Using a non-invasive secure skin closure following total knee arthroplasty leads to fewer wound complications and no patient home care visits compared to surgical staples

Wound Management following Total Knee Arthroplasty: An Updated Review

Optimal wound closure techniques following total knee arthroplasty (TKA) have focused on enhancing healing potential, preventing infection, yielding satisfactory cosmesis, and allowing early ambulation and functionality. An appropriate layered closure and management of the TKA typically involves addressing the (1) deep fascial layer; (2) subdermal layer; (3) intradermal layer, including the subcuticular region; and (4) final application of a specific aseptic dressing, each of which are covered here in detail. This focused critical review of the literature discusses traditional techniques used in all layers of wound closure following TKA while introducing several emerging popular techniques. For example, absorbable barbed skin sutures and occlusive dressings have the potential to reduce operative time, limit the need for early postoperative visits, obviate the need for suture or staple removal, and safely promote patient communication via telemedicine. As novel wound closure techniques continue to emerge and traditional approaches are improved upon, future comparative studies will assist in elucidating the key advantages of various options. In an extremely important field that has tremendous variability, these efforts may enable the reaching of a classically elusive standard of care for these techniques.

Efficacy and safety of external tissue expansion technique in the treatment of soft tissue defects: a systematic review and meta-analysis of outcomes and complication rates

Background

Currently, various external tissue expansion devices are becoming widely used. Considering the scarcity of relevant application standards, this systematic review was performed to explore the effectiveness and safety of external tissue expansion techniques for the reconstruction of soft tissue defects.

Method

A systematic review and meta-analysis on the efficacy and safety of external tissue expansion technique was conducted. A comprehensive search was performed in the following electronic databases: PubMed/Medline, Embase, Cochrane Library (Wiley Online Library), and Web of Science. Studies reporting patients with soft tissue defects under the treatment of external tissue expansion technique were included.

Results

A total of 66 studies with 22 different types of external tissue expansion devices met the inclusion criteria. We performed a descriptive analysis of different kinds of devices. A single-arm meta-analysis was performed to evaluate the efficacy and safety of the external tissue expansion technique for different aetiologies. The pooled mean wound healing time among patients with defects after fasciotomy was 10.548 days [95% confidence interval (CI) = 5.796-15.299]. The pooled median wound healing times of patients with defects after excisional surgery, trauma, chronic ulcers and abdominal defects were 11.218 days (95% CI = 6.183-16.253), 11.561 days (95% CI = 7.062-16.060), 15.956 days (95% CI = 11.916-19.996) and 12.853 days (95% CI=9.444-16.227), respectively. The pooled wound healing rates of patients with defects after fasciotomy, excisional surgery, trauma, chronic ulcers and abdominal defects were 93.8% (95% CI=87.1-98.2%), 97.2% (95%CI=92.2-99.7%), 97.0% (95%CI=91.2-99.8%), 99.5% (95%CI=97.6-100%), and 96.8% (95%CI=79.2-100%), respectively. We performed a subgroup analysis in patients with diabetic ulcers and open abdominal wounds. The pooled median wound healing time of patients with diabetic ulcers was 11.730 days (95% CI = 10.334-13.125). The pooled median wound healing time of patients with open abdomen defects was 48.810 days (95% CI = 35.557-62.063) and the pooled successful healing rate was 68.8% (95% CI = 45.9-88.1%). A total of 1686 patients were included, 265 (15.7%) of whom experienced complications. The most common complication was dehiscence (n = 53, 3.14%).

Conclusions

Our systematic review is the first to demonstrate the efficacy and safety of external tissue expansion in the management of soft tissue defects. However, we must interpret the meta-analysis results with caution considering the limitations of this review. Large-scale randomized controlled trials and long-term follow-up studies are still needed to confirm the effectiveness and evaluate the quality of healing.

A Prospective, Randomized, Controlled Comparison of Adhesive Wound Closure Devices in an Orthopaedic Patient

The objective of this study was to compare Zip and Clozex with a typical closure using a running 3-0 Prolene suture.

Comparison of the zip skin closure system with conventional suture for skin closure of ventral midline incisions in horses

OBJECTIVE

To compare the application and healing of the zip skin closure system (ZSCS) with sutured closure by use of a split-scar model of ventral midline incisions in horses in a prospective, randomized experimental study.

ANIMALS

8 adult horses.

PROCEDURES

All horses underwent an exploratory ventral midline celiotomy with a standardized 30-cm skin incision. Each horse was randomized to have either the cranial 15 cm closed with suture and caudal 15 cm with the ZSCS or vice versa (split-scar model). Skin closure time was recorded and compared. Photography and skin biopsies were taken preoperatively and 14 days postoperatively. Cosmetic appearance was assessed by use of a proposed equine celiotomy incision score. Healing at 14 days was assessed by histopathology.

RESULTS

Skin closure times were faster with the ZSCS compared to sutured incisions. At 14 days postoperatively, the cosmetic appearance (equine celiotomy incision scores) for ZSCS incisions were better than sutured closure and histologic healing scores were not different between methods of closure. Subcuticular sutures were associated with deep dermal inflammation and necrosis independent of epidermal closure methods.

CLINICAL RELEVANCE

While limitations to the utility of the ZSCS are recognized, the potential benefits of expedient closure, good cosmetic outcome, and satisfactory healing make this method viable for closure of linear wounds or incisions in horses.

Comparison of 2-octyl cyanoacrylate skin adhesive and interrupted polypropylene sutures for wound closure in total ankle arthroplasty

BACKGROUND

Adhesive skin materials have increasingly been used in orthopedic surgery. We aimed to compare the efficacy and safety of skin adhesive (2-octyl cyanoacrylate and polymer mesh, Dermabond Prineo) and interrupted polypropylene sutures for wound closure in patients undergoing total ankle arthroplasty (TAA).

METHODS

We prospectively enrolled 107 consecutive patients (108 ankles) undergoing TAA and divided them into two groups: skin adhesive group (36 ankles) and suture group (72 ankles). The primary outcome assessment included wound complications and patient satisfaction for wound cosmesis. The secondary outcome assessment included duration of surgery, length of hospital stay, and the Ankle Osteoarthritis Scale (AOS) pain and disability score.

RESULTS

There was one case of allergic contact dermatitis, three cases of wound dehiscence, and one case of superficial surgical site infection in the skin adhesive group. Among them, one case each with allergic contact dermatitis and wound dehiscence finally progressed to deep surgical site infection. Three cases of wound dehiscence were also reported in the suture group; however, there was no case of surgical site infection. Patient satisfaction for wound cosmesis was significantly higher in the skin adhesive group than in the suture group (p = 0.001). There was no statistically significant difference between the groups in terms of secondary outcomes (p > 0.05).

CONCLUSIONS

Although the use of Dermabond Prineo showed better patient satisfaction for wound cosmesis, it showed significantly high wound complication rates and no other clinical benefits compared to interrupted polypropylene suture in TAA. Our results suggest that awareness of the possibility of wound complications is necessary when Dermabond Prineo is used in TAA.

Similar infection rates in a new wound closure method following knee arthroplasty

Surgical site infections, defined as acute wound infections requiring surgical intervention within 90 days post-surgery, were retrospectively compared between a novel, zipper-like closure method (ZM) and staples in 682 patients (904 knees) and 772 patients (971 knees), respectively. The incidence of deep infections was 0.6% for staples and 0.2% for ZM (p = 0.169) and superficial infections was 0.1% for staples and 0.0% for ZM (p = 0.518). With no difference in wound complications, the ZM may be preferred since the two-week post-operative clinic visit required for wound check and staple removal was eliminated, thereby, decreasing clinic volume.

A Single-Center Randomized Prospective Study Investigating the Efficacy of Various Wound Closure Devices in Reducing Postoperative Wound Complications

Background

Sutures and staples are the mainstay wound closure techniques in total joint arthroplasty. Newer techniques such as zipper devices and novel skin adhesives have emerged because of their potential to decrease operative time and possibly minimize complications. The aim of this study is to compare these newer techniques against conventional sutures with respect to wound complications, closure time, and costs.

Methods

A single-center randomized control trial was conducted on 160 patients (52 zipper, 55 suture, 53 mesh) who underwent primary total hip or knee arthroplasty between February 2017 and May 2018. Patients were divided into 3 closure groups: zipper device, monofilament suture plus adhesive, and monofilament plus polyester mesh with adhesive. The primary endpoint was closure time (superficial skin layer). Secondarily we collected perioperative complication rates, including infection, persistent (14-day) wound drainage, 90-day readmission, and emergency room visit rates as well as compared material costs.

Results

There were no differences in baseline characteristics between groups for age, body mass index, and American Society of Anesthesiologists classification. There was a trend toward decreased time to closure for the suture group. There were no significant differences between groups for our secondary endpoint, complications.

Conclusions

Our study shows that the suture group trended toward shorter closure time but suggests that each of the closure methods after total joint arthroplasty has equivalent complication rates. With small differences in closure time and no significant differences in complications, the decision to use one wound closure device or technique over another should be driven by institutional costs and provider familiarity.

Comparison between Zip-Type Skin Closure Device and Staple for Total Knee Arthroplasty: A Meta-Analysis

Purpose

To compare the efficacy and safety of zip-type skin closure device (SCD) and staple in total knee arthroplasty (TKA).

Methods

Potential academic articles were identified from PubMed, Springer, ScienceDirect, and Cochrane Library from the inception of electronic databases to July 2020. The statistical analyses were performed with RevMan 5.1.

Results

One randomized controlled trial (RCT) and 5 non-RCTs met the inclusion criteria. Present meta-analysis reveals that SCD is associated with lower wound pain score, scar score, and readmission compared with a staple. No significant differences are identified in terms of wound total complications, dehiscence, blisters, and infection.

Conclusions

Comparing with a staple, zip-type SCD is a less painful skin closure method with fewer medical cost undergoing TKA.

A Novel Skin Closure Device for Total Knee Arthroplasty: Randomized Controlled Trial versus Staples

Twenty-five patients undergoing simultaneous, bilateral total knee arthroplasty (TKA) were randomized to receive skin closure with Zip device on one knee and staples on the other. Patients' pain and scar appearance were rated from 0 (best) to 10 (worst). Knee arc of motion was measured by a physical therapist. At 2 weeks postoperatively, pain scores were significantly better with the Zip device during device wear (p = 0.03) and during device removal (p = 0.003); arc of motion was significantly better with the Zip device (p = 0.002). At 8 weeks of follow-up, scar appearance was significantly better in the Zip device knee as rated by the patients (1.3 vs. 2.6, p = 0.04), the surgeon (1.9 vs. 3.3, p = 0.0006), and three independent plastic surgeons (3.7 vs. 4.8, p < 0.001). Results of this randomized controlled trial show that skin closure with the Zip device resulted in less pain and better scar appearance and knee arc of motion than with staples.

A novel zipper device versus sutures for wound closure after surgery: a systematic review and meta-analysis

We performed an updated meta-analysis to compare the efficacy of the zipper device and sutures for wound closure after surgery. A computerised literature search was performed for published trials in PubMed, Web of Science, the Cochrane Library, and Google Scholar. Two reviewers independently scrutinised the trials, extracted data, and assessed the quality of trials. The primary outcome was surgical site infections (SSI). The secondary outcomes were wound dehiscence, total wound complications, wound closure time, and scar score. Statistical analysis was performed in the Stata 12.0. Of the 130 citations, eight trials (1207 participants) met eligibility criteria and were included. The zipper device achieved a lower SSI rate (RR: 0.63, [95% CI: 0.41-0.96, P = 0.032]), a shorter wound closure time (SMD: -8.53 [95% CI: -11.93 to -5.13, P = 0.000]) and a better scar score (SMD: 0.42 [95% CI: 0.22-0.62, P = 0.000]) than sutures. No significant difference was shown in the incidence of wound dehiscence and total wound complications. Therefore, the zipper device provides the advantages of anti-infection, time-saving, and cosmesis for wound closure.

Adhesive strips as the sole method for skin closure is effective in total knee arthroplasty

OBJECTIVE

Adhesive strips are used as the sole method for skin closure in many operations except total knee arthroplasty. The claims are decreased wound closure time, less tissue reaction, and lack of stitch marks. The purpose of this study was to compare the efficacy of closure using adhesive strips versus running subcuticular stitches.

METHODS

This study was a retrospective case-matched study. Running subcuticular stitches or adhesive strips were used for skin closure in 151 and 137 patients, respectively. All of the patients had an operation by a single surgeon and had the same patient care protocol. All of the patients were evaluated postoperatively for wound complication at 2 weeks, 6 weeks, and 3 months follow-up.

RESULTS

The wounds of most patients in both groups had healed. The incidence of superficial infection was not different between the groups (1.32% in the running subcuticular suture group and 1.46% in the adhesive strip group) (p = 0.92). One case (0.66%) in the running subcuticular suture group had deep infection, which required reoperation (p = 0.34). The patients in the running subcuticular suture group had higher unabsorbable sutures, which required further removal compared to the adhesive strip group (p < 0.001).

CONCLUSION

The use of adhesive strips is an effective skin closure method with a low rate of infection and skin complications. This technique is easy and there is no need for suture removal. Furthermore, there are no stitch marks and the cost of suturing is lower.

Use of Zipper Ratcheting Straps as a Bailout for Postoperative Cerebrospinal Fluid Leaks: Our Experience

STUDY DESIGN

Technical note.

OBJECTIVES

Management of postoperative cerebrospinal fluid (CSF) leaks is a challenge. Reexploration increases the morbidity risks. The main objective was to evaluate the outcomes of noninvasive zipper-like system (Zip surgical skin closure system, ZipLine Medical, Inc, Campbell, CA, USA) as a bailout technique for postoperative CSF leaks.

METHODS

Retrospective case series. Consecutive patients with postoperative CSF leaks that occurred secondary to spinal surgeries performed between January 2017 and September 2018 were part of the study. All these patients were managed conservatively by reinforcement with zipper ratcheting straps over the sutured surgical wound. Successful clinical outcomes included cessation of CSF leaks and adequate wound healing in the postoperative period and at follow-up.

RESULTS

Ten patients underwent the application of zipper ratcheting straps. The mean follow-up was 6 months (range 6 months to 1 year). In 7 cases, the dural tears were recognized postoperatively and in 3 cases, the tears were noted intraoperatively and repaired and reinforced with fibrin sealants. None of the patients developed wound soakage or subsequent CSF leak from the wound after the application of zipper ratcheting straps.

CONCLUSIONS

Zipper ratcheting straps as augmentation to sewing of the wound seem to be a good alternative and bailout in treating patients with postoperative CSF leaks. The ease of its application, the ability in minimizing the complications associated with CSF leaks, and negating the need of surgical reexploration makes it a worthy option.

Multimodal Conservative Treatment of Complicated Open Wound After Total Knee Replacement Arthroplasty in Patients With Comorbidities

Total knee replacement arthroplasty is a common procedure and postoperative wound complications are sometimes inevitable. Although invasive reconstructive surgery may be an option for nonhealed wounds, such procedures can limit early rehabilitation, adversely affecting the range of joint motion. Patients can achieve a wider range of motion if they undergo early rehabilitation with a conservative approach. From 2015 to 2017, 5 patients with comorbidities who underwent total knee replacement arthroplasty were referred to the reconstructive surgery department for nonhealed open wounds. Depending on their comorbidities and conditions, the patients underwent negative-pressure wound therapy based on multimodal conservative treatment. During the treatment, the patients continued rehabilitation. In the 5 patients, the mean duration of complete wound healing was 65.2 days (range = 57-81), during which all open wounds were well healed. For final wound closure, the patients underwent skin grafting, dermatotraction, or collagen dressing. Four patients achieved ranges of joint motion over 100 degrees after treatment. We believe that early coverage is important for open wounds. For complicated open wounds after total knee replacement arthroplasty in patients with comorbidities, less invasive multimodal treatment along with early rehabilitation may be more effective to achieve adequate final range of joint motion.

Wound Complications after 2-Octyl Skin Closure Systems for Total Joint Arthroplasty

Introduction: Total joint arthroplasty is projected to expand rapidly by 2030. With large numbers of patients undergoing TJA, the choice of incisional closure has come into question. We compared the 2-Ocyl cyanoacrylate closure system of Dermabond ® Prineo ® with Exofin Fusion ® to compare rates of adverse wound outcomes after total joint arthroplasty. Secondary outcome measures were age, sex, and medical comorbidities between groups.

Methods: We retrospectively reviewed adverse wound outcomes with skin closure in TJA in 281 patients (160 Dermabond Prineo and 121 Exofin Fusion). Clinical charts were analyzed out to the 6-week post-op visit.

Results: The rate of overall adverse superficial wound outcomes was similar between the two groups with Dermabond Prineo (N=20) and Exofin Fusion (N=19). The rate of cellulitis was significantly higher for Dermabond Prineo when compared to Exofin Fusion (P=0.033). No other significant differences were found for rate of superficial or deep wound complications or for secondary outcomes.

Conclusions: The two 2-octyl wound closure systems had similar adverse superficial wound complications. Except for Dermabond Prineo having a higher rate of post-operative cellulitis, there were no statistically significant differences for other superficial or deep adverse wound outcomes or secondary outcomes. A future randomized control trial or prospective cohort study is needed for a more robust analysis.

Patient Satisfaction and Cosmetic Outcome in a Randomized, Prospective Study of Total Knee Arthroplasty Skin Closure Comparing Zip Surgical Skin Closure with Staples

Background

Evaluation of the Zip surgical skin closure device (Zip) versus metal staples regarding patient satisfaction and cosmesis after total knee arthroplasty (TKA).

Methods

Patients undergoing TKA at Einstein Medical Center Montgomery were randomized to receive skin closure using Zip or staples. Patient satisfaction was assessed by surveys at discharge, three weeks and six weeks post-operatively. Cosmesis according to patients and observers was assessed using the Patient and Observer Scar Assessment Scale (POSAS).

Results

Randomization resulted in 21 Zip and 20 staple patients. Two subjects were lost to follow-up and one patient suffered cardiac arrest. Surgeon satisfaction favored Zip over staples on day of surgery and patient discharge. At three weeks, Zip was favored over staples for patient-reported movement and device removal pain. Patient satisfaction results favored Zip for comfort, ease of wound care, and hospital selection based on wound closure. POSAS favored Zip for appearance, pain, itching, color, stiffness, thickness, irregularity, vascularity, pigmentation, relief, pliability, surface area, and observer opinion. Subject opinion resulted in no difference between groups. At six weeks, no differences were found for patient-rated movement pain or ease of wound care. POSAS favored Zip for color, stiffness, thickness, vascularity, pigmentation, thickness, relief, pliability, surface area and observer opinion.

Conclusion

Satisfaction with the closure method and patient and physician assessments of cosmesis were superior with Zip. Orthopedic surgeons strive to optimize TKA patient satisfaction. Skin closure can influence patient satisfaction as the memory of their recovery fades and the scar remains the most visible reminder of their experience.

Skin Closure Tape and Surgical Staples in Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Background

Staples closure technology has been widely used in total knee arthroplasty (TKA) and achieved good results. In recent years, a new type of material called skin closure tape (SCT) has been applied to TKA which also showed good treatment results. However, since it is still not clear yet which one is better, this paper collects literatures for statistical analysis so as to provide evidence for the use of SCT in TKA.

Methods

The comparative study on effects between SCT and staples is reviewed after the primary release of TKA in PubMed, the Cochrane library, and the EMBASE database up to March 2019. The two researchers independently screened the literature and evaluated the quality of the literature using bias risk tools.

Results

A total of four studies (3330 knees) have been included in our meta-analysis. For the main point, the results show that the SCT can reduce readmission rates compared to staples (RR 0.68, 95% CI 0.49–0.95, P=0.03), with no significant difference in complications (RR 0.85, 95% CI 0.27–2.64, P=0.77). Secondly, the results suggest that although there is no significant difference in removal time between the two groups, the SCT can reduce pains, save time and costs, and have a better cosmetic effect.

Conclusions

Our study indicates SCT as a closure method with fewer complications and faster speed compared with staples. Nevertheless, the cost and pain need to be further confirmed because of the small sample size included in this study.

Comparison between noninvasive and conventional skin closure methods in off-pump coronary artery bypass grafting using bilateral internal thoracic artery

Background

Sternal wound complications could increase the hospital cost while decreasing the satisfaction of surgery. Furthermore, it can potentially also lead to life-threatening mediastinitis especially after coronary artery bypass grafting using bilateral internal thoracic artery (BITA). Skill levels of suture technique vary among surgeons and may contribute to an increased wound complication rate. Thus, standardization of surgical wound closure could potentially decrease the surgeon factor. The aim of the study is to compare the wound complication rate between non-invasive surgical skin closure devices (zip surgical skin closure device, Zipline Medical, Campbell, CA, USA) and conventional suture closure.

Methods

Three hundred seventy-nine patients who underwent off-pump coronary artery bypass grafting (OPCAB) using BITAs at our institution between 2016 and 2018 were included in this study. Patients were divided into two groups; the Zipline group (zip-group, N=100), and conventional group (con-group, N=279). Following propensity score matching, 95 con-group patients were matched to 169 zip-group patients.

Results

The average age and history of cancer were significantly higher in the zip-group (P=0.021 and P=0.023, respectively). However, after propensity score matching, no differences were observed in the demographic data between the groups. In total patients (unmatched), although there was no significant difference in the incidence of deep sternal wound infection (DSWI) between the two groups (zip vs. con, 0% vs. 1.1%, P=0.569), the incidence of post-operative superficial sternal wound infection (SSWI) or dehiscence was significantly higher in the con-group than in the zip-group (1.0% vs. 7.9%, P=0.013). The results were consistent in the matched patients. (DSWI: 0% vs. 0.6%, P>0.999; SSWI or dehiscence: 1.1% vs. 7.1%, P=0.036). Multivariable analysis revealed use of the zip surgical skin closure device showed a preventive effect against wound complications [odds ratio (OR): 0.128, 95% confidence interval (CI): 0.017-0.976, P=0.029].

Conclusions

Zip surgical skin closure devices could decrease superficial wound complication rates compared to conventional suture techniques in OPCAB using BITAs.