Comparison of Three Skin Closure Methods in Knee Mid-Anterior Incisions

Abstract

Background:

Few clinical trials have studied the functional and cosmetic outcomes using different closure techniques for surgical incisions. Since wound and rupture closure methods may influence the healing process and cosmetic outcome, the present study aims at comparing three different suture techniques.

Methods:

In a clinical trial, sixty patients with an anterior cruciate ligament rupture were studied. At the end of the operation and after subcutaneous tissue closure, the skin incision was divided into three equal parts. Each part was randomly sutured using one of three techniques: simple, vertical mattress, or semisubcuticular suture techniques. After six months follow-up, we take a picture of the healed wound in each individual. The cosmetic outcome was rated and evaluated by three Orthopedic Surgeons according to the visual analogue scale (zero to 10). During the study, wounds were followed up for inflammation, infection, or discharges.

Results:

There were no significant differences between cosmetic results of different suturing methods. The mean and standard deviation of VAS scores for three different observer were 5.62±1.39, 5.62±1.13, 5.65±1.29 in the simple suture; 6.05±1.33, 6.13±1.01, 5.93±1.02 in the vertical mattress technique and 5.72±1.82, 5.81±097 and 5.77±0.99 in the semisubcutaneous method. Overall agreements between observers were weak to moderate. Slight superiority of the semisubcuticular sutures were not statistically significant.

Conclusions:

The methods used for suturing an anterior midline incision of the knee does not seem to affect the final cosmetic outcome. The concept of different surgeons from a favorable cosmetic result could totally differ.

Introduction

Repair technique may play a significant role in keloid formation and development of hypertrophic scar and hyperpigmentation at the repaired site (1). The depth and extension of the wound as well as infection and local irritation could affect the scar and scab formation (1). The wounds and ruptures are differently repaired depending on various parameters. Several studies have confirmed the effects of choosing repair technique on outcomes. The other factors are patient features and wound types (2). Surgical wounds are generally closed with sutures (polydioxanon, polypropylene) and lead to quick recovery of the wound by placing tissue layers of derma and epidermis together (3).

Suture type and technique are significant factors that may affect wound closure outcomes (4). Choosing the technique and material typically depends on the surgeon. Except for some trials evaluating efficiency of functional and cosmetic outcomes of tissue adhesives; there are few clinical trials exclusively focused on functional and cosmetic outcomes of different incision closure techniques. Since wound and rupture repair methods affect recovery process, the present study aimed to evaluate three different repair techniques in patients whom underwent knee surgery (5-9).

Materials and Methods

In a clinical trial, we studied sixty patients who underwent open knee anterior cruciate ligament reconstruction by bone-patella tendon-bone graft techniques, which required knee anterior midline incision at the Orthopedic Department of Shahid-Ghazi Hospital, Tabriz, Iran. In this study, three methods of skin repair were used to close the incision in each patient, so that the wound was divided into three equal parts and each part was repaired randomly by a method.

The inclusion criteria allow for those interested in participation in the study (the subjects should declare their personal consent before operation and repair) between the ages of 15 and 70 years old. Our exclusion criteria were vascular disorders or microvascular diseases, systemic diseases such as diabetes, lupus and other skin diseases, and allergy to material of the used suture. The ethical research committee of Tabriz University approved the study.

Operation method

We used the anterior midline approach in order to pick patella tendon graft. At the end of operation and after subcutaneous tissue repair in layers with vicril sutures, skin incision was divided into three equal parts and each part was accidentally sutured by one of the simple, vertical mattress or vertical semisubcuticular suture techniques. We used Nylon 0-2 for skin closure.

Simple suture:

The key to employ this technique is to evert the wound edges, which requires that the needle enter the skin at a 90-degree angle approximately 1-2 millimeters from the wound edge. After penetration, the needle should be redirected to proceed at a slightly oblique angle away from the wound edge to the desired depth and then across to the other side of the wound, where its course should follow a mirror image of the first side (2).

Vertical mattress suture:

The vertical mattress stitch is placed in a “far-far-near-near” order of bites. The “farfar” loop enters and exits the skin surface at a 90 degree angle, some 4mm to 8mm from the wound margin. It passes relatively deeply into the dermis (2). The “near-near” loop enters and exits the skin surface one to two millimeters from the wound margin, traversing the wound at a depth of one millimeter. Because of the precise degree of control that the vertical mattress stitch requires, bites must be symmetrical, especially the depth of the near-near loop, or the wound will invariably misalign and heal with a “shelf” on one side (2). The knot is tightened only until sufficient opposition and eversion is achieved..

Vertical semisubcuticular suture:

Semisubcuticular sutures are placed totally within the dermis in a vertical orientation in one side, and like a vertical mattress far and near method on the other side where the suture enters and exits.

Vascular cefazolin (one gram per six hours) was the prescribed antibiotic for all patients after operation for two days. We followed the patients on second and third weeks for wound infection or other skin complications. Additionally, the patients were followed up to examine the repaired wounds during 15th and 42nd weeks for late complications and final satisfaction. The follow-up period lasted for six months (Figure 1).

Figure 1.

Skin closure with three different suturing methods of with simple, vertical mattress and vertical semisubcuticular methods.

Visual analogue scale was used to study cosmetic outcomes (10). In this method, frequent images were taken from wound healing procedure. Three orthopedic surgeons rated the cosmetic outcome of each wound independently using a 0-10 scale system (zero and 10 indicates the worst and best outcome, respectively). During the study, images were taken from all stages of the repair and healing process. Moreover, digital images of scars were taken using a digital camera when the patients were visited six months after operation (Figures 1, 2). The wounds were examined for complications such as inflammation, infection or discharges during the study.

Figure 2.

Final outcome six month after operation incision closer in the same patient.

SPSS16 statistical software (SPSS.Inc.,Chicago, IL) was used in all statistical tests. Once observers’ results were recorded, the data were descriptively analyzed using central descriptive statistical methods (mean) and distribution (standard deviation and variance). In order to refer to agreement level of observers, Kappa statistical test was calculated. For assessing the cosmetic scores in different types of sutures techniques we used ANOVA test. In all statistical tests, a P value of less than 0.05 was deemed significant. For agreement between observers, we used ICC test. We rate the kappa value according to Table 1.

Table 1.

Classification of Kappa value report used in our study

No agreement	0<
Slight agreement	0.0-0.2
Fair agreement	0.21-0.40
Moderate agreement	0.41-0.60
Substantial	0.61-0.80
Almost perfect	0.80-1.00

Results

All of the 60 patients who participated in our study finished the six months follow-up period. Table 2 demonstrates the average scores of each suture technique rated by each observer. There was not any significant difference between the scores between all three techniques (p =0. 20).

Table 2.

Mean scores of VAS regarding to cosmetic outcome given by the observers to each suture technique

	Simple suture	Vertical mattress	Vertical subcuticular
First observer	5.62±1.39	6.05±1.33	5.72±1.82
Second observer	5.62±1.13	6.13±1.01	5.81±0.97
Third observer	5.65±1.29	5.93±1.02	5.77±0.99

According to the findings, the highest rate of similarity between the agreement of observers is in the vertical subcuticular method. More information is demosterated in Table 3.

Table 3.

Configuration of Kappa Value between three observer to each suture techniques

	Second observer	Third observer
First observer	Simple suture: 0.19	Simple suture:0.17
	Vertical mattress :0.13	Vertical mattress:0.14
	Vertical subcuticular:0.35	Vertical subcuticular:0.22
Third observer	Simple suture:0.61
	Vertical mattress:0.54
	Vertical subcuticular:0.67

Evaluating patients who underwent surgery revealed no observed complications such as infection and dehiscence.

Discussion

The ideal wound closure technique should be cost-effective, time-effective, and user-friendly with optimal cosmetic outcomes. An interrupted stitch type with favorable tissue characteristics will reduce local wound complications (5) while superficial wound dehiscence may be reduced by using continuous subcuticular sutures (6,7).

Our study showed that the method of suturing in anterior mid-line approach did not affect the final cosmetic results. Furthermore, different surgeons had different perspectives from the cosmetic result of a healed wound. The vertical semisubcuticular approach provided the highest rate of similarity of the scores and agreement between the observers. Simple suture technique occupied the next rank considering agreement of observers. The lowest rate of concordance among observers belongs to the vertical mattress method. Although there was not any significant difference, better cosmetic outcomes resulted from the vertical semisubcuticular technique.

According to Quinn et al, visual analogue scale was calculated 83mm for repair with vertical semisubcuticular suture (11). In the study conducted by Ende et al., the wound cosmetic result was estimated 8.6 for the vertical semisubcuticular suture group (12). In the study conducted by Gennari et al., there was not any difference between skin adhesive and suture groups considering cosmetic score (13). Gandham et al. compared conventional and dynamic sliding loop suture techniques and two observers found that there is not any significant difference between the intervention methods considering the wounds repair. Although there was not any significant difference, visual analogue scores had higher values for the sliding loop technique (14).

Angelini et al. found that final cosmetic outcomes demonstrated that subcuticular suture is better than the nylon vertical mattress one (15). Quinn et al. suggested that there is not any difference between octylcyanoacrylate and sutures considering optimal wound score (73% versus 68%) or cosmetic score of visual analogue scale (69 mm versus. 69mm) (16).

Bernard et al. found that suture group obtained higher score in visual analogue scale in comparison with tissue adhesive (63.3mm versus 47.8mm). The study concludes that cosmetic outcomes of surgical wounds closed with standard suture are better than wounds closed with octylcyanoacrylate (17). Evaluating the potential complications in patients who underwent surgery, there was not any complication and the operations were free from infection and dehiscence.

There was not any difference between skin adhesive and suture groups considering the short-term complications after six months as well as during the one-year follow up period in the study conducted by Gennari et al (13). Gandham et al compared conventional suture and dynamic sliding loop technique and reported one case of infection in every group. Evidences of skin edge necrosis were observed in two patients of conventional suture group (14). According to Angelini et al., subcuticular suture results in less secretion than nylon vertical mattress suture. In Webster and Davis’ study, the wound infection was estimated 8.4% in suture repair (18). Ende et al. did not observe any case of wound dehiscence in the suture group (12). In their study, Ong et al. did not report any case of rash, wound infection, or wound dehiscence in their patients (19). Additionally, Shetty et al. did not report any wound infection or dehiscence in repairing with subcuticular technique (20).

Although semisubcuticular suture technique brings better cosmetic outcomes than the other methods evaluated, statistically we could not find difference between all these techniques. Semisubcuticular suture technique may lead to more satisfaction of patients from the operation results. However, further studies are required to completely approve it.