Question:
In patients having orthopaedic surgery, how do staples and sutures for skin closure compare in terms of wound infection?
Data sources:
Studies were identified in the Allied and Complementary Medicine Database (AMED; 1985 to July 2009), British Nursing Index (1985 to July 2009), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to July 2009), Excerpta Medica Database (EMBASE; 1974 to July 2009), Medical Literature Analysis and Retrieval System Online (MEDLINE; 1950 to July 2009), Scopus, the Cochrane Library, System for Information on Grey Literature in Europe (SIGLE), National Technical Information Service, National Research Register, and Current Controlled Trials databases. Reference lists of relevant articles were reviewed and authors in the field were contacted.
Study selection and assessment:
Studies were included if they were randomized or nonrandomized clinical trials comparing staples and sutures after orthopaedic surgery (elective or trauma) and they evaluated wound closure. Studies were excluded if they assessed synthetic adhesives, included cadavers or animals, or provided insufficient information on population characteristics, surgical procedure, or outcomes. Study quality was assessed with use of the Physiotherapy Evidence Database critical appraisal tool (11-item scoring system).
Main outcome measures:
The primary outcome was the incidence of wound infection. Secondary outcomes included incidences of wound dehiscence, inflammation, discharge, wound necrosis, abscess formation, and allergic reaction.
Main results:
6 studies met the inclusion criteria. The methodological quality varied greatly across studies. 3 studies were randomized controlled trials. In total, 683 patients were included. 57 men and 117 women were in the staple group and 60 men and 131 women were in the suture group (4 studies). Mean age was 82 years in the staple group and 80 years in the suture group (3 studies). Follow-up ranged from 10 to 364 days (mean 95 days). The types of surgery were hip (3 studies), hip and knee (2 studies), and upper-limb and lower-limb trauma (1 study). Meta-analysis of all 6 studies showed the risk for wound infection was greater with staples than with sutures (Table). The groups did not differ for dehiscence, inflammation, discharge, necrosis, or allergic reaction (Table). Results for wound infection in the 5 studies of hip surgery were similar to those of the overall meta-analysis (relative risk [RR] = 4.79; 95% confidence interval, 1.24 to 18.47). In the 2 studies of knee surgery, the results were similar in direction for wound infection, but not significantly different (RR 3.29, CI 0.54 to 20.04).
Conclusion:
On the basis of evidence with numerous methodological limitations, patients having orthopaedic surgery are at greater risk for wound infection after skin closure with staples than they are after skin closure with sutures.
The two main methods of wound closure in orthopaedic surgery are metal staples and sutures. In the review by Smith and colleagues, the authors have attempted to answer the important clinical question of whether postoperative wound infections and complications depend on type of skin closure. Their meta-analysis, which included six studies, concluded that the risk for postoperative wound infection was higher with the use of staples than with suture closure.
This meta-analysis has several limitations on the basis of quality of available studies. First, there is no clear definition of infection as opposed to skin reaction to metal staples. Second, the time for removal of the closure material varied among the studies. Third, antibiotic prophylaxis was used in only four of the six studies. Fourth, elective hip and knee procedures were mixed with trauma cases. Finally, the experience of the surgeon who closed the wounds (consultant surgeon or junior medical student) was not reported and it is unknown if it was consistent within and between the six studies.
The evidence of greater wound infections with staples requires further confirmation before making any clear recommendations for or against the use of staples.