Evidence-Based Orthopaedics   |    
Risk of Wound Infection Is Greater After Skin Closure with Staples Than with Sutures in Orthopaedic Surgery

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Source of funding: No external funding.
For correspondence: Mr. T.O. Smith, University of East Anglia, Norwich NR2 7TJ, UK. E-mail address: toby.smith@uea.ac.uk
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Smith  TO,  Sexton  D,  Mann  C,  Donell  S. Sutures Versus Staples for Skin Closure in Orthopaedic Surgery: Meta-Analysis. BMJ.2010Mar 16;340:c1199.

J Bone Joint Surg Am, 2010 Nov 17;92(16):2732-2732. doi: 10.2106/JBJS.9216.ebo818
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In patients having orthopaedic surgery, how do staples and sutures for skin closure compare in terms of wound infection?
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    Anne J. Vochteloo
    Posted on March 19, 2011
    Fundamental Limitations of “Sutures Versus Staples for Skin Closure in Orthopaedic Surgery..."
    Orthopaedic Surgeon, Leiden University Medical Center, Leiden, The Netherlands

    To the Editor:

    With pleasure we read the analysis and commentary by Syed and co-workers entitled, "Risk of Wound Infection Is Greater After Skin Closure with Staples Than with Sutures in Orthopaedic Surgery" (2010;92:2732) on the meta-analysis of Smith et al. (1) in the November 17 issue of your journal.

    As you might know, many letters to the Editor of BMJ regarding this article have been published on the BMJ website (2). We sent a reaction as well, of which an outline was published (3). Our complete reaction is available on the BMJ website through http://bmj.com/cgi/eletters/340/mar16_1/c1199#234630.

    The take-home message of the meta-analysis by Smith and colleagues as broadcasted in the media was that the risk of developing a wound infection after orthopaedic surgery is significantly higher when the wound is closed with staples rather than sutures (1, 4-6). Patients and medical caregivers will confront orthopaedic surgeons with the presented results and will ask them why they continue to use staples for skin closure. However, this meta-analysis does not support the broadly advertised conclusion.

    We opposed this article because of the following:

    Firstly, we found three new studies in a Pub Med search that should have been included (7-9). All are randomized controlled trials comparing sutures with staples in orthopaedic wounds, and report the presence of infection.

    Smith and colleagues do mention the study by Graham et al. in their discussion but do not say why they excluded this and the other two studies (7).

    Furthermore, the included study by Khan et al. reports on two patients with an abscess in the suture group, which can be considered as deep infections (10). When we redid the meta-analysis including the three studies the increased infection rate for staples compared with sutures was not significant (3). The significant difference for the hip surgery sub-analysis was also lost (3).

    Secondly, clinical heterogeneity is also substantial in this meta-analysis, such as variation in suture techniques (both transcutaneous and subcuticular), suture materials, follow-up, and assessment of infection.

    Thus the studies should not be pooled, even with a significant summary effect. The main reason for this heterogeneity is a lack of clarity in the research question.

    Finally, the meta-analysis lacks a clear a priori design and a list of excluded studies. The overall methodological quality of the included studies is poor, as recognized by the authors. In addition, the authors do not discuss the presence and potential influence of publication bias on the results, although they provide a funnel plot. Therefore, the conclusion of the prevalence of more infections when using staples is not justified. Their conclusion should have been: “definitive randomized trials are still needed to assess this research question.”


    1. Smith TO, Sexton D, Mann C, Donell S. Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis. BMJ. 2010;340:c1199.

    2. Vochteloo AJ, Pijls BG, van der Heide HJ. Sutures v staples. Let's add three other studies. BMJ. 2010;340:c2627.

    3. http://bmj.com/cgi/eletters/340/mar16_1/c1199#234630.

    4. Reuters Health. Staple skin closure ups infection risk with orthopedic surgery. 2010 Mar 23. http://www.thedoctorschannel.com/video/3067.html.

    5. Staples significantly increase risk of postoperative infection, researchers say. 2010 Mar 31. http://www.orthosupersite.com/view.aspx?rid=62584.

    6. Using staples to close wounds may cause a greater risk of infection. 2010 Mar 17. http://abcnews.go.com/Health/video/staples-stitches-10127689.

    7. Graham DA, Jeffery JA, Bain D, Davies P, Bentley G. Staple vs. subcuticular vicryl skin closure in knee replacement surgery: a spectrophotographic assessment of wound characteristics. Knee. 2000;7:239-43.

    8. Bhatia R, Blackshaw G, Barr V, Savage R. Comparative study of "staples versus sutures" in skin closure following Dupuytren's surgery. J Hand Surg Br. 2002;27:53-4.

    9. Liew SM, Haw CS. The use of taped skin closure in orthopaedic wounds. Aust N Z J Surg. 1993;63:131-3.

    10. Khan RJ, Fick D, Yao F, Tang K, Hurworth M, Nivbrant B, Wood D. A comparison of three methods of wound closure following arthroplasty. A prospective, randomised, controlled trial. J Bone Joint Surg Br. 2006;88:238-42.

    Khalid A. Syed, MD
    Posted on March 19, 2011
    Dr. Syed and colleagues respond to Dr. Vochteloo and colleagues
    Orthopedic Surgeon
    University of Toronto, Canada

    This letter essentially reiterates what was indicated in our commentary on this article. The data used in the meta-analysis is quite heterogenous. The final conclusion of the paper is affected by poor data, poor study design, lack of standardization in closure technique and hence an unreliable result from the analysis. We agree with the authors of the letter and in our comment on this paper, we did state that the only true messege from the paper is that it identifies an interesting and relevant question of infection related to wound closure technique which warrants appropriately designed randomized controlled trials for adequate study and conclusions.

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