A comparison of three methods of wound closure following arthroplasty

Determining risk factors for surgical wound dehiscence: a literature review

Postoperative wound healing plays a significant role in facilitating a patient's recovery and rehabilitation. Surgical wound dehiscence (SWD) impacts on mortality and morbidity rates and significantly contributes to prolonged hospital stays and associated psychosocial stressors on individuals and their families. A narrative review of SWD was undertaken on English-only studies between 1945 and 2012 using three electronic databases Ovid CINHAL, Ovid Medline and Pubmed. The aim of this review was to identify predisposing factors for SWD and assessment tools to assist in the identification of at-risk patients. Key findings from the included 15 papers out of a search of 1045 revealed the most common risk factors associated with SWD including obesity and wound infection, particularly in the case of abdominal surgery. There is limited reporting of variables associated with SWD across other surgical domains and a lack of risk assessment tools. Furthermore, there was a lack of clarity in the definition of SWD in the literature. This review provides an overview of the available research and provides a basis for more rigorous analysis of factors that contribute to SWD.

Prevention of Periprosthetic Joint Infection

Periprosthetic joint infection (PJI) has moved into the first place as the cause of failure following total knee arthroplasty (TKA). Recent studies have shown that PJI results in higher mortality in patients than many cancers. The economic burden of treating PJI is likely to exceed $1 billion this year in the US. Thus, it is paramount that all efforts are invested to prevent this dreaded complication after total joint arthroplasty (TJA). This article summarizes some of the most effective and proven strategies for prevention of PJI. It is hoped that the article will be of benefit to the readers of the journal.

Tissue adhesives for closure of surgical incisions

BACKGROUND

Sutures (stitches), staples and adhesive tapes have been used for many years as methods of wound closure, but tissue adhesives have entered clinical practice more recently. Closure of wounds with sutures enables the closure to be meticulous, but the sutures may show tissue reactivity and can require removal. Tissue adhesives offer the advantages of an absence of risk of needlestick injury and no requirement to remove sutures later. Initially, tissue adhesives were used primarily in emergency room settings, but this review looks at the use of tissue adhesives in the operating room/theatre where surgeons are using them increasingly for the closure of surgical skin incisions.

OBJECTIVES

To determine the effects of various tissue adhesives compared with conventional skin closure techniques for the closure of surgical wounds.

SEARCH METHODS

In March 2014 for this second update we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We did not restrict the search and study selection with respect to language, date of publication or study setting.

SELECTION CRITERIA

Only randomised controlled trials were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We conducted screening of eligible studies, data extraction and risk of bias assessment independently and in duplicate. We expressed results as random-effects models using mean difference for continuous outcomes and risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes. We investigated heterogeneity, including both clinical and methodological factors.

MAIN RESULTS

This second update of the review identified 19 additional eligible trials resulting in a total of 33 studies (2793 participants) that met the inclusion criteria. There was low quality evidence that sutures were significantly better than tissue adhesives for reducing the risk of wound breakdown (dehiscence; RR 3.35; 95% CI 1.53 to 7.33; 10 trials, 736 participants that contributed data to the meta-analysis). The number needed to treat for an additional harmful outcome was calculated as 43. For all other outcomes - infection, patient and operator satisfaction and cost - there was no evidence of a difference for either sutures or tissue adhesives. No evidence of differences was found between tissue adhesives and tapes for minimising dehiscence, infection, patients' assessment of cosmetic appearance, patient satisfaction or surgeon satisfaction. However there was evidence in favour of using tape for surgeons' assessment of cosmetic appearance (mean difference (VAS 0 to 100) 9.56 (95% CI 4.74 to 14.37; 2 trials, 139 participants). One trial compared tissue adhesives with a variety of methods of wound closure and found both patients and clinicians were significantly more satisfied with the alternative closure methods than the adhesives. There appeared to be little difference in outcome for different types of tissue adhesives. One study that compared high viscosity with low viscosity adhesives found that high viscosity adhesives were less time-consuming to use than low viscosity tissue adhesives, but the time difference was small.

AUTHORS' CONCLUSIONS

Sutures are significantly better than tissue adhesives for minimising dehiscence. In some cases tissue adhesives may be quicker to apply than sutures. Although surgeons may consider the use of tissue adhesives as an alternative to other methods of surgical site closure in the operating theatre, they need to be aware that sutures minimise dehiscence. There is a need for more well designed randomised controlled trials comparing tissue adhesives with alternative methods of closure. These trials should include people whose health may interfere with wound healing and surgical sites of high tension.

A comparison of 2-octyl cyanoacrylate with nylon for wound closure of knee arthroscopy portals

OBJECTIVE

To compare the cosmetic results, complications and patient satisfaction of 2-octyl cyanoacrylate (Dermabond, Ethicon Inc. Somerville, NJ, USA), a liquid bonding agent, with 3-0 nylon sutures (Ethilon, Ethicon Inc) skin closure in two groups of patients undergoing elective knee arthroscopy at 6 weeks.

METHOD

The retrospective clinical audit recruited patients undergoing knee surgery for the first time between October 2010 and August 2011. The patients were either treated with the liquid bonding agent or nylon sutures. The patients in the bonding agent group were allowed to shower as normal on postoperative day one, while patients in the suture group kept their wounds dry for 2 weeks.

RESULTS

Between the two groups (40 patients per group) there was no difference in the cosmetic outcome (p=0.285), patient satisfaction (p=0.29), pain scores (p=0.44) or wound complication rate (p<0.05). Patient satisfaction was high in both groups. Furthermore, 83.75% of all patients indicated they would prefer the liquid bonding closure over nylon sutures if undergoing the same procedure in the future as they could shower the next day and avoid suture removal.

CONCLUSION

2-octyl cyanoacrylate is safe to use in the short term in knee arthroscopy providing comparable results to nylon suture closure. Allowing patients to shower the next day appears to cause no adverse effects.

DECLARATION OF INTEREST

The authors would like to state that they do not have any economic or social interest in any of the products used or mentioned. No grant or finance was received for this study, nor any input from other sources.

Superficial wound closure complications with barbed sutures following knee arthroplasty

As quality measures may be increasingly used in knee surgery reimbursement, an important focus in outcome assessment will shift toward minimizing complications and increasing efficiency in knee arthroplasty reconstruction. The purpose of this study was to evaluate the efficacy of barbed, absorbable sutures in closure of the longitudinal surgical incision following knee arthroplasty, using post-operative complication occurrences. In 416 operations, primary outcomes assessed were deep infection, superficial infection, dehiscence, or stitch abscesses. Secondary outcomes included self-limiting eschar, severe effusion, arthrofibrosis, and keloid formation. Evaluation of overall primary outcomes showed a higher rate of wound complications using barbed sutures (P < 0.001). With increased rates of infection and overall closure related complications, this study shows that barbed suture use for superficial closure after knee arthroplasty should be avoided.

A prospective randomized comparison of two skin closure techniques in acetabular fracture surgery

Background

Recent publications have shown an infection rate of 5–7 % for acetabular fractures treated with the Kocher-Langenbeck (K-L) approach. Using metallic staples to close hip skin incisions has been considered the gold standard. The purpose of this study was to answer the following: (1) will closure of a K-L incision after acetabular fracture surgery with a running subcuticular monocryl suture, then sealing the wound with 2-octyl cyanoacrylate (OCA), result in a lower infection rate compared to metallic staple closure? (2) Do incisions closed with subcuticular monocryl and OCA exhibit decreased drainage? (3) Is there a cost difference between these two methods?

Materials and methods

In a prospective clinical study, 103 patients with acetabular fractures treated using the K-L approach were randomized into two groups: skin closure with metallic staples (n = 52) versus subcuticular running monocryl suture sealed with OCA (n = 51).

Results

Two postoperative deep infections (4 %) in the staples group required multiple debridements; no infections developed in the OCA group. However, there was no statistical difference between the groups, (p = 0.495). There was a statistically significant difference (p = 0.032) comparing days from surgery to a dry incision favoring OCA (4.2 versus 5.85 days). The patient charge was approximately $900 greater on average in the OCA group due to the increased time in the operating room required for the subcuticular closure.

Conclusions

Closure with OCA and subcuticular monocryl showed no clinical disadvantages and appears to have a clinical advantage when compared to standard metallic staple skin closure in acetabular fracture surgery. However, additional patient costs may be incurred.

Level of evidence

II.

Mussel-inspired hyperbranched poly(amino ester) polymer as strong wet tissue adhesive

Current medical adhesives based on cyanoacrylates typically exhibit cellular toxicity. In contrast, fibrin adhesives are non-toxic but have poor adhesive properties. To overcome these drawbacks we designed a simple and scalable adhesive precursor inspired by marine mussel adhesion that functioned with strong adhesion in wet conditions and with low cytotoxicity. Dopamine, an-amine derivative of an amino acid abundantly present in mussel adhesive proteins, was co-polymerised with a tri-functional vinyl monomer, to form a hyperbranched poly(β-amino ester) polymer termed poly(dopamine-co-acrylate) (PDA). A variety of molecular weights and crosslinking methods were analysed using an ex vivo porcine skin model and an almost 4 fold increase in wet adhesion strength was observed compared to TISSEEL(®) fibrin sealant. With a fast curing time, degradable properties and low cytotoxicity, PDA is highly attractive for medical purposes and could have a broad impact on surgeries where surgical tissue adhesives, sealants, and haemostatic agents are used.

Subcuticular sutures versus staples for skin closure after open gastrointestinal surgery: a phase 3, multicentre, open-label, randomised controlled trial

BACKGROUND

Staples have been widely used for skin closure after open gastrointestinal surgery. The potential advantages of subcuticular sutures compared with staples have not been assessed. We assessed the differences in the frequency of wound complications, including superficial incisional surgical site infection and hypertrophic scar formation, depending on whether subcuticular sutures or staples are used.

METHODS

We did a multicentre, open-label, randomised controlled trial at 24 institutions between June 1, 2009, and Feb 28, 2012. Eligible patients aged 20 years or older, with adequate organ function and undergoing elective open upper or lower gastrointestinal surgery, were randomly assigned preoperatively to either staples or subcuticular sutures for skin closure. Randomisation was done via a computer-generated permuted-block sequence, and was stratified by institution, sex, and type of surgery (ie, upper or lower gastrointestinal surgery). Our primary endpoint was the incidence of wound complications within 30 days of surgery. Analysis was done by intention to treat. This study is registered with UMINCTR, UMIN000002480.

FINDINGS

1080 patients were enrolled and randomly assigned in a one to one ratio: 562 to subcuticular sutures and 518 to staples. 1072 were eligible for the primary endpoint and 1058 for the secondary endpoint. Of the 558 patients who received subcuticular sutures, 382 underwent upper gastrointestinal surgery and 176 underwent lower gastrointestinal surgery. Wound complications occurred in 47 of 558 patients (8·4%, 95% CI 6·3-11·0). Of the 514 who received staples, 413 underwent upper gastrointestinal surgery and 101 underwent lower gastrointestinal surgery. Wound complications occurred in 59 of 514 (11·5%, 95% CI 8·9-14·6). Overall, the rate of wound complications did not differ significantly between the subcuticular sutures and staples groups (odds ratio 0·709, 95% CI 0·474-1·062; p=0·12).

INTERPRETATION

The efficacy of subcuticular sutures was not validated as an improvement over a standard procedure for skin closure to reduce the incidence of wound complications after open gastrointestinal surgery.

FUNDING

Johnson & Johnson.

Which is the better method of wound closure in patients undergoing hip or knee replacement surgery: sutures or skin clips?

Surgical wound closure plays an important part in any procedure and there are a considerable number of closure techniques in use today. This literature review will discuss the use of skin clips (staples) and sutures as used in an orthopaedic setting, specifically among patients having hip or knee replacement surgery. This subject has generated a considerable amount of debate and both types of closure are widely used. We were therefore interested in which technique had a lower incidence of infection.

The use of dermabond® as an adjunct to wound closure after total knee arthroplasty: examining immediate post-operative wound drainage

Wound drainage after total knee arthroplasty (TKA) can be detrimental to surgical outcome. This IRB-approved randomized, prospective, blinded study examined the use of Dermabond® as an adjunct to wound closure after TKA. We proposed that Dermabond® supplementation to wound closure would result in a significant decrease in wound drainage after TKA. After standardized closure, patients were randomized into experimental or control groups with the experimental group receiving Dermabond® supplementation. Standardized dressings were evaluated postoperatively and drainage units were compared using a Mann-Whitney U Test. The median drainage for the Dermabond group (153) was lower than the drainage for the control group (657) at a statistically significant level (P<0.001).

Staples equal sutures for skin closure after soft tissue tumor resection

BACKGROUND

Wound closure accounts for a relatively constant portion of the time required to complete a surgical case. Both longer closure times and wound infections contribute to higher medical costs and patient morbidity.

QUESTIONS/PURPOSES

We therefore determined whether (1) biologic and treatment factors greater influenced wound healing than the choice of sutures or staples; and (2) different times to closure affected cost when sutures or staples are used in patients with musculoskeletal tumors.

METHODS

We retrospectively reviewed 511 patients who had sarcoma resections of the buttock, thigh, and femur from 2003 to 2010; 376 had closure with sutures and 135 with staples. Data were abstracted on patient demographics, comorbidities, select procedural data, and wound complications. Wound complications were defined by hospitalization within 6 months postoperatively for a wound problem, irrigation and débridement, or infection treated with antibiotics. We determined the association between staples versus sutures and wound complications after controlling for confounding factors. The minimum followup was 2 weeks. A prospective, timed analysis of wounds closed with either sutures or staples was also performed.

RESULTS

We found an association between obesity and radiation and wound complications. Wounds were closed an average of 5.3 minutes faster with staples than with suture (0.29 minutes versus 5.6 minutes, respectively), saving a mean 2.1% of the total operating time although the total operating time was similar in the two groups.

CONCLUSIONS

We found no difference in wound complications after closure with sutures or staples, although obesity and radiation treatment appear to affect wound outcomes. Data suggest that time saved in the operating room by closing with staples compensates for added material costs and does not compromise wound care in patients with lower extremity sarcomas.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Management of haemostasis in surgery: sealant and glue applications

Blood loss has always been a sensitive issue in surgery. Traditional techniques, such as suturing and electrocautery, have drastically reduced operatory bleeding. Unfortunately, wound edges and point application devices are frequently characterized by bleeding and infections. Over the past 20 years, haemostatic agents and tissue sealants have been developed and now are currently used, along with classic suture in various surgical specialties. Their fluid nature allows management of blood loss along any point of the wound and tissue repair. This review presents an overview of the most diffused haemostatic sealants, focusing on their main use in surgery and their adverse effects.

Wound closure and wound monitoring in total hip arthroplasty. An overview

Wound closure in primary and revision total hip arthroplasty is an essential and crucial step of the procedure. A recently published meta-analysis comparing metallic staples and sutures with stitches in hip procedures revealed that the risk of infection was four times greater when staples were used. This statement created concern among orthopaedic surgeons. The aim of this overview is to address the problem of THA wound closure and wound monitoring. Further well designed, randomised, controlled trials comparing staples vs traditional stitches and eventually vs skin adhesive are necessary in order to draw conclusions in elective THA, revision surgery and hip fractures. Orthopaedic surgeons need to have more evidence in order to be able to justify their method of wound closure. Monitoring of the wound by the surgeon in the postoperative period is recommended.

Sutures versus staples for wound closure in orthopaedic surgery: a pilot randomized controlled trial

Background

In the spectrum of surgical decision-making, wound closure material is often an afterthought. However, the findings of a recent meta-analysis suggest that the rate of surgical site infections (SSIs) is increased by using staples to close surgical wounds. Less clear is the effect of closure material on the incidence of non-infectious wound complications.

The aim of this study was to compare sutures and staples in terms of: incidence of wound complications to determine the sample size for a definitive trial comparing wound closure methods.

Methods

Eligible adult orthopaedic patients were randomized to have wounds closed with sutures or staples. Time for skin closure was recorded. Wounds were assessed for complications for six weeks. The incidence of complications was compared using Fisher’s exact test. Time to close and pain with removal of closure material were compared using a Student’s t-test.

Results

The total number of patients reporting a wound complication was 59 of 148 patients completing six-week followup (41%), with no differennce between sutures and staples (RR = 0.77, CI = 0.52–1.14). The time to close wounds was shorter in the staple group (mean=4.8 min, CI = 2.6–7.1) than the suture group (mean=12 min, CI = 7.9–16). Patients in the staple group (mean=3.7, CI =2.8–4.6) reported more pain with removal than suture group (mean=2.5, CI =1.6–3.4).

Conclusions

This study suggests that 42% of patients report a wound complication with no difference between sutures and staples. It was demonstrated that suturing skin requires more time and staples are more painful to remove.

Trial registration

Clinicaltrials.gov identifier NCT01146236 (registered June 14, 2010)

Sutures versus staples for wound closure in orthopaedic surgery: a randomized controlled trial

Background

A recently published meta-analysis comparing metallic staples to sutures in orthopaedic procedures revealed three fold increase in risk for infection in stapled wounds. The studies included in the meta-analysis are at risk of bias due to experimental design limitations. A large randomized controlled trial is proposed to direct orthopaedic surgeons in their choice of wound closure material.

Methods/Design

A parallel group randomized controlled trial with institutional review board approval will be conducted. Patients will be randomized intraoperatively to have skin wounds closed with sutures or staples. Dressings will be used to maintain blinding outcome assessors. The primary outcome measure will be a composite all-cause wound complication outcome measure composed of: infection, wound drainage, wound necrosis, blistering, dehiscence, suture abscess and material sensitivity reaction. An independent review board blinded to treatment assignment will adjudicate suspected complications based on clinical data. All deceased patients will also be reviewed. An interim analysis of complications will take place after half of the patients have been recruited. All data will be analyzed by a blinded statistician. Dichotomous primary and secondary outcome measures will be analyzed using the Chi-squared statistic. Continuous outcome measures will be analyzed using Student's t-test. Subgroup analysis will compare infection rates using sutures versus staples in each anatomic area (upper extremity, pelvis/acetabulum, hip/femur, knee, ankle). A further subgroup analysis will be conducted comparing trauma patients to elective surgery patients. Non-infected revision surgery will also be compared to primary surgery.

Discussion

Wound closure material is an afterthought for many orthopaedic surgeons. The combined results of several comparative trials suggests that the choice of wound closure materials may have an impact on the rate of surgical site infections. However, the strength of the evidence is poor given the heterogeneity of the methods employed in previous studies. The following study protocol aims to guide surgeons in their choice of wound closure material by determining if there is a difference in complication rates in sutured and stapled wounds.

Trial Registration

This trial was registered at ClinicalTrials.gov under the identifier NCT01146236 (registered June 14, 2010)

Wound complications in joint arthroplasty: comparing traditional and modern methods of skin closure

Various methods of skin closure exist in joint replacement surgery. Although subcuticular skin closure techniques offer an aesthetic advantage over conventional skin stapling, no measurable differences have been reported. Furthermore, newer barbed sutures, such as the V-Loc absorbable suture (Covidien, Mansfield, Massachusetts), theoretically distribute tension evenly through the wound and help decrease knot-related complications. The purpose of this study was to evaluate whether wound complication rates were (1) lower in V-Loc closure cases as theoretically suggested, (2) lower for subcuticular closure vs staples, and (3) significantly different for knee and hip joint reconstruction.A retrospective chart review was conducted of 278 consecutive cases of primary joint reconstruction performed by a single surgeon (L.P.). The study group comprised 106 men and 161 women. Average patient age at surgery was 63 years (range, 18-92 years), and average body mass index of the cohort was 33.7 kg/m(2) (range, 25-51 kg/m(2)). Skin was closed via staple gun or subcuticular stitch (3-0 Biosyn [Covidien] vs V-Loc). Seven (3.9%) wound complications occurred in 181 cases closed with staples. Four (7.8%) wound complications occurred in 51 cases closed via subcuticular Biosyn suture. Six (13.0%) wound complications occurred in 46 cases closed with V-Loc suture. The staple group had a lower rate of complications when compared with the suture group as a whole (P=.033) and when compared specifically with the V-Loc suture group (P=.017).

Modality of wound closure after total knee replacement: are staples as safe as sutures? A retrospective study of 181 patients

Background

Surgical site wound closure plays a vital role in post-operative success. This effect is magnified in regard to commonly performed elective procedures such as total knee arthroplasty. The use of either sutures or staples for skin re-approximation remains a contested subject, which may have a significant impact on both patient safety and surgical outcome. The literature remains divided on this topic.

Methods

Two cohorts of patients at a level one trauma and regional referral center were reviewed. Cohorts consisted of consecutive total knee arthroplasties performed by two surgeons who achieved surgical wound re-approximation by either staples or absorbable subcuticular sutures. Outcome variables included time of surgery, wound dehiscence, surgical site infection per Center for Disease Control criteria and repeat procedures for debridement and re-closure.

Results

181 patients qualified for study inclusion. Staples were employed in 82 cases (45.3% of total) and sutures in 99 cases (54.7%). The staples group had no complications while the sutures group had 9 (9.1%). These consisted of: 4 infections (2 superficial, one deep, one organ/space); three patients required re-suturing for dehiscence; one allergic type reaction to suture material; and one gout flare resulting in dehiscence. The mean surgical time with sutures was 122.3 minutes (sd = 33.4) and with staples was 114 minutes (sd = 24.4).

Conclusion

This study demonstrated significantly fewer complications with staple use than with suture use. While all complications found in this study cannot be directly attributed to skin re-approximation method, the need for further prospective, randomized trials is established.

Coaptive film versus subcuticular suture: comparing skin closure time after posterior spinal instrumented fusion in pediatric patients with spinal deformity

STUDY DESIGN

A prospective, randomized trial comparing skin closure time between coaptive film and subcuticular Monocryl sutures in children undergoing posterior instrumented spinal fusion.

OBJECTIVE

To prospectively compare skin closure time, complication rate and cosmetic result between coaptive film and subcuticular Monocryl wound closures in pediatric spine surgery.

SUMMARY OF BACKGROUND DATA

Posterior instrumented spinal fusions for spinal deformity in children are time-consuming ventures that are demanding on both the patient and physician. Minimizing the time for skin closure at the end of prolonged surgery diminishes the physical burden on the surgeon, the operating room personnel, and reduces operating room costs.

METHODS

Twenty-five children (mean age, 14.1 year) underwent posterior instrumented spinal fusion. Twenty-five incisions in 25 patients (12 closed with 3-0 subcuticular Monocryl sutures, 13 closed with coaptive film [Steri Strip S; 3 M company]) were evaluated. The method of skin closure was randomized before beginning the procedure and the surgeon informed just before skin closure. Closure time was recorded. A blinded plastic surgeon using a visual analogue scale assessed the cosmetic results at a minimum 3-month follow-up.

RESULTS

Incisions closed with coaptive film required less time to complete than incisions closed with subcuticular suture. The mean time for skin closure using coaptive film was 290.62 seconds compared to the mean time of 674.75 seconds using Monocryl sutures (P < 0.000001). The average length of incisions closed with coaptive film was similar to the corresponding incisions that were closed with subcuticular Monocryl sutures (30.8 and 34.0 cm, respectively, P = 0.22). There was no significant difference in the cosmetic results or the number of wound complications using either technique.

CONCLUSION

Coaptive film is a time-saving option for skin closure following pediatric spine surgery with comparable cosmetic results and no difference in complication rates.

A randomized, prospective study of total hip wound closure with resorbable subcuticular staples

Resorbable subcuticular staples are a new way to close surgical wounds and have not been reported in the orthopedic literature. This randomized, controlled study compared a resorbable subcuticular staple system with stainless steel wound stapling in patients undergoing unilateral primary total hip arthroplasty (THA). Institutional Review Board approval and patient consent was obtained for all patients. Sixty patients (30 each group) were randomized to receive either resorbable subcuticular staples or stainless steel staples after primary THA. Incision length, number of staples used, and any staple insertion problems were recorded. Subjective reports of pain levels or incision complaints were solicited, and wound photographs were obtained on days 1 and 14 and 6 weeks postoperatively. The presence of wound drainage, erythema, wound separation, or echymosis was recorded at each visit, as well as all postoperative complications. The average incision length in the resorbable group was 13.2 cm and required 16 staples for closure, compared to 15 cm and 20 staples for the metal staple group. No infections occurred in either group, although the incidence of erythema and wound drainage at 2 weeks was higher for patients in the stainless steel group. One patient with metal staples had a postoperative hematoma requiring secondary irrigation and debridement. Patient satisfaction was higher with the resorbable staples. A resorbable subcuticular staple system can provide comparable wound closure to stainless steel staples following THA and may do so with less local discomfort, wound drainage, or erythematous reaction.

Postoperative outcomes associated with topical skin adhesives among women having hysterectomies

BACKGROUND

Multiple options are available for closure of hysterectomy incisions. This study compared postoperative clinical and economic outcomes using topical skin adhesive (2-octyl cyanoacrylate; OCA) vs. conventional skin closure in women undergoing total abdominal hysterectomy.

METHODS

A multi-hospital administrative database was used to identify women discharged in 2005 who had undergone total abdominal hysterectomy. Patients, classified by skin closure as suture (n = 21,201), staples (n = 23,441), OCA (n = 880), or staples + OCA (n = 489), were compared on length of inpatient stay (LOS), total inpatient cost, and non-prophylactic antibiotic treatment after day four.

RESULTS

The unadjusted mean LOS was 3.9, 4.5, 3.7, and 5.2 days for suture, staples, OCA, and staples + OCA, respectively; and the percentages of patients having antibiotic treatment were 12.93, 17.51, 11.14, and 23.72. There were overall differences in adjusted mean LOS, mean total cost, and antibiotic treatment (p < 0.0001). Pairwise comparisons indicated no difference between sutures and OCA, whereas the outcomes for each of the non-staple groups were more favorable than those for the staple group (p < 0.01). Results were similar in adjusted comparisons, with pairwise comparisons between OCA and staples at or near the threshold for significance.

CONCLUSIONS

2-octyl cyanoacrylate appears to be a safe and cost-effective alternative to topical sutures for patients having total abdominal hysterectomy. There were less favorable outcomes in groups receiving staples.

Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis

OBJECTIVE

To compare the clinical outcomes of staples versus sutures in wound closure after orthopaedic surgery.

DESIGN

Meta-analysis.

DATA SOURCES

Medline, CINAHL, AMED, Embase, Scopus, and the Cochrane Library databases were searched, in addition to the grey literature, in all languages from 1950 to September 2009. Additional studies were identified from cited references. Selection criteria Two authors independently assessed papers for eligibility. Included studies were randomised and non-randomised controlled trials that compared the use of staples with suture material for wound closure after orthopaedic surgery procedures. All studies were included, and publications were not excluded because of poor methodological quality. Review methods Two authors independently reviewed studies for methodological quality and extracted data from each paper. Final data for analysis were collated through consensus. The primary outcome measure was the assessment of superficial wound infection after wound closure with staples compared with sutures. Relative risk and mean difference with 95% confidence intervals were calculated and pooled with a random effects model. Heterogeneity was assessed with I(2) and chi(2) statistical test.

RESULTS

Six papers, which included 683 wounds, were identified; 332 patients underwent suture closure and 351 staple closure. The risk of developing a superficial wound infection after orthopaedic procedures was over three times greater after staple closure than suture closure (relative risk 3.83, 95% confidence interval 1.38 to 10.68; P=0.01). On subgroup analysis of hip surgery alone, the risk of developing a wound infection was four times greater after staple closure than suture closure (4.79, 1.24 to 18.47; P=0.02). There was no significant difference between sutures and staples in the development of inflammation, discharge, dehiscence, necrosis, and allergic reaction. The included studies had several major methodological limitations, including the recruitment of small, underpowered cohorts, poorly randomising patients, and not blinding assessors to the allocated methods of wound closure. Only one study had acceptable methodological quality.

CONCLUSIONS

After orthopaedic surgery, there is a significantly higher risk of developing a wound infection when the wound is closed with staples rather than sutures. This risk is specifically greater in patients who undergo hip surgery. The use of staples for closing hip or knee surgery wounds after orthopaedic procedures cannot be recommended, though the evidence comes from studies with substantial methodological limitations. Though we advise orthopaedic surgeons to reconsider their use of staples for wound closure, definitive randomised trials are still needed to assess this research question.

The use of 2-octylcyanoacrylate (Dermabond(®)) for the treatment of nail bed injuries in children: results of a prospective series of 30 patients

PURPOSE

The use of 2-octylcyanoacrylate (OCA) has been evaluated for the treatment of nail bed injuries in adults. We propose to validate this technique in a continuous paediatric population of 30 children.

METHODS

Patients with nail bed injuries associated with displaced fractures of the distal phalanx were excluded from the study. However, parcellar fractures of the tuft were included. After removal of the nail, wound detersion and anatomic positioning of the nail bed was done and maintained under the nail plate using a single dose of OCA. Follow-up evaluation was done at day 7 and 1 and 3 months.

RESULTS

The mean delay between the trauma and the surgery was 13.5 h. The nail bed lesion was a single transversal wound in 27 cases. A pulpar wound was associated in 22 cases. At 3 months control (final follow-up), no pain or functional impairment was noted. The cosmetic result was excellent for the patient and his family in 30 out of 31 cases. It was excellent for the surgeon in 25 cases and good in six cases.

CONCLUSIONS

In the OCA technique, meticulous primary detersion and exact anatomic positioning of the damaged nail bed is mandatory before applying the cyanoacrylate adhesive. In our experience, we found that the OCA technique provided a fast and safe result in nail bed lesions. The final cosmetic appearance, function and patient satisfaction were good in our series. In these lesions, discomfort and inconvenience associated with suture removal could be avoided by the use of OCA.

Skin closure after total hip replacement: a randomised controlled trial of skin adhesive versus surgical staples

We undertook a randomised controlled trial to compare the outcomes of skin adhesive and staples for skin closure in total hip replacement. The primary outcome was the cosmetic appearance of the scar at three months using a surgeon-rated visual analogue scale. In all, 90 patients were randomised to skin closure using either skin adhesive (n = 45) or staples (n = 45). Data on demographics, surgical details, infection and oozing were collected during the in-patient stay. Further data on complications, patient satisfaction and evaluation of cosmesis were collected at three-month follow-up, and a photograph of the scar was taken. An orthopaedic and a plastic surgeon independently evaluated the cosmetic appearance of the scars from the photographs. No significant difference was found between groups in the cosmetic appearance of scars at three months (p = 0.172), the occurrence of complications (p = 0.3), or patient satisfaction (p = 0.42). Staples were quicker and easier to use than skin adhesive and also less expensive. Skin adhesive and surgical staples are both effective skin closure methods in total hip replacement.

A prospective clinical audit of a new dressing design for lower limb arthroplasty wounds

An audit of wound healing in patients undergoing total hip or knee arthroplasty in a Scottish hospital found that use of a barrier film made no difference to the effectiveness of a new Hydrofiber/hydrocolloid dressing combination.

Frog glue enhances rotator cuff repair in a laboratory cadaveric model

SUMMARY

Rotator cuff tendons are typically reattached to the proximal humerus using transosseous sutures or suture anchors. Their primary mode of failure is at the tendon-bone interface. We investigated the addition of a novel adhesive secreted from a species of Australian frog (Notaden bennetti) to different methods of rotator cuff repair. We hypothesized that the addition of frog glue would increase the strength of the repaired rotator cuff construct. Three techniques were used to repair 42 fresh frozen sheep infraspinatus tendons with a mattress stitch configuration: transosseous sutures; 2 traditional metallic suture anchors with 1 suture per anchor, and 2 knotless metallic anchors with 1 suture per anchor. In each group, 7 shoulders were repaired with the addition of frog glue to the infraspinatus "footprint," whereas 7 were used as control with no adhesive. Failure occurred in all constructs at the tendon-bone-suture interface. Repair with suture anchors was stronger than with sutures through bone (P < .05). Frog glue significantly increased the load to failure, total energy required for failure, and maximum energy at failure in all repair techniques (P < .01). A 2-fold increase occurred in load to failure of the 2 common anchor types (143 +/- 8 and 165 +/- 20 N). The load to failure for the transosseous repair (86 +/- 8 N) increased 1.7-fold. The addition of an adhesive to the tendon-bone-suture interface significantly enhances ultimate load and total energy required to failure in 3 types of rotator cuff repair. The unique properties of this frog glue (strong, flexible and sets in water) may ultimately lead to its use as an adjunct to rotator cuff repair in humans.

LEVEL OF EVIDENCE

Basic science study.

Prospective study of long-term patient perceptions of their skin cancer surgery

BACKGROUND

We identified factors that influence patient perceptions of their skin cancer surgery through a prospective study of patients referred to a single surgeon during 18 months.

METHOD

Patients having surgery resulting in a wound sutured and dressed were surveyed 6 to 9 months later. Monitoring for complaints continued for 3 years.

RESULTS

In all, 74% of patients returned the survey (576 of 778). A total of 250 (43%) rated their scar excellent, 177 (31%) very good, 72 (12.5%) good, 40 fair (6.9%), and 14 (2.4%) poor or very poor. Age, sex, diagnosis, or closure method did not result in a variation in scar perception. In all, 27.3% of scars (21/77) on the trunk were rated neutral or negative compared with 6.9% (33/476) of scars elsewhere (P < .001) and only 5% (15/305) of head and neck scars (P < .001). Complications did not change scar or overall evaluation ratings. In all, 393 patients (68%) rated the overall service excellent, 145 (25%) very good, 22 (4%) good, and 3 (0.5%) fair. No patient rated the service poor or very poor. Patients rating the service lower were most dissatisfied with scar appearance, time waiting before surgery, pain from the local anesthetic, nursing care, follow-up care, cost, and written material. In all, 99% of patients who rated their scar very good or excellent rated the overall service optimally, compared with only 85% of patients who rated their scar as good or worse.

LIMITATIONS

A single experienced surgeon in a southern Australia locale might not reflect the perceptions in other clinicians and locations.

CONCLUSION

Complications and patient complaints do not identify patient dissatisfaction from cutaneous surgery. The patients' perception of their scars markedly influences their overall service perception. Patients experienced more dissatisfaction with repairs on the trunk.

A Randomized Controlled Trial of High-Viscosity 2-Octyl Cyanoacrylate Tissue Adhesive versus Sutures in Repairing Facial Wounds Following Mohs Micrographic Surgery

BACKGROUND

High-viscosity 2-octyl cyanoacrylate (HVOCA) is a rapidly polymerizing liquid topical adhesive indicated for epidermal approximation of superficial lacerations and surgical wounds. Use of HVOCA in repair of facial wounds after Mohs micrographic surgery (MMS) has not been reported.

OBJECTIVE

To compare aesthetic outcome of HVOCA versus sutured epidermal closure of linearly repaired facial wounds following MMS.

METHODS

Patients undergoing MMS for facial tumors with postoperative wounds >3 cm appropriate for linear closure were recruited. After placement of dermal sutures, half the wound was randomly selected for closure with HVOCA and the other half was closed with 5-0 polypropylene suture.

RESULTS

Fourteen patients (13 men and 1 woman; mean age, 72+/-8.8 years; range, 52-81 years) with basal cell or squamous cell carcinoma of the face (n=12) or neck (n=2) were enrolled. The mean wound length was 4.9+/-1.9 cm (range, 3.1-10 cm). No postoperative complications, including bleeding, infection, or dehiscence, occurred. Using photographs obtained 3 months postoperatively, five dermatologists (including two Mohs surgeons) blinded to the intervention rated cosmesis using a visual analog scale from 1 (worst) to 10 (best). The mean ratings for HVOCA half (6.64+/-1.55) versus sutured half (6.77+/-1.88) were not significantly different (p=.35). Paired comparisons of rater preferences similarly showed no cosmetic differences. All 14 patients preferred OCA for ease of postoperative care.

CONCLUSION

HVOCA tissue adhesive is cosmetically equivalent to epidermal sutures in the linear repair of facial wounds following MMS. This technique represents an additional option for Mohs surgeons.