Question:
In patients undergoing primary total hip replacement, how does skin closure with skin adhesive compare with staples for cosmetic appearance of the scar?
Design:
Randomized (allocation concealed), blinded (patients and outcome assessors), controlled trial with 3-month follow-up.
Setting:
Southmead Hospital, Bristol, United Kingdom.
Patients:
90 patients undergoing primary total hip replacement. Exclusion criteria were revision total hip replacement, previous incision in the hip area, local skin conditions, history of keloid formation, malignancy, peripheral vascular disease, diabetes, or allergy to skin adhesive or staples. 77 patients (86%) (mean age, 70 y; 66% women) were included in the analysis.
Intervention:
Patients were allocated to skin closure with LiquiBand Surgical skin adhesive (MedLogic Global Limited, Plymouth, United Kingdom) (n = 45) or staples (Appose UCL 35W; Tyco, Norfolk, Connecticut) (n = 45). Operative and perioperative care, with the exception of skin closure, were identical in the 2 groups. All patients had a posterolateral or anterolateral approach to the hip and 3 layers of sutures before the skin closure.
Main outcome measures:
The primary outcome was the cosmetic appearance of the scar assessed by a plastic surgeon and an orthopaedic surgeon with use of a 100-mm visual analogue scale (VAS) (100 = the best outcome). The surgeons were blinded to the skin closure method and to each other's scores. Secondary outcomes included evaluation of the cosmetic appearance of the scars by the plastic surgeon with use of a modified version of the Hollander wound evaluation score, the Vancouver scar score, and a Likert scale; complications; and patient-assessed cosmetic appearance and satisfaction.
Main results:
The mean VAS scores of the plastic surgeon and the orthopaedic surgeon for cosmetic appearance were not significantly different between the skin adhesive and staple groups (Table). The study had 80% power to detect a difference between the 2 methods of closure. The groups also did not differ for cosmetic appearance when evaluated by the plastic surgeon using the other assessment measures. 1 case of self-reported infection occurred in each group. The skin adhesive and staple groups were not significantly different for patient-assessed cosmesis (median VAS score, 92.5 vs 89; p = 0.64) or patient satisfaction (median VAS score, 96 vs 95; p = 0.42).
Conclusion:
In patients undergoing primary total hip replacement, the cosmetic appearance of the scar did not differ after skin closure done with skin adhesive or with staples.
The study by Livesey and colleagues addresses a topic that is of interest to orthopaedic surgeons who perform total hip arthroplasty. Surgeons are seeking a skin closure method that provides an excellent cosmetic appearance, is easy to use, has a low complication rate, and is cost-effective. While they are effective in closing a wound, staples require removal, which may necessitate a trip back to the physician's office within the first two weeks after surgery, and their use is sometimes associated with wound drainage. Recently, surgeons have become interested in using skin adhesive for wound closure because it has a number of potential advantages, including the fact that it seals the wound at the time of application, it may be faster to apply, no removal step is required, and it may be associated with a better cosmetic appearance.
Livesey and colleagues assessed a variety of outcomes from both the surgeon and the patient perspective. Overall, there was no significant difference between the two methods of wound closure with respect to patient or surgeon evaluation, complication rates, or patient satisfaction. While the staples were faster and easier to use, this may have been because the surgeons had used the adhesive only five times before commencing the trial. The inpatient assessment revealed there was less oozing from the wound in the skin adhesive group (39.5%) than in the staple group (51.3%), but this difference was not significant (p = 0.30).
In conclusion, both staples and skin adhesive seem to be effective in closing skin wounds. Although the staples were less expensive, the cost-effectiveness of each closure method needs to be determined in a study specifically designed to assess this question.