back-translation into English) were evaluated and discussed by all authors of this study (experts in knee surgery and/or epidemiology), obtaining the final version adapted to Colombian Spanish after including, by consensus, the adjustments suggested in said review.

Phase 2. Validation (internal consistency, reliability, and construct validity)

The methodology implemented by van Eck et al.10 in the initial validation of the original AARSC was applied. To test internal consistency, reliability, and construct validity, 18 articles describing ACLR techniques were selected.19-36 This selection was based on the results of a systematic review conducted by the lead author of the Checklist (i.e., van Eck).37

Subsequently, four senior orthopedists (JBA, JFF, CR, RG), all specialists in knee surgery, individually provided an overall rating of the surgical techniques described in each of the articles based on their personal opinion and expertise, rating the “anatomy” of each surgical technique on a four-point scale (1 = not anatomical, 2 = somewhat anatomical, 3 = almost anatomical, and 4 = completely anatomical). The experts evaluated the 18 articles without using any pre-established guidelines. These ratings were then categorized as either anatomical ACLR (score 3 or 4) or non-anatomical ACLR (score 1 or 2).

Afterwards, another 6 orthopedists with experience in ACLR individually rated the surgical reconstruction technique described in the selected articles using the Colombian Spanish version of the AARSC. Each of these orthopedists was randomly assigned 9 of the 18 articles, for a total of 54 evaluations (i.e., each article was evaluated by three different surgeons). The scores obtained for each article per evaluator were calculated.

Altogether, there were 7 assessments for each surgical technique: 4 by senior knee surgery specialists without a pre-established guideline and 3 by orthopedists with ACLR experience using the Colombian Spanish version of the AARSC. All articles were blinded to prevent their identification and only the figures and information contained in the “methods or methodology” section were used. The main characteristics of the studies are described in Table 1.

Table 1. Main characteristics of the studies used to validate the Colombian Spanish version of the Anatomical Anterior Cruciate Ligament Reconstruction Score Checklist.

Author/year	Title	Country/Region	Study type	Population	Sample (n)	Single or double-bundle	Underreporting
Aglietti et al., 200719	Single- and double-incision double-bundle ACL reconstruction	Italy	Comparative, descriptive, observational	Patients with isolated chronic unilateral ACL tear	75 patients	Single bundle: 25 patients Double bundle: 50 patients	The authors do not report: Lens type Accessory portal Anatomical repairs of the footprint or its measurements
Ahn & Lee, 200720	Anterior cruciate ligament Double-bundle reconstruction with hamstring tendon autografts	South Korea	Technical note	N/A	N/A	Double bundle	The authors do not report: Lens type Accessory portal (mention transtibial) Footprint measurement Anatomical repairs such as non-bifurcated intercondylar ridge
Brucker et al., 200521	Intraarticular EndoButton displacement in anatomic anterior cruciate ligament double-bundle reconstruction: A case report	United States	Case report	Complete ACL tear and inferior surface tear of the posterior horn of the medial meniscus.	1 patient	Double bundle	The authors do not describe: Lens type Anatomical adjustments Footprint measurement
Brucker et al., 200622	Aperture fixation in arthroscopic anterior cruciate ligament double-bundle reconstruction	United States and Germany	Technical note	N/A	N/A	Double bundle	The authors do not describe: Lens type Anatomical repairs
Caborn & Chang, 200523	Single femoral socket double-bundle anterior cruciate ligament reconstruction using tibialis anterior tendon: Description of a new technique	United States and Singapore	Technical note	N/A	N/A	Double bundle	The authors do not describe: Lens type Anatomical repairs Footprint measurement
Christel et al., 200824	Anatomic double-bundle anterior cruciate ligament reconstruction with anatomic aimers	Saudi Arabia, United States, and Greece	Technical note	N/A	N/A	Double bundle	The authors do not describe: Lens type Anatomical repairs Footprint measurement
Colombet et al., 200625	Two-bundle, four-tunnel anterior cruciate ligament reconstruction	France	Descriptive observational	ACL tear	35 patients	Double bundle	The authors do not describe: Lens type Anatomical repairs Footprint measurement
Colombet et al., 200826	Computer-assisted, anatomic, double-bundle anterior cruciate ligament reconstruction	France and England	Technical note	N/A	N/A	Double bundle	The authors do not describe: Lens type Footprint measurement is calculated with a navigation system using laxity testing and searching for isometry and anisometry points.
Ishibashi et al., 200827	Intraoperative biomechanical evaluation of anatomic anterior cruciate ligament reconstruction using a navigation system: Comparison of hamstring tendon and bone-patellar tendon-bone graft.	Japan	Cross-sectional	Knees with ACL insufficiency	125 patients	Single bundle: 45 patients Double bundle: 80 patients	The authors do not describe: Lens type Anatomical repairs Footprint measurement
Kurosaka et al., 200828	Double-bundle anatomic anterior cruciate ligament reconstruction: The technique and clinical experience	Japan	Technical note	N/A	N/A	Double bundle	The authors do not describe: Anatomical repairs Footprint measurement The authors discuss anatomical footprints based on remnants and the clock position.
Lee et al., 200629	Arthroscopic anterior cruciate ligament reconstruction with the tibial-remnant preserving technique using a hamstring graft	South Korea	Technical note	N/A	N/A	Single bundle	The authors do not describe: Lens type Anatomical repairs Footprint measurement
Mae et al., 200630	Force sharing between two grafts in the anatomical two-bundle anterior cruciate ligament reconstruction	Japan	Descriptive observational	Unilateral ACL injury	11 patients	Double bundle	The authors do not describe: Lens type Anatomical repairs Footprint measurement Accessory medial portal
Morgan & Caborn, 200531	Anatomic graft fixation using a retrograde biointerference screw for endoscopic anterior cruciate ligament reconstruction: single-bundle and 2-bundle techniques	United States	Technical note	N/A	N/A	Single bundle and double bundle	The authors do not describe: Lens type Anatomical landmarks Technique details (they refer to another article)
Seon et al., 200932	Stability comparison of anterior cruciate ligament between double- and single-bundle reconstructions	South Korea	Comparative, descriptive, observational	Patients awaiting ACL reconstruction with anterior tibial tendon allograft	40 patients	Single bundle: 20 patients Double bundle: 20 patients	The authors do not describe: Lens type Anatomical landmarks Footprint measurement
Silva & Sampaio, 200933	Anatomic ACL reconstruction: does the platelet-rich plasma accelerate tendon healing?	Portugal	Comparative, descriptive, observational	Acute ACL injury	40 patients	Double bundle	The authors do not describe: Lens type Anatomical repairs Footprint measurement
Sonnery-Cottet & Chambat, 200634	Anatomic Double Bundle: A New Concept in Anterior Cruciate Ligament Reconstruction Using the Quadriceps Tendon	France	Technical note	N/A	N/A	Double bundle	The authors do not describe: Lens type Anatomical repairs Footprint measurement Accessory portals
Streich et al., 200835	Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes	Germany	Randomized clinical trial	Complete ACL tear	49 patients	Single bundle: 25 patients Double bundle: 24 patients	The authors do not describe: Lens type Anatomical repairs. Instead, they use a femoral guide. Footprint measurement Accessory portals
Tsuda e Ishibashi, 200836	Computer-Navigated Double-Bundle Anterior Cruciate Ligament Reconstruction	Japan	Technical note	N/A	N/A	Double bundle	The authors do not describe: Lens type Footprint measurement The authors: use a navigation system to map the footprint. discuss the clock position and the cortex, but do not address anatomical concerns such as the lateral intercondylar ridge or the bifurcated ridge.

ACL: Anterior cruciate ligament.

Source: Own elaboration.

The AARSC has 18 items. The first 17 inquire whether the ACLR is more or less anatomical in binary terms (Yes/No), and each positive response is worth one point. The last item is about the level of documentation used for ACL tunnel positioning and has three response options (0-2 points). Thus, the maximum score is 19 points. Following the methodology proposed by the authors of the original AARSC version,9 an ACLR technique is considered “anatomical” if it obtains a score ≥10 and “non-anatomical/unspecified” if the score is <10.

The reliability of the Colombian Spanish version of the AARSC was determined by using a bidirectional mixed model (≤0 null; 0.01–0.2 mild; 0.21–0.4 moderate; 0.41-0.6 moderate; 0.61-0.8 substantial; 0.81-1.0 nearly perfect). The intraclass correlation coefficient (ICC) was calculated to determine both consistency and absolute agreement between the scores obtained by the orthopedists who evaluated the items using this AARSC instrument.

Moreover, Cohen’s Kappa coefficient of agreement (0-0.2 negligible; 0.21-0.4 poor; 0.41-0.6 moderate; 0.61-0.8 good; 0.81-1.0 excellent) was used to establish the agreement between the overall ratings assigned to each item by the senior orthopedists based on their personal opinion and taking as a reference the ratings of the senior researcher with the most years of experience in ACLR. To determine construct validity, Spearman’s rank correlation coefficient was used to compare the ratings given by senior researchers for the 18 items with the scores obtained by the other six orthopedists using the Colombian Spanish version of the AARSC.

Finally, the internal consistency of the Checklist was evaluated to ensure that all items consistently contributed to the measurement of the construct of ACLR technique "anatomy" of the ACLR technique. Cronbach’s alpha was calculated for the entire instrument (18 items), as well as for each item by sequentially removing it from the total set of items. If the Cronbach’s alpha increased when an item was removed, it was considered that that item did not consistently measure the anatomy of the ACLR.

All data were analyzed using SPSS for Windows, version 25.0. A significance level of 5% was considered.

Ethical considerations

The study adhered to the ethical principles for research involving human subjects established in the Declaration of Helsinki38 and the health research guidelines set forth in Resolution 8430 of 1993 issued by the Colombian Ministry of Health.39 It was approved by the institutional ethics committee of the Clínica del Campestre (Minutes AD-SC-9 of June 10, 2021).

Results

The medians (min–max) of the scores obtained from the three evaluations of each article performed by the six orthopedists using the Colombian Spanish version of the AARSC were 10.5 (8–14), 9 (4–14), and 12 (6–15) in evaluations #1, #2, and #3, respectively (Figure 1). Furthermore, according to the scores assigned to the different surgical techniques by these six orthopedists, reconstruction was anatomical in 13, 8, and 12 articles in evaluations #1, #2, and #3, respectively. The ICC was 0.613 for consistency and 0.610 for absolute agreement, which shows a substantial correlation.

On the other hand, high variability was observed between the evaluations performed by the senior orthopedists (without pre-established guidelines): 12 articles were anatomically reconstructed according to senior orthopedist #1; 14 for senior orthopedist #2; 11 for senior orthopedist #3; and 7 for senior orthopedist #4 (Figure 1). Cohen’s Kappa coefficient for senior researchers 1, 2, and 3 compared to researcher 4 (with more experience in ACLR) was 0.48, 0.31, and 0.36, respectively, i.e., moderate or poor agreement.

Figure 1. Evaluation of surgical techniques for anterior cruciate ligament reconstruction in 18 articles by both groups of orthopedists. The graph shows the number of techniques described in the 18 scientific articles that were considered anatomical and non-anatomical by senior orthopedists and orthopedists who used the Colombian Spanish version of the Checklist.

Source: Own elaboration.

When evaluating the validity of the construct, we obtained a matrix that showed no correlation between the assessments made by the senior researchers and the assessments carried out using the Colombian Spanish version of the AARSC in most cases. Only one significant correlation was observed between assessment #2 using the Checklist and the assessment made by senior orthopedist #3 (Figure 2 and Table 2).

Table 2. Correlation matrix between evaluations.

		Senior 1	Senior 2	Senior 3	Senior 4	Checklist 1	Checklist 2	Checklist 3
Senior 1	Spearman’s rank correlation coefficient	1	0.472	0.161	0.564	-0.439	0.158	0.250
	p-value		0.048*	0.523	0.015*	0.069	0.531	0.317
Senior 2	Spearman’s rank correlation coefficient	0.472	1	0.122	0.426	-0.033	0.209	0.189
	p-value	0.048*		0.630	0.078	0.896	0.405	0.453
Senior 3	Spearman’s rank correlation coefficient	0.161	0.122	1	0.403	0.014	0.484	0.1610.523
	p-value	0.523	0.630		0.098	0.956	0.042*
Senior 4	Spearman’s rank correlation coefficient	0.564	0.426	0.403	1	0.240	0.433	0.322
	p-value	0.015*	0.078	0.098		0.337	0.073	0.192
Checklist 1	Spearman’s rank correlation coefficient	-0.439	-0.033	0.014	0.240	1	0.305	0.351
	p-value	0.069	0.896	0.956	0.337		0.218	0.153
Checklist 2	Spearman’s rank correlation coefficient	0.158	0.209	0.484	0.433	0.305	1	0.158
	p-value	0.531	0.405	0.042*	0.073	0.218		0.531
Checklist 3	Spearman’s rank correlation coefficient	0.250	0.189	0.161	0.322	0.351	0.158	1
	p-value	0.317	0.453	0.523	0.192	0.153	0.531

* The correlation is significant at the 0.05 level (two-tailed).

Source: Own elaboration.

Figure 2. Graphical representation of the ratings given to each item by senior orthopedists versus those obtained with the Spanish version of the Checklist.

Source: Own elaboration.

Cronbach’s alpha for the entire instrument was 0.591 and did not change significantly when any of the items were sequentially removed from the calculation, with a slight increase observed when items 1, 2, and 18 were removed (Table 3).

Table 3. Internal consistency of the Checklist after removing each item.

Items on the Anatomical ACL Reconstruction Score Checklist – Colombian Spanish Version*	Number of positive responses	Cronbach’s alpha
1.Individualización de la cirugía para cada paciente	25	0.615
2.Uso de un artroscopio de 30°	44	0.638
3.Uso de un portal medial accesorio	14	0.523
4.Visualización directa del sitio de inserción del LCA femoral	48	0.550
5.Medición de las dimensiones del sitio de inserción del LCA femoral	8	0.573
6.Visualización de la cresta intercondílea lateral	9	0.589
7.Visualización de la cresta bifurcada lateral	8	0.573
8.Colocación de los túneles femorales en el lugar de inserción del LCA femoral	40	0.511
9.Perforación de transporte de los túneles del LCA femoral	20	0.544
10.Visualización directa del sitio de inserción del LCA tibial	48	0.560
11.Medición de las dimensiones del sitio de inserción del LCA tibial	6	0.573
12.Colocación de los túneles tibiales en el lugar de inserción del LCA tibial	41	0.532
13.Documentación del método de fijación femoral	54	0.593
14.Documentación del método de fijación tibial	53	0.587
15.Documentación del ángulo de flexión de la rodilla durante la perforación del túnel femoral	28	0.569
16.Documentación del tipo de injerto	54	0.593
17.Documentación del ángulo de flexión de la rodilla durante el tensado del injerto	47	0.581
18.El más alto nivel de documentación utilizada para la posición del túnel LCA		0.643
Dibujo. diagrama. nota operativa. dictado o referencia de la esfera del reloj	42
Imágenes artroscópicas. radiografías. RM 2D o TAC 2D	7
RM 3D. TAC 3D o navegación	5

LCA: Ligamento cruzado anterior; RM: Resonancia magnética; TAC: Tomografía axial computarizada.

* Original version (English) available in Desai et al.9

Discussion

The objective of this study was to validate the Colombian Spanish version of the AARSC in terms of inter-rater reliability, construct validity, and internal consistency. The validation method used replicated the method described by the creators of the AARSC,10 comparing the results of the ACLR surgical technique classification described in the literature as anatomical or non-anatomical depending on the score obtained in the Checklist versus the subjective assessment of senior orthopedists specializing in knee surgery.

The AARSC allows establishing the anatomical accuracy of an ACLR technique by evaluating 18 items with a maximum score of 19 points where the higher the score, the more anatomical the reconstruction.9,10 This Checklist has been used in several studies to evaluate how anatomically accurate ACLR surgical techniques described in the literature are; however, most of these studies have been conducted by the same authors who developed and validated the Checklist.9,13,40

In the present study, the Spanish version of the AARSC had poor internal consistency with a Cronbach’s alpha of 0.591, a value much lower than that reported in the validation of the original Checklist (α= 0.82).10 This finding may suggest that the items are not strongly related to each other, as the Checklist assigns the same score to both important and less important aspects when determining whether an ACLR is anatomical or not.

According to the literature, the key aspects that are considered to make an anatomical ACLR are the functional restoration of the ligament to its native dimensions, collagen orientation, and insertion sites.2,4 However, several conflicting findings concerning the responses to AARSC items during the assessment of the surgical methods described in the selected articles are noteworthy.

In this regard, the items with the lowest number of affirmative responses were, in ascending order, #11 (measurement of the dimensions of the tibial ACL insertion site), #5 (measurement of the femoral ACL insertion site dimensions), #6 (visualization of the lateral intercondylar ridge), and #7 (visualization of the lateral bifurcate ridge). These aspects, according to the literature4,9 and the opinion of the authors of the present study, are useful when defining how anatomically accurate an ACLR is. Nevertheless, most responses were positive (48 each) for items such as direct visualization of the tibial ACL insertion site and femoral ACL insertion site (#4 and #10), demonstrating that other key aspects for an anatomical reconstruction were indeed considered in the studies evaluated.

On the contrary, a non-essential item such as documentation of the type of graft (#16) seems to be considered in all surgical methods described in the articles evaluated; however, the “anatomical” feature of the reconstruction refers to the location of the graft occupying the native footprint, as well as its orientation, but not to other aspects such as the type of graft.4 This divergence in the surgical methods described in the studies evaluated, in which non-essential items are sometimes described while other essential items are not considered, may reflect that the Checklist contains items that do not correlate well with each other or that may not be relevant in the description of ACLR surgical methods.

On this point, the authors of this study find that the AARSC includes some items that are unrelated to whether the reconstruction is anatomical or not and that, instead, could interfere when classifying a reconstruction as anatomical, namely, individualization of surgery, use of a 30° arthroscope, documentation of the femoral and tibial fixation method, and documentation of the graft type. Furthermore, this opinion is supported by the poor internal consistency of the Checklist observed in the present study, in which Cronbach’s alpha tends to increase with the elimination of items such as the individualization of surgery for each patient, the use of a 30° arthroscope, and the level of documentation used for ACL tunnel placement, that is, these items do not correlate well with the others when assessing an ACLR as anatomical.

In contrast to the findings reported by van Eck et al.,10 agreement among experts (senior orthopedists), considering the one with the most years of experience in arthroscopic ACLR as a reference, was low to moderate. Accordingly, the most experienced expert concluded that the technique described could be considered an anatomical reconstruction in only 7 of the 18 articles evaluated, while the other experts were less “strict” and considered that the reconstruction technique was anatomical in 11 to 14 articles. These conclusions differ from the results of the evaluation of the same articles using the Colombian Spanish version of the AARSC. Based on the three evaluations performed for each article, it was found that between 8 and 13 articles described anatomical reconstruction techniques, with a substantial correlation between the three evaluations. In other words, while the evaluations of the experts with their own criteria coincide little or moderately with each other, those carried out using the AARSC by orthopedists with experience in ACLR substantially agree, meaning that there is no correlation between the concepts expressed by the experts and the scores obtained using the Checklist.

This situation represents a challenge for the analysis and interpretation of the results. Senior evaluators did not have a pre-established tool or guideline to evaluate reconstruction, which may have led them to be more critical when evaluating the methodology of the articles, or, in the absence of sufficient information regarding the descriptions of surgical techniques, to question whether the result was actually an anatomical reconstruction. Furthermore, considering that the AARSC includes items that are unrelated to whether the reconstruction is anatomical or not and assigns them the same weight as those that are indeed related, the evaluation carried out using this Checklist may have led to an overestimation of the techniques described in the articles.

Finally, this study has some limitations. First, most of the articles used for validation employed a dual-bundle technique (12 out of 18), which, added to the fact that senior orthopedists (authors 2 to 5 of this study) use a single-bundle technique in their clinical practice, could lead to evaluation bias, given that, despite the masking of the articles, they may perceive a technique that is different from the one they use as non-anatomical. Second, substantial underreporting of surgical data was identified for both single-bundle and dual-bundle techniques in the studies used for validation (Table 1). This underreporting makes it difficult to analyze, compare, and group the results reported in these studies. Third, the fact that the assessments by senior knee surgeons were performed without any standardized guidelines may have contributed to the lack of agreement between them, thus resulting in the inability to validate the AARSC in the Colombian context.

Conclusion

Even though it was not possible to validate the Colombian Spanish version of the AARSC in our study, some of its items could be useful for assessing how anatomically accurate ACLR reconstruction techniques described in the literature are. However, according to our findings, the Checklist items, as currently designed, do not allow for a reliable classification of ACLR as anatomical. Further studies involving modifications to the AARSC and its subsequent validation could contribute to the development of a reliable instrument for the adequate evaluation of ACLR.

Conflicts of interest

None stated by the authors.

Funding

None stated by the authors.

Acknowledgments

The authors would like to thank Dr. Carlos Alberto Ochoa Sierra and Dr. Juan Esteban Osorio Salas from Hospital Pablo Tobón Uribe in Medellín, and Dr. Rodrigo Jaramillo Quintero from Hospital Universitario San Ignacio in Bogotá, for their contributions to the evaluation of the articles.

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