Do Surgeons Agree on Severity and Origin of Complications in Bone-lengthening Nails? An Inter- and Intra-rater Reliability Study

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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.

Original languageEnglish
JournalStrategies in Trauma and Limb Reconstruction
Issue number3
Pages (from-to)153-158
Number of pages6
Publication statusPublished - 1 Sept 2022

Bibliographical note

Copyright © 2022; The Author(s).


  • Bone nails (mesh)
  • Bone-lengthening nail
  • Intraoperative complications (mesh)
  • Observer variation (mesh)
  • Post-operative complications (mesh)


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