Scientific Basis for Selecting Staple and Tape Skin Closures

Clinical and economic outcomes of cesarean deliveries with skin closure through skin staples plus waterproof wound dressings versus 2-octyl cyanoacrylate plus polymer mesh tape

PURPOSE

To compare clinical and economic outcomes of cesarean deliveries with skin closure through skin staples plus waterproof wound dressings (SSWWD) versus 2-octyl cyanoacrylate plus polymer mesh tape (2OPMT). We hypothesized that cesarean deliveries with skin closure through 2OPMT may be associated with a lower rate of wound complications and infections as compared with skin closure through SSWWD; we also hypothesized that, accordingly, 2OPMT may be associated with lower hospital length of stay (LOS), hospital costs, and all-cause readmissions as compared with SSWWD.

METHODS

Retrospective, observational study using a research database derived from administrative records routinely contributed by hundreds of hospitals in the USA. We queried the database for patients aged 18-49 years who had an in-hospital low transverse cesarean delivery between 1 January, 2012 and 31 March, 2017. Using records of medical supplies used during deliveries, we identified deliveries for which skin closure was performed by either SSWWD (SSWWD group) or 2OPMT (2OPMT group). Our primary study outcome was a composite endpoint of infection/wound complication diagnosis during the hospital stays in which the deliveries were performed. Our secondary outcomes included: length of stay (LOS) and total hospital costs for the hospital stays in which the deliveries were performed, and all-cause readmissions (30/60/90 days post discharge) to the same hospital in which the delivery was performed. We compared outcomes between propensity-score matched groups using regressions accounting for hospital-level clustering and non-Gaussian empirical outcome distributions.

RESULTS

Each group comprised 2133 patients (4266 total patients; mean age = 30.3 years [SD = 4.6]). Compared with the SSWWD group, the 2OPMT group had statistically significant lower rates of complications (infection, 0.7 versus 1.6%, p = .011; wound complication, 0.6 versus 1.3%, p = .036; composite, 0.9 versus 2.0%, p = .002), shorter LOS (mean = 3.5 days [SD = 1.6] versus 3.7 days [SD = 1.8], p = .007), and lower total hospital costs (mean = $8879 [SD = $3157] versus $9313 [SD = $3311], p = .025). Between-group differences for 30/60/90-day all-cause readmissions were statistically insignificant.

CONCLUSIONS

This large observational study is the first of its kind and provides evidence that cesarean delivery skin closure with 2OPMT is associated with lower rates of in-hospital infection and wound complications, lower LOS, lower total hospital costs as compared with SSWWD.

Nylon sutures versus skin staples in foot and ankle surgery: is there a clinical difference?

BACKGROUND

Staple sutures have already been proven as a good alternative to nylon sutures for wound closure in hip and knee surgeries. One such advantage to using staple sutures is the significant decrease in surgical time. In foot surgeries, staple sutures are still considered critical and are only used sporadically.

OBJECTIVE

The aim of this retrospective study was to compare nylon sutures and skin staples for wound closure in foot and ankle surgeries with respect to complications and patient satisfaction.

METHODS

A total of 61 patients underwent different operations in the fore-, mid-, and hindfoot areas, which were performed by a single surgeon. Twenty-nine patients received staple wound closures, while 32 patients received nylon suture closures using the Donati back-and-forth technique. Incision length, surgery time, in-patient stay, and wound complications were recorded. Furthermore, a patient survey using the verbal numeric rating scale (VNRS) for subjective pain and cosmetic results at the time of stitch removal (14 days) and after a 6-week follow-up was conducted.

RESULTS

A significant between-group difference was found for surgery time (p = .041) and VNRS for pain (p < .001), with better results seen for staple sutures. Four patients with staple sutures and five with nylon sutures experienced wound dehiscence 14 days postoperatively. However, all patients had completely healed wounds at their 6-week follow-up. No revisional surgeries were necessary.

CONCLUSION

The present results indicate that a skin staple wound closure is a considerable alternative to the nylon suture closure in foot and ankle surgeries. Nevertheless, further prospective randomized trials must cement these insights.

A randomised controlled trial comparing skin closure in total knee arthroplasty in the same knee: nylon sutures versus skin staples

OBJECTIVES

Nylon sutures and skin staples are used commonly in total knee arthroplasty (TKA) surgical wound closure. However, there is no study that compares the wound healing efficacy and patient satisfaction scores of both techniques in the same knee.

METHODS

We randomised 70 patients who underwent primary TKA into two groups. In one group of 34 patients, the skin at the upper half of the wound was closed with skin staples and the lower half of the wound was closed with simple interrupted nylon sutures. In the other group of 36 patients, the skin at the upper half of the wound was closed with nylon stitches and the lower half of the wound was closed with skin staples. We recorded the wound closure time, pain score at the time of stitch removal, wound complication rate, patient satisfaction score, and the Hollander wound evaluation score at the post-operative periods of five days, 14 days, six weeks, three months, and six months. Each half wound was analysed separately.

RESULTS

The mean patient body mass index was 26.8 kg/m(2) (standard deviation 6.3). A total of 70 nylon stitched wounds and 70 skin stapled wounds were analysed. There were no significant differences in wound complication rates, patient satisfaction score, and the Hollander wound evaluation score between both types of wounds (p > 0.05). The wound closure time for skin stapled wounds was significantly lower than the nylon stitched wounds (p < 0.001). However, the skin stapled wounds had a significantly higher pain score at the time of stitch removal (p < 0.001).

CONCLUSION

Skin staples and nylon stitches had comparable results with respect to wound healing and patient satisfaction in TKA wound closure in non-obese patients. The benefit of skin staples over nylon stitches was a decrease in operative time, but was more painful upon removal.Cite this article: V. Yuenyongviwat. A randomised controlled trial comparing skin closure in total knee arthroplasty in the same knee: nylon sutures versus skin staples. Bone Joint Res 2016;5:185-190. DOI: 10.1302/2046-3758.55.2000629.

[Bases and methods of suturing]

If pharmaceutic modulation of scar formation does not improve the quality of the healing process over conventional healing, the surgeon must rely on personal skill and experience. Therefore a profound knowledge of wound healing based on experimental and clinical studies supplemented by postsurgical means of scar management and basic techniques of planning incisions, careful tissue handling, and thorough knowledge of suturing remain the most important ways to avoid abnormal scarring. This review summarizes the current experimental and clinical bases of surgical scar management.

Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: a prospective, randomized trial

OBJECTIVE

The purpose of this study is to compare the cosmetic outcome of scalp wound closure with staples to traditional skin sutures.

METHODS

A prospective, randomized trial was conducted using a convenience sample of children (aged 1-16 y) with simple scalp lacerations admitted to the pediatric emergency department. After parental consent was obtained, patients were randomly assigned to either a stapling or suturing procedure. A trained attending physician completed the procedure following a standard protocol. Based on previously published data, a sample size of 18 patients per group was calculated to give 85% power to detect a 10% difference on a visual analogue scale (VAS) score (two-sided alpha 0.05). Initial outcome of wound healing at 7 to 10 days and final cosmetic outcome after 6 to 18 months were estimated using a VAS. Cosmetic outcome was assessed by a physician blinded to the procedure. Data were analyzed using SPSS (Version 8.02; SPSS Inc., Chicago, IL). The VAS scores for the two treatment groups were compared using the two-tailed Student t test. Analysis of age, race, mode of injury, time interval, and size of the wound were performed to estimate the strength of the association of VAS score with the treatment, adjusted for the covariates.

RESULTS

A total of 42 patients were enrolled. Of the 42, 38 (90.5%) finished the initial follow-up and 31 of those 38 (81.6%) finished the final follow-up. There were no significant demographic differences between groups at recruitment and first follow-up. Among those patients who completed the final follow-up, 15 underwent stapling, and 16 underwent suturing. There were no significant demographic or baseline differences between the groups. Procedure time was significantly lower in the stapling group (P = 0.001). Final follow-up evaluations were completed in 12 +/- 4 months. The mean VAS scores at first and final follow-up were 78.75 +/- 16.16 and 96.31 +/- 8.06 for the suturing group and 86.67 +/- 9.76 and 97 +/- 7.02 for the stapling group (P = 0.17). There remained no significant difference in the final follow-up VAS score between groups when adjusted for covariates.

CONCLUSION

Stapling appears to be a fast and cosmetically acceptable alternative to suturing for simple scalp lacerations.

5th Annual David R. Boyd, MD Lecture: Revolutionary advances in wound repair in emergency medicine during the last three decades. A view toward the new millennium

This lecture provides an overview of advances in wound repair devised by our multidisciplinary team of physicians, scientists, and students. Our collective efforts have devised products, drugs, and concepts that are facilitating wound repair without infection and with the least possible scar. Some of the beneficial products and drugs developed or identified by our laboratory include nitrile examination and surgical gloves, magnification loupes, high pressure syringe irrigation, Shur Clens, as well as a wide variety of different wound closure techniques. In addition, our studies of the mechanism of wound injury, soil infection-potentiating fractions, dynamic and static skin tensions, and microflora of the skin have become important predictors of the outcomes of wound repair. During the new millennium, the computerized clinical information system as well as studies of tissue regeneration should dramatically change our approaches to wound repair.

Staple vs. subcuticular vicryl skin closure in knee replacement surgery: a spectrophotographic assessment of wound characteristics

Staple closure is a popular method of skin closure for patients undergoing knee replacement surgery. There are no guidelines regarding spacing of staples and some concern exists with regard to wound oxygenation in knees subject to early movement. We compared cutaneous wound characteristics in terms of blood oxygenation and blood content, using two types of skin closure. Staples or 4/0 subcuticular vicryl were used. We found favourable blood perfusion characteristics when using stapled closure. Our results also suggest that optimum wound oxygenation requires staple spacing of 6 mm or more.

Closure of the rectus sheath with a continuous looped suture and the skin with staples in dogs: speed, safety, and costs compared to closure of the rectus sheath with interrupted sutures and the skin with a continuous subdermal suture

In dogs requiring a midline celiotomy, closure of the rectus sheath with a continuous polyglyconate looped suture and closure of the skin with stainless steel staples (group 1, 20 dogs) were compared with closure of the rectus sheath with interrupted polyglyconate sutures and closure of the skin with a continuous subdermal polyglactin suture (group 2, 20 dogs) with respect to speed, safety, and costs. The subcutis was closed with a continuous polyglactin suture in all dogs. The use of a looped suture saved 3.4 minutes and the use of staples saved 5.6 minutes. Total mean time saved for all layers was 7.7 minutes (38%). Wound healing was not significantly different between group 1 and group 2. There was one case of dehiscence of the rectus sheath in group 2 and two cases of wound infection in group 1. It was concluded that closing the rectus sheath with a continuous looped suture and the skin with staples is equally safe and significantly faster than closing the rectus sheath with simple interrupted sutures and the skin with a continuous subdermal suture. Additional costs were balanced by the reduction in surgery time.

Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations: a randomized study of cost and time benefits

OBJECTIVE

To compare the total costs and the physician time requirements for suture and staple repair of pediatric scalp lacerations.

STUDY DESIGN

Eighty-eight children, 13 months to 16 years of age, coming to a children's hospital emergency department with simple scalp lacerations were prospectively randomly selected to receive staple or suture repair. Wound lengths, times required for initial wound care and closure, and equipment use were recorded. Patients returned in 1 week for suture or staple removal and wound reevaluation. The two methods were compared in terms of both time expended and costs of equipment and physician compensation.

RESULTS

Forty-five children underwent staple repair and 43 underwent suture repair. There were no differences in age, sex, wound length, number of sutures or staples per centimeter, or physician experience. Stapling resulted in shorter wound closure times (65 vs 397 seconds; p < 0.0001) and shorter overall times for wound care and closure (395 vs 752 seconds; p < 0.0001). Staple repair was less expensive in terms of equipment ($12.55 vs $17.59; p < 0.0001) and total cost based on equipment and physician time ($23.55 vs $38.51; p < 0.0001). The follow-up rate was 91%, with no cosmetic or infectious complications in either group.

CONCLUSIONS

Stapling is faster and less expensive than suturing in the repair of uncomplicated pediatric scalp lacerations, with no additional complications. Physicians who treat children with scalp lacerations should consider the use of stapling devices.

Wound care after posterior spinal surgery. Does early bathing affect the rate of wound complications?

STUDY DESIGN

The study was a prospective clinical trial with historic control.

OBJECTIVES

To determine if early bathing after posterior spinal surgery resulted in increased wound problems.

SUMMARY OF BACKGROUND DATA

Little is known about the time needed for wound healing before patients may get the wound wet. Traditional teaching usually calls for the wound to be kept clean and dry for 10-14 days or until shortly after the sutures are removed. Studies have shown wound closure with skin staples to be resistant to external contamination.

METHODS

One hundred consecutive patients undergoing posterior spinal surgery with skin closure using steel skin staples were prospectively allowed to shower and wet the surgical wound 2-5 days after surgery. These results were compared with a historic control of 100 consecutive patients done in the previous year by the same surgeon with a similar patient profile, albeit with fewer patients who underwent revision surgery and instrumentation in the control group. Follow-up evaluation was done by an independent reviewer. Certain high risk patients were excluded from the trial and control groups.

RESULTS

Ninety-five patients in the historic control group were available for follow-up evaluation, and 97 of the experimental (early bathing group) were available. There was one deep infection in the control group and none in the experimental group. There were three superficial wound problems in the control group, and two in the early bathing group. All superficial wound troubles healed without sequelae. Operating time, complexity, and revision rates were slightly higher in the experimental group.

CONCLUSIONS

Prohibition of showering of patients after uncomplicated posterior spinal surgery and wound closure with skin staples may be unnecessary beyond the first few days.

Staples and gamgee for securing large-area burns dressings

Securing large area burns dressings can be troublesome and time-consuming. Circumferentially applying gamgee and stapling it to itself was discovered to be easily done, very secure and also had a notably tidy appearance.

The use of taped skin closure in orthopaedic wounds

The cosmetic result, cost effectiveness, and complication rate of three different types of skin closure: staples, tapes, and interrupted nylon were compared. In 68 wounds, skin closure was randomized to staples, tapes, or interrupted 3/0 nylon sutures. All wounds were closed subcutaneously with interrupted undyed 2/0 dexon. For 3 months, 59 wounds were followed and assessed by an independent observer at 1 and 3 months postoperatively in the outpatient department. In three different skin closures, the cosmetic result was superior for tapes because the wound line itself was finer and there were no dot scars. Tapes were the most cost-effective because they are the cheapest although they were not as quick to apply as staples. There was no difference in complication rate. Tapes also afforded the greatest patient comfort.