Sutures versus staples for wound closure in orthopaedic surgery: a pilot randomized controlled trial

A Comparative Study of Wound Infections Following Wound Closure Using Staples and Absorbable Sutures Among Obese Patients Undergoing Lumbar Fusion Surgery

Background Infections of the wounds, organs, or spaces that develop following surgery are known as surgical site infections (SSIs). The incidence of wound infections in obese patients undergoing lumbar spine surgery with the use of absorbable sutures versus staples for skin closure has not been studied previously. Materials and methods We conducted a retrospective observational study in our hospital where cases of lumbar spine surgery meeting the inclusion criteria were chosen retrospectively from March 2021 to March 2023. A total of 40 patients aged >18 years and <75 years who underwent lumbar spine surgery were covered by this investigation. Two cohorts with 20 patients in each were chosen from the population. Group A used a skin stapler to close wounds, whereas group B used absorbable sutures. The number of wound infections was the main result. Using SPSS version 23.0 (IBM SPSS Statistics, Armonk, NY), all data were analyzed after being entered into an Excel sheet (Microsoft Corp., Redmond, WA). Results A total of 40 participants were included in this study, and it revealed that there was no discernible variation in the groups' mean age or gender distribution. There is a significantly higher incidence of SSI in the absorbable suture group (35%) compared to the staple group (15%). The mean duration in days for the development of SSI in the absorbable suture group (9.86±2.12) was early compared to the staple group (12.67±2.08), which was statistically significant (p<0.05). Conclusion Compared to absorbable sutures, the current study showed a decreased incidence of surgical site infection in obese individuals receiving skin staples for wound closure.

Optimal Method of Skin Wound Management for Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Skin closure for total knee arthroplasty (TKA) typically focuses on promoting optimal healing, while preventing wound complications and infection, allowing for functionality and immediate ambulation, and providing for excellent cosmesis. In this systematic review and meta-analysis of the literature, we will focus on closure of the skin. Specifically, we assessed: (1) wound complication risk of different techniques and (2) closing time of different sutures/techniques. There were 20 reports on infection risk and closing time. Meta-analyses focused on the qualifying studies for closing time and wound complication risk reports were also performed. These studies (378 patients) demonstrated overall lower wound complication risks with the use of barbed compared with traditional sutures (3% vs. 6%, p < 0.05). The subsequent meta-analysis included 749 patients demonstrating overall significant closing time reductions of a mean of 7 minutes with the use of barbed sutures (p < 0.05). Therefore, multiple recent reports suggest superior outcomes and faster results when using barbed sutures for TKA skin closure.

Effect of suture closure and staple closure on postoperative wound complications in patients undergoing knee replacement surgery: A meta-analysis

The purpose of this meta-analysis is to determine if the application of stitching in the closed area of the knee arthroplasty remains significantly superior to that of the staples. Data sources: EMBASE, Cochrane Libraryand, publications, and the Web of Science. Patients were treated with staples for closure of their wounds, or with conventional stitches for closure of wounds. The main findings were surgical site infection, wound dehiscence, and cutting time. The secondary results were the time to completion, the duration of the hospitalization, and the time to discharge. We incorporated the SIX trial into the meta-analyses with Review Manager V.5.3. The hazard ratio was computed as a therapeutic outcome with respect to the heterogeneity. For more than 50% of heterogeneous samples, we employed a stochastic effect model. The results showed that there was no significant difference in the degree of infection, the degree of dehiscence, the length of the cut and the degree of satisfaction of the wound. But the time to close the wound and the time to operate were significantly different. The time needed to close the wound was shorter than that of the suture (OR, -227. 22; 95% CI, -238. 74, -215. 69 p < 0. 0001); The time taken to replace the knee was also significantly lower among those who had been stapled sutures (OR, -5.46; 95% CI, -10. 43, -0.49 p = 0. 03). Wound closing materials are an afterthought for many orthopaedic surgeons. Together, the findings from a number of comparative studies indicate that the selection of wound closure materials might affect the outcome of the surgery. The evidence, however, is weak because of the heterogeneous approach adopted in earlier research. This study program is intended to provide guidance on how to select the best wound closure material for the purpose of identifying if there is any difference in the incidence of injuries among traditional stitches and staples.

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.

Occlusive wound closure prevents prolonged wound discharge-A randomised controlled trial in patients undergoing tumour resection and endoprosthetic reconstruction of the proximal femur because of metastatic bone disease

Prolonged wound discharge is a common postoperative complication of orthopaedic procedures and a risk factor for implant-related infection. Occlusive wound closure methods have previously been suggested to reduce or even prevent this complication. We performed a randomised controlled trial on 70 patients who underwent surgical treatment for metastatic bone disease involving the proximal femur at our centre between January 2017 and August 2018. At conclusion of the tumour resection and endoprosthetic reconstruction procedure, patients were randomised to either occlusive wound closure (n = 35), using the Dermabond Prineo-22 skin closure system, or routine wound closure with conventional skin staples (n = 35). Skin closure with occlusive wound closure resulted in a lesser degree (P < .0001) and shorter duration of postoperative wound discharge (HR 2.89 [95% CI 1.6-5.05], P < .0018). Compared with staples, surgical wounds were already dry after a mean of 3.5 days [95% CI 3.2-3.9] versus 6.1 days [95% CI 4.8-7.3] (P < .0001). Prolonged wound discharge for 7 days or more was observed in 23% of patients (n = 8) in the Staples-group but was entirely absent in the occlusive wound closure group (P < .003). This study provides strong evidence that occlusive wound closure reduces frequency, degree, and duration of wound discharge in a patient population at particularly high risk for this complication.

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.

Wound Management following Total Knee Arthroplasty: An Updated Review

Optimal wound closure techniques following total knee arthroplasty (TKA) have focused on enhancing healing potential, preventing infection, yielding satisfactory cosmesis, and allowing early ambulation and functionality. An appropriate layered closure and management of the TKA typically involves addressing the (1) deep fascial layer; (2) subdermal layer; (3) intradermal layer, including the subcuticular region; and (4) final application of a specific aseptic dressing, each of which are covered here in detail. This focused critical review of the literature discusses traditional techniques used in all layers of wound closure following TKA while introducing several emerging popular techniques. For example, absorbable barbed skin sutures and occlusive dressings have the potential to reduce operative time, limit the need for early postoperative visits, obviate the need for suture or staple removal, and safely promote patient communication via telemedicine. As novel wound closure techniques continue to emerge and traditional approaches are improved upon, future comparative studies will assist in elucidating the key advantages of various options. In an extremely important field that has tremendous variability, these efforts may enable the reaching of a classically elusive standard of care for these techniques.

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.

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.

Effect of Wound Closure Technique in Proximal Femoral Fractures: A Prospective Cohort Study

OBJECTIVES

To compare the effect of different wound closure techniques on wound drainage, postoperative length of stay, and complications in patients with proximal femoral fractures, including femoral neck fractures (31A fractures) and peritrochanteric fractures (31B fractures).

DESIGN

Prospective cohort study.

SETTING

Footscray Hospital, Western Health, Victoria, Australia; an acute teaching hospital.

PATIENTS AND PARTICIPANTS

All inpatients receiving surgery for proximal femoral fractures at our facility between May 2016 and August 2017. A total of 486 consecutive patients who presented during the study period were included in the study.

INTERVENTION

Three cohorts of consecutive patients were assigned to use either skin staples, monofilament absorbable subcuticular sutures (Monocryl), or, sutures with the addition of 2-octylcyanoacrylate (OCA) (Monocryl and Dermabond), respectively, for skin closure according to when the patients entered the study.

MAIN OUTCOME MEASUREMENTS

The primary outcome of interest was prolonged wound drainage measured using a standardized technique after postoperative day 3. Secondary outcomes included inpatient length of stay and overall complications.

RESULTS

We found a statistically significant increase in prolonged wound drainage in the staples cohort compared with the subcuticular sutures cohort and the sutures and OCA cohort (21.1% vs. 8.5% vs. 4.4%, P < 0.001). Inpatient length of stay was also significantly increased in the staples cohort (5.83 days vs. 4.78 days vs. 5.5 days, P = 0.005). There were no statistically significant differences between the 3 cohorts when comparing incidence of any medical complications, withholding of thromboprophylactic agents, or usage of topical negative pressure dressings.

CONCLUSIONS

In patients with proximal femoral fractures, closure with staples has the highest rate of prolonged wound drainage and length of stay. Subcuticular sutures in combination with OCA result in the lowest incidence of prolonged wound drainage.

LEVEL OF EVIDENCE

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

Surgical wound closure by staples or sutures?: Systematic review

AIM

To compare the effects of sutures and staples for skin closure of surgical wounds.

MATERIAL AND METHODS

We included published and unpublished randomized controlled trials (RCTs) and cluster-randomized trials comparing staples with sutures. Patients were adults (aged 18 years or over) who had undergone any type of surgery. The primary outcomes were risk of overall and severe wound infection. Secondary outcomes included length of hospital stay, readmission rate, adverse events, patient satisfaction with cosmetic results, postoperative pain.

RESULTS

Forty-two very low to low quality RCTs with a total of 11,067 patients were included. Sutures resulted in slightly fewer overall wound infections (4.90%) compared to staples (6.75%) but it is uncertain whether there is a difference between the groups (risk ratio [RR] 1.20, 95% confidence intervals [CI] 0.80-1.79; patients = 9864; studies = 34; I = 70%). The evidence was also insufficient to state a difference in terms of severe wound infection (staples 1.4% vs sutures 1.3%; RR 1.08, 95% CI 0.61-1.89; patients = 3036; studies = 17; I = 0%), grade of satisfaction (RR 0.99, 95% CI 0.91-1.07; patients = 3243; studies = 14; I = 67%) and hospital stay. Staples may increase the risk of adverse events (7.3% for staples vs 3.5% for sutures; RR 2.00, 95% CI 1.44-2.79; patients = 6246; studies = 21; I = 33%), readmission rate (RR 1.28, 95% CI 0.18-9.05; patients = 2466; studies = 5; I = 66%) and postoperative pain (standardized mean difference [SMD] 0.41,95%CI -0.35 to 1.16; I = 88%, patients = 390 patients, studies = 5).

CONCLUSIONS

Due to the lack of high quality evidence, we could not state if sutures are better than staples in terms of wound infection, readmission rate, adverse events, and postoperative pain. With a low quality of evidence, sutures reduce postoperative pain and improve grade of satisfaction with the cosmetic outcome.

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.

Wound closure and follow-up after total knee arthroplasty - Do they affect the rate of antibiotic prescription?

BACKGROUND

This study aimed to evaluate risk factors for oral antibiotic prescription in the first six weeks after primary TKA, particularly whether the wound closure method (staples or sutures) and two-week follow-up clinician (surgeon or general practitioner (GP)) altered antibiotic use.

METHODS

Four thousand eight hundred forty-six TKAs from January 2013 to December 2016 at three tertiary hospitals in Auckland, New Zealand were analysed by manual review of patient electronic records and a national prescription database. Surgeon preference dictates the method of wound closure and whether wound review is followed up by the operating surgeon or by the patient's GP. Univariate and multivariate analysis was carried out to identify significant patient and surgical risk factors for oral antibiotic prescribing.

RESULTS

Oral antibiotics were prescribed in 24% of patients following primary TKA. Twenty-six percent of patients closed with staples were prescribed oral antibiotics versus 19% with sutures (adjusted OR = 1.4, p < 0.004). Excluding re-presentations and readmissions, GPs prescribed oral antibiotics in 22% of patients compared to seven percent of patients seen by surgeons (adjusted OR = 2.8, p < 0.001). Other risk factors for antibiotic prescription included increasing age, BMI and ASA score.

CONCLUSION

Oral antibiotic prescribing rates are higher if the wound was closed with staples and if a GP performed the two-week follow-up. Improved communication between surgeons and GPs are required to ensure adequate follow-up following TKA and appropriate oral antibiotic use.

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.

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

BACKGROUND

Two previous meta-analyses comparing staples versus sutures have led to conflicting relative risks for surgical site infection between skin closure methods after orthopaedic surgery. Consequently, the choice of sutures or staples for skin closure continues to be a subject of conversation. Recently, additional randomized trials have been published, and an updated meta-analysis is needed to inform this debate.

QUESTIONS/PURPOSES

To determine using a meta-analysis of randomized trials (1) whether there is a difference in surgical site infection (SSI) between staples and sutures for skin closure after orthopaedic surgery, and (2) whether that finding remains the same when the analysis is limited to randomized trials with a low risk of bias.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) comparing staples with sutures for skin closure after orthopaedic surgery was conducted. We excluded barbed sutures, surgical zippers, and skin adhesives from this meta-analysis. Medline, Embase, CINAHL, Cochrane Library, and Global Index Medicus were searched from date of inception to October 18, 2017. The sole outcome of interest was SSI as defined by the original study authors, with preference given to Center for Disease Control and Prevention (CDC) definitions whenever possible, recognizing that this may result in the pooling of more common minor events with rarer, more severe events, and in so doing, overestimate between-group differences. Because of this, subgroup analysis was planned based on severity of infection. Relative risk was calculated using a random-effects model (relative risk [RR], 95% confidence interval [CI]). Heterogeneity was estimated using I. Publication bias was explored using visual inspection of the funnel plot and Egger's test. Subgroup analysis was planned for type of orthopaedic surgery, suture material, SSI category, and country development index. Subgroup interaction p values were calculated. The Cochrane risk of bias tool was used to assess study quality. Sensitivity analysis was planned to assess whether the results changed when the analysis was limited to studies with low risk of bias. In total, 17 RCTs (2446 patients) were eligible, of which five RCTs (501 patients) were at low risk of bias.

RESULTS

In the primary analysis, patients randomized to staples had a higher risk of SSI versus those who received sutures for skin closure (RR, 2.05; 95% CI,1.38-3.06; I = 0%). However, most of the events were driven by superficial SSI, and only two deep infections were explicitly reported in total (one in each group). After a post-hoc sensitivity analysis excluded a highly influential trial with high risk of bias, the results were highly fragile, relying on a difference of only four additional events in the staples group. When we limited the analysis to RCTs with low risk of bias, no difference was found between sutures and staples in terms of SSI (RR, 1.45; 95% CI, 0.31-6.79; I = 46%). Effect sizes were consistent across subgroups (p value for subgroup interaction was not significant for elective versus trauma; hip versus knee arthroplasty; suture material; high versus middle- versus low-income settings).

CONCLUSIONS

Even in this relatively large meta-analysis, existing RCTs do not provide definitive evidence of a difference in SSI risk when staples are used instead of sutures for skin closure after orthopaedic surgery. Currently, the total body of evidence remains weak and, even when limiting to only low risk of bias studies, it is not possible to rule in or rule out clinically important differences between staples and sutures. Until randomized studies of adequate power and followup duration are performed to definitively inform this issue, the choice between staples versus sutures should be based on other factors such as local availability, surgeon preference, and cost.

LEVEL OF EVIDENCE

Level I, therapeutic study.

The use of absorbable staples for skin closure after tibial plateau leveling osteotomy

OBJECTIVE

To compare the use of stainless steel staples with absorbable staples for closure of skin incisions in dogs undergoing tibial plateau leveling osteotomy (TPLO).

STUDY DESIGN

Prospective study.

SAMPLE POPULATION

Client-owned dogs (n = 80).

METHODS

With client consent, dogs were randomly assigned a staple type (stainless steel or absorbable) immediately prior to closure of a TPLO skin incision. Incisions were compared for length, staple type and number, and an inflammation-infection score 2 weeks after surgery.

RESULTS

Overall, 18.8% of incisions were diagnosed with inflammation or infection. No difference was found between inflammation-infection scores, incision length, number of staples used, or general anesthetic time between the 2 staple groups. However, wound closure was faster with stainless steel staples (22.50 seconds; range, 11-180) by approximately 30 seconds compared with absorbable staples (56.50 seconds; range, 18-190; P < .001). Time taken to close the incision correlated negatively with the number of occasions that absorbable staples were used (P = .01).

CONCLUSION

Absorbable skin staples were successfully used to close skin incisions after TPLO and were not associated with an increased level of inflammation or infection in our clinical setting.

CLINICAL SIGNIFICANCE

Absorbable staples may be considered to close surgical wounds when subsequent suture removal would be impractical, without specific concerns over inflammation or infection of the wound.

Inorganic Nanomaterials for Soft Tissue Repair and Regeneration

Inorganic nanomaterials have witnessed significant advances in areas of medicine including cancer therapy, imaging, and drug delivery, but their use in soft tissue repair and regeneration is in its infancy. Metallic, ceramic, and carbon allotrope nanoparticles have shown promise in facilitating tissue repair and regeneration. Inorganic nanomaterials have been employed to improve stem cell engraftment in cellular therapy, material mechanical stability in tissue repair, electrical conductivity in nerve and cardiac regeneration, adhesion strength in tissue approximation, and antibacterial capacity in wound dressings. These nanomaterials have also been used to improve or replace common surgical materials and restore functionality to damaged tissue. We provide a comprehensive overview of inorganic nanomaterials in tissue repair and regeneration, and discuss their promise and limitations for eventual translation to the clinic.

Complication rate of different wound closures after primary hip arthroplasty - A survey of 373 patients

BACKGROUND

Wound closure is highly associated with wound complications and the best wound closure method was controversial in total hip arthroplasty.

METHODS

We performed a retrospective study of primary hip arthroplasty and compared three types of closure method.

RESULTS

155 cases were closed using continuous subcuticular sutures then with staples, 111 using staples, 141 using interrupted sutures. 28 cases of wound complications occurred. Wound complication rates in subcuticular suture group, staple group and interrupted suture group were 1.9%, 11.7% and 8.5%, respectively (p < 0.01).

CONCLUSION

Wound complication rate was significantly lower when wound was closed with continuous subcuticular suturue.

A prospective randomised comparison of 2 skin closure techniques in primary total hip arthroplasty surgery

INTRODUCTION

As an essential step of total hip arthroplasty (THA), an effective and secure skin closure technique after primary THA is important. Metallic staples closure and subcuticular suture are the 2 common techniques for skin closure. However, which closure technique is the optimal skin-closure method remains unclear. The purpose of this prospective randomised clinical study was to compare the clinical outcomes and costs between staples and subcuticular suture techniques.

METHODS

In this clinical study, 165 patients who underwent primary unilateral THA through a posterolateral approach from August 2014 to May 2015 were included. According to skin closure technique, the patients were randomised into staples group (interrupted suture with staples, 83 cases) and sutures group (running 4-0 absorbable subcuticular suture, 82 cases). The same operative and perioperative care were provided to all patients. The surgical site infections (SSIs) rate, closure time, time to dry wounds and postoperative hospital stay were recorded and compared. Besides, cosmetic results and patient's satisfaction were evaluated with Hollander wound evaluation score (HWES) and VAS score at postoperative 3 months follow-up respectively. Relative total costs were recorded as well.

RESULTS

It was shown that no infections developed in sutures group, while 2 postoperative superficial infections (2.4%) occurred in the staples group. There was a statistically significant difference in the time to dry surgical incisions and postoperative hospital stay favoring sutures (4.8 vs. 5.0 days, p = 0.028; 6.0 vs. 12.0 days, p<0.001, respectively). The cutaneous incision closure using staples consumed significantly less time than that with subcuticular suture (24.7 vs. 357.7 seconds, p<0.001). Moreover, there was no significant difference in HWES and patient's satisfaction between the 2 groups. Finally, the application of subcuticular suture saved an average of $82.2 per case.

CONCLUSIONS

Closure with running subcuticular suture is cheaper and appears to have a clinical advantage when compared with metallic staples skin closure in primary THA surgery. However, additional operating time may be incurred.

Topical anesthesia for staple removal from surgical wounds on the knee: a prospective, double-blind, randomized trial

BACKGROUND

Staple removal from surgical wounds is painful. Only a few articles have provided expert opinions using anesthetic cream for such a problem; however, direct application of the anesthetic cream to a wound may cause infection. A safe alternative can be an anesthetic patch without wound contact.

MATERIALS AND METHODS

This was a prospective, double-blind, randomized clinical trial. Sixty patients who underwent primary total knee replacement were assigned to an experimental group or control group. One lidocaine patch was applied around the surgical wound for each patient in the experimental group. Alternatively, the adhesive sides of the lidocaine patches were shielded with waterproof films in the control group. A resident peeled off the patch before a single nursing practitioner removed the staples. Pain was assessed with the 10-cm visual analog scale, and a face pain scale-revised was performed. The patients and the nursing practitioner were blind to the management.

RESULTS

Mean visual analog scale and face pain scale-revised scores were significantly lower in the experimental group. The mean pain score was significantly lower in the experimental group if the application time was >47 min; for patients with application time of 47 min or shorter, the score was comparable with the mean pain scores of the control group (P = 0.215).

CONCLUSIONS

Removal of the metal skin staples after total knee arthroplasty is associated with moderate-to-severe pain. The lidocaine patch applied topically around the surgical wound could effectively reduce the pain during the procedure, without remarkable complications such as systemic adverse effects or wound contamination.

Cardiac Device Implant Skin Closure with a Novel Adjustable, Coaptive Tape-Based Device

BACKGROUND

The purpose of this study was to compare a unique zip-type adjustable coaptive tape-based skin closure device to traditional subcuticular sutures in three domains: time, cosmesis, and wound closure-related outcomes in cardiac implantable electronic device (CIED) procedures.

METHODS

A total of 40 patients were enrolled in a prospective randomized controlled trial to assess time to wound closure, as well as cosmesis and wound closure-related outcomes.

RESULTS

The adjustable coaptive tape-based skin closure device had shorter overall closure time (78 ± 6.6 seconds vs 216 ± 21.5 seconds; P < 0.001) and mean closure time per centimeter (18.0 ± 2.0 s/cm vs 50.1 ± 6.7 s/cm; P < 0.001) versus sutures, with less intersurgeon and interpatient variability with the use of adjustable coaptive device versus sutures (P < 0.001). There was no difference between groups in postoperative pain or scar cosmesis during the follow-up period. Neither group had any closure-related adverse events.

CONCLUSIONS

The adjustable coaptive tape-based skin closure device demonstrated shorter closure times with less variability when compared to sutures. It is a safe and acceptable alternative to sutures for skin closure following CIED implantation.

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.

Comparing sutures versus staples for skin closure after orthopaedic surgery: systematic review and meta-analysis

OBJECTIVE

To determine whether there still remains a significant advantage in the use of sutures to staples for orthopaedic skin closure in adult patients.

DESIGN

Systematic Review/ Meta-Analysis.

DATA SOURCES

MEDLINE-OVID, EMBASE-OVID, CINAHL and Cochrane Library. Grey and unpublished literature was also explored by searching: International Clinical Trial Registry, Grey Matters BIOSIS Previews, Networked Digital Library of Theses and Dissertations, ClinicalTrials.gov, UK Clinical Trials Gateway, UK Clinical Research Network Study Portfolio, Open Grey, Grey Literature Report, and Web of Science.

SELECTION CRITERIA

Articles were from any country, written in English and published after 1950. We included all randomised control trials and observational studies comparing adults (≥ 18 years) undergoing orthopaedic surgery who either received staples or sutures for skin closure. The primary outcome was the incidence of surgical site infection. Secondary outcomes included closure time, inflammation, length of stay, pain, abscess formation, necrosis, discharge, wound dehiscence, allergic reaction and health-related quality of life.

RESULTS

13 studies were included in our cumulative meta-analysis conducted using Review Manager V.5.0. The risk ratio was computed as a measure of the treatment effect taking into account heterogeneity. Random-effect models were applied. There was no significant difference in infection comparing sutures to staples. The cumulative relative risk was 1.06 (0.46 to 2.44). In addition, there was no difference in infection comparing sutures to staples in hip and knee surgery, respectively. Lastly, except for closure time, there was no significant difference in secondary outcomes comparing sutures to staples.

CONCLUSIONS

Except for closure time, there was no significant difference in superficial infection and secondary outcomes comparing sutures to staples was found. Given that there may in fact be no difference in effect between the two skin closure and the methodological limitations of included studies, authors should begin to consider the economic and logistic implications of using staples or sutures for skin closure.

PROSPERO REGISTRATION NUMBER

CRD42015017481.

Effects of incision closure method on infection prevalence following tibial plateau leveling osteotomy in dogs

The goal of this study was to retrospectively investigate the effect of incisional closure with either stainless steel skin staples or intradermal poliglecaprone 25 on the prevalence of surgical site infection following tibial plateau leveling osteotomy in dogs. Medical records were reviewed for dogs treated with unilateral tibial plateau leveling osteotomy at Memphis Veterinary Specialists between 2006 and 2013. Procedures (n = 306) from 242 dogs were included in the study. The association of potential risk factors with the occurrence of postoperative infection was assessed using logistic regression. A value of P < 0.05 was considered significant. Weight and administration of postoperative antimicrobials were found to significantly influence surgical site infection prevalence. No significant association was noted between closure method and prevalence of postoperative infection.

Outcomes of staple closure of the donor area during hair transplant by follicular unit transfer

Background:

Donor area closure in hair transplantation by follicular unit transfer (FUT) is being done by various techniques. This study aims to assess the outcomes of staple closure for donor area in FUT.

Aim:

To study the outcome, efficacy and complications of staples in donor area closure for FUT.

Materials and Methods:

A total of 50 consecutive patients who underwent staple closure for donor area in FUT were included in the study and their data were collected retrospectively. Patients were followed up one year after the surgery and photographic documentation of the scar at the donor site was done. Objective measurement of the width of the scar was done for all the patients.

Results:

The average length of the donor area was 22 cm. The average width of the scar was 1.82 mm. There was no infection or tissue necrosis at the staple closure site in any of the patients.

Conclusion:

Staple closure resulted in cosmetically acceptable scar, but post operative discomfort was the major limitation. The potential to conserve the hair follicles along the line of closure makes using staples worthwhile if conservation of follicles is the goal.

A prospective randomized comparison of two skin closure techniques in acetabular fracture surgery

Background

Recent publications have shown an infection rate of 5–7 % for acetabular fractures treated with the Kocher-Langenbeck (K-L) approach. Using metallic staples to close hip skin incisions has been considered the gold standard. The purpose of this study was to answer the following: (1) will closure of a K-L incision after acetabular fracture surgery with a running subcuticular monocryl suture, then sealing the wound with 2-octyl cyanoacrylate (OCA), result in a lower infection rate compared to metallic staple closure? (2) Do incisions closed with subcuticular monocryl and OCA exhibit decreased drainage? (3) Is there a cost difference between these two methods?

Materials and methods

In a prospective clinical study, 103 patients with acetabular fractures treated using the K-L approach were randomized into two groups: skin closure with metallic staples (n = 52) versus subcuticular running monocryl suture sealed with OCA (n = 51).

Results

Two postoperative deep infections (4 %) in the staples group required multiple debridements; no infections developed in the OCA group. However, there was no statistical difference between the groups, (p = 0.495). There was a statistically significant difference (p = 0.032) comparing days from surgery to a dry incision favoring OCA (4.2 versus 5.85 days). The patient charge was approximately $900 greater on average in the OCA group due to the increased time in the operating room required for the subcuticular closure.

Conclusions

Closure with OCA and subcuticular monocryl showed no clinical disadvantages and appears to have a clinical advantage when compared to standard metallic staple skin closure in acetabular fracture surgery. However, additional patient costs may be incurred.

Level of evidence

II.