Adhesive strips as the sole method for skin closure is effective in total knee arthroplasty

Abstract

Objective:

Adhesive strips are used as the sole method for skin closure in many operations except total knee arthroplasty. The claims are decreased wound closure time, less tissue reaction, and lack of stitch marks. The purpose of this study was to compare the efficacy of closure using adhesive strips versus running subcuticular stitches.

Methods:

This study was a retrospective case-matched study. Running subcuticular stitches or adhesive strips were used for skin closure in 151 and 137 patients, respectively. All of the patients had an operation by a single surgeon and had the same patient care protocol. All of the patients were evaluated postoperatively for wound complication at 2 weeks, 6 weeks, and 3 months follow-up.

Results:

The wounds of most patients in both groups had healed. The incidence of superficial infection was not different between the groups (1.32% in the running subcuticular suture group and 1.46% in the adhesive strip group) (p = 0.92). One case (0.66%) in the running subcuticular suture group had deep infection, which required reoperation (p = 0.34). The patients in the running subcuticular suture group had higher unabsorbable sutures, which required further removal compared to the adhesive strip group (p < 0.001).

Conclusion:

The use of adhesive strips is an effective skin closure method with a low rate of infection and skin complications. This technique is easy and there is no need for suture removal. Furthermore, there are no stitch marks and the cost of suturing is lower.

Keywords

adhesive tape skin closure subcuticular stitches total knee arthroplasty

Introduction

Wound complication after total knee arthroplasty (TKA) affects the overall outcome of the treatment. This complication might prolong recovery time and increase the cost of treatment. Appropriate skin closure technique is a factor that provides complete wound healing. Many skin closure techniques are used in TKA, such as interrupted nylon stitches,¹ subcuticular stitches,² staple,³ zip-type skin-closing devices,⁴ and octyl-2-cyanoacrylate.⁵

The running subcuticular suture technique is one of the popular methods for skin closure. This method was reported to provide the most robust skin perfusion after TKA compared to vertical mattress and skin staple.² The other benefit of this method is no need for suture removal, which is in contrast with vertical mattress stitches, simple interrupted stitches, and skin staples, which produce pain upon removal. Moreover, running subcuticular stitches do not produce suture marks as in some methods. However, we found in our institute that some patients who had running subcuticular stitches had late wound complications that required further treatment, as reported in a previous study.⁶

Adhesive strips claim to decrease wound closure time, have less tissue reaction and a lack of stitch marks.⁷ A study in median sternotomy wound closure demonstrated that adhesive strips have comparable results with running stitches in terms of superficial wound infection, wound dehiscence, and cosmetic appearance. Furthermore, the adhesive strips provided a lower amount of wound erythema.⁸

We hypothesize that using adhesive strips as the sole method for skin closure in TKA is comparable to running subcuticular stitches. The purpose of this study was to compare the incidence of complications of TKA skin closure between adhesive strips and running subcuticular stitches.

Materials and methods

This study was a retrospective case-matched study. The data of osteoarthritic patients who had primary TKA between May 2016 and July 2018 were retrieved from the electronic hospital database. All of the patients had an operation by a single surgeon. The surgeon performed skin closure with running subcuticular stitches in all TKA patients between May 2016 and June 2017 and the surgeon performed skin closure in all patients with only adhesive strips between July 2017 and July 2018. The data of both groups of patients were evaluated for wound complications. This study was approved by the Ethics Committee and Institutional Review Board of the Faculty of Medicine, Prince of Songkla University (EC 61-153-11 -1). Consent was waived by the ethics committee. The hospital gave permission to extract information from the database.

The inclusion criteria were patients in the age range of 45–85 years, who had TKA for primary osteoarthritis with a minimum 3-month postoperative follow-up visit. The exclusion criteria were patients, who had previous knee surgery. Finally, the study patients were placed into either the adhesive strip group or running subcuticular suture group.

All patients had surgery by a single surgeon with the same surgical techniques and patient care protocol except for the skin closure technique. The anterior skin incision was done at the proximal pole of the patella to the medial border of the tibial tuberosity. Medial parapatellar arthrotomy and a cemented posterior-stabilized total knee prosthesis were used in all patients. A pneumatic tourniquet was inflated from the initial incision until complete capsular closure with 150 mmHg of pressure over systolic blood pressure. Prophylaxis antibiotic was either cefazolin or clindamycin in the case of penicillin or cephalosporin allergy, which was injected 30 min prior to starting the incision.

All patients received capsular closure with figure-of-eight stitches by no. 1 polyglactin 910 (Coated Vicryl Plus, Ethicon Inc., Somerville, NJ, USA). The subcutaneous layers were stitched with buried knots by 3-0 polyglactin 910 (Coated Vicryl Plus, Ethicon Inc.). The buried knots were placed throughout the wound until all of the subcutaneous layers were approximated. The skin closure method depended on the group of patients. The first group received 4-0 polydioxanone (PDS-II, Ethicon Inc.) using the running subcuticular technique followed by 25-mm wide adhesive strips (Steri-Strip™, 3 M HealthCare, St Paul, Minnesota, USA). Adhesive strips were placed throughout the incision to align perpendicularly with the wound incision by a 0.5 mm separation between each strip. The second group received skin closure with adhesive strips only. Skin closure was performed in the 45° knee flexion position. The wounds were covered with a sterile gauze after skin closure was done.

Early ambulation with a supportive device and range of motion exercise was started at postoperative day 1. A polyurethane film surgical dressing (Opsite Post-Op, Smith & Nephew, Hull, UK) was applied instead of sterile gauze dressing on postoperative day 3 and removed on postoperative day 14. The patients were followed up at day 14, 6 weeks, and 3 months after surgery.

Statistical analysis

The analyses were conducted using R version 3.1.0 software (R Foundation for statistical computing, Vienna, Austria). Normal distribution of the data was determined by the Kolmogorov–Smirnov test. Patient’s age, body weight, height, body mass index (BMI), and operative time were evaluated with the Student’s t-test. Patient sex, side of operation, underlying condition, such as diabetes, rheumatoid arthritis, or history of steroid use, used the Pearson’s χ ² test for a comparison between the groups.

The sample size estimation was performed based on a previous study,⁹ 83 samples per group were required to detect a 15% difference in the wound complication rate with a significance level set to 0.05 and a power set to 0.8.

Demographics and description of study population

A total of 288 patients were included in this study. Running subcuticular stitches were used for skin closure in 151 patients and adhesive strips in 137 patients. The patient demographic data had no differences between the two groups (Table 1). There were no significant differences in patient age, sex, side of operation, body weight, height, BMI, or percentages of patients with diabetes, rheumatoid arthritis, or steroid use between the two groups.

Table 1.

Demographic data.

Characteristics	Group 1 (running subcuticular, n = 151)	Group 2 (adhesive strips, n = 137)	p Value
Age (years)	68.60 ± 10.48^a	68.61 ± 7.95^a	0.99
Sex (male:female)	23:128	11:126	0.59
Side (right:left)	76:75	63:74	0.46
Weight (kg)	64.64 ± 10.3^a	64.64 ± 9.71^a	0.99
Height (cm)	153.47 ± 7.77^a	152.39 ± 7.19^a	0.22
BMI (kg/m²)	27.47 ± 4.03^a	27.83 ± 4.04^a	0.44
Diabetes	29	27	0.91
Rheumatoid arthritis	9	5	0.36
Steroid use	11	6	0.30

BMI: body mass index; SD: standard deviation.

^a Values are expressed as mean ± SD, unless indicated otherwise.

Results

Most wounds of the patients in both groups had healed without the need for reoperation (150 patients (99.34%) in the running subcuticular suture group and 137 patients (100%) in the adhesive strips). The incidence of superficial infection was not different between the groups (two patients (1.32%) in the running subcuticular suture group and two patients (1.46%) in the adhesive strips) (p = 0.92). All of the superficial infections were stitch abscess found at 2 weeks. The patients had a small abscess with minimal purulent discharge without systemic symptoms. All patients were successfully treated with cephalexin (500 mg) capsule four times a day and the dressings were changed every day for a week without a microbiological study of the discharge. There were no cases in either group that required resuturing. However, one case (0.66%) in the running subcuticular suture group had a deep infection, which required reoperation for debridement and polyethylene exchange (p = 0.34).

The patients in the running subcuticular suture group had more unabsorbable stitches, which required further removal (42.45%) compared to 3.65% in the adhesive strip group (p = 0.001). The incidence of stitches that eroded through the skin and required removal was found mostly at 6 weeks postoperatively (82.2% in the running subcuticular suture group and all patients in the adhesive strip group). At 3-month and 2-weeks follow-up, 15.56% and 2.22%, respectively, of the patients in the running subcuticular stitches group needed removal of the stitches. A summary of the wound complications is shown in Table 2.

Table 2.

Wound complication.

Characteristics	Group 1 (running subcuticular, n = 151)	Group 2 (adhesive strips, n = 137)	p Value
Superficial infection	2 (1.32%)	2 (1.46%)	0.92
Deep infection	1 (0.66%)	0	0.34
Suture removed	45 (42.45%)	5 (3.65%)	<0.001
Resuture	0	0	1.00

Discussion

Complete wound healing without complication is one of the factors that affect overall outcome and patient satisfaction. A good wound closure technique should be easy to apply, use less time, have minimal wound complication, be comfortable for the patients, and easy to remove.¹⁰ The adhesive strip is one type of skin closure techniques that are used in many operations.^11
−13 This technique requires shorter operative time compared with other methods, no pain upon removal, and no suture marks after removal. However, no study has reported the efficacy of using adhesive strips as the sole method for skin closure in TKA, which has higher tissue tension and motion.

This current study found that the incidence of wound infection in the adhesive strip group was comparable with the running subcuticular suture group. This result was the same as a previous study in ankle arthroscopy, which reported a prospective crossover study that compared skin closure methods between nylon stitches and adhesive strips in patients, who had ankle arthroscopy. The results showed that both skin closure methods had comparable results in wound description, infection rate, and cosmetic appearance.¹⁴ However, another randomized control study, which compared running subcuticular stitches and adhesive strips for skin closure in median sternotomy for a cardiac surgical procedure, demonstrated that the adhesive strips had a lower incidence of wound erythema and edema than the running subcuticular stitches.⁸

Our study found a high incidence of skin reaction with running subcuticular stitches. Some parts of the suture had eroded through the wound and needed to be withdrawn. We hypothesized that this complication was from the type of suture material used in this study which was PDS. Our results were the same as a study by Casha and Hadden that found skin reaction in 20% of TKA cases that used subcuticular PDS sutures for closure.⁶ In this current study, the complication usually appeared at 6 weeks postoperatively, which was not much different than the Casha and Hadden study that found complications at 7 weeks.⁶ This study suggested that subcuticular PDS should not be used for skin closure after TKA. The exact cause of the reaction from PDS is unknown. A report stated that it might be from marked resilience of the suture, slow rate of degradation, and a persistent knot.¹⁵

To our knowledge, this is the first study to report the results of adhesive strips as the sole method for skin closure in TKA. The limitation of this study was the retrospective study design. However, the surgical technique and patient care protocol were not different in the two groups. Furthermore, the strict follow-up protocol after TKA in our institute combined with the electronic patient record form limited the loss of important clinical information.

Conclusions

The use of adhesive strips is an effective skin closure method with a low rate of infection and skin complications. This technique is easy and there is no need for suture removal. Also, there are no stitch marks and the cost of suturing is lower. The authors do not recommend using PDS as the suture material for running subcuticular stitches in TKA. We now use adhesive strips as the sole method for skin closure of the wound following TKA.

Footnotes

Acknowledgements

The authors wish to thank Glenn Shingledecker for his assistance in proofreading the English of this report.

Availability of data and materials

The datasets generated during the current study are available from the corresponding author upon reasonable request.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand (grant number 61-153-11 -1).

ORCID iD

Varah Yuenyongviwat

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