Skin closure in arthroplasty surgery: Current practice

Barbed sutures and skin adhesives improve wound closure in hip and knee arthroplasty

PURPOSE

This study aimed to formulate evidence-based recommendations for optimising wound management in hip and knee arthroplasty by exploring alternative methods such as barbed sutures and skin adhesives.

METHODS

A Delphi panel, comprising seven orthopaedic surgeons, one musculoskeletal infectious disease specialist, and one health economics expert, was convened to evaluate the use of barbed sutures and skin adhesives for wound closure in hip and knee arthroplasty. Two systematic reviews informed the development of questionnaires, with panelists ranking their agreement on statements using a 5-point Likert scale. Consensus was achieved if ≥75% agreement. Unresolved statements were revisited in a second round.

RESULTS

Consensus was reached on 11 statements, providing evidence-based recommendations. The expert panel advocates for a multilayer watertight technique using barbed sutures to prevent surgical site infections (SSI), reduce complications, shorten surgical times, optimise resources and improve cosmetic appearance. For skin closure, the panel recommends topical adhesives to decrease wound dehiscence, enhance cosmetic appearance, promote patient compliance, prevent SSIs, and optimise resources.

CONCLUSION

The Delphi consensus by Italian total joint arthroplasty experts underscores the pivotal role of barbed sutures and skin adhesives in optimising outcomes. While guiding clinical decision-making, these recommendations are not prescriptive and should be adapted to local practices. The study encourages further research to enhance current evidence.

LEVEL OF EVIDENCE

Level III.

Wound complications are affected by different skin closure methods in primary hip and knee arthroplasty

INTRODUCTION

There is a lack of consensus on optimal skin closure and dressing strategies to reduce early wound complication rates after primary total hip (THA) and total knee arthroplasty (TKA).

METHODS

All 13,271 patients at low risk for wound complications undergoing primary, unilateral THA (7,816) and TKA (5,455) for idiopathic osteoarthritis at our institution between August 2016 and July 2021 were identified. Skin closure, dressing type, and post-operative events related to wound complications were recorded during the first 30 postoperative days.

RESULTS

The need for unscheduled office visits to address wound complications was more frequent after TKA than THA (2.74 vs 1.78%, p<0.001), and after direct-anterior vs. posterior approach THA (2.94 vs 1.39%, p<0.001). Patients who developed a wound complication, had a mean of 2.9 additional office visits. Compared to the use of topical adhesives, skin closure with staples had the highest risk of wound complications (Odds Ratio 1.8 [1.07-3.11], p=0.028). Topical adhesives with polyester mesh had higher rates of allergic contact dermatitis than topical adhesives without mesh (1.4 vs 0.5%, p<0.0001).

DISCUSSION

Wound complications after primary THA and TKA were often self-limited but increased burden on the patient, surgeon, and care team. These data, which suggest different rates of certain complications with different skin closure strategies, can inform a surgeon on optimal closure methods in their practice. Adoption of the skin closure technique with the lowest risk of complications in our hospital would conservatively result in a reduction of 95 unscheduled office visits and save a projected $585,678 annually.

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.

Comparison of Surgical Site Infection After Skin Closure by Prolene or Staples in Bilateral Simultaneous Knee Arthroplasty Patients: A Parallel Design Randomized Controlled Trial Protocol

Introduction:

Knee arthroplasty also known as the total knee replacement is an orthopedic surgical procedure done to resurface the knee that has been severely damaged by arthritis. After the completion of the surgical procedure, the skin closure is done. The optimal goal of skin closure after the procedure is to promote rapid healing and an acceptable cosmetic result while minimizing the risk of infection. Skin closure after knee arthroplasty is done by using either of the two widely used sutures i.e., polypropylene (Prolene) sutures or the skin staple sutures. There are no standard guidelines as which type of the suture should be used. The present study aims to compare the incidence of surgical site infections (superficial and deep) for Prolene vs staple sutures in the bilateral knee arthroplasty patients within 6 weeks for superficial and within 90 days for deep infection.

Methods:

This study will be conducted as an open blinded, parallel design, equivalence randomized controlled trial. The patients would be selected and randomized in 1:1 ratio to receive either of the two interventions i.e., Prolene or Staples. Patients undergoing unilateral or staged total knee replacement (TKR) were excluded.

Analysis:

The normality assessment will be done using Shapiro Wilk test. Cox proportional hazard regression will be used to check the univariate and multi-variable associations of independent variables with the outcome. Both intention to treat analysis and per protocol analysis would be performed.

Ethics and Dissemination:

All the required approvals will be taken from the ethical review committee. Informed consent will be taken form the patient to enroll him/her in the study. Results of the study will be disseminated to the study participants, public health and clinical professionals and would also be published in a reputable international journal.

The trial is registered at clinicaltrials.gov and UIN of the registry is NCT04492852.

Highlights

Octyl-2-cyanoacrylate tissue adhesive without subcuticular suture for wound closure after total hip arthroplasty: a prospective observational study on thirty-two cases with controls for 3 months follow-up

BACKGROUND

Whether using tissue adhesive alone after subcutaneous suture can close the skin incision with safety as well as cosmetic appearance after total hip arthroplasty was not clear.

METHODS

A prospective study was conducted. The same surgical methods were consistent throughout the entire study. After implanting prosthesis, the joint capsule was reconstructed. Fascial and subcutaneous layer were respectively closed by continuous running barbed suture. Patients were randomized allocated to group A with octyl-2-cyanoacrylate tissue adhesive alone, to group B with tissue adhesive after continuous subcuticular suture, or to group C with skin staples. Time of closure, drainage, pain, wound complications, and cosmesis were compared. All data were analyzed statistically.

RESULTS

There was no significant difference in drainage, Visual Analog Scale score or early wound complications between the three groups. However, there was significant difference in time of closure (P = 0.013). In pairwise comparison, time of closure in groups A and B was significantly longer than those in group C (P = 0.001 and P = 0.023, respectively); time of closure in group A was significantly shorter than those in group B (P = 0.003). Patient and Observer Scar Assessment Scale total scores were not significantly different at 6 weeks and 3 months postoperatively (P = 0.078 and P = 0.284, respectively).

CONCLUSION

Tissue adhesive without subcuticular suture was similar with a combination of subcuticular suture and tissue adhesive as well skin staples in terms of safety and cosmetic appearance after total hip arthroplasty.

Skin closure in arthroplasty surgery: Current practice

The study by Smith et al. (2010) concluded that clips are associated with 3 times the infection rate compared with subcuticular sutures in orthopaedic surgery (P = .01).For hip surgery, there was a 4-fold increase. We aimed to determine the trends and influences in skin closure and wound care for hip and knee arthroplasty in the northwest region as well as what would change surgeons' current practice. A short online survey was emailed to consultants in the northwest of England enquiring about their current practice in superficial skin closure, what has influenced this, and finally what would change their practice. Returned surveys were then analysed. A total of 45 consultants responded (response rate of 40.2%). In both hip and knee arthroplasty, clips were the most commonly used superficial skin closure material (53% and 63%, respectively). Personal experience was the greatest influence on the choice of closure material in both hip and knees (84% and 93% respectively). A total of 66% of hip and 76% of knee surgeons would change their closure material if there was evidence to support this. Hip and knee arthroplasty surgeons are influenced by their personal experience, and most use clips as their skin closure method. Most would change their practice with evidence of one material over another. We conclude that there is need for a prospective, well-powered, multi-centre randomised control trial to determine the skin closure material that has the lowest return-to-theatre rate in arthroplasty surgery.