Skin closure in arthroplasty surgery: Current practice

Abstract

The study by Smith et al. (2010) concluded that clips are associated with 3 times the infection rate compared with subcuticular sutures in orthopaedic surgery (P = .01).For hip surgery, there was a 4‐fold increase. We aimed to determine the trends and influences in skin closure and wound care for hip and knee arthroplasty in the northwest region as well as what would change surgeons' current practice. A short online survey was emailed to consultants in the northwest of England enquiring about their current practice in superficial skin closure, what has influenced this, and finally what would change their practice. Returned surveys were then analysed. A total of 45 consultants responded (response rate of 40.2%). In both hip and knee arthroplasty, clips were the most commonly used superficial skin closure material (53% and 63%, respectively). Personal experience was the greatest influence on the choice of closure material in both hip and knees (84% and 93% respectively). A total of 66% of hip and 76% of knee surgeons would change their closure material if there was evidence to support this. Hip and knee arthroplasty surgeons are influenced by their personal experience, and most use clips as their skin closure method. Most would change their practice with evidence of one material over another. We conclude that there is need for a prospective, well‐powered, multi‐centre randomised control trial to determine the skin closure material that has the lowest return‐to‐theatre rate in arthroplasty surgery.

1. INTRODUCTION

Skin closure in total hip and knee arthroplasty (THA and TKA) surgery has been the subject of repeated investigation. The landmark study by Smith et al. concluded that clips are associated with 3 times the infection rate compared with subcuticular sutures in orthopaedic surgery (P = .01).1 In hip surgery, there was a 4‐fold increase in infection associated with clips.

The optimal goal of skin closure “is to promote rapid skin healing and an acceptable cosmetic result while minimising the risk of dehiscence or infection”.1 More recently, Krishnan et al. performed a meta‐analysis concluding that the only significant difference between staples and sutures was that staples reduced the closure time.2 However, they believed that their results lent support to the Smith et al. conclusion that clips have a higher infection rate in hip surgery than sutures. Both articles concluded that large, well‐powered randomised controlled trials were necessary to determine the method of skin closure with the lowest complication rate.

To our knowledge, there is no study that investigates the current practice amongst arthroplasty surgeons with regard to how they close their skin wounds. In our study, we aim to determine the current trend of skin close in total hip and knee arthroplasty surgery, as well as identify what would cause surgeons to change their current practice.

2. METHODS

Consultants in the northwest of England, obtained using a database, were emailed and asked to participate in a short online questionnaire about their practice in wound closure in hip and knee arthroplasty. The questionnaire was created using Google Forms (Google, California). The results were collated and analysed. Information was collected with regard to the number of arthroplasty surgeries performed each year, current skin closure, dressing material, influences for skin closure, factors that would change practice, when the wound is reviewed, who reviews the wound, and when the clips or sutures are removed. The surgeons were asked to score, on a scale of 1 (not important) to 5 (very important), the importance of different endpoints in an arthroplasty skin closure study.

3. RESULTS

The survey was sent to 288 consultants in the northwest region. Of the consultants, 112 were identified as actively performing hip or knee arthroplasty surgery. A total of 45 consultants responded to the questionnaire, giving a response rate of 40.2%. A total of 34 consultants performed both THA and TKA, with 7 performing only TKA and 4 performing only THA.

3.1. Hip

Of the consultants, 38 returned questionnaires for THA. On average, each consultant performed 85 THA per year, with a range of 10 to 250 (asked to list to nearest 10).

3.2. Material used for superficial skin closure

A total of 53% of the consultants used clips as a single agent for their superficial skin closure. Table 1 shows the other combinations used for THA and TKA.

Table 1.

Materials used for superficial skin closure in total hip arthroplasty (THA) and total knee arthroplasty (TKA)

Material for skin closure	Number of users TKA	Percentage THA (%)	Number of users TKA	Percentage TKA (%)
Clips	20	53	25	63
Subcuticular absorbable barbed suture	2	5	3	8
Subcuticular absorbable braided suture and clips	2	5	3	8
Non‐absorbable continuous suture	4	11	2	5
Subcuticular absorbable braided suture	4	11	4	10
Subcuticular absorbable monofilament suture and glue	1	3	0	0
Subcuticular absorbable monofilament suture and non‐absorbable interrupted suture	1	3	0	0
Subcuticular absorbable monofilament suture	4	11	3	8

TKA, total knee arthroplasty.

3.3. What has influenced the choice of material?

Of the respondents, 84% stated that personal experience was the main influence on their choice of wound closure material in THA; 32% chose their material based on wound aesthetic appearance and 29% because it saved time. Only 26% of the consultants chose their skin closure material based on the evidence available. Cost was only a factor for 8% of the respondents, with logic, colleagues, and cessation of wound leakage a factor for 3%.

3.4. What would change the choice of material?

Of the respondents, 66% would change their choice of superficial skin closure material if there was evidence to support this; 29% would never consider changing their skin closure in THA; and 16% would change if cost became a factor, with 8% stating personal experience and time saving would potentially alter their closure method.

3.5. Type of dressing

Of the respondents, 53% used a standard self‐adhesive dressing for their wounds, and 39% used a long‐term waterproof dressing to cover their wounds. Three consultants listed other dressing types, which included Charnley dressings, DuoDERM dressing, and a highly absorbable honeycomb dressing.

3.6. First removal of the dressing

Postoperatively, 26% of surgeons have the THA dressing removed at day 2 to inspect the wound; 21% did not have a specific time, and 13% removed the dressing only at day 14 for the first time. Of the respondents, 8% removed the dressing at day 3, and 5% removed the dressing at days 1, 4, 5, and 7. The wound was never reviewed in 5%, and in 3%, the wound was reviewed at day 10 and 12. Figure 1 demonstrates when the dressings were first removed from the wound in THA.

Figure 1.

Pie chart showing when the wound in total hip arthroplasty (THA) is first reviewed postoperatively

3.7. Who first reviews the wounds?

Of the wounds, 50% were first reviewed by ward nurses and 26% by the district or practice nurses. Consultants and specialist nurses first reviewed 8% of the postoperative THA wounds. Specialist registrars reviewed 5% of the wounds, and 3% of the wounds were reviewed by the patients themselves.

3.8. How often is the wound reviewed post operatively?

Of the respondents, 39% do not have specific times to review their wounds following THA; 13% review the wound every 2 days, and 11% review the wound only once before discharge. Of the consultants, 8% only review wounds if the dressing is soaked or had been removed; 8% review wounds twice in a 14‐day period; and 5% review the wound every 5 days, and 3% review the wound 3 times in 14 days, the same at day 14, and 3% again only review the wound only if clinically required.

3.9. When are the clips or sutures removed or trimmed?

3.9.1. Clips

Most clips are removed at 14 days in 39% of all the THA respondents; 18% are removed at day 12, 8% at day 10, and 3% at day 9.

3.9.2. Sutures

For all the THA responders, 16% do not remove their sutures as they are absorbable, and 5% trim the suture ends at 10 and 14 days, with 3% trimming at day 2 and 12.

3.10. Knee

A total of 41 consultants returned questionnaires for TKA; 34 perform both TKA and THA surgery, with 7 only performing TKA surgery. On average, each consultant performed 75 TKA operations per year, with a range of 10 to 180 (asked to record to nearest 10).

3.11. Material used for superficial skin closure

Of the surgeons, 63% use clips as a single material for their superficial skin closure. Table 1 shows the combinations in use for skin closure in TKA.

3.12. What has influenced the choice of material?

Of the respondents, 93% stated personal experience was the main influence for their wound closure in TKA; 32% chose their material for the aesthetic appearance and 27% because it saved time. Only 24% of the consultants chose their skin closure material based on the evidence available. Cost was only a factor for 10% of the respondents, with patient preference and bleeding a concern for 2%.

3.13. What would change the choice of material?

Of the respondents, 76% would change their choice of superficial skin closure material if there was evidence to support this; 20% would never consider changing their skin closure in TKA; 15% would change their skin closure if cost was a factor; 12% would change to improve their closure time; and 10% would change based on their personal experience, but 2% would change their closure if they believed it was clinically superior.

3.14. Type of dressing

Of surgeons, 37% use a long‐term waterproof dressing to cover their TKA wounds; 32% use a standard self‐adhesive dressing, and 29% use a non‐adhesive.

3.15. First removal of the dressing

Postoperatively, 27% of TKA dressings are removed at day 2 to review the wound. Of surgeons, 17% have the dressing removed day 1 postoperatively; 15% do not have a specific time to remove the dressings, and 12% do not review the wound; and 7% first remove the dressing on day 3 and day 14, 5% on days 4 and 5, and 2% on days 10 and 12.

3.16. Who first reviews the wounds?

Of the wounds, 55% are first reviewed by ward nurses and 21% by the district or practice nurses. Specialist nurses first review 10% of the postoperative TKA wounds. Only 7% of consultants review their wounds first. Specialist registrars reviewed 5% of the wounds, and 2% of the wounds were reviewed by the patients themselves.

3.17. How often is the wound reviewed postoperatively?

Of the consultants, 51% do not have a specific time to review their wounds following TKA; 12% review the wound every 2 days. Of the responding consultants, 10% only review the wound if the dressing is soaked or removed; 7% review wounds daily, and the same review the wound twice in the first 14 days; 5% review the wound once before discharge; and 2% review the wound every 5 days, 3 times in 14 days, and the same only if clinically required.

3.18. When are the clips or sutures removed or trimmed?

3.18.1. Clips

Of surgeons, 49% remove the clips at 14 days; 12% remove after 12 days, with 5% removing after 10 days and 2% removing at days 9 and 11.

3.18.2. Sutures

Of the THA responders, 15% do not remove their sutures as they are absorbable; 10% trim the suture ends at 14 days, with 5% trimming at day 12.

3.19. Primary outcome measures in THR and TKA

In both hip and knee arthroplasty surgery, the responding consultants believed that return to theatre for a wound complication was the most important primary outcome, with a mean of 4.42 in THA and 4.39 in TKA. For both THA and TKA, the least important outcome was believed to be the overall cost of the superficial skin closure, with a mean score of 3.39 in THA and 3.24 in TKA. Table 2 demonstrates the outcome measures and the ranked average scores. Table 2 also shows the mean score for the mean importance of each primary outcome measure from responding consultants in a trial looking at a skin closure trial in arthroplasty surgery.

Table 2.

Primary outcome measure importance from total hip arthroplasty (THA) and total knee arthroplasty (TKA) responders

	THA	TKA
Primary outcome measure	Scale 1 (not important) to 5 (very important)
Deep infection	4	4
Superficial infection	4.24	4.17
Return to theatre	4.42	4.39
Patient satisfaction	4	3.88
Cosmetic appearance	3.53	3.59
Total cost	3.39	3.24

4. DISCUSSION

The skin closure method causing the least complications in hip and knee arthroplasty is still unknown, as highlighted by Smith et al. and Krishnan et al. in the British Medical Journal. Our study has shown that arthroplasty surgeons primarily make their choice using their own personal experience. Most surgeons expressed that they would change their practice if evidence was presented to them showing an advantage of one method of skin closure. We acknowledge that our trial only has a response rate of 40%, with only 45 responses, and this is a limitation.

The current evidence is lacking, and it requires a well‐powered randomised control trial to determine if there is a difference in return‐to‐theatre rate between different skin closure methods in hip and knee arthroplasty. Campbell et al. have published the largest skin closure trial to date comparing 416 TKA patients with the skin closed by barbed knotless sutures and clips.3 They concluded that wounds closed with barbed sutures were significantly more likely to develop both superficial and deep infection (P < .001). A limitation of this study is that it was not randomised and was underpowered. This is a theme reflected in the large volume of literature published regarding wound closure in arthroplasty surgery. We have shown that surgeons will consider changing practice with robust evidence. As part of a skin closure trial, we believe that randomisation is essential to influence surgeons in changing their practice. This has also been shown previously with 94% of surgeons stating that randomisation is essential in the design of a trial that would change their current practice.4

In a 3‐armed trial comparing clips, subcuticular sutures and barbed sutures for skin closure in 278 hip and knee arthroplasty surgeries found that skin wounds closed using sutures were significantly more likely to have complications than staples (P = .033).5 There was also a significant difference in complications between staples and barbed sutures (P = .017). This study was limited as it was a retrospective single‐surgeon series, with the results underpowered for the endpoint.

5. CONCLUSION

Hip and knee arthroplasty surgeons are largely influenced by their personal experience, and most use clips as the superficial skin closure method. Most would change their practice if there was strong evidence for one material over another. From our findings and the current literature, we conclude that there is need for a prospective, well‐powered, multi‐centre randomised control trial to determine the skin closure material that has the lowest return‐to‐theatre rate in TKA and THA surgery.

Barrow J, Divecha H, Board T. Skin closure in arthroplasty surgery: Current practice. Int Wound J. 2018;15:966–970. 10.1111/iwj.12956