Is the Risk of Infection Lower with Sutures than with Staples for Skin Closure After Orthopaedic Surgery? A Meta-analysis of Randomized Trials

Wound healing after intracutaneous vs. staple-assisted skin closure in lumbar, non-instrumented spine surgery: a multicenter prospective randomized trial

PURPOSE

Superficial surgical site infection (SSSI) is a prominent problem in spine surgery. Intracutaneous sutures and staple-assisted closure are two widely used surgical techniques for skin closure. Yet, their comparative impact on wound healing and infection rates is underexplored. Our goal was to address this gap and compare wound healing between these two techniques.

METHODS

This study was a multicenter international prospective randomized trial. Patient data were prospectively collected at three large academic centers, patients who underwent non-instrumented lumbar primary spine surgery were included. Patients were intraoperatively randomized to either intracutaneous suture or staple-assisted closure cohorts. The primary endpoint was SSSI within 30 days after surgery according to the wound infection Centers for Disease Control and Prevention (CDC) classification system.

RESULTS

Of 207 patients, 110 were randomized to intracutaneous sutures and 97 to staple-assisted closure. Both groups were homogenous with respect to epidemiological as well as surgical parameters. Two patients (one of each group) suffered from an A1 wound infection at the 30-day follow up. Median skin closure time was faster in the staple-assisted closure group (198 s vs. 13 s, p < 0,001).

CONCLUSION

This study showed an overall low superficial surgical site infection rate in both patient cohorts in primary non instrumented spine surgery.

Incision Closure for Direct Anterior Total Hip Arthroplasty: Is There a Difference in the Rate of Superficial Wound Complications With Suture Versus Staples?

Background Direct anterior total hip arthroplasty (DA-THA) has increased in popularity over recent decades. However, DA-THA has been reported to have a higher incidence of superficial wound complications, including infection and incisional dehiscence, compared to other surgical approaches to hip arthroplasty. While this indicates a need for optimal wound closure, little research exists on the preferred method of skin closure following DA-THA. This study aimed to determine if there was any difference in rates of superficial infection, wound dehiscence, or overall wound complications with skin closure using a running subcuticular 3-0 Monocryl® suture compared to surgical staples following DA-THA.  Methods Records of patients who underwent DA-THA at our institution between July 2017 to July 2022 were retrospectively reviewed. Data were abstracted on patient demographics, comorbidities, skin closure method, and wound complications from the electronic medical record. Superficial infection and wound dehiscence were classified based on explicit diagnosis in post-operative records and incision photographs taken during follow-up visits. Overall wound complications were classified in patients who experienced either superficial infection, incisional dehiscence, or both complications following surgery. Descriptive statistics and chi-squared measures were obtained from post-operative patient data, and significance was set at p [Formula: see text] 0.05. Results A total of 365 DA-THAs were completed in 349 patients. A running subcuticular 3-0 Monocryl® suture closed 207 surgeries (56.7%), while surgical staples closed 158 surgeries (43.3%). There was no significant difference in independent rates of superficial infection (p = 0.076) or wound dehiscence (p = 0.118) between suture and staple cohorts; however, suture closure (10, 2.7%) was associated with a significantly higher rate of overall wound complications compared to staple closure (1, 0.3%) (p = 0.020). Conclusion DA-THA carries the risk of overall wound complications, including superficial infection and wound dehiscence. Our findings suggest superficial skin closure with staples may be preferred over sutures due to lower rates of overall wound complications. Further studies are needed to determine the optimal method of skin closure following DA-THA.

Frequency and Risk Factors of Surgical Site Infection among Sudanese Patients with Oral Squamous Cell Carcinoma

Background

In Sudan, patients with oral squamous cell carcinoma (OSCC) presented lately in advanced stages. Surgical site infection (SSI) is one of the most common complications of surgical treatment of OSCC which significantly affects the clinical outcomes. The present study aimed to assess the frequency and risk factors of postoperative surgical site infection among OSCC patients underwent surgery at Khartoum Teaching Dental Hospital (KTDH).

Methods

This is a prospective, analytical, hospital-based study conducted at KTDH during the period from 2022 to 2023. Patients with OSCC were surgically treated and assessed carefully for the development of the SSI.

Results

Sixty patients were enrolled in the present study. Twenty-nine (48.3%) patients were above 61 years, with the predominance of males with 42 (70%) patients. The most involved site of OSCC was the lower gingivolabial region in 35 (39.3%) patients. Forty-seven (78%) patients were in advanced stages III and IV. Forty-five (80%) patients had modified radical neck dissection. Blood transfusion was administered in 50 (83.3%) patients. Twenty-six (43.4%) patients developed SSI; 15 (57.7%) patients of them were Toombak dippers. Development of SSI was found to be significantly associated with the tumour site (P value 0.9), clinical stage (P value 0.6), the number of transfused blood units (P value 0.04), and the duration of hospital stay (P value 0.04). In contrast, use of sutures for wound closure was associated with a reduced risk of developing SSI (P value 0.005).

Conclusion

Surgical site infection was found in 43.4% of the OSCC patients. It was associated with advanced clinical stage and tumour site. Minimizing the number of blood units transfused intraoperatively, we decrease the duration of hospital stay and the use of sutures for wound closure decreases the risk of SSI significantly.

Prevention of Surgical Site Infections in Spine Surgery: An International Survey of Clinical Practices Among Expert Spine Surgeons

STUDY DESIGN

Questionnaire-based survey.

OBJECTIVES

Surgical site infection (SSI) is a common complication in spine surgery but universal guidelines for SSI prevention are lacking. The objectives of this study are to depict a global status quo on implemented prevention strategies in spine surgery, common themes of practice and determine key areas for future research.

METHODS

An 80-item survey was distributed among spine surgeons worldwide via email. The questionnaire was designed and approved by an International Consensus Group on spine SSI. Consensus was defined as more than 60% of participants agreeing to a specific prevention strategy.

RESULTS

Four hundred seventy-two surgeons participated in the survey. Screening for Staphylococcus aureus (SA) is not common, whereas preoperative decolonization is performed in almost half of all hospitals. Body mass index (BMI) was not important for surgery planning. In contrast, elevated HbA1c level and hypoalbuminemia were often considered as reasons to postpone surgery. Cefazoline is the common drug for antimicrobial prophylaxis. Alcohol-based chlorhexidine is mainly used for skin disinfection. Double-gloving, wound irrigation, and tissue-conserving surgical techniques are routine in the operating room (OR). Local antibiotic administration is not common. Wound closure techniques and postoperative wound dressing routines vary greatly between the participating institutions.

CONCLUSIONS

With this study we provide an international overview on the heterogeneity of SSI prevention strategies in spine surgery. We demonstrated a large heterogeneity for pre-, peri- and postoperative measures to prevent SSI. Our data illustrated the need for developing universal guidelines and for testing areas of controversy in prospective clinical trials.

Fixation of the Compressive Dressing for Nipple-areola Complex Graft during Double Incision Chest Contouring Surgery for Assigned-female-at-birth Persons with Diagnosis of Gender Dysphoria: Sutures or Staples?

Background

When transplanting skin grafts, a compressive dressing is usually used to hold the skin graft in place. Dressing fixation can be achieved with either sutures or staples. The purpose of this study was to compare sutures and staples as a method of fixation for the compressive dressings of the nipple-areola complex (NAC) grafts, during double incision chest contouring surgery in assigned-female-at-birth persons with diagnosis of gender dysphoria. The two methods of fixation were compared according to pain at removal, time consumption, difficulty of removal, costs, and sustainability.

Methods

Forty patients were randomized to dressing fixation with either sutures or staples. Timing for dressing fixation during surgery and removing the dressing was measured. Pain during removal was measured using vNRS-11. Difficulty of removal was measured with VAS-100. Costs of materials were compared.

Results

All NAC grafts survived, and no complications such as infection or bleeding occurred. Staples were significantly more painful to remove when compared to sutures [mean vNRS-11 2.98 (SD ± 2.43) versus 1.25 (SD ± 0.92), P < 0.001]. Fixation with staples was faster than fixation with sutures (5.3 versus 94.6 s). No difference in removal time was found. Nurses found staples easier to remove. Sutures were slightly less costly (18 SEK) compared to staples (30 SEK). Finally, sutures produce less material waste.

Conclusion

Being that all other outcomes are similar or insignificant, the less-pain experienced at removal of sutures makes this the preferable method for fixation of the compressive dressing for NAC grafts during double incision chest contouring surgery.

Staples versus sutures wound closure in hip and knee arthroplasty: a prospective cohort study

OBJECTIVE

This study aimed to compare two methods of wound skin closure-staples versus vertical mattress nylon sutures-in patients undergoing primary total hip (THR) and total knee replacements (TKR). The comparison was for wound complications as a primary outcome, and satisfaction of patient and nurse as secondary outcomes.

METHOD

A prospective cohort study was conducted at an academic teaching hospital. All the patients who were admitted for either primary THR or TKR from September 2018 to September 2019 were included. Revision surgeries, patients >85 years of age, and those who were on steroid therapy were excluded. Patients were divided into two groups (staples and sutures) to compare the two methods of wound closure. Patients in each group were assessed for characteristics such as age, sex, weight, height, comorbidities, smoking status, postoperative wound complications, reoperation and patient/nurse satisfaction.

RESULTS

A total of 100 patients met the inclusion criteria. In the staples group (n=50), 26 patients underwent THR while 24 patients underwent TKR. In the sutures group (n=50), 23 patients underwent THR and 27 patients underwent TKR. Overall, there was no significant difference between the two groups (staples versus sutures) in terms of wound complications (p=0.401), patient satisfaction (p=0.357) and nurse satisfaction (p=0.513). Further analysis compared THR and TKR subgroups (THR staples versus THR sutures and TKR staples versus TKR sutures). The results showed no significant difference between the staples and sutures subgroups of THR and TKR in terms of wound complications, patient satisfaction and nurse satisfaction.

CONCLUSION

In THR and TKR, there was no significant difference between either vertical mattress nylon sutures or staples primary skin closure in terms of wound complications and patient satisfaction in this study. The decision on wound closure method should be based on the availability of resources in the institution/country.

Controlling the controls: what is negative pressure wound therapy compared to in clinical trials?

AIM

Surgical site infections (SSIs) are common following colorectal operations. Clinical trials suggest that closed incision negative pressure wound therapy (ciNPWT) may reduce SSIs compared to a 'standard of care' group. However, wound management in the standard of care group may vary. The aim of this review was to assess the control arms in trials of ciNPWT for potential confounding variables that could influence the rates of SSI and therefore the trial outcomes.

METHODS

A mapping review of the PubMed database was undertaken in the English language for randomized controlled trials that assessed, in closed surgical wounds, the use of ciNPWT compared to standard of care with SSI as an outcome. Data regarding wound care to assess potential confounding factors that may influence SSI rates were compared between the ciNPWT and standard of care groups. Included were the method of wound closure, control dressing type, frequency of dressing changes and postoperative wound care (washing).

RESULTS

Twenty-seven trials were included in the mapping review. There was heterogeneity in ciNPWT duration. There was little control in the comparator standard of care groups with a variety of wound closure techniques and different control dressings used. Overall standard of care dressings were changed more frequently than the ciNPWT dressing and there was no control over wound care or washing. No standard for 'standard of care' was apparent.

CONCLUSION

In randomized trials assessing the intervention of ciNPWT compared to standard of care there was considerable heterogeneity in the comparator groups and no standard of care was apparent. Heterogeneity in dressing protocols for standard of care groups could introduce potential confounders impacting SSI rates. There is a need to standardize care in ciNPWT trials to assess potential meaningful differences in SSI prevention.

Impact of Infection Control on Prevalence of Surgical Site Infections in a Large Tertiary Care Hospital in Haiphong City

Few point prevalence surveys (PPS) have been conducted in Vietnam on Surgical Site Infections (SSI) or antimicrobial use in surgery. The objective of this study was to evaluate the PPSs of SSI before and after implementation of antibiotic stewardship programs (ASP) and infection control (IC) in a Vietnamese tertiary care hospital. ASP and IC practices were implemented in operating rooms and the orthopedic department, including antibiotic training, skin preparation, hand hygiene, gloves and sterile instruments, and SSIs risk factors. A PPS of SSIs and antimicrobial use was performed in January 2016 according to methods from the Centers for Disease Control and Prevention, before ASP and IC, and in December 2019. Information recorded included surgical data, antibiotic prophylaxis, microorganisms, and SSI risk factors. Skin preparation compliance assessed preoperative washing and antisepsis. SSI prevalence was 7.8% in 2016 versus 5.4% in 2019 (p = 0.7). The use of prophylactic antibiotics decreased from 2016 to 2019. A third-generation cephalosporin was prescribed more than 48 h after surgery for most patients. Skin preparation compliance increased from 54.4% to 70.5% between assessments. The decreased SSI, although non-statistically significant, warrants continuing this program. Vietnamese hospitals must provide comprehensive IC education to healthcare workers to address the prevention of SSI and establish IC policies.

Foot and Ankle Surgical Incision Closure With Three Different Materials

There is no clear recommendation for wound closure material in foot and ankle surgery. Thus, we hypothesized that there was no difference in clinical outcomes among 3 suture materials, namely, absorbable sutures, nonabsorbable sutures, and metallic staples. This study compared the 3 materials for wound closure in foot and ankle surgery. In this prospective randomized study, 124 patients were randomly divided into the nonabsorbable suture group, absorbable suture group, and staple group. ASEPSIS score, Hollander Wound Evaluation Scale, and numerical rating scale (regarding pain and satisfaction) were collected at first dressing changes, suture removal, and 6 weeks after surgery. Suture time and incision length were recorded. No significant differences were detected for the ASEPSIS and Hollander Wound Evaluation Scale scores. There was significantly more pain after 6 weeks in the nonabsorbable suture group. The closure time (13 s/cm) with staples was significantly lower in the nonabsorbable suture group than in the other groups. Regardless of wound closure material, male sex and obesity appeared to be associated with a higher risk for the occurrence of wound complications. The 3 suture materials showed no significant differences regarding the frequency of wound complications. Staples and absorbable sutures should therefore be considered in the repertoire of suture materials used in foot and ankle surgery.

Strategies to Minimize Surgical Scarring: Translation of Lessons Learned from Bedside to Bench and Back

Significance: An understanding of the physiology of wound healing and scarring is necessary to minimize surgical scar formation. By reducing tension across the healing wound, eliminating excess inflammation and infection, and encouraging perfusion to healing areas, surgeons can support healing and minimize scarring. Recent Advances: Preoperatively, newer techniques focused on incision placement to minimize tension, skin sterilization to minimize infection and inflammation, and control of comorbid factors to promote a healing process with minimal scarring are constantly evolving. Intraoperatively, measures like layered closure, undermining, and tissue expansion can be taken to relieve tension across the healing wound. Appropriate suture technique and selection should be considered, and finally, there are new surgical technologies available to reduce tension across the closure. Postoperatively, the healing process can be supported as proliferation and remodeling take place within the wound. A balance of moisture control, tension reduction, and infection prevention can be achieved with dressings, ointments, and silicone. Vitamins and corticosteroids can also affect the scarring process by modulating the cellular factors involved in healing. Critical Issues: Healing with no or minimal scarring is the ultimate goal of wound healing research. Understanding how mechanical tension, inflammation and infection, and perfusion and hypoxia impact profibrotic pathways allows for the development of therapies that can modulate cytokine response and the wound extracellular microenvironment to reduce fibrosis and scarring. Future Directions: New tension-off loading topical treatments, laser, and dermabrasion devices are under development, and small molecule therapeutics have demonstrated scarless wound healing in animal models, providing a promising new direction for future research aimed to minimize surgical scarring.

Closing Time: One Last Call for Patient Preference

Background

Wound closure method in total hip and knee arthroplasty is a controversial topic with no differences in clinical outcomes between surgical staples (SS) and subcutaneous sutures with Dermabond (SCD). When clinically appropriate, providers should focus more on what the patient may prefer. This study aimed to collect data on patient preference between SS and SCD and analyze differences in preference based on gender and previous surgical histories.

Methods

Patients were surveyed on their wound closure preferences prior to surgery. The handout given collected preference and patient demographics. Risk ratios and risk difference with 95% confidence intervals (95% CI) were calculated along with Firth-corrected logistic regressions.

Results

A total of 163 participants were analyzed (53% female) (average age = 63.8 years), in which 12 participants selected SS as their preferred method. Males demonstrated no difference in relative risk (risk ratio: 2.3 [95% CI: 0.7, 7.3], P = .150) or absolute risk (risk difference: 5.9 [-2.2, 14.1], P = .156) in choosing SS over SCD. Patients that previously sustained SS for other surgeries demonstrated no difference in adjusted odds (adjusted: 0.9 [95% CI: 0.2, 3.2], P = .839) in choosing SS over SCD.

Conclusion

More patients favored SCD over SS. There was no difference in preferences based on gender or previous surgical history. Current literature shows that successful wound closure is achieved with minimized risks for infection and other complications using both methods. Providers should adopt a patient-centric approach and perform the closure method that most patients prefer when medically warranted.

Surgical site infection after wound closure with staples versus sutures in elective knee and hip arthroplasty: a systematic review and meta-analysis

Purpose

This systematic review and meta-analysis aimed to study surgical site infection of wound closure using staples versus sutures in elective knee and hip arthroplasties.

Methods

A systematic literature review was performed to search for randomized controlled trials that compared surgical site infection after wound closure using staples versus sutures in elective knee and hip arthroplasties. The primary outcome was surgical site infection. The risk of bias was assessed with the Cochrane risk of bias assessment tool. The relative risk and 95% confidence interval with a random-effects model were assessed.

Results

Eight studies were included in this study, including 2 studies with a low risk of bias, 4 studies having ‘some concerns’, and 2 studies with high risk of bias. Significant difference was not found in the risk of SSI for patients with staples (n = 557) versus sutures (n = 573) (RR: 1.70, 95% CI: 0.94–3.08, I² = 16%). The results were similar after excluding the studies with a high risk of bias (RR: 1.67, 95% CI: 0.91–3.07, I² = 32%). Analysis of studies with low risk of bias revealed a significantly higher risk of surgical site infection in patients with staples (n = 331) compared to sutures (n = 331) (RR: 2.56, 95% CI: 1.20–5.44, I² = 0%). There was no difference between continuous and interrupted sutures (P > 0.05). In hip arthroplasty, stapling carried a significantly higher risk of surgical site infection than suturing (RR: 2.51, 95% CI: 1.15–5.50, I² = 0%), but there was no significant difference in knee arthroplasty (RR: 0.87, 95% CI: 0.33–2.25, I² = 22%; P > 0.05).

Conclusions

Stapling might carry a higher risk of surgical site infection than suturing in elective knee and hip arthroplasties, especially in hip arthroplasty.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42836-021-00110-7.

Wound Closure Following Intervention for Closed Orthopedic Trauma

The method of skin closure and post-operative wound management has always been important in orthopedic surgery and plays an even larger role now that surgical site infection (SSI) is a national healthcare metric for both surgeons and hospitals. Wound related issues remain some of the most feared complications following orthopedic trauma procedures and are associated with significant morbidity. In order to minimize the risk of surgical site complications, surgeons must be familiar with the physiology of wound healing as well as the patient and surgical factors affecting healing potential. The goal of all skin closure techniques is to promote rapid healing with acceptable cosmesis, all while minimizing risk of infection and dehiscence. Knowledge of the types of closure material, techniques of wound closure, surgical dressings, negative pressure wound therapy, and other local modalities is important to optimize wound healing. There is no consensus in the literature as to which closure method is superior but the available data can be used to make informed choices. Although often left to less experienced members of the surgical team, the process of wound closure and dressing the wound should not be an afterthought, and instead must be part of the surgical plan. Wounds that are in direct communication with bony fractures are particularly at risk due to local tissue trauma, resultant swelling, hematoma formation, and injured vasculature.

The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations for Surgical Technique for Spinal Cord Stimulation

INTRODUCTION

The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice.

MATERIALS AND METHODS

Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant.

RESULTS

This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion.

CONCLUSIONS

The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community.

Staples versus sutures for skin closure in hip arthroplasty: a meta-analysis and systematic review

Objective

The purpose of the present study was to estimate complications and other outcomes associated with staple and suture closure after hip arthroplasty through meta-analysis techniques and a systematic review.

Methods

We searched for articles in EMBASE, PubMed, Medline, Web of Science and the Cochrane Library. To determine the eligibility of the searched trials, Cochrane Collaboration's Review Manager software was used to perform the meta-analysis.

Results

Five randomized controlled trials and one retrospective cohort trial were included in our study. Our study indicated that for skin closure after hip arthroplasty, the risks of superficial infection and prolonged discharge were higher with staples than with sutures. There was no significant difference between the two groups in terms of allergic reaction, dehiscence, inflammation, abscess formation, the Hollander Wound Evaluation Scale or patient's satisfaction with skin closure methods. However, suturing required a longer operating time.

Conclusions

Closure with sutures is associated with lower risks of superficial infection and prolonged discharge than closure with staples following hip arthroplasty, but it may take more time.

Randomized Controlled Trial of Topical Skin Adhesive vs Nylon Sutures for Incision Closure in Forefoot Surgery

BACKGROUND

There are many options for incision closure in forefoot surgery. The aim of this study was to compare topical skin adhesive (2-octyl-cyanoacrylate) to simple interrupted nylon sutures.

METHODS

A prospective randomized controlled trial comparing topical skin adhesive (TSA) and nylon sutures (NSs) for elective open forefoot surgery. Primary outcome was Hollander Wound Evaluation Scale (HWES) assessed 2 weeks following surgery. Secondary objectives included time taken for wound closure, wound assessment, patient satisfaction with wound cosmesis, incision pain, and infection rate.

RESULTS

Between January and December 2018, 84 feet (70 patients) underwent hallux valgus scarf/Akin osteotomy or first metatarsophalangeal arthrodesis and were randomized to receive either intervention (topical skin adhesive) or control (3/0 nylon sutures). We found worse HWES scores when using TSA compared to NSs (1.07 vs 0.60). Incision closure time was slower for TSA (mean, 272 vs 229 seconds). At 2 weeks postoperatively, wound care was faster for TSA (mean 71 secs) vs NSs (mean 120), and patient-reported pain was less with TSA (visual analog scale: TSA 1.2 vs NSs 2.1). A high degree of overall patient satisfaction was reported in both groups, without significant difference.

CONCLUSION

Closure of elective forefoot surgery incisions with topical skin adhesive or interrupted nylon sutures offers high satisfaction rates, low pain scores, and low complications. However, topical skin adhesive was associated with more inflammation and areas of wound separation compared to nylon sutures. We recommend the use of sutures for wound closure in forefoot surgery.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Subcuticular sutures versus staples for skin closure in patients undergoing abdominal surgery: A meta-analysis of randomized controlled trials

Background

Surgical site infections (SSIs) are common postoperative complications. Whether the use of staples or sutures makes a difference in abdominal surgery’s infection rate remains elusive.

Methods

A systematic review was performed to identify randomized clinical trials comparing staples and sutures after abdominal surgeries. Eligibility criteria involved the SSI occurrence as the primary outcome and the incidence of wound dehiscence, closure time, cosmesis, and patient satisfaction as the secondary outcomes.

Results

Of the 278 studies identified, seven randomized controlled trials representing 3705 patients were included in this review. There was no significant difference in SSI rates between sutures and staples in general (OR = 0.98, 95% CI = 0.79–1.22, I² = 44%, P = 0.1) or in a subgroup of gastrointestinal surgery, where subcuticular suturing was found with a comparable SSI risk with skin stapling (OR = 0.85, 95% CI = 0.66–1.09). Staple closure was associated with a shorter surgery duration, whereas sutures appeared to provide better cosmesis and patient satisfaction. Sutures and staples achieved a comparable incidence of dehiscence. There was no significant between-study publication bias.

Conclusion

Our study demonstrated similar outcomes in SSI rate between subcuticular sutures and staples for skin closure in patients undergoing abdominal surgery.

Prevention of infection in primary THA and TKA

Rates of peri-prosthetic joint infection (PJI) in primary total hip and total knee arthroplasty range between 0.3% and 1.9%, and up to 10% in revision cases. Significant morbidity is associated with this devastating complication, the economic burden on our healthcare system is considerable, and the personal cost to the affected patient is immeasurable.

The risk of surgical site infection (SSI) and PJI is related to surgical factors and patient factors such as age, body mass index (BMI), co-morbidities, and lifestyle. Reducing the risk of SSI in primary hip and knee arthroplasty requires a multi-faceted strategy including pre-operative patient bacterial decolonization, screening and avoidance of anaemia, peri-operative patient warming, skin antisepsis, povidone-iodine wound lavage, and anti-bacterial coated sutures.

This article also considers newer concepts such as the influence of bearing surfaces on infection risk, as well as current controversies such as the potential effects of blood transfusion, laminar flow, and protective hoods and suits, on infection risk.

Cite this article: EFORT Open Rev 2020;5:604-613. DOI: 10.1302/2058-5241.5.200004

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.

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.

Wound complications after total hip arthroplasty: a prospective, randomised controlled trial comparing staples with sutures

OBJECTIVE

Does the use of staples or sutures for wound closure have a lower surgical site infection rate in patients receiving primary total hip arthroplasty (THA)?

DESIGN

Prospective, randomised controlled multicentre trial.

METHODS

535 patients undergoing THA were included and randomised into 2 groups: 268 wounds were closed with staples, and 267 with sutures. Primary outcome was surgical site infection (SSI). Secondary outcomes were prosthetic joint infection (PJI), other wound complications (dehiscence, necrosis and prolonged drainage) and duration of admittance. Follow-up occurred at 2, 6, and 12 weeks, and at 1 year.

RESULTS

There were no significant demographic differences between the 2 groups. SSI occurred more frequently when wounds were closed with staples (4% compared to 1% with sutures; OR 2.8; CI, 0.885-0.952; p = 0.057). SSI was treated with oral antibiotics. The staples group showed significantly more wound complications (17% compared to 5%; OR 3.943, CI 2.073-7.498; p = 0.000). Wound discharge was significantly prolonged in the staples group (n = 40, compared to n = 12 in the sutures group; OR 3.728; CI, 1.909-7.281; p = 0.000). There was no significant difference in PJI (p = 0.364).

CONCLUSIONS

In this large RCT comparing staples with sutures after THA, the use of staples is associated with a nearly 3 times greater risk of SSI (OR 2.8; p = 0.057). Staples significantly prolong wound discharge. The use of sutures for wound closure after THA is advised. Trial registration: Staples Or Sutures trial (S.O.S. trial) http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3946 , NTR3946.

Contemporary Strategies to Prevent Infection in Hip and Knee Arthroplasty

PURPOSE OF REVIEW

Prosthetic joint infection (PJI) remains a serious concern in lower limb arthroplasty. Despite the significant consequences of PJI, the assessment of the safety and efficacy of preventative measures is challenging due to a low event rate. Notwithstanding, enormous efforts have been made in this arena, and prevention strategies continue to evolve. This review provides an update on contemporary literature (published within the last 5 years) pertaining to infection prevention in primary hip and knee arthroplasty.

RECENT FINDINGS

Patient optimization has been highlighted as a critical preoperative factor in mitigating PJI risk. Recent evidence emphasizes the importance of preoperative glycaemic control, nutritional status, weight optimization and smoking cessation prior to hip and knee arthroplasty. Perioperatively, attention to detail in terms of surgical skin preparation agent and technique as well as prophylactic antibiotic agent, spectrum, dose and timing is important with statistically and clinically significant differences seen between differing strategies. Intraosseous regional antibiotic administration is an emerging technique with promising preclinical data. Dilute betadine lavage also shows promise. Data supporting bundled interventions continues to grow. A multimodal approach is required in PJI prevention, and attention to detail is important with each element. Patient optimization is critical, as is the execution of the planned perioperative infection prevention strategy.

Nylon Skin Sutures Carry a Lower Risk of Post-Operative Infection than Metal Staples in Open Posterior Spine Surgery: A Retrospective Case-Control Study of 270 Patients

Background: Controversy still exists regarding the optimal method for post-operative skin closure in orthopedic surgery. In total knee replacement, closure with metal staples is faster but carries a higher surgical site infection (SSI) risk. Other studies have found differing results in foot and ankle and hip surgery. Very little evidence exists on this subject after spine surgery. The aim of this study was to determine whether closure of the skin incision in open posterior spine surgery carries a different rate of post-operative SSI when using nylon sutures compared with metal staples. Methods: Up to 2006, virtually all skin incisions at our spine surgery unit were closed with metal staples and from 2006 onward with nylon sutures. This was a retrospective historical control study comparing the incidence of SSIs in patients operated on before (n = 127; staples) and after (n = 143; sutures) the transition date. Results: The staples group had an overall 11.8% combined deep and superficial infection rate whereas the nylon suture group had a 4.2% rate (p = 0.017). The two groups also differed in the type of antibiotic prophylaxis used, likelihood of incisional discharge, and the number of days the vacuum drains remained. Conclusions: In our departmental setting, closure of the skin incision with nylon sutures after open posterior spine surgery carried a significantly lower risk of post-operative SSI compared with metal staples. The generalizability of our findings is unclear, but they warrant further investigation.