Impact of Skin Suture Pattern on Incision Perfusion Using Intraoperative Laser Angiography: A Randomized Clinical Trial of Patients With Ankle Fractures

The Routine Use of Running Subcuticular Closures in Orthopaedic Trauma Patients Does Not Increase Wound Complications

OBJECTIVE

To investigate whether the routine use of running subcuticular closures (RSC) in orthopaedic trauma patients increases the rate of wound complications and reoperations.

DESIGN

Retrospective comparative study.

SETTING

Urban Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundred sixty-six patients undergoing orthopaedic trauma procedures between June 2020 and March 2022.

INTERVENTION

Adoption of an RSC protocol where any incision/wound that could be approximated with interrupted subcuticular 2-0 monofilament sutures was closed with a running subcuticular 3-0 monofilament suture.

MAIN OUTCOME MEASUREMENTS

Wound complications and subsequent reoperations.

RESULTS

With adoption of the RSC protocol, 91.0% of all orthopaedic trauma procedures were closed with RSC compared with 7.5% of the historical control group. There were no observed differences in the rate of wound complications (proportional difference (PD) 6.0%, confidence interval (CI) -2.3% to 14.1%; P = 0.15) or reoperations (PD 5.2%, CI -1.9% to 12.2%; P = 0.14) between the RSC and the control group. Wound complications were not associated with RSC on univariate analysis (PD 7.2%, CI -10.0% to 24.0%; P = 0.41). On multivariate analysis, an ASA>2 (odds ratio (OR) 2.4, CI 1.0 to 5.7; P = 0.03), lower extremity injuries (OR 4.9, CI 1.3 to 17.8; P = 0.01), and open reduction internal fixation procedures (OR 2.8, CI 1.1 to 7.2; P = 0.02) were found to be independently associated with wound complications.

CONCLUSION

RSC for orthopaedic trauma procedures was not associated with increased wound complications when compared a historical cohort.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tensile strength of a novel superficial suture pattern compared to traditional suture patterns in a cadaveric human skin model

BACKGROUND

The suture material and pattern utilized to maintain the skin edges in proximity allows for successful primary wound healing. No prior studies have evaluated the tensile strength of different suture patterns on human cadaveric skin. This study evaluates the tensile strength of four single suture patterns: simple (S), horizontal-mattress (HM), vertical-mattress (VM), and a novel stich termed Lindeque locking (LL).

METHODS

Four skin closure patterns were tested on human cadaveric skin using 3-0 nylon - S, HM, VM, LL - totaling four groups with twelve samples each. A tensioning device applied 1 N of force/second in a linear fashion. The primary outcome measures were: (i) wound dehiscence force, and (ii) ultimate load to failure. Statistics included one-way ANOVA with post-hoc Tukey tests.

RESULTS

The LL stitch had the greatest dehiscence force (198.60 N) and ultimate load to failure force (211.13 N) but was only significantly greater on both outcomes versus HM (104.81 N; 95% confidence interval [CI], 65.7 to 121.9; p< 0.001) and (120.79 N; 95% CI, 63.5 to 117.2; p < 0.001), respectively. There was no significant difference between LL and S for dehiscence, nor for the ultimate load to failure (186.90 N and 195.08 N, respectively). The LL pattern was significantly greater for an ultimate load to failure, but not for dehiscence when compared to VM (173.9 N and 171.1 N, respectively). Of all patterns, HM had significantly less withstanding force.

CONCLUSIONS

The Lindeque Locking stitch demonstrated the greatest dehiscence force and tensile strength. It may decrease the risk of wound dehiscence for high tension wounds.

Effect of Modified Allgöwer-Donati Suture Technique on Wound Cosmetics in Spinal Surgery

Objective

To analyze the efficacy of modified Allgöwer–Donati suture (MADS) technique on cosmetic outcomes compared with vertical mattress suture (VMS) technique in spinal surgery wounds.

Methods

This randomized controlled trial was conducted at the First Hospital of Lanzhou University (Gansu, China) from September 2019 to August 2020. The patients were randomly divided into two groups, a VMS group and a MADS group, by staff not involved in the treatment using a computer‐based random number table program (no restrictions on age or sex). Both procedures were performed by the same group of physicians as well as assistants. All suture wounds were completed by the same person. The primary endpoint was the scar area, and the postoperative scar area was scored by the Patient and Observer Scar Scale Assessment (POSAS). The scar area was calculated by ImageJ software. The second outcome measure was wound complications, including poor wound healing, wound edge necrosis, and infection. The trial was recorded in the Chinese Clinical Trial Register on 18 August 2019 (ChiCTR1900024548).

Results

A total of 143 patients were included: 72 in the VMS group and 71 in the MADS group. There was no significant difference in their demographics in terms of age (49.71 ± 8.91 vs 50.15 ± 6.79 years, P = 0.737), sex (M/F, 30/41 vs 31/41, P = 0.923), suture time (3.39 ± 0.22 vs 3.47 ± 0.25 s/mm, P = 0.057), or body mass index (BMI, 23.88 ± 3.50 vs 24.05 ± 3.50, P = 0.765) for MADS to VMS. The postoperative scar area was compared between the two groups transversely on day 12, the MADS wound scars decreased by 58.95% (75,133.24/127,452.58). In the POSAS evaluation, after MADS treatment, surface area score decreased from 5 (4, 5) to 2 (2, 3) (P < 0.0001), observer's overall opinion from 5 (4, 5) to 3 (2, 3) (P < 0.0001), itching from 3 (3, 4) to 3 (2, 3) (P = 0.001), color from 4 (4, 5) to 3 (2–4) (P < 0.0001), stiffness 4 (3–4.75) to 3 (3, 4) (P < 0.0001), or thickness from 4 (3–5) to 4 (3, 4) (P = 0.004). In terms of overall opinion evaluation, the MADS showed a significant difference in observer's overall opinion to the VMS (5 (4, 5) vs 3 (2, 3), P < 0.0001) and in patient's overall opinion 5 (5, 6) to 3 (3, 4), (P < 0.0001). There was no significant statistical difference in poor wound healing (3 vs 0, P = 0.245), wound edge necrosis (3 vs 0, P = 0.245), and infection (1 vs 0, P = 1.000) with the MADS to the VMS.

Conclusion

The results of this study show that the MADS effectively reduced the surgical scar area to 58.95% with no additional adverse events compared with that of the VMS in spine surgery.

Assessing Soft Tissue Perfusion Using Laser-Assisted Angiography in Tibial Plateau and Pilon Fractures: A Pilot Study

OBJECTIVES

To determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol.

DESIGN

Prospective cohort study.

SETTING

Academic trauma center.

PATIENTS

Eight pilon fracture patients and 19 tibial plateau fracture patients who underwent open reduction internal fixation.

MAIN OUTCOME MEASURES

Skin perfusion (fluorescence units) as measured by LA-ICGA.

RESULTS

Six patients were classified as Tscherne grade 0, 9 as grade 1, 10 as grade 2, and 2 as grade 3. Perfusion decreased by 14 fluorescence units (95% confidence interval, -21 to -6; P < 0.01) with each increase in Tscherne grade. Sixteen patients underwent staged fixation with an external fixator (mean time to definitive fixation 14.1 days). The mean perfusion increased significantly at the time of definitive fixation by a mean of 13.9 fluorescence units (95% confidence interval 4.8-22.9; P = 0.01).

CONCLUSIONS

LA-ICGA perfusion measures are associated with severity of soft tissue injury surrounding orthopaedic trauma fractures and appear to improve over time when fractures are stabilized in an external fixator. Further research is warranted to investigate whether objective perfusion measures are predictive of postoperative wound healing complications and whether this tool can be used to effectively guide timing of safe surgical fixation.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Soft Elastomeric Capacitor for Strain and Stress Monitoring on Sutured Skin Tissues

Sutures are ubiquitous medical devices for wound closures in human and veterinary medicine, and suture techniques are frequently evaluated by comparing tensile strengths in ex vivo studies. Direct and nondestructive measurement of tensile force present in sutured biological skin tissue is a key challenge in biomechanical fields because of the unique and complex properties of each sutured skin specimen and the lack of compliant sensors capable of monitoring large levels of strain. The authors have recently proposed a soft elastomeric capacitor (SEC) sensor that consists of a highly compliant and scalable strain gauge capable of transducing geometric variations into a measurable change in capacitance. In this study, corrugated SECs are used to experimentally characterize the inherent biomechanical properties of canine skin specimens. In particular, an SEC corrugated with a re-entrant hexagonal honeycomb pattern is studied to monitor strain and stresses for three specific suture patterns: simple interrupted, cruciate, and intradermal patterns. Stress is estimated using constitutive models based on the Fractional Zener and the Kelvin-Voigt models, parametrized using a particle swarm algorithm from experimental data and results from a validated finite element model. Results are benchmarked against findings from the literature and show that SECs are valuable for clinical evaluation of tensile force in biological skins. It was found that both the ranking of suture pattern performance and the sutured skin's Young's modulus using the proposed approach agreed with data reported in the literature and that the estimated stress at the suture level closely matched that of an approximate finite element model.