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Barrett et al: Comparison of two postoperative complication grading systems after treatment of stifle and shoulder instability in 68 dogs
Veterinary Surgery 1, 2023

🔍 Key Findings

  • Cook system had good reliability across all cases (ICC = 0.848), even when complications, sequelae, and failure-to-cure were included.
  • aCD system had excellent reliability when excluding sequelae/failure-to-cure cases (ICC = 0.975) but only moderate reliability when including them (ICC = 0.620).
  • Majority of complications (60–63%) were graded as Grade 3 in the aCD system, corresponding to surgical or anesthetic intervention.
  • Cook system classified most cases (78–81%) as major complications.
  • Assessors had difficulty distinguishing sequelae from Grade 1 complications, and failure-to-cure from Grades 1–2, reducing aCD reliability.
  • The aCD system offers more resolution (5 grades vs. 3) and less subjectivity through objective definitions.
  • Novel terminology (e.g., sequelae, failure to cure) in the aCD system may hinder its uptake without proper training.
  • Reclassifying expected events (e.g., swelling, bruising) as sequelae could significantly reduce reported complication rates in other studies.

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← Articles

Barrett et al: Comparison of two postoperative complication grading systems after treatment of stifle and shoulder instability in 68 dogs
Veterinary Surgery 1, 2023

🔍 Key Findings

  • Cook system had good reliability across all cases (ICC = 0.848), even when complications, sequelae, and failure-to-cure were included.
  • aCD system had excellent reliability when excluding sequelae/failure-to-cure cases (ICC = 0.975) but only moderate reliability when including them (ICC = 0.620).
  • Majority of complications (60–63%) were graded as Grade 3 in the aCD system, corresponding to surgical or anesthetic intervention.
  • Cook system classified most cases (78–81%) as major complications.
  • Assessors had difficulty distinguishing sequelae from Grade 1 complications, and failure-to-cure from Grades 1–2, reducing aCD reliability.
  • The aCD system offers more resolution (5 grades vs. 3) and less subjectivity through objective definitions.
  • Novel terminology (e.g., sequelae, failure to cure) in the aCD system may hinder its uptake without proper training.
  • Reclassifying expected events (e.g., swelling, bruising) as sequelae could significantly reduce reported complication rates in other studies.

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Multiple Choice Questions on this study

In Barrett 2023 et al., on complication grading systems, what percentage of complications were graded as **Grade 3** using the aCD system?

A. 20–30%
B. 30–40%
C. 40–50%
D. 60–63%
E. 75–80%

Answer: 60–63%

Explanation: Grade 3 complications (requiring surgery or anesthesia) were the most frequently assigned using the aCD system.
In Barrett 2023 et al., on complication grading systems, which system showed **higher interobserver reliability** when evaluating only true complications?

A. The Cook system
B. The adapted Clavien–Dindo (aCD) system
C. Neither showed improved reliability
D. Both showed equal reliability
E. Reliability could not be assessed

Answer: The adapted Clavien–Dindo (aCD) system

Explanation: When sequelae and failure-to-cure cases were excluded, the aCD system had **excellent reliability** (ICC = 0.975) versus good reliability for Cook (ICC = 0.857).
In Barrett 2023 et al., on complication grading systems, what was the **main limitation** in applying the aCD system to veterinary cases?

A. Lack of assessor training
B. Too few grading levels
C. Inadequate sample size
D. Difficulty distinguishing sequelae and failure to cure from true complications
E. Lack of radiographic data

Answer: Difficulty distinguishing sequelae and failure to cure from true complications

Explanation: The aCD system's reliability dropped when assessors misclassified these outcomes as complications.
In Barrett 2023 et al., on complication grading systems, which grading system demonstrated **greater detail** and less subjectivity in defining complication types?

A. Cook 3-point system
B. aCD 5-point system
C. Clavien–Dindo (original) system
D. Modified Accordion system
E. None provided more detail

Answer: aCD 5-point system

Explanation: The aCD system includes more specific definitions and examples, offering **greater discrimination** and reduced subjectivity.
In Barrett 2023 et al., on complication grading systems, what is an example of a **Grade I complication** in the aCD system?

A. Postoperative osteomyelitis
B. Superficial wound infection requiring clinic visits
C. Implant failure needing revision
D. Postoperative fever requiring no treatment
E. Death due to surgical complication

Answer: Postoperative fever requiring no treatment

Explanation: Grade I complications require no intervention beyond supportive care (e.g., fever, mild skin irritation, or self-resolving issues).

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