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Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USACentre for Sport, Exercise, and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK
Wound closure method in total hip and knee arthroplasty is a controversial topic with no differences in clinical outcomes between surgical staples (SS) and subcutaneous sutures with Dermabond (SCD). When clinically appropriate, providers should focus more on what the patient may prefer. This study aimed to collect data on patient preference between SS and SCD and analyze differences in preference based on gender and previous surgical histories.
Methods
Patients were surveyed on their wound closure preferences prior to surgery. The handout given collected preference and patient demographics. Risk ratios and risk difference with 95% confidence intervals (95% CI) were calculated along with Firth-corrected logistic regressions.
Results
A total of 163 participants were analyzed (53% female) (average age = 63.8 years), in which 12 participants selected SS as their preferred method. Males demonstrated no difference in relative risk (risk ratio: 2.3 [95% CI: 0.7, 7.3], P = .150) or absolute risk (risk difference: 5.9 [−2.2, 14.1], P = .156) in choosing SS over SCD. Patients that previously sustained SS for other surgeries demonstrated no difference in adjusted odds (adjusted: 0.9 [95% CI: 0.2, 3.2], P = .839) in choosing SS over SCD.
Conclusion
More patients favored SCD over SS. There was no difference in preferences based on gender or previous surgical history. Current literature shows that successful wound closure is achieved with minimized risks for infection and other complications using both methods. Providers should adopt a patient-centric approach and perform the closure method that most patients prefer when medically warranted.
With an aging population in the United States and globally, the demand for total hip (THA) and knee arthroplasties (TKA) is projected to grow by 174% (THA) and 673% (TKA) by 2030, as common surgical interventions to treat end-stage degenerative arthritis [
]. Although joint replacements are a boney procedure, great attention is also placed on balancing the soft tissues and meticulous soft tissue closures [
]. The goals of total joint replacement are to reduce pain, regain mobility, minimize infection rates, and enhance recovery times, all while driving efforts toward successful high-tension wound healing [
]. Draining wounds after total joint procedures constitutes a significant source of contamination and high risk for deep infection, which drastically affects long-term outcomes and patient satisfaction [
]. As a result, there has been ongoing research to assess the efficacy of the various wound closure methods and evaluate the rates of complications and quality-associated expectations of different closure techniques following THA and TKA [
There are two primary skin-level wound-closing techniques used in THA and TKA, namely surgical staples (SS) and subcuticular sutures with Dermabond (Ethicon, Cincinnati, OH) (SCD) [
]. As demonstrated in a large meta-analysis of existing randomized controlled trials, the current literature shows insignificant differences between these two methods of wound closures [
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.
]. Glennie et al. demonstrated that their patient groups, either receiving SS or SCD, had no differences in the Patient and Observer Scar Assessment Scale [
MONOCRYL and DERMABOND vs staples in total hip arthroplasty performed through a lateral skin incision: a randomized controlled trial using a patient-centered assessment tool.
On average, a wound site following total joint arthroplasty is about 14 cm. At our institution, the cost breakdown is as follows, 1 stapler ($46.20), 1 3.0 Monocryl antibacterial version 8-count CRP (Ethicon) ($8.89), 1 Dermabond ($54.83), Staple Removal kit (Ethicon) ($0.63). Previous research has observed a significant difference in the suturing time for physicians, with SS averaging 81 seconds for wound closure compared with 290 seconds for SCD [
Použití kovových klipů při sutuře kůže u totální endoprotézy kolene [Metal staples versus conventional suture for wound closure in total knee arthroplasty].
Použití kovových klipů při sutuře kůže u totální endoprotézy kolene [Metal staples versus conventional suture for wound closure in total knee arthroplasty].
]. Another study examining TKA closure times from the joint capsule to the cutaneous layer demonstrated that SS took 26 seconds/cm, Dermabond took 45 seconds/cm, and Monocryl Sutures took 54 seconds/cm [
]. As these numbers are different from those in the study conducted by Hlubek et al., the current literature is inconclusive as to the superior method in time of application [
Použití kovových klipů při sutuře kůže u totální endoprotézy kolene [Metal staples versus conventional suture for wound closure in total knee arthroplasty].
THA/TKA are intensive procedures, and it is crucial to have a patient-centered approach to ensure each patient is comfortable and understands the risks involved. Previous research demonstrates that patients undergoing major surgeries, such as total joint replacements, often conduct extensive research on choosing a surgeon that fits their individual needs [
]. Additionally, the concept of shared decision-making (SDM) in surgery highlights improved patient outcomes in alleviating internal stress, improving compliance routines, and decreasing the burden of costs for preventable complications [
]. Therefore, it is vital for surgeons to better understand patients' preferences concerning wound closing as it is one of the few things the patient can see, and so it gives them a powerful feeling of control over their bodies and promotes patient-surgeon SDM.
On all major factors, the use of SS vs SCD for wound closure after THA/TKA is insignificant, and therefore, when clinically appropriate, providers should focus more on patient preference. Since preferences vary based on patient demographics, it is important to understand the prevalence of preferences based on the factors of gender and previous surgical history. We hypothesize that most patients undergoing elective THA/TKA operations would prefer a SCD closure for the incision site. Therefore, the aims of this study were to (1) determine and describe patient preference in wound closure methods following hip and knee replacement surgery; (2) evaluate the relationship between gender and previous surgical history on patient preference in wound closure methods.
Material and methods
Collecting patient perspectives
A cross-sectional study design was utilized to assess wound closure preference in patients undergoing THA or TKA. Patients were given a patient handout survey assessing preference in wound closure technique following total joint replacement surgery (Fig. 1). The patient was questioned by the researcher on whether they preferred wound closure using SS or SCD. It was made clear to the patient that the response to the survey had no impact on the actual closure method utilized during their surgery. The survey was phrased based on a hypothetical situation, asking if patients could select a wound closure method for their operation, to know which method is more desirable from patients' perspective. Each patient was briefly informed of the two options, always in the order of SS then SCD, including the removal process and the expectations for wound evaluation after 2 weeks. Description of SS highlighted the superficial clips made of titanium, plastic, or stainless steel, involving a removal process at 2 weeks postoperatively. Description of SCD included a closure in the second layer of skin using absorbable sutures, with no removal process, along with a supplemental application of a skin adhesive (Dermabond). The hospital institutional review board approved this study.
Patient surveys were performed at an outpatient orthopedic clinic between May 2021 and July 2021. Inclusion criteria included any patient scheduled for a total joint arthroplasty surgery, including those patients consenting for revision surgery or partial joint replacement surgery. In those patients eligible for and undergoing future THA or TKA, there were no study exclusion criteria based on existing medical conditions, previous surgical history, or other factors. Sample size determination was based on recent cross-sectional studies assessing patient opinions and preferences in which an average sample size of 100-200 was recorded in most studies. A pre-hoc power analysis was not performed.
Patient details collected
In addition to assessing patient preference by a check-off section on the handout, the study also collected brief patient demographics such as the patient’s age and sex. The handout also recorded the current procedure the patient was scheduled for, either being a hip or knee arthroplasty, along with the side of the body (left/right or bilateral). Lastly, the form also recorded patients’ past surgical histories along with the method used to close the wound of their previous operation (Fig. 1).
Standard wound closure materials
The standard choice of SS was applied using the device Visistat 35W stapler (Teleflex Corp, Morrisville, NC), an Food and Drug Administration (FDA)-approved Weck staple system with stainless steel staples [
]. Monocryl sutures (poliglecaprone 25; Ethicon) are FDA-approved dissolving monofilament sutures for soft tissue ligations with varying tensile strengths from 30% to 40% at the 2-week mark [
]. Dermabond (2-octyl-cyanoacrylate; Ethicon) is an FDA-approved high-viscosity skin adhesive used for wound closures over the past 30 years and is proven to be an effective method for bonding the superficial layers of cutaneous tissues [
All data collected were deidentified and uploaded into REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the Wake Forest School of Medicine [
Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support.
Prior to analysis, missing data were assessed. Missing data were 0% for all variables; thus, complete case analyses were performed. Descriptive statistics were reported as mean (standard deviation) for continuous variables and percent for count variables. Relative and absolute risk were assessed for sex and previous surgical wound closure history through risk ratios (RRs) and risk difference (RD) with 95% confidence intervals (95% CI). RR provides a relative risk calculation, which is the ratio of risk between the exposure group (ie, males or staples for previous surgical wound closure) and the nonexposure group (ie, females or sutures with Dermabond for previous surgical wound closure). RD, or attributable risk, provides an absolute risk calculation, which is the difference between the exposure group (ie, males or staples for previous surgical wound closure) and the unexposed group (ie, females or sutures with Dermabond for previous surgical wound closure). A series of Firth-corrected logistic corrections were performed to assess the relationship between sex and surgical wound closure choice and previous surgical wound closure history and current surgical wound closure choice. Firth-corrected logistic regressions were controlled for previous surgical history and current surgical procedure (THA vs TKA) for the sex analysis and controlled for sex and current surgical procedure (THA vs TKA) for the previous surgical wound closure history analysis. All analyses were performed in R version 4.02 (R Core Team [2013]; R: a language and environment for statistical computing, using the dplyr package for cleaning and coding, epiR package for risk calculations, and logistf for Firth corrected logistic regressions).
Results
A total of 163 patients participated, with 12 (7%) choosing staples for wound closure preference (Table 1). Males demonstrated no difference in relative risk (RR: 2.3 [95% CI: 0.7, 7.3], P = .150) or absolute risk (RD: 5.9 [−2.2, 14.1], P = .156) in choosing staples over sutures with Dermabond for surgical wound closure. Patients that previously sustained staples for surgical wound closure demonstrated no difference in relative risk (RR: 0.70 [95% CI: 0.19, 2.6], P = .584) or absolute risk (RD: −2.8 [95% CI: −12.1, 6.7], P = .567) in choosing staples over sutures with Dermabond for surgical wound closure.
Table 1Descriptive statistics.
Variable
All participants (n = 163)
Participants who chose staples (n = 12)
Participants who chose sutures with Dermabond (n = 151)
Age
63.8 (11.2)
63.7 (11.4)
64.5 (8.5)
Sex (% female)
53%
33%
55%
Procedure
THA
39%
25%
40%
TKA
53%
58%
52%
Revision THA
4%
0%
4%
Revision TKA
4%
17%
3%
Side of body (% left)
48%
42%
48%
Previous surgery history
84%
83%
84%
Previous closure preference (% staples)
5%
25%
3%
All descriptive statistics are reported as mean (standard deviation) or percentage.
Males demonstrated no difference in unadjusted or adjusted odds (unadjusted: 2.3 [95% CI: 0.7, 8.3], P = .157; adjusted: 2.3 [95% CI: 0.7, 8.2], P = .161) in choosing staples over sutures with Dermabond for surgical wound closure. Patients that previously sustained staples for surgical wound closure demonstrated no difference in unadjusted or adjusted odds (unadjusted: 0.8 [95% CI: 0.2, 2.7], P = .672; adjusted: 0.9 [95% CI: 0.2, 3.2], P = .839) in choosing staples over sutures with Dermabond for surgical wound closure (Table 2).
Table 2Firth-corrected logistic regression results for sex and previous surgical wound closure.
The main finding of this study was that 93% of patients preferred to have a closure with SCD over SS. There was no difference in preference for SCD based on previous surgical history or gender. The shared preferences between varying factors are a favorable outcome noted in our study and highlight that surgeons should give attention to patient preference and perform the SCD closure method that most patients prefer when clinically applicable.
While SCD was shown to be the preferred closure method, it is imperative to acknowledge the possible risks associated with Dermabond. Studies assessing postoperative wound closure complications after THA/TKA procedures have documented a rare yet severe allergic contact dermatitis (ACD) response to Dermabond (2-octyl cyanoacrylate). A recent study conducted by Chalmers et al. demonstrated an ACD incidence of 0.5%, with ACD occurrence on average at day 11.8 after operation. The patients were treated with oral antihistamines and topical corticosteroids, in which all cases resolved on average at postoperative day 22 [
Characterizing the diagnosis and treatment of allergic contact dermatitis to 2-octyl cyanoacrylate used for skin closure in elective orthopedic surgery.
]. While these allergic reactions are severe in nature, if the warning signs are recognized early, the treatment with oral and topical medications is very effective. Overall, ACD is an uncommon adverse effect with proven treatment interventions, which significantly diminish risks for the patient.
The findings imply that when a surgeon deems SS and SCD as both plausible methods based on the patient's clinical conditions, SCD should be the method of closure used. Of the total selections for an SCD closure, 55% of responses were from females, indicating a homogenous preference for SCD shared by males and females. In the study, the average age of patients was 63.8 years, and this represented a generalizable population for patients undergoing THA and TKA operations. SDM and electing to use the preferred method of SCD and the lack of a suture-removal process may alleviate some concerns for surgery.
Future research
While our study focuses on the quantitative aspect of wound closure choice, a follow-up study should thoroughly analyze qualitative reasons to understand patient perspectives. It is critical to acknowledge the basis for patient preferences, such as the minority group favoring SS. Future studies should elaborate on how the removal process of SS impacts preference. Additionally, it was noticed that women with a previous surgical history of a Cesarean section often underwent a SS closure. It would be beneficial to understand the relationship between females that had previously undergone C-sections and an SS closure and determine if these patients have a bias against SS for future surgical closures.
Limitations
The study has several limitations. Patients could not physically see how each wound closure method appears on the skin. Pictures were not given to patients as this could add biases depending on the quality of the images shown. Additionally, patients who had already undergone a THA or TKA with the current clinic physicians were included in the study. These patients received prior closures of SCD. Therefore, it is likely that these patients were influenced to select the same method based on their previous experience. While the sample size of participants was based on similar studies, sample size determination would have been more accurate if an initial pre-hoc power analysis was completed. Lastly, a significant drawback with the study is the comparably small number of participants in the SS outcome group, which potentially adds the risk of a type II error. However, a Firth-corrected logistic regression was performed to aid in minimal outcome analyses.
Conclusions
Based on our findings, most patients prefer a wound closure with SCD over SS, with variables of patient gender, age, and past surgical history as nonfactors. Among the patients undergoing THA compared with those undergoing TKA, there were also no differences in preference for closure with SCD. Given the complexity of individual surgical cases, surgeons cannot always use sutures or staples, but in situations where it is plausible to choose, the doctor should consider using SCD as that is the preferred method of closure for most patients. Therefore, our study encourages providers to engage in SDM with patients and, when applicable, use the method of wound closure that is in line with most patients undergoing THA or TKA procedures.
Acknowledgments
The authors would like to thank Chloe Scott, MD, MSc, FRCSEd, and Dustin Schuett, DO, FAAOS, for their contributions.
Funding
This work was supported by the Department of Student Affairs, Wake Forest School of Medicine.
Conflicts of interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: J. S. Shields is a paid consultant for Smith & Nephew.
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.
MONOCRYL and DERMABOND vs staples in total hip arthroplasty performed through a lateral skin incision: a randomized controlled trial using a patient-centered assessment tool.
Použití kovových klipů při sutuře kůže u totální endoprotézy kolene [Metal staples versus conventional suture for wound closure in total knee arthroplasty].
Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support.
Characterizing the diagnosis and treatment of allergic contact dermatitis to 2-octyl cyanoacrylate used for skin closure in elective orthopedic surgery.
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