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Reliability of the International Knee Documentation Committee Radiographic Grading System

Vishal M. Mehta, MD^,*, Liz W. Paxton, MA, Stefan X. Fornalski, MD, Rick P. Csintalan, MD and Donald C. Fithian, MD

From the Fox Valley Orthopaedic Institute, Geneva, Illinois, and the Southern Permanente Medical Group, El Cajon, California

^* Address correspondence to Vishal M. Mehta, MD, Fox Valley Orthopaedic Institute, 2525 Kaneville Road, Geneva, IL 60134 (e-mail: vishal{at}mehtas.com).

Background: The International Knee Documentation Committee (IKDC) forms are commonly used to measure outcomes after anterior cruciate ligament (ACL) reconstruction. The knee examination portion of the IKDC forms includes a radiographic grading system to grade degenerative changes. The interrater and intrarater reliability of this radiographic grading system remain unknown.

Hypothesis: We hypothesize that the IKDC radiographic grading system will have acceptable interrater and intrarater reliability.

Study Design: Case series (diagnosis); Level of evidence, 4.

Methods: Radiographs of 205 ACL-reconstructed knees were obtained at 5-year follow-up. Specifically, weightbearing posteroanterior radiographs of the operative knee in 35° to 45° of flexion and a lateral radiograph in 30° of flexion were used. The radiographs were independently graded by 2 sports medicine fellowship–trained orthopaedic surgeons using the IKDC 2000 standard instructions. One surgeon graded the same radiographs 6 months apart, blinded to patient and prior IKDC grades. The percentage agreement was calculated for each of the 5 knee compartments as defined by the IKDC. Interrater reliability was evaluated using the intraclass correlation coefficient (ICC) 2-way mixed effect model with absolute agreement. The Spearman rank-order correlation coefficient (r_s) was applied to evaluate intrarater reliability.

Results: The interrater agreement between the 2 surgeons was 59% for the medial joint space (ICC = 0.46; 95% confidence interval [CI] = 0.35–0.56), 54% for the lateral joint space (ICC = 0.45; 95% CI = 0.27–0.58), 49% for the patellofemoral joint (ICC = 0.40; 95% CI = 0.26–0.52), 63% for the anterior joint space (ICC = 0.20; 95% CI = 0.05–0.34), and 44% for the posterior joint space (ICC = 0.28; 95% CI = 0.15–0.40). The intrarater agreement was 83% for the medial joint space (r_s = .77, P < .001), 86% for the lateral joint space (r_s = .76, P < .001), 81% for the patellofemoral joint (r_s = .79, P < .001), 91% for the anterior joint space (r_s = .48, P < .001), and 69% for the posterior joint space (r_s = .64, P < .001).

Conclusions: While intrarater reliability was acceptable, interrater reliability was poor. These findings suggest that multiple raters may score the same radiographs differently using the IKDC radiographic grading system. The use of a single rater to grade all radiographs when using the IKDC radiographic grading system maximizes reliability.

Key Words: IKDC • grading systems • outcome measures • radiographs • ACL