Redefining Surgical Incision Outcomes: International Consensus and Validation of a Novel Universal Classification System

Introduction Incisional complications following orthopaedic procedures—including dehiscence, infection, seroma, and haematoma—are clinically and economically significant, yet inconsistently defined and reported across studies and specialties. The purpose of this study was to establish and validate a universal classification system consisting of these four elements, graded by severity, enabling standardisation of reporting and evaluation of postoperative outcomes. Methods A modified Delphi study was conducted, comprising a five-member expert Steering Committee and a panel of 32 international experts, including four orthopaedic surgeons, who participated in four rounds of voting. Likert-based statements sought ≥75% agreement/disagreement as consensus. Statements defined each element of the proposed system, with grades of severity for clinical management and presentation. Statements without consensus were revised for subsequent rounds until consensus was reached. To validate the classification system, computer generated case vignettes created using constrained random sampling were used to assess inter-rater agreement and intra-rater reproducibility. Cross-domain agreement was evaluated using patient-level double entry intraclass correlation coefficient (DE-ICC) for both measures. Results Following Round 4 of the modified Delphi study, 35 consensus statements were generated, and a novel surgical incision classification system was established, defined by Dehiscence (D), Infection (I), Seroma (S) and Haematoma (H). The new system describes the clinical presentation of surgical site outcomes independently from the performed clinical management for each of the four elements. The clinical management grade for each element begins at 0, indicating non-presence of a given element. The grades then ascend in severity; for all elements (D, I, S, H), with grade 4 corresponding to surgical reintervention. Clinical presentation grades are denoted by letters a–d, corresponding to ascending severity, assessed independently of clinical management. The final ‘score’ presents all elements of clinical presentation and corresponding management collectively, e.g. D1a I2b S0 H0, providing a snapshot of the presentation of an incision and the management received. Sixty-four surgeons validated the scale. Mean patient-level inter-rater DE-ICC was 0.93 (median 1.00; 95% CI 0.91–0.96), indicating very high concordance in raters' 8-domain scoring profiles for the same case. Intra-rater DE-ICC was similarly high (mean 0.95; median 1.00; 95% CI 0.93–0.96). Discussion and Conclusion This novel classification system provides a standardised and validated framework for reporting surgical incision outcomes in all procedures, including orthopaedic surgery, improving the precision and interpretability of the four elements. Future research should assess the performance of DISH in clinical practice.