Do Surgeons Agree on Severity and Origin of Complications in Bone-lengthening Nails? An Inter- and Intra-rater Reliability Study
Markus Winther Frost, Ole Rahbek, Marie Fridberg, Mindaugas Mikuzis, Søren Kold
Bone-lengthening nail, Bone nails (mesh), FITBONE®, GRAAS, Intraoperative complications (mesh), Observer variation (mesh), PRECICE®, Post-operative complications (mesh)
Citation Information :
Frost MW, Rahbek O, Fridberg M, Mikuzis M, Kold S. Do Surgeons Agree on Severity and Origin of Complications in Bone-lengthening Nails? An Inter- and Intra-rater Reliability Study. 2022; 17 (3):153-158.
Background: Bone-lengthening nails result in various complications with different severity and origin. However, no universal reporting system for complications has been agreed upon, making it difficult to compare different nail designs and patient populations. This study aimed to assess the inter- and intra-rater agreement of a classification system of complications according to severity and origin.
Materials and methods: Four orthopaedic surgeons assessed 48 complications retrieved from patient charts in a single-centre cohort and 49 literature complications cases. Complications were classified according to severity grading (I, II, IIIA and IIIB) from Black et al. and origin with eight main types and 33 subtypes. A blinded independent assessment was performed twice at least six weeks apart. Cohen/Congers kappa estimated for the inter- and intra-rater agreement was interpreted after Svanholm et al.
Results: The surgeons had a good inter-rater agreement for complication severity with a kappa value of 0.68 [95% confidence interval (CI): 0.56–0.79] and complication origin with a kappa value of 0.63 (CI: 0.53–0.73), respectively, on the cohort cases. In literature cases, a good agreement on complication severity and origin grading was shown by kappa values of 0.64 (CI: 0.53–0.75) and 0.74 (CI: 0.65–0.83). The intra-rater assessment of complication severity and origin grading had good to excellent agreement with kappa values ranging from 0.51 to 0.97.
Conclusion and clinical significance: The study presents the first structured complication classification on severity and origin in intramedullary bone-lengthening nails. A good reproducibility agreement in both severity and origin was found between four orthopaedic surgeons for both cohort and literature complication cases. For clinical and research purposes, a shared language for communicating complications is essential. We encourage future studies to use a structured and validated complication classification.
Simpson AHWR, Shalaby H, Keenan G. Femoral lengthening with the intramedullary skeletal kinetic distractor. J Bone Joint Surg Br 2009;91:955–961. DOI: 10.1302/0301-620X.91B7.21466.
Frost MW, Rahbek O, Traerup J, et al. Systematic review of complications with externally controlled motorized intramedullary bone lengthening nails (FITBONE and PRECICE) in 983 segments. Acta Orthop 2021;92:120–127. DOI: 10.1080/17453674.2020.1835321.
Frommer A, Roedl R, Gosheger G, et al. What are the potential benefits and risks of using magnetically driven antegrade intramedullary lengthening nails for femoral lengthening to treat leg length discrepancy? Clin Orthop Relat Res 2021;480(4):790–803. DOI: 10.1097/CORR.0000000000002036.
Mikužis M, Rahbek O, Christensen K, et al. Complications common in motorized intramedullary bone transport for non-infected segmental defects: A retrospective review of 15 patients. Acta Orthop 2012;92(4):485–492. DOI: 10.1080/17453674.2021.1910777.
Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res 1990;250:81–104. PMID: 2403498.
Dinçyürek H, Kocaoglu M, Eralp IL, et al. Functional results of lower extremity lengthening by motorized intramedullary nails. Acta Orthop Traumatol Turc 2012;46(1):42–49. DOI: 10.3944/aott.2012.2671.
Dahl MT, Gulli B, Berg T. Complications of limb lengthening. A learning curve. Clin Orthop Relat Res 1994;301:10–18. PMID: 8156659.
Black SR, Kwon MS, Cherkashin AM, et al. Lengthening in congenital femoral deficiency: A comparison of circular external fixation and a motorized intramedullary nail. J Bone Joint Surg Am 2015;97(17):1432–1440. DOI: 10.2106/JBJS.N.00932.
Sabharwal S. CORR Insights®: What are the potential benefits and risks of using magnetically driven antegrade intramedullary lengthening nails for femoral lengthening to treat leg length discrepancy? Clin Orthop Relat Res 2022;480(4):804–806. DOI: 10.1097/CORR.0000000000002079.
Cherkashin AM, Samchukov ML, Birch JG, et al. Evaluation of complications of treatment of severe Blount’s disease by circular external fixation using a novel classification scheme. J Pediatr Orthop Part B 2015;24(2):123–130. DOI: 10.1097/BPB.0000000000000138.
Garbuz DS, Masri BA, Esdaile J, et al. Classification systems in orthopaedics. J Am Acad Orthop Surg 2002;10(4):290–297. DOI: 10.5435/00124635-200207000-00007.
Klein D. Implementing a general framework for assessing interrater agreement in stata. Stata J 2018;18(4):871–901. DOI: 10.1177/1536867X1801800408.
Gwet KL. Testing the difference of correlated agreement coefficients for statistical significance. Educ Psychol Meas 2016;76(4):609–637. DOI: 10.1177/0013164415596420.
Svanholm H, Starklint H, Gundersen HJG, et al. Reproducibility of histomorphologic diagnoses with special reference to the kappa statistic. APMIS 1989;97(8):689–698. DOI: 10.1111/j.1699-0463.1989.tb00464.x.
Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 1992;111(5):518–526. PMID: 1598671.
Feinstien AR, Cicchetti D V. High agreement but low kappa. J Clin Epidemiol 1990;43(6):551–558. DOI: 10.1016/0895-4356(90)90159-m.