Postoperative contact dermatitis caused by skin adhesives used in orthopedic surgery: Incidence, characteristics, and difference from surgical site infection

2-Octyl-Cyanoacrylate Mesh Dressings for Total Joint Arthroplasty: Dressing Design Influences Risks of Wound Complications

BACKGROUND

Recent liquid adhesive skin closure systems with a mesh patch and a 2-octyl cyanoacrylate liquid formula have shown promising results in total joint arthroplasty. Chemical accelerators are typically included to promote the rapid polymerization of 2-octyl cyanoacrylate. The goal of the study is to distinguish designs and wound complication differences between 2 similar systems.

METHODS

An 18-week retrospective study was conducted from July to December 2023, including 207 total hip arthroplasty and 212 total knee arthroplasty cases from 4 attending surgeons at 1 institution that used 1 of 2 dressing designs. Both dressings had a 2-octyl cyanoacrylate liquid adhesive formula that applied topically to a polyester-based mesh overlaying the wound. Mesh A (used in 274 cases) included an accelerator, a quaternary ammonium salt, on the mesh patch, whereas Mesh B (used in 145 cases) included a similar accelerator within the adhesive applicator.

RESULTS

Wound complications (3.2 versus 7.6%; X2 = 3.86; df = 1; P = .049), early periprosthetic joint infections (0 versus 2.8%; X2 = 7.63; df = 1; P = .006), and 90-day reoperations for wound complications (0.4 versus 3.4%; X2 = 6.39; df = 1; P = .011) were significantly lower in patients who received Mesh A versus B, respectively. There was no difference in superficial surgical site infections (0.7 versus 0%; X2 = 1.06; df = 1; P = .302) or allergy rates (3.3 versus 4.1%; X2 = 0.12; df = 1; P = .655) between Mesh A and B.

CONCLUSIONS

We observed significantly different performance in wound complications, early postoperative periprosthetic joint infections, and 90-day reoperation between the 2 designs. Having the accelerator in the applicator rather than on the mesh patch may lead to premature polymerization before bonding appropriately with the mesh to create the desired wound closure and seal.

LEVEL OF EVIDENCE

Level III.

Allergic Contact Dermatitis to Octyl Cyanoacrylate Skin Glue After Surgical Wound Closure: A Systematic Review

The rising incidence of allergic contact dermatitis (ACD) after cyanoacrylate adhesive use necessitates a comprehensive understanding of its clinical presentations, risk factors, and management. In this systematic review, we conducted an exhaustive search following PRISMA guidelines within Medline and PubMed databases to identify studies reporting cases of ACD resulting from cyanoacrylate adhesive application in wound closure. A total of 47 studies, covering 193 ACD cases, were included in our analysis. These cases involved 35 male, 120 female patients, and 38 cases without gender information (M:F ratio = 1:3.43), with ages ranging from 7 to 92 years (mean age 43.9 years). The majority of cases (n = 140) were part of 6 orthopedic studies, focusing on joint replacements (n = 68), orthopedic surgeries (n = 38), and breast surgeries (n = 29). The remaining 58 cases encompassed various surgical procedures. Common clinical manifestations included swelling, pruritic rash, erythema, vesicles, and itching around the surgical sites, typically appearing around 10 days post-adhesive application (within a range of 6 hours to 6 weeks). Patients with prior exposure to 2-octyl cyanoacrylate tended to exhibit earlier symptoms. Similar rates of dermatitis were observed across different adhesive brands, suggesting brand independence. Treatment strategies involved adhesive removal, administration of steroids and antihistamines, meticulous wound care, and, in some cases, surgical intervention. Notably, 3.1% of the 193 cases required surgical intervention. Risk factors, including a history of atopic dermatitis, high body mass index, diabetes, prior adhesive exposure, and surgical history, were identified in the studies. Patch tests confirmed 2-octyl cyanoacrylate as the allergen in 21 studies. Our review aims to enhance health care professionals' understanding of ACD resulting from the use of cyanoacrylate adhesive, facilitating improved postsurgical management and prevention strategies. Recognizing diverse risk factors, understanding varying clinical presentations, distinguishing ACD from infection, and employing appropriate treatment approaches are essential for achieving optimal outcomes in such cases.

Incidence of Skin Sensitivity Following Dermabond Application in Pediatric Orthopedic Surgery

BACKGROUND

Dermabond (Dermabond; Ethicon, Sommerville, NJ), is a skin adhesive commonly utilized in pediatric orthopedic surgery for postoperative wound care. Few studies have examined outcomes of Dermabond exposure in children. The purpose of this study is to estimate the incidence of skin reactions following Dermabond exposure in pediatric orthopedic surgery and investigate potential risk factors associated with Dermabond sensitivity.

METHODS

This was a retrospective study of a level-one pediatric trauma center. All orthopaedic surgeries in 2019 were screened for Dermabond application. Three surgeons with the highest rates of Dermabond application defined our cohort. Out of 2990 surgeries in 2019, the 3 surgeons performed 234 surgeries with Dermabond. Postoperative reactions and repeat Dermabond exposures were collected for these 234 patients. Subjects with known allergies to Dermabond were excluded. Reactions were defined. as discoloration, irritation, and wound dehiscence. Significant differences between patients with repeat Dermabond exposures and those without were determined using χ 2 analysis. Associations between patient characteristics and sensitivity were determined using logistic regression analysis. P values less than 0.05 were considered significant.

RESULTS

In all, 234 patients were included for analysis. The mean age at surgery was 12.5 years (SD 6.1), and 39% (92/234) of the cohort was male. Thirty-two patients (14%) experienced skin reactions during the study period (95% CI=7%-19%). Reactions most frequently included. erythema (10/32; 31%) and itchiness (10/32; 31%). Reactions were most frequently treated with oral antibiotics, Benadryl, or a dressing change. Of 144 patients with 1 Dermabond exposure, 17 (12%) experienced reactions (95% CI=7%-18%). Of 128 patients experiencing a repeat Dermabond exposure, 27 (21%) experienced reactions (95% CI=19%-34%, P =0.03). Age, surgical procedure, and surgical location were not, associated with a variable rate of sensitivity.

CONCLUSIONS

Sensitivity to Dermabond after pediatric orthopedic surgery occurred at a higher rate than seen in adults, and patients with multiple Dermabond exposures experienced significantly higher sensitivity than patients with a single exposure. Increased awareness of this potential complication is needed to help inform decisions regarding Dermabond's application in pediatric orthopedics.

Skin Reactions Following Primary Total Knee Arthroplasty With an Adhesive Superficial Closure System: A Case Series

BACKGROUND

We investigated a skin adhesive closure device consisting of a self-adhesive polyester mesh placed over the surgical incision, followed by a liquid adhesive that is spread over the mesh and surrounding the skin. It is intended to reduce wound closure times, scarring, and skin complications associated with traditional closure with sutures or staples. The aim of this study was to report on skin reactions in patients who underwent primary total knee arthroplasty (TKA) using the skin adhesive closure system.

METHODS

A retrospective review of patients who underwent TKA using adhesive closure between 2016 to 2021 at a single institute was performed. A total of 1,719 cases were analyzed. Patient demographics were collected. The primary outcome was any postoperative skin reaction. Skin reactions were classified as allergic dermatitis, cellulitis, or other. Treatment(s), duration of symptoms, and surgical infections were also collected.

RESULTS

A total of 5.0% (86) of patients were found to have any type of skin reaction following their TKA. Of these 86, 39 (2.3%) had symptoms of allergic dermatitis (AD), 23 (1.3%) had symptoms of cellulitis, and 24 (1.4%) had other symptoms. A total of 27 (69%) allergic dermatitis patients were treated with a topical corticosteroid cream only; their symptoms resolved within an average of 25 days. There was only 1 case of superficial infection (<0.001%). No prosthetic joint infections were observed.

CONCLUSION

Despite skin reactions appearing in 5.0% of cases, the rate of infection was low. A patient-specific preoperative workup and effective treatment strategies can minimize complications associated with adhesive closure system and increase patient satisfaction following TKA.

Silk Bioprotein as a Novel Surgical-Site Wound Dressing: A Prospective, Randomized, Single-Blinded, Superiority Clinical Trial

Background

Medical adhesive-related skin injuries (MARSIs) affect about 1.5 million patients annually in the United States. Complications include allergic contact dermatitis, skin blistering, skin tears, and surgical-site infections (SSIs). The authors hypothesize that a natural hypoallergenic silk bioprotein wound dressing will decrease the incidence of MARSI in comparison to a synthetic alternative.

Objectives

This study aimed to assess the efficacy and safety of a silk bioprotein wound dressing compared to the Dermabond Prineo (Ethicon, Inc., Somerville, NJ) skin closure system.

Methods

This prospective, randomized, single-blinded trial studied 25 patients who were dressed with Dermabond Prineo on one side of their body and on the contralateral side with the silk bioprotein dressing after undergoing abdominoplasty or reduction mammaplasty procedures. Data were collected over 5 postoperative visits using photographs and an investigator administered questionnaire to track rash, itch, discomfort, erythema, edema, SSIs, need for pharmaceutical intervention, mechanical injury, removal time, and bathing routines.

Results

Sixty-four percent (16/25) of patients characterized the severity of discomfort as a score of 4 out of 10 or greater on the Dermabond Prineo control side and only 4% (1/25) for the silk-dressing side (P < .001). Fifty-two percent (13/25) had a visible rash of 4 or higher on the Dermabond Prineo side of their incision and 0% (0/25) had a rash on the silk side (P < .001). Fifty-two percent (13/25) required steroids or antibiotics to treat MARSI to Dermabond Prineo and 0% (0/25) required pharmaceutical intervention on the silk side (P < .001).

Conclusions

The use of a silk bioprotein wound dressing significantly reduces the incidence of MARSI throughout the postoperative period.

Level of Evidence 2

Rash and Poor Wound Healing After Mastectomy

A patient who had recently undergone bilateral mastectomy had erythema, edema, pain, pruritus, serous fluid drainage at the incision sites, and an erythematous papulovesicular rash on the trunk and extremities. A skin swab bacterial culture result was negative, and the skin findings did not improve with antibiotics. What is the diagnosis and what would you do next?

Documented Contact Allergy Impacts Risk for Surgical Adhesive-Associated Contact Dermatitis after Shoulder Arthroplasty

Purpose

The purpose of this study is to report on the incidence and risk factors for allergic contact dermatitis (ACD) in patients who received Prineo after total shoulder arthroplasty (SA).

Methods

A retrospective case-control study was conducted to investigate patients who experienced ACD after having SA by a single surgeon during a defined period when Prineo was routinely used as an adjunct to wound closure. Known risk factors for ACD (e.g., history of contact dermatitis, smoking) were analyzed for association development of Prineo-associated ACD using Fisher exact and Wilcoxon rank sum tests.

Results

From June 2019 through July 2021, 236 consecutive patients were identified as having Prineo applied after SA. Nine cases of Prineo-ACD (3.8%) were documented, whereas 227 patients were unaffected. In all 9 affected patients, the complication was identified and treated without compromising the outcome of the SA. Previous allergy to medical adhesives was a statistically significant risk factor for Prineo-associated ACD in this series (P = .01). The odds of having Prineo-associated ACD among those with adhesive or contact allergy was 38.5 times that of their nonallergic counterparts in a multivariate model.

Conclusions

Prineo adhesive ACD had an incidence of 3.8% in this study, and a history of adhesive or contact allergy was highly associated with its development.

Level of Evidence

Level III, case-control study.

Allergic Contact Dermatitis (ACD) to Topical Products in Orthopedic Surgery: Clinical Characteristics and Treatment Strategies

The potential for many of the commonly used surgical site wound adhesives, skin antiseptic solutions, topical antibiotics, and suture materials to sensitize and subsequently result in allergic contact dermatitis (ACD) has become increasingly recognized within orthopedic surgery. Particularly with subsequent exposure to the offending allergen, the cutaneous allergic reaction may present in a similar fashion to cellulitis, thus making early differentiation between the two etiologies to initiate the appropriate and timely treatment crucial. Recognition of the characteristic appearance and severity of ACD surrounding a surgical wound often drives the initial management. This typically consists of anti-histamines, topical corticosteroids, and possible removal of the offending allergen for low grade findings and oral steroids and prophylactic oral antibiotics for the more severe reactions. Multidisciplinary care, including the expertise of a dermatologist or wound care specialist when faced with this challenging clinical scenario is critical and elective patch testing may be indicated to ascertain the exact allergen involved, particularly in patients with a prior history of wound issues. Finally, any clinical cases of ACD following an orthopedic procedure should be documented in the patient's chart so that exposure can be avoided with any future surgery.

Severe Hypersensitivity Reaction to Dermabond Prineo After Anterior Cervical Discectomy and Fusion: A Case Report

CASE

A 68-year-old woman underwent an anterior cervical discectomy and fusion for cervical radiculopathy and subsequently developed a severe contact hypersensitivity reaction in response to Dermabond Prineo, beginning 10 days postoperatively. The Dermabond Prineo mesh was removed, and the patient was treated symptomatically with diphenhydramine, systemic steroids, and oral antibiotics, with complete resolution of her symptoms.

CONCLUSION

This is the first reported contact hypersensitivity reaction to Dermabond Prineo in the context of spine surgery. Surgeons should be able to recognize this presentation and treat this appropriately.