Citation Information :
Groenewoud R, Chhina H, Bone J, Sabharwal S, Iobst C, Bafor A, Cooper A. Inter- and Intra-rater Reliability of the Checketts’ Grading System for Pin-site Infections across All Skin Colours. 2023; 18 (1):2-6.
The Checketts’ grading system (CGS) is the only classification that provides both a description of how to visually grade the infection and the appropriate course of treatment. There are no studies on the reliability of this system nor on whether skin colour can influence applicability. This study aims to determine the inter-rater and intra-rater reliability of the CGS to assess whether this scale could be used as a universal grading system across all skin colours.
A survey consisting of 134 anonymised photographs of pin-site infections was sent out to orthopaedic surgeons specialising in limb lengthening and reconstruction and to patients or carers of individuals who had external fixators. For each photograph, the participants were asked to grade the infection using the CGS, rate their confidence in their chosen grade on a Likert scale and assign a treatment option. The participants were supplied with the CGS at the beginning of the survey, after the 45th and 90th photographs.
The inter-rater reliability of the CGS between the surgeons, expressed as an intraclass correlation coefficient (ICC), was poor-to-moderate at both time points (ICC = 0.56 for baseline survey and ICC = 0.48 for follow-up). This was similar for the patient or caretaker group. There was a lower inter-rater reliability for grading of dark skin as opposed to light skin by surgeons but not for patients or caretakers. The inter-rater reliability of treatment decisions between the surgeons was poor at both time points (kappa = 0.30 and 0.22) with similar inter-rater reliability for dark (kappa = 0.26 and 0.23) compared with light skin (kappa = 0.29 and 2.6). This was similar for the patient or caretaker group. The surgeons’ confidence (Table 4) in grading was low (median = 1). The patient or caretaker group's confidence in their grading was modest (median = 2).
The reliability of the CGS as assessed here demonstrates poor-to-moderate inter-rater reliability which makes interpretation of published pin site infection rates using this scale difficult. The design of new grading systems will need to consider skin colour to reduce inequities in medical decision-making.
Iobst CA. Pin-track infections: Past, present and future. J Limb Lengthen Reconstr 2017;3(2):78–84. DOI: 10.4103/jllr.jllr_17_17.
Jauregui JJ, Bor N, Thakral R, et al. Life- and limb-threatening infections following the use of an external fixator. Bone Joint J 2015;97-B(9):1296–1300. DOI: 10.1302/0301-620X.97B9.35626.
Patterson MM. Multicenter pin care study. Orthop Nurs 2000;24(5): 349–360. DOI: 10.1097/00006416-200509000-00011.
Parameswaran AD, Roberts CS, Seligson D, et al. Pin tract infection with contemporary external fixation: How much of a problem? J Orthop Trauma 2003;17(7):503–507. DOI: 10.1097/00005131-200308000-00005.
Schalamon J, Petnehazy T, Ainoedhofer H, et al. Pin tract infection with external fixation of pediatric fractures. J Pediatr Surg 2007;42(9): 1584–1587. DOI: 10.1016/j.jpedsurg.2007.04.022.
Davies R, Holt N, Nayagam S. The care of pin sites with external fixation. J Bone Joint Surg 2005;87(5):716–719. DOI: 10.1302/0301-620X.87B5.15623.
Lethaby A, Temple J, Santy-Tomlinson J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database of Systematic Reviews 2013. Available at: https://doi.org/10.1002/14651858.CD004551.pub3.
Paley D. Problems, obstacles, and complications of limb lengthening by the ilizarov technique. Clin Orthop Relat Res 1990;250:81–104.
Dahl MT, Gulli B, Berg T. Complications of limb lengthening: A learning curve. Clin Orthop Relat Res 1994;301:10–18. PMID: 8156659.
Checketts’ RG, Otterburn M, MacEachern G. Checketts’ Pin track infection definition, incidence and prevention. Int J Orthop Trauma Suppl 1993;3(3):16–18.
Saw A, Chan C, Penafort R, Sengupta S. A Simple Practical protocol for care of metal-skin interface of external fixation. Med J Malaysia. 2006;61(A):62–65.
Saleh M, Scott BW. Pitfalls and complications in leg lengthening: The Sheffield experience. Semin Orthop 1992;7:207–222.
Clint SA, Eastwood DM, Chasseaud M, et al. The “Good, Bad and Ugly” pin site grading system. A reliable and memorable method for documenting and monitoring ring fixator pin sites. Injury 210;41(2):147–150. DOI: 10.1016/j.injury.2009.07.001.
Santy J, Vincent M, Duffield B. The principles of caring for patients with Ilizarov external fixation. Nurs Stand 2009;23(26):50–55. DOI: 10.7748/ns2009.03.23.26.50.c6835.
Ward P. Care of skeletal pins: a literature review. Nurs Stand 1998;12(39):34–38. DOI: 10.7748/ns1998.06.12.39.34.c2514.
Taylor SC. Skin of colour: Biology, structure, function, and implication for dermatologic disease. J Am Acad Dermatol 2002;46(2):S41–S46. DOI: 10.1067/mjd.2002.120790.
Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin 2012;30(1):53. DOI: 10.1016/j.det.2011.08.002.
Altieri L, Hu J, Nguyen A, et al. Interobserver reliability of teledermatology across all Fitzpatrick skin types. J Telemed Telecare 2017;23(1):68–73. DOI: 10.1177/1357633X15621226.
R Core Team. R. A language and environment for statistical computing. R Foundation for Statistical Computing, 2021. Available at: https://www.R-project.org/.
Spencer WG. Celsus De Medicina. Cambridge, Massachusetts. Harvard University Press. 1971 (Republication of the 1935 edition).
Ibrahim LF, Hopper SM, Donath S, et al. Development and validation of a cellulitis risk score: The Melbourne ASSET score. Pediatrics 2019;143(2):e20181420. DOI: 10.1542/peds.2018-1420.
Rizzi AM, Polachek WS, Dulas M, et al. The new ‘normal’: Rapid adoption of telemedicine in orthopaedics during the COVID-19 pandemic. Injury 2020;51(12):2816–2821. DOI: 10.1016/j.injury.2020.09.009.
