A comparison of three methods of wound closure following arthroplasty

Comparison of 2-octyl cyanoacrylate with polyester mesh with standard suture and staples in total knee and hip arthroplasty

OBJECTIVE

The use of 2-octyl cyanoacrylate with polyester mesh (OCA-M) has become common in total hip and knee arthroplasty (THA, TKA). We aimed to compare the safety and cosmetic outcomes between OCA-M and standard suture techniques and staples, and determine whether OCA-M can safely be used for TKA.

METHOD

Inclusion criteria were patients who underwent THA or TKA from January 2010 to October 2011 (Suture group), November 2011 to August 2013 (Staple group), March 2017 to September 2018 (OCA-M group). Exclusion criteria was loss of imaging data. Complications during hospitalisation (early complication) and after discharge (late complication) were compared in groups. Plastic and orthopaedic surgeons performed cosmetic evaluations with the modified Vancouver Scar Scale (VSS) and Likert scale at three and six months postoperatively and compared in groups.

RESULTS

A total of 249 arthroplasties (suture group=88 patients; staple group=94 patients; OCA-M group=67 patients) were included in the study. The OCA-M group had a significantly lower early complication rate than the suture group (p=0.015). For THA, the OCA-M group had a significantly lower total complication rate than the suture group (p=0.048). For TKA, there was no significant difference among the three groups. The complication rate in the OCA-M group showed no significant difference between THA/TKA. With regards to the VSS, the OCA-M group was significantly better for cosmetic qualities than the suture group (p=<0.001, p=0.021 at three and six months, respectively). For the Likert scale, the OCA-M group was also significantly better for cosmetic qualities than the suture group and staple group (suture-OCA-M, p=0.003 (three months), p=<0.001 (six months); staple-OCA-M, p=0.027 (three months)).

CONCLUSION

In this study, the OCA-M complication rate was low compared to suturing and similar to stapling. Moreover, better cosmetic outcomes were achieved compared to suturing and stapling.

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.

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.

Subjective scar assessment scales in orthopaedic surgery and determinants of patient satisfaction: A systematic review of the literature

PURPOSE

Scar assessment tools can be utilized during the post-operative period to monitor scar progress. The primary aim of this systematic review was to evaluate current subjective scar assessment scales utilized in orthopaedic surgery. The secondary aim was to identify determinants of patients' satisfaction with their scars and evaluate current measurement scales.

METHODS

The preferred reporting items for systematic reviews and meta-analyses checklist was followed. Electronic databases, currently registered studies, conference proceedings and the reference lists of included studies were searched. There were no constraints based on language or publication status. A narrative synthesis provided a description and evaluation of scales utilized in orthopaedic surgery. Determinants of patient satisfaction were identified along with the scales used to measure satisfaction.

RESULTS

A total of 6059 records were screened in the initial search. Twenty-six articles satisfied the inclusion criteria, assessing 7130 patients. In the literature, six validated subjective scar scales were identified, including the Vancouver scar scale, patient and observer scar assessment scale, Manchester scar scale, Stony Brook scar evaluation scale, visual analogue scale, and Hollander wound evaluation scale. Studies utilizing these scales to evaluate scars following orthopaedic procedures did so successfully. These were total hip arthroplasty, total knee arthroplasty, and limb reconstruction. The scales demonstrated satisfactory validity. Functional outcomes such as restoration of movement ranked among patients' highest concerns. Scar cosmesis was found to be amongst patients' lowest priorities.

CONCLUSIONS

Subjective scar assessment scales identified in the literature were not designed specifically for orthopaedic surgery. However, these were able to appropriately assess scars in the studies identified in this review. Current evidence suggests the effect of scar cosmesis on patient satisfaction with orthopaedic procedures is limited.

No Difference in the Rate of Periprosthetic Joint Infection in Patients Undergoing the Posterolateral Compared to the Direct Anterior Approach

BACKGROUND

There remains inconsistent data about the association of surgical approach and periprosthetic joint infection (PJI). We sought to evaluate the risk of reoperation for superficial infection and PJI after primary total hip arthroplasty (THA) in a multivariate model.

METHODS

We reviewed 16,500 primary THAs, collecting data on surgical approach and all reoperations within 1 year for superficial infection (n = 36) or PJI (n = 70). Considering superficial infection and PJI separately, we used Kaplan-Meier survivorship to assess survival free from reoperation and a Cox Proportional Hazards multivariate models to assess risk factors for reoperation.

RESULTS

Between direct anterior approach (DAA) (N = 3,351) and PLA (N = 13,149) cohorts, rates of superficial infection (0.4 versus 0.2%) and PJI (0.3 versus 0.5%) were low and survivorship free from reoperation for superficial infection (99.6 versus 99.8%) and PJI (99.4 versus 99.7%) were excellent at both 1 and 2 years. The risk of developing superficial infection increased with high body mass index (BMI) (hazard ratio [HR] = 1.1 per unit increase, P = .003), DAA (HR = 2.7, P = .01), and smoking status (HR = 2.9, P = .03). The risk of developing PJI increased with the high BMI (HR = 1.04, P = .03), but not surgical approach (HR = 0.68, P = .3).

CONCLUSION

In this study of 16,500 primary THAs, DAA was independently associated with an elevated risk of superficial infection reoperation compared to the PLA, but there was no association between surgical approach and PJI. An elevated patient BMI was the strongest risk factor for superficial infection and PJI in our cohort.

LEVEL OF EVIDENCE

III, retrospective cohort study.

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 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.

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.

Evaluation of Incisional Wound Healing in Dogs after Closure with Staples or Tissue Glue and Comparison to Intradermal Suture Pattern

The study aimed to monitor the healing process in the canine skin following surgical incision and closure using staples or tissue glue and to compare them with the intradermal suture pattern. Surgically created skin incisions in 10 dogs were apposed with staples, tissue glue (n-butyl cyanoacrylate) and continuous intradermal pattern. The cosmetic appearance of the wounds was blindly evaluated on days 7, 14 and 28 and once a month until the end of the experiment, i.e., one year after the incision. Ultrasonographic and clinical evaluation was performed on days 0-10, 12, 14, 16, 18, 21, 24 and 28, once a week until the end of the 3rd month and once a month until the end of the experiment. Histopathological evaluation was performed on days 7, 14, 28, 180 and 365. The median time required for the performance of each technique differed significantly between techniques; stapling lasted 21 s, glue 2 min 16 s and intradermal 15 min 37 s. Cosmetic appearance with glue was statistically worse than staples and intradermal. The clinical appearance of intradermal was significantly better than glue and staples. No significant differences were found at histological evaluation; however, glue had the worst score throughout the experiment. The overall evaluation of the techniques showed that glue had the worst score compared to intradermal and staples, with the difference being statistically significant in the first postoperative week. Intradermal suture pattern is much better than glue application for skin closure in dogs, whilst is not significantly better than staples. Staples should be preferred when time is an important factor.

Combination of Spirulina platensis, Ganoderma lucidum and Moringa oleifera Improves Cardiac Functions and Reduces Pro-Inflammatory Biomarkers in Preclinical Models of Short-Term Doxorubicin-Mediated Cardiotoxicity: New Frontiers in Cardioncology?

Anthracyclines are essential adjuvant therapies for a variety of cancers, particularly breast, gastric and esophageal cancers. Whilst prolonging cancer-related survival, these agents can induce drug-related cardiotoxicity. Spirulina, Reishi (Ganoderma lucidum) and Moringa are three nutraceuticals with anti-inflammatory effects that are currently used in cancer patients as complementary and alternative medicines to improve quality of life and fatigue. We hypothesize that the nutraceutical combination of Spirulina, Reishi and Moringa (Singo) could reduce inflammation and cardiotoxicity induced by anthracyclines. Female C57Bl/6 mice were untreated (Sham, n = 6) or treated for 7 days with short-term doxorubicin (DOXO, n = 6) or Singo (Singo, n = 6), or pre-treated with Singo for 3 days and associated with DOXO for remaining 7 days (DOXO−Singo, n = 6). The ejection fraction and radial and longitudinal strain were analyzed through transthoracic echocardiography (Vevo 2100, Fujifilm, Tokyo, Japan). The myocardial expressions of NLRP3, DAMPs (galectin-3 and calgranulin S100) and 13 cytokines were quantified through selective mouse ELISA methods. Myocardial fibrosis, necrosis and hypertrophy were analyzed through immunohistochemistry (IHC). Human cardiomyocytes were exposed to DOXO (200 nM) alone or in combination with Singo (at 10, 25 and 50 µg/mL) for 24 and 48 h. Cell viability and inflammation studies were also performed. In preclinical models, Singo significantly improved ejection fraction and fractional shortening. Reduced expressions of myocardial NLRP3 and NF-kB levels in cardiac tissues were seen in DOXO−Singo mice vs. DOXO (p < 0.05). The myocardial levels of calgranulin S100 and galectin-3 were strongly reduced in DOXO−Singo mice vs. DOXO (p < 0.05). Immunohistochemistry analysis indicates that Singo reduces fibrosis and hypertrophy in the myocardial tissues of mice during exposure to DOXO. In conclusion, in the preclinical model of DOXO-induced cardiotoxicity, Singo is able to improve cardiac function and reduce biomarkers involved in heart failure and fibrosis.

A Comparative Study Between Conventional Sutures, Staples, and Adhesive Glue for Clean Elective Surgical Skin Closure

As long as medicine has subsisted, wound closure has existed. When assessing a surgical wound, physicians are more than ever confronted with various sutures and other closure materials. The surgeon must choose the most appropriate material for that specific closure because not one substance is perfect in all circumstances. The history of suturing wounds is intertwined with the history of surgery. Wound suturing is a critical component of wound therapy, including suturing materials and techniques. Suturing has been practiced for thousands of years. Although suture materials and techniques have changed, the goals like closing dead space, supporting and strengthening wounds until healing increases their tensile strength, approximating skin edges for an aesthetically pleasing and functional result, and reducing the risk of bleeding and infection remain the same. Traditional skin closure with sutures requires time and effort, creates an unsightly scar, and requires infection removal. In this modern era, patients find it appealing when the operated location has a decent cosmetic appearance. The quicker, more comfortable, and most aesthetically pleasing method of skin closure is what surgeons are searching for. Assessing whether newer methods are superior to sutures and staples is necessary. Better cosmesis, flexibility, water resistance, painless sealed skin closure, and ease of application are all advantages of 2-octyl cyanoacrylate. This article aims to provide an overview of the critical characteristics of traditional sutures, common suture materials, sticky glue, and staples, as well as additional closure materials.

Comparing Dermabond PRINEO versus Dermabond or staples for wound closure: a randomized control trial following total shoulder arthroplasty

BACKGROUND

The method of surgical incision closure after total shoulder arthroplasty is an important factor to consider, as it affects operating room time, procedure cost, cosmetic outcomes, and patient satisfaction. The optimal method of wound management is unknown, but should be cost-effective, reproducible, and provide a reliable clinical result. This study aimed to compare the following wound closure methods after total shoulder arthroplasty: staples, Dermabond, and Dermabond PRINEO. We hypothesized that wound closure time for Dermabond PRINEO would be faster than Dermabond and comparable to that of staples, and Dermabond PRINEO would be more cost-effective than Dermabond and staples, and provide equal or superior closure outcomes to Dermabond and staples.

METHODS

A randomized, prospective clinical trial comparing wound closure time and cost for 2 surgeons' traditional technique with that of Dermabond PRINEO was conducted. This study included at least 18 subjects in each group. Surgeon 1's patients were randomized to traditional Dermabond or Dermabond PRINEO, whereas surgeon 2's patients were randomized to staples or Dermabond PRINEO. Cosmetic outcomes and satisfaction scores were collected at 6 weeks and 3 months, postoperatively. Incisions were photographed, at both the 6-week and 3-month visits, and subsequently evaluated by a plastic surgeon blinded to the treatment method.

RESULTS

The wound closure time for surgeon 1 was significantly faster for Dermabond PRINEO vs. Dermabond, and surgeon 2 closed significantly faster with staples vs. Dermabond PRINEO. The mean cost of closure was significantly less with Dermabond PRINEO compared with Dermabond, whereas the mean cost of staples was significantly less than Dermabond PRINEO. For both surgeons 1 and 2, there were no significant differences in patient satisfaction at 6 weeks or 3 months. In addition, the wound closure methods did not produce differing cosmetic outcomes.

CONCLUSIONS

Although significant, the closing time for each method did not differ by a clinically relevant amount. Staples were the most cost-effective closing method, followed by Dermabond PRINEO. As neither method was superior over the other in terms of patient satisfaction, adverse events, and cosmetic outcomes, cost-effectiveness may be the greatest differentiator between the 3 methods.

A Prospective, Randomized, Controlled Comparison of Adhesive Wound Closure Devices in an Orthopaedic Patient

The objective of this study was to compare Zip and Clozex with a typical closure using a running 3-0 Prolene suture.

Optimization of tissue adhesive curing time for surgical wound closure

Aims

Tissue adhesives (TAs) are a commonly used adjunct to traditional surgical wound closures. However, TAs must be allowed to dry before application of a surgical dressing, increasing operating time and reducing intraoperative efficiency. The goal of this study is to identify a practical method for decreasing the curing time for TAs.

Methods

Six techniques were tested to determine which one resulted in the quickest drying time for 2-octyle cyanoacrylate (Dermabond) skin adhesive. These were nothing (control), fanning with a hand (Fanning), covering with a hand (Covering), bringing operating room lights close (OR Lights), ultraviolet lights (UV Light), or prewarming the TA applicator in a hot water bath (Hot Water Bath). Equal amounts of TA were applied to a reproducible plexiglass surface and allowed to dry while undergoing one of the six techniques. The time to complete dryness was recorded for ten specimens for each of the six techniques.

Results

Use of the Covering, OR Lights, and Hot Water Bath techniques were associated with a 25- (p = 0.042), 27- (p = 0.023), and 30-second (p = 0.009) reduction in drying time, respectively, when compared to controls. The UV Light (p = 0.404) and Fanning (p = 1.000) methods had no effect on drying time.

Conclusion

Use of the Covering, OR Lights, and Hot Water Bath techniques present a means for reducing overall operating time for surgeons using TA for closure augmentation, which can increase intraoperative efficiency. Further studies are needed to validate this in vivo. Cite this article: Bone Jt Open 2022;3(8):607–610.

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.

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.

No Additional Benefits of Tissue Adhesives for Skin Closure in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

This systematic review is aimed to compare the performance of tissue adhesives (TA) as an adjunct or closure method with traditional wound closure methods for cutaneous closure in arthroplasty and evaluate whether they have any added benefits in terms of decreasing wound complications and increasing postoperative patient satisfaction.

METHODS

Cochrane Library, PubMed, and EMBASE were searched until February 2021. Randomized controlled trials (RCTs) comparing outcomes of TA with emphasis on skin closure time, in-hospital stay, complication rates, cosmetic scoring systems, and patient satisfaction scores (PSS) compared to subcuticular sutures (SCS) and skin staples (ST) in arthroplasty. The quality of RCTs was assessed using the National Institutes of Health quality assessment tool.

RESULTS

Ten RCTs were included. The pooled and the subgroup analysis revealed no significant difference in the wound infection rates, discharge rates, dehiscence rates, and PSS between TA (as an adjunct or closure method) and SCS or ST. TA (as an adjunct or closure method) was significantly (P < .00001) associated with a longer time to closure compared to ST and a shorter time compared to SCS as a closure method. Length of stay was comparable in all groups.

CONCLUSION

Using TA in combination with subcuticular sutures or ST or as a cutaneous method of closure does not provide additional benefits in terms of decreased hospital stay, decreased infection rates, or wound discharge rates. The PSS and pain scores of the scars also appear to be comparable to standard wound closure methods. No clear conclusion could be drawn regarding cosmetic scoring systems, because of the paucity of data.

LEVEL OF EVIDENCE

Level I (Meta-analysis of RCTs).

Impact of Whole-Layer Barbed Suture Closure on the Postoperative Effect and Aesthetic Satisfaction with Incision After Knee Arthroplasty

OBJECTIVE

To evaluate the effect of whole-layer barbed suture for incision closure on the clinical outcome and aesthetic satisfaction of patients with the incision following total knee arthroplasty (TKA).

MATERIALS AND METHODS

A retrospective analysis was conducted on 94 patients (37 men and 57 women, 50-84 years old) who underwent a first TKA between May 2018 and April 2021. The enrolled patients were divided into two groups according to the suture mode, with 45 cases (group A) receiving closure of the deep tissue with a barbed suture and intradermal suture of the incision with another barbed suture and 49 cases (group B) receiving closure of the deep tissue with absorbable suture and interrupted suture of the incision with nonabsorbable suture. Further comparisons were performed regarding incision length, suture time, postoperative incision complications, Hollander Wound Evaluation Score (HWES), Hospital for Special Surgery (HSS) knee score, American Knee Society (AKS) score, and Patient and Observer Scar Assessment Scale (POSAS). The clinical effects of the two suture modes in TKA and the patients' aesthetic satisfaction with the incision were also evaluated at 2 weeks, 3 months and 6 months after the operation.

RESULTS

Compared with group B, group A had higher HWES at 2 weeks after the operation (P < 0.05), shorter suture times (P < 0.05) and lower POSAS scores at 3 and 6 months after the operation (P < 0.05). However, no significant difference was observed between the two groups in incision length, complication rate, HSS or AKS scores (P > 0.05).

CONCLUSION

Compared with the interrupted suture, the use of whole-layer barbed suture for incision closure after TKA has the advantages of a safe and effective outcome, short operation time, high cosmesis degree of the wound scar and high patient satisfaction.

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.

Barbed Sutures in Total Knee Arthroplasty: A Meta-analysis of Randomized-Controlled Trials

Newer methods of wound closure such as barbed sutures hold the potential to reduce closure time and equivalent wound complications in various surgeries. However, few studies have compared barbed suture and conventional wound closure techniques in total knee arthroplasty (TKA). The purpose of this review was to appraise the efficacy and safety of the barbed suture in closure of TKA. We conducted a meta-analysis to identify relevant randomized-controlled trials involving barbed sutures and conventional sutures in TKA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, Wanfang database, up to August 2019. Finally, we identified 1,472 TKAs (1,270 patients) assessed in 13 randomized-controlled trials. Compared with conventional wound closure techniques, barbed sutures resulted in shorter total wound closure time (p < 0.001), fewer needle puncture injuries to members of the surgical team (p = 0.02). There were no significant differences in terms of blister formation (p = 1.0), superficial infection (p = 0.82), range of motion (p = 0.94), incisional exudate (p = 0.75), suture abscess (p = 0.26), or suture breakage (p = 0.11), wound-related complications (p = 0.10), ecchymosis (p = 0.08) between barbed and conventional wound closure. Based on the available level I evidence, we thus conclude that a knotless barbed suture is a safe and effective approach for wound closure in TKA. Given the relevant possible biases in our meta-analysis, more adequately powered and better-designed randomized-controlled trials studies with long-term follow-up are required to recommend barbed sutures for routine administration in TKA.

A Prospective, Randomized Evaluation of the Quality of Wound Closure With Barbed Versus Standard Suture After Total Joint Arthroplasty

Complications such as joint infection or delayed wound healing can lead to morbidity and elevated health care costs after total joint arthroplasty. The purpose of this study was to compare the quality of running knotless barbed suture vs standard monofilament suture wound closure with respect to wound drainage and healing complications after total joint arthroplasty. For this study, 1000 joint arthroplasty patients were prospectively randomized to have fascial, soft tissue, and skin closure with knotless barbed suture vs standard suture during the period 2016 to 2018. An absorptive dressing was used for 1 week postoperatively. Each dressing was weighed and the saturated surface area of the dressing measured. A total of 939 dressings were available for evaluation. Incisions were evaluated for wound healing at each postoperative visit. Of the 1000 joint arthroplasties performed, suture breakage or needle disengagement occurred similarly with the standard monofilament suture and the running barbed suture (13 times vs 6 times; P=.17). Dressings were weighed, and when standard monofilament sutures were used, an average of 1.2 g more postoperative bandage weight was recorded (P<.002). Postoperative wound complications including stitch abscess or wound irritation occurred more often with standard monofilament sutures than with running barbed sutures (16 times vs 5 times; P<.025). Optimal wound closure after joint replacement is critical to enhance soft tissue healing and minimize infection risk, which can be caused by excessive wound drainage. The positive results shown for the running barbed suture of this prospective study indicate the difference in quality of closure between the standard monofilament suture and the running barbed suture in hip and knee arthroplasty surgical sites. [Orthopedics. 2021;44(4):216-222.].

Multilayer Watertight Closure to Address Adverse Events From Primary Total Knee and Hip Arthroplasty: A Systematic Review of Wound Closure Methods by Tissue Layer

Background

Wound closure is a key, and often underrecognized, component of hip and knee arthroplasty. Methods for wound closure are an important consideration to better avoid wound-related adverse events; however, there is a lack of consensus on optimal methods. The objective of the following review was twofold: to characterize the wound closure methods used by layer in the total knee arthroplasty and total hip arthroplasty literature and summarize optimal wound-healing strategies to address the risk of adverse events.

Methods

A systematic literature review was performed to identify total knee arthroplasty and total hip arthroplasty randomized controlled trials and nonrandomized studies reporting wound closure methods by layer and wound-healing adverse events (including superficial, deep, or periprosthetic joint infections, wound dehiscence, or prolonged wound drainage). Studies on revision procedures were excluded. Wound closure methods and adverse events were summarized qualitatively as meta-analyses were not possible because of study heterogeneity.

Results

Forty studies met the inclusion criteria: 22 randomized controlled trials and 18 observational studies. Across studies, 6 categories and 22 unique techniques for closure were identified. Conventional closure methods exhibited large ranges of adverse event rates. Studies of multilayer barbed sutures with topical skin adhesives and polyester mesh or multilayer antimicrobial sutures reported narrow ranges of adverse events rates.

Conclusions

Considerable variability exists for wound closure methods, with a wide range reported in adverse events. Recent technologies and methods for standardized watertight, multilayer closure show promise for avoiding adverse events and unnecessary health-care costs; however, higher quality, comparative studies are required to enable future meta-analyses.

Level of Evidence

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

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.

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

Subcuticular sutures versus staples for skin closure after primary hip arthroplasty

High-quality and cost-effective health care are highly recommended especially in joint replacement surgeries, particularly in total hip arthroplasty. Therefore, it is indispensable for orthopaedic surgeons to spot the potential areas of quality improvement. Evaluating the efficacy of the different ways of skin closure is an unacknowledged topic. We performed this study following both the Preferred Reporting Items for Systematic Reviews and Meta- analyses Statement (PRISMA) and the Cochrane Handbook for systematic reviews and meta-analysis. Articles were from any country, written in any language. We included all randomised control trials and retrospective cohort studies undergoing primary total hip arthroplasty who either received staples or subcuticular sutures for skin closure. The primary outcome was the incidence of wound infection. Secondary outcomes included length of stay (LOS), time to skin closure, total cost, and patient’s satisfaction. We included five studies in our cumulative meta- analysis. We conducted them using Review Manager V.5.0. We computed the risk ratio as a measure of the treatment effect, taking into account heterogeneity. We used Random-effect models. Primary skin closure with subcuticular sutures had insignificant marginal advantages for wound infections, LOS, and wound oozing. On the contrary, staples were more cost- effective and had less time for closure with higher patient’s satisfaction. Except for closure time and patient satisfaction , no significant difference between the two groups. The use of staples after THA may have several slight clinical advantages over the subcuticular sutures. However, owing to the complexities associated with wound closure, future clinical and laboratory studies assessing their complication outlines must be examined before an optimum technique can be determined.

Comparison between Zip-Type Skin Closure Device and Staple for Total Knee Arthroplasty: A Meta-Analysis

Purpose

To compare the efficacy and safety of zip-type skin closure device (SCD) and staple in total knee arthroplasty (TKA).

Methods

Potential academic articles were identified from PubMed, Springer, ScienceDirect, and Cochrane Library from the inception of electronic databases to July 2020. The statistical analyses were performed with RevMan 5.1.

Results

One randomized controlled trial (RCT) and 5 non-RCTs met the inclusion criteria. Present meta-analysis reveals that SCD is associated with lower wound pain score, scar score, and readmission compared with a staple. No significant differences are identified in terms of wound total complications, dehiscence, blisters, and infection.

Conclusions

Comparing with a staple, zip-type SCD is a less painful skin closure method with fewer medical cost undergoing TKA.

The use of 2-octyl cyanoacrylate as an adjuvant to wound closure in total knee arthroplasty

PURPOSE

The efficacy of the use of 2-octyl cyanoacrylate (OCA) as an adjuvant to wound closure in preventing wound complications after total knee arthroplasty (TKA) is rarely reported. This study was aimed to determine whether the use of OCA as a supplement to conventional wound closure reduces the incidence of wound complications following TKA.

PATIENTS AND METHODS

This retrospective study reviewed 1106 consecutive patients who underwent TKA for symptomatic end-stage osteoarthritis (OA) between 2012 and 2017. The first 562 patients who did not receive OCA were grouped into the Control group, and the subsequent 544 patients who received OCA as an adjuvant to wound closure were grouped into the OCA group. All patients were followed up for at least 2 years. The main outcome was the development of operative site complications, including aseptic and infectious complications. Aseptic wound complications were wound leakage, hematoma, wound dehiscence and delayed wound healing, and infectious complication was mainly referred to the superficial infection.

RESULTS

No significant difference with regard to hematoma was observed between groups (3.0% vs. 3.7%, P = 0.617, φ = - 0.02). The incidences were significantly higher in the Control group versus the OCA group in regard to wound leakage (9.4% vs. 2.0%, P = 0.000, φ = 0.16), wound dehiscence (5.7% vs. 1.3%, P = 0.000, φ = 0.12), delayed wound healing (4.4% vs. 1.5%, P = 0.004, φ = 0.09) and superficial infection (2.0% vs. 0.4%, P = 0.022, φ = 0.07). No serious adverse events (AEs) occurred.

CONCLUSIONS

The present study showed that the addition of OCA reduced the incidence of wound leakage, wound dehiscence, delayed wound healing and superficial infection after TKA compared to conventional wound closure. Based on the outcomes above, we decide to use OCA routinely for wound closure after TKA.

LEVEL OF EVIDENCE

III, retrospective, cohort study.

Peri-incisional perfusion does not differ between running versus interrupted Allgöwer-Donati suture technique in ankle fracture surgery: a pilot randomized controlled trial of wound perfusion

Objectives:

To compare peri-incisional perfusion, perfusion impairment and wound closure time between the conventional interrupted Allgöwer-Donati (IAD) technique and a modified running Allgöwer-Donati (RAD) technique in ankle fracture surgery.

Design:

Prospective, randomized controlled clinical trial.

Setting:

Level I and II trauma centers.

Patients:

Twenty-five healthy adults with ankle fractures (AO/OTA 44-A, 44-B, or 44-C) between November 2017 and December 2018. (Of 26 patients enrolled in this study, 1 was lost to follow-up.)

Intervention:

Participants were randomized into the IAD or the RAD group (13 patients each). All participants were followed for at least 3 months after surgery to assess for wound complications.

Main Outcome Measurements:

Skin perfusion was assessed immediately after wound closure with laser-assisted indocyanine green angiography. Wound closure time, mean incision perfusion, and mean perfusion impairment were measured and compared with analysis of variance. Alpha = 0.05.

Results:

The RAD technique was significantly faster in terms of mean (± standard deviation) wound closure time (6.2 ± 1.4 minutes) compared with the IAD technique (7.3 ± 1.4 minutes) (P = 0.047). We found no differences in mean incision perfusion and mean perfusion impairment (all, P > 0.05).

Conclusion:

The IAD and RAD techniques resulted in similar peri-incisional perfusion and perfusion impairment. Closure time was significantly shorter for the RAD technique compared with the IAD technique.

Level of Evidence:

I

A Novel Skin Closure Device for Total Knee Arthroplasty: Randomized Controlled Trial versus Staples

Twenty-five patients undergoing simultaneous, bilateral total knee arthroplasty (TKA) were randomized to receive skin closure with Zip device on one knee and staples on the other. Patients' pain and scar appearance were rated from 0 (best) to 10 (worst). Knee arc of motion was measured by a physical therapist. At 2 weeks postoperatively, pain scores were significantly better with the Zip device during device wear (p = 0.03) and during device removal (p = 0.003); arc of motion was significantly better with the Zip device (p = 0.002). At 8 weeks of follow-up, scar appearance was significantly better in the Zip device knee as rated by the patients (1.3 vs. 2.6, p = 0.04), the surgeon (1.9 vs. 3.3, p = 0.0006), and three independent plastic surgeons (3.7 vs. 4.8, p < 0.001). Results of this randomized controlled trial show that skin closure with the Zip device resulted in less pain and better scar appearance and knee arc of motion than with staples.

The use of tissue adhesive as an adjunct to wound closure in knee arthroplasty does not reduce wound ooze

Introduction

Persistent wound ooze has been associated with prolonged length of hospital stay and increased risk of infection. Recently, the use of tissue adhesive after hip and knee arthroplasty has been described. We believe that knee arthroplasty wounds exhibit different behavior compared to hip arthroplasty due to the increased wound-margin tension associated with knee flexion.

Patients and methods

Forty-three patients undergoing total knee arthroplasty (TKA) by a single surgeon were studied. All wounds were closed using staples with or without tissue adhesive. Post-operatively, the wounds were reviewed daily for ooze. Dressings were changed only if soaked > 50% or if there was persistent wound discharge of more than 2 × 2 cm at 72 h.

Results

There were 21 patients in the tissue adhesive (group 1), 22 in the non-tissue adhesive (group 2) with the average age for group 1 of 72.2 years and for group 2 of 69.3 years. The median length of stay for both groups was 4 days (range of 3–7 days for group 1 and 2–6 days for group 2) (P = 0.960). The tissue adhesive group showed a statistically significant reduction in wound ooze on day 1 (P = 0.019); however, the difference was not significant on the following days. The median for the number of dressing changes for group 1 was zero changes and for group 2, one change. This was not statistically significant (P = 0.112). No complications were observed in both groups and there were no reactions to the tissue adhesive.

Conclusion

The data from this case series suggest that the use of tissue adhesive may reduce wound ooze on day 1 only. The latter is most likely due to significant tensile forces to which the knee arthroplasty wound is subjected in the immediate post-operative rehabilitation. Further, the cost of tissue adhesive is not offset by reduced dressing changes or length of hospital stay.

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.

Three wound-dressing strategies to reduce surgical site infection after abdominal surgery: the Bluebelle feasibility study and pilot RCT

BACKGROUND

Surgical site infection (SSI) affects up to 20% of people with a primary closed wound after surgery. Wound dressings may reduce SSI.

OBJECTIVE

To assess the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of dressing types or no dressing to reduce SSI in primary surgical wounds.

DESIGN

Phase A - semistructured interviews, outcome measure development, practice survey, literature reviews and value-of-information analysis. Phase B - pilot RCT with qualitative research and questionnaire validation. Patients and the public were involved.

SETTING

Usual NHS care.

PARTICIPANTS

Patients undergoing elective/non-elective abdominal surgery, including caesarean section.

INTERVENTIONS

Phase A - none. Phase B - simple dressing, glue-as-a-dressing (tissue adhesive) or 'no dressing'.

MAIN OUTCOME MEASURES

Phase A - pilot RCT design; SSI, patient experience and wound management questionnaires; dressing practices; and value-of-information of a RCT. Phase B - participants screened, proportions consented/randomised; acceptability of interventions; adherence; retention; validity and reliability of SSI measure; and cost drivers.

DATA SOURCES

Phase A - interviews with patients and health-care professionals (HCPs), narrative data from published RCTs and data about dressing practices. Phase B - participants and HCPs in five hospitals.

RESULTS

Phase A - we interviewed 102 participants. HCPs interpreted 'dressing' variably and reported using available products. HCPs suggested practical/clinical reasons for dressing use, acknowledged the weak evidence base and felt that a RCT including a 'no dressing' group was acceptable. A survey showed that 68% of 1769 wounds (727 participants) had simple dressings and 27% had glue-as-a-dressing. Dressings were used similarly in elective and non-elective surgery. The SSI questionnaire was developed from a content analysis of existing SSI tools and interviews, yielding 19 domains and 16 items. A main RCT would be valuable to the NHS at a willingness to pay of £20,000 per quality-adjusted life-year. Phase B - from 4 March 2016 to 30 November 2016, we approached 862 patients for the pilot RCT; 81.1% were eligible, 59.4% consented and 394 were randomised (simple, n = 133; glue, n = 129; no dressing, n = 132); non-adherence was 3 out of 133, 8 out of 129 and 20 out of 132, respectively. SSI occurred in 51 out of 281 participants. We interviewed 55 participants. All dressing strategies were acceptable to stakeholders, with no indication that adherence was problematic. Adherence aids and patients' understanding of their allocated dressing appeared to be key. The SSI questionnaire response rate overall was 67.2%. Items in the SSI questionnaire fitted a single scale, which had good reliability (test-retest and Cronbach's alpha of > 0.7) and diagnostic accuracy (c-statistic = 0.906). The key cost drivers were hospital appointments, dressings and redressings, use of new medicines and primary care appointments.

LIMITATIONS

Multiple activities, often in parallel, were challenging to co-ordinate. An amendment took 4 months, restricting recruitment to the pilot RCT. Only 67% of participants completed the SSI questionnaire. We could not implement photography in theatres.

CONCLUSIONS

A main RCT of dressing strategies is feasible and would be valuable to the NHS. The SSI questionnaire is sufficiently accurate to be used as the primary outcome. A main trial with three groups (as in the pilot) would be valuable to the NHS, using a primary outcome of SSI at discharge and patient-reported SSI symptoms at 4-8 weeks.

TRIAL REGISTRATION

Phase A - Current Controlled Trials ISRCTN06792113; Phase B - Current Controlled Trials ISRCTN49328913.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 39. See the NIHR Journals Library website for further project information. Funding was also provided by the Medical Research Council ConDuCT-II Hub (reference number MR/K025643/1).

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.

Skin closure with surgical staples in ankle fractures: a safe and reliable method

PURPOSE

The purpose of this study is to examine the rates of surgical site complications of staple closure versus suture closure following open reduction and internal fixation of closed unstable ankle fractures.

METHODS

Between 2014 and 2016, a total of 545 patients with closed ankle fractures were treated at our level-1 trauma centre by means of open reduction and internal fixation. A total of 360 patients matched the inclusion criteria and were included in the final analysis of this study. This included 119 patients undergoing wound closure using sutures and 241 patients using surgical staples. The demographics, clinical data, and injury characteristics were recorded. The primary outcome measure was the adverse event of any type of surgical site complication.

RESULTS

The overall rate of patients with a surgical site complication was 15.6%. There was a trend towards a higher risk of surgical site complication in patients undergoing wound closure with sutures as compared with staples (20.2% versus 13.3%); however, this difference was not statistically significant (P = 0.0897). The rate of superficial surgical site infection also trended higher in patients undergoing wound closure with sutures versus staples without demonstrating statistical significance (10.1% versus 5%, P = 0.0678). The rate of deep surgical site infection was similar in both groups.

CONCLUSION

The use of metal staples remains controversial in the setting of orthopedic surgery, particularly involving the foot and ankle. The current study supports that metal staples are a safe and reliable option in the closure of traumatic ankle fractures.

A Prospective, Randomized and Controlled Study on Tissue Adhesive for Skin Incision in Total Knee Arthroplasty

Background

The study focusing on the tissue adhesive in total knee arthroplasty (TKA) was rare. This study aimed to evaluate the clinical outcomes and economic costs of tissue adhesive when acting as the adjunct to standard incision closure in TKA.

Patients and Methods

From September 2019 to November 2019, we prospectively enrolled the consecutive patients who underwent simultaneous bilateral TKA in our institute. The allocation using the tissue adhesive was done after the subcuticular suture in right knee first and another method was applied in the left knee automatically. The patients’ demographics, length of stay (LOS), times of dressing changes and incision-related cost, range of motion (ROM), incision-related complications and incision evaluation scores were recorded.

Results

Thirty-two patients were enrolled in this study and followed at two months after surgery. In the knees of tissue adhesive, the times of dressing change and patient scar assessment scores (PSAS) were significantly less than those standard skin closure (p=0.000; p=0.003). Although there were no significant differences of the delayed discharge, incision-related cost, ROM, incision-related complications and Vancouver scar score (VSS) between two groups, 65.6% (21/32) patients preferred the tissue adhesive and only 15.6% (5/32) patients preferred the standard incision closure.

Conclusion

Tissue adhesive could effectively reduce postoperative wound drainage and improve patients’ satisfaction rate with no difference in medical costs and ROM in TKA. The application of tissue adhesive and subcuticular sutures might be one safe and convenient method of skin closure in TKA.

Chinese Clinical Trial Registry

ChiCTR1900025730; Registered 6 September 2019.

Cosmetic outcomes and patient satisfaction compared between staples and subcuticular suture technique for wound closure after primary total knee arthroplasty: a randomized controlled trial

INTRODUCTION

Staples and subcuticular suture are commonly used wound closure techniques after total knee arthroplasty (TKA). To date, only a few studies have investigated the differences between these two wound closure methods in TKA. Accordingly, this study aimed to compare cosmetic outcome and patient satisfaction between staples and subcuticular suture for post-TKA wound closure.

MATERIALS AND METHODS

This prospective randomized controlled trial included patients scheduled to undergo TKA at the Department of Orthopaedic Surgery of Siriraj Hospital (Bangkok, Thailand) during June 2018-March 2019. Patients were randomized into the staples or subcuticular suture groups. Hollander Wound Evaluation Scale (HWES), cosmetic-visual analogue scale (VAS), and patient satisfaction-VAS were evaluated at the 6-week and 3-month follow-ups. Functional outcome by the modified Knee Society Knee Scoring System and wound complications were also assessed.

RESULTS

Sixty-two patients (31 per group) were included. There were no significant differences in the HWES, cosmetic-VAS, patient satisfaction-VAS, or wound complication rate between groups at the 6-week or 3-month follow-ups. Wound closure time was significantly shorter in the staples group (p < 0.001), but the total operative time was not significantly different between groups. Modified knee score was significantly better in the suture group at 6 weeks (p = 0.024), but there was no significant difference between groups at 3 months. Significant association was observed between patient satisfaction-VAS and cosmetic-VAS at the 6-week (p = 0.03) and 3-month (p = 0.021) follow-ups.

CONCLUSION

Subcuticular suture and staples were found to be comparable wound-closure options after TKA relative to cosmetic outcome, patient satisfaction, functional outcome, and wound complication rate at 3-months post-operation.

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.

Adhesive strips as the sole method for skin closure is effective in total knee arthroplasty

OBJECTIVE

Adhesive strips are used as the sole method for skin closure in many operations except total knee arthroplasty. The claims are decreased wound closure time, less tissue reaction, and lack of stitch marks. The purpose of this study was to compare the efficacy of closure using adhesive strips versus running subcuticular stitches.

METHODS

This study was a retrospective case-matched study. Running subcuticular stitches or adhesive strips were used for skin closure in 151 and 137 patients, respectively. All of the patients had an operation by a single surgeon and had the same patient care protocol. All of the patients were evaluated postoperatively for wound complication at 2 weeks, 6 weeks, and 3 months follow-up.

RESULTS

The wounds of most patients in both groups had healed. The incidence of superficial infection was not different between the groups (1.32% in the running subcuticular suture group and 1.46% in the adhesive strip group) (p = 0.92). One case (0.66%) in the running subcuticular suture group had deep infection, which required reoperation (p = 0.34). The patients in the running subcuticular suture group had higher unabsorbable sutures, which required further removal compared to the adhesive strip group (p < 0.001).

CONCLUSION

The use of adhesive strips is an effective skin closure method with a low rate of infection and skin complications. This technique is easy and there is no need for suture removal. Furthermore, there are no stitch marks and the cost of suturing is lower.

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.

Subcuticular sutures for skin closure in non-obstetric surgery

BACKGROUND

Following surgery, surgical wounds can be closed using a variety of devices including sutures (subcuticular or transdermal), staples and tissue adhesives. Subcuticular sutures are intradermal stitches (placed immediately below the epidermal layer). The increased availability of synthetic absorbable filaments (stitches which are absorbed by the body and do not have to be removed) has led to an increased use of subcuticular sutures. However, in non-obstetric surgery, there is still controversy about whether subcuticular sutures increase the incidence of wound complications.

OBJECTIVES

To examine the efficacy and acceptability of subcuticular sutures for skin closure in non-obstetric surgery.

SEARCH METHODS

In March 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

All randomised controlled trials which compared subcuticular sutures with any other methods for skin closure in non-obstetric surgery were included in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials, extracted data and carried out risk of bias and GRADE assessment of the certainty of the evidence.

MAIN RESULTS

We included 66 studies (7487 participants); 11 included trials had more than two arms. Most trials had poorly-reported methodology, meaning that it is unclear whether they were at high risk of bias. Most trials compared subcuticular sutures with transdermal sutures, skin staples or tissue adhesives. Most outcomes prespecified in the review protocol were reported. The certainty of evidence varied from high to very low in the comparisons of subcuticular sutures with transdermal sutures or staples and tissue adhesives; the certainty of the evidence for the comparison with surgical tapes and zippers was low to very low. Most evidence was downgraded for imprecision or risk of bias. Although the majority of studies enrolled people who underwent CDC class 1 (clean) surgeries, two-thirds of participants were enrolled in studies which included CDC class 2 to 4 surgeries, such as appendectomies and gastrointestinal surgeries. Most participants were adults in a hospital setting. Subcuticular sutures versus transdermal sutures There may be little difference in the incidence of SSI (risk ratio (RR) 1.10; 95% confidence interval (CI) 0.80 to 1.52; 3107 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce wound complications (RR 0.83; 95% CI 0.40 to 1.71; 1489 participants; very low-certainty evidence). Subcuticular sutures probably improve patient satisfaction (score from 1 to 10) (at 30 days; MD 1.60, 95% CI 1.32 to 1.88; 290 participants; moderate-certainty evidence). Wound closure time is probably longer when subcuticular sutures are used (MD 5.81 minutes; 95% CI 5.13 to 6.49 minutes; 585 participants; moderate-certainty evidence). Subcuticular sutures versus skin staples There is moderate-certainty evidence that, when compared with skin staples, subcuticular sutures probably have little effect on SSI (RR 0.81, 95% CI 0.64 to 1.01; 4163 participants); but probably decrease the incidence of wound complications (RR 0.79, 95% CI 0.64 to 0.98; 2973 participants). Subcuticular sutures are associated with slightly higher patient satisfaction (score from 1 to 5) (MD 0.20, 95% CI 0.10 to 0.30; 1232 participants; high-certainty evidence). Wound closure time may also be longer compared with staples (MD 0.30 to 5.50 minutes; 1384 participants; low-certainty evidence). Subcuticular sutures versus tissue adhesives, surgical tapes and zippers There is moderate-certainty evidence showing no clear difference in the incidence of SSI between participants treated with subcuticular sutures and those treated with tissue adhesives (RR 0.77, 95% CI 0.41 to 1.45; 869 participants). There is also no clear difference in the incidence of wound complications (RR 0.62, 95% CI 0.35 to 1.11; 1058 participants; low-certainty evidence). Subcuticular sutures may also achieve lower patient satisfaction ratings (score from 1 to 10) (MD -2.05, 95% CI -3.05 to -1.05; 131 participants) (low-certainty evidence). In terms of SSI incidence, the evidence is uncertain when subcuticular sutures are compared with surgical tapes (RR 1.31, 95% CI 0.40 to 4.27; 354 participants; very low-certainty evidence) or surgical zippers (RR 0.80, 95% CI 0.08 to 8.48; 424 participants; very low-certainty evidence). There may be little difference in the incidence of wound complications between participants treated with subcuticular sutures and those treated with surgical tapes (RR 0.90, 95% CI 0.61 to 1.34; 492 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce the risk of wound complications compared with surgical zippers (RR 0.55, 95% CI 0.15 to 2.04; 424 participants; very low-certainty evidence). It is also uncertain whether it takes longer to close a wound with subcuticular sutures compared with tissue adhesives (MD -0.34 to 10.39 minutes; 895 participants), surgical tapes (MD 0.74 to 6.36 minutes; 169 participants) or zippers (MD 4.38 to 8.25 minutes; 424 participants) (very low-certainty evidence). No study reported results for patient satisfaction compared with surgical tapes or zippers.

AUTHORS' CONCLUSIONS

There is no clear difference in the incidence of SSI for subcuticular sutures in comparison with any other skin closure methods. Subcuticular sutures probably reduce wound complications compared with staples, and probably improve patient satisfaction compared with transdermal sutures or staples. However, tissue adhesives may improve patient satisfaction compared with subcuticular sutures, and transdermal sutures and skin staples may be quicker to apply than subcuticular sutures. The quality of the evidence ranged from high to very low; evidence for almost all comparisons was subject to some limitations. There seems to be no need for additional new trials to explore the comparison with staples because there are high-quality studies with large sample sizes and some ongoing studies. However, there is a need for studies exploring the comparisons with transdermal sutures, tissue adhesives, tapes and zippers, with high-quality studies and large sample sizes, including long-term assessments.

Wound Complications after 2-Octyl Skin Closure Systems for Total Joint Arthroplasty

Introduction: Total joint arthroplasty is projected to expand rapidly by 2030. With large numbers of patients undergoing TJA, the choice of incisional closure has come into question. We compared the 2-Ocyl cyanoacrylate closure system of Dermabond ® Prineo ® with Exofin Fusion ® to compare rates of adverse wound outcomes after total joint arthroplasty. Secondary outcome measures were age, sex, and medical comorbidities between groups.

Methods: We retrospectively reviewed adverse wound outcomes with skin closure in TJA in 281 patients (160 Dermabond Prineo and 121 Exofin Fusion). Clinical charts were analyzed out to the 6-week post-op visit.

Results: The rate of overall adverse superficial wound outcomes was similar between the two groups with Dermabond Prineo (N=20) and Exofin Fusion (N=19). The rate of cellulitis was significantly higher for Dermabond Prineo when compared to Exofin Fusion (P=0.033). No other significant differences were found for rate of superficial or deep wound complications or for secondary outcomes.

Conclusions: The two 2-octyl wound closure systems had similar adverse superficial wound complications. Except for Dermabond Prineo having a higher rate of post-operative cellulitis, there were no statistically significant differences for other superficial or deep adverse wound outcomes or secondary outcomes. A future randomized control trial or prospective cohort study is needed for a more robust analysis.

Tissue adhesive for wound closure in enhanced-recovery total hip arthroplasty: a prospective, randomized and controlled study

Background

We aimed to present our experience of adopting tissue adhesive as adjunct to standard wound closure in total hip arthroplasty (THA) and evaluate its performance.

Methods

From September 2019 to November 2019, we prospectively enrolled consecutive patients who underwent simultaneous bilateral THA in this randomized and controlled study. Standard wound closure was applied on one side of hip while additional tissue adhesive was applied on the other side at random. We collected and analyzed patients’ information, including age, gender, body mass index (BMI), diagnosis, postoperative length of stay (LOS), dressing changes, wound evaluation scores, wound-related cost and complications.

Results

Thirty patients with simultaneous bilateral THA were enrolled in this study. During the hospital stay, the times of dressing change in hips with tissue adhesive was significantly less than that in the other hips (p = 0.000). However, the wound-related cost in hips with tissue adhesive was significantly higher (p = 0.000). According to patients’ feedback at one-month follow-up, wound evaluation of hips with tissue adhesive was significantly better than the other hips (p = 0.004). Seventeen patients preferred tissue adhesive and only five patients preferred standard wound closure.

Conclusions

Tissue adhesive could significantly reduce wound drainage and increase patients’ satisfaction, which can be an ideal adjunct to standard wound closure in enhanced-recovery THA.

Trial registration

Chinese Clinical Trial Registry; ChiCTR1900025730; Registered 6 September 2019.

Skin Closure Tape and Surgical Staples in Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Background

Staples closure technology has been widely used in total knee arthroplasty (TKA) and achieved good results. In recent years, a new type of material called skin closure tape (SCT) has been applied to TKA which also showed good treatment results. However, since it is still not clear yet which one is better, this paper collects literatures for statistical analysis so as to provide evidence for the use of SCT in TKA.

Methods

The comparative study on effects between SCT and staples is reviewed after the primary release of TKA in PubMed, the Cochrane library, and the EMBASE database up to March 2019. The two researchers independently screened the literature and evaluated the quality of the literature using bias risk tools.

Results

A total of four studies (3330 knees) have been included in our meta-analysis. For the main point, the results show that the SCT can reduce readmission rates compared to staples (RR 0.68, 95% CI 0.49–0.95, P=0.03), with no significant difference in complications (RR 0.85, 95% CI 0.27–2.64, P=0.77). Secondly, the results suggest that although there is no significant difference in removal time between the two groups, the SCT can reduce pains, save time and costs, and have a better cosmetic effect.

Conclusions

Our study indicates SCT as a closure method with fewer complications and faster speed compared with staples. Nevertheless, the cost and pain need to be further confirmed because of the small sample size included in this study.

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.

Barbed suture and glue in skin closure during lower limb arthroplasty: reduced delayed discharge due to wound exudate

Objective:

The number of hip and knee replacement performed is rising, causing increased pressure for the timely management of these patients. A dry incision is considered a prerequisite for discharge. This is a retrospective cohort study comparing two treatments for skin closure during elective hip and knee arthroplasty.

Methods:

A barbed monofilament absorbable 3.0 subcuticular suture (Quill), with the additional surface application of n-butyl-2-cyanoacrylate glue, was used for the study group and metal clips or a smooth monofilament absorbable 3.0 subcuticular suture (Monocryl) for the control group. Each group comprised 46 hip and 27 knee replacement patients and data on predisposing risk factors for prolonged wound exudate were collected. We have calculated the proportion of patients who have exceeded their expected length of stay due to a wound exudate, the additional days required for the wound to dry and the derived cost.

Results:

No significant differences were identified with regards to risk factors. The study group demonstrated a significantly lower incidence of exudating wounds of excessive duration (1% versus 14%, p=0.005, relative risk: 10; 95% confidence interval: 1.31–76.13). The combined additional stay was 22 days more for the control group, producing an average financial benefit of £80 per patient for the study group. There were seven knee replacement and two hip replacement patients treated with a nozzled glue applicator who presented with delayed (> 2 weeks) wound healing issues.

Conclusion:

Barbed subcuticular suture with surface glue application is a viable option for skin closure after elective lower limb joint arthroplasty and can reduce the incidence of prolonged wound discharge. A brushed glue applicator should be preferred over the nozzled one.

Enhanced recovery short-stay hip and knee joint replacement program improves patients outcomes while reducing hospital costs

INTRODUCTION

An attractive option to reduce hospital length of stay (LOS) after hip or knee joint replacement (THA, TKA) is to follow the Enhanced Recovery After Surgery principles (ERAS) to improve patient experience to a level where they will feel confident to leave for home earlier. The objective of this study was to evaluate the implementation of short-stay protocol following the ERAS principles.

HYPOTHESIS

We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital LOS and reduced direct health care costs compared to our standard procedure.

MATERIAL AND METHODS

We compared the complications rated according to Clavien-Dindo scale, hospital LOS and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA.

RESULTS

Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). No difference was found between the 2 groups for Grade 3, 4, or 5 complications. The mean hospital LOS for the ERAS short-stay group decreased by 2.8 days for the THAs (0.1 vs 2.9 days, p<0.001) and 3.9 days for the TKAs (1.0 vs 4.9 days, p<0.001). The mean estimated direct health care costs reduction with the ERAS short-stay protocol was 1489 CAD per THA and 4158 CAD per TKA.

DISCUSSION

In many short-stay protocols, focus has shifted from ERAS goals of a reduction in complications and improved recuperation to use length of stay as the main factor of success. Implementation of an ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital LOS, but also in improved patient care and reduced direct health care costs.

LEVEL OF EVIDENCE

Level II.

Comparison of two alternative wound closure methods for tumor arthroplasty of the hip: A frequency matched cohort study

OBJECTIVE

To examine the effect of an alternative wound closure method after tumor arthroplasty of the hip compared to routine wound closure with skin staples.

METHOD

Single center, frequency matched cohort study. We reviewed all patients who underwent tumor resection and endoprosthetic reconstruction of the proximal femur for pathologic fracture due to metastatic bone disease or malignant hematologic bone disease at our center between 2010 and 2014. All patients treated with occlusive wound closure (OWC), a combination of intradermal suture, Steri-Strips™, and an occlusive skin adhesive, during this period ( n = 35), were compared to an equally sized frequency matched group of patients having undergone routine wound closure with conventional skin staples.

RESULTS

Patients with OWC were significantly faster to achieve dry wound status and consequently had significantly shorter administration of antibiotics and hospital stay. Compared to the patients with conventional wound closure with staples, their wounds were already dry after a mean 3.4 days (vs. 6.7 days [95%CI: 3-3.8 vs. 5.5-7.9], p < 0.0001), they received antibiotics for a mean 4.2 days (vs. 6.8 days [95%CI: 3.7-4.8 vs. 5.5-8.0], p < 0.0003) and their mean hospital stay was 6.3 days (vs. 8.0 days [95%CI: 5.5-7 vs. 6.8-9.3], p < 0.015). Prolonged wound discharge (PWD) for 7 days or more was observed in 34% of patients ( n = 12) in the conventional group, whereas this complication was completely absent ( n = 0) in the investigational group. For every three patients treated with OWC, one complication of PWD over 7 days is avoided (number needed to treat = 3).

CONCLUSION

Compared to conventional staples, OWC appears to significantly reduce wound complications, use of antibiotics, and hospital stay in patients undergoing tumor arthroplasty procedures of the hip. As such, it may also contribute to a reduction of the substantially increased risk for prosthetic joint infection in this patient population.