Comparing sutures versus staples for skin closure after orthopaedic surgery: systematic review and meta-analysis

Abstract

Objective: To determine whether there still remains a significant advantage in the use of sutures to staples for orthopaedic skin closure in adult patients.

Design: Systematic Review/ Meta-Analysis.

Data sources: MEDLINE-OVID, EMBASE-OVID, CINAHL and Cochrane Library. Grey and unpublished literature was also explored by searching: International Clinical Trial Registry, Grey Matters BIOSIS Previews, Networked Digital Library of Theses and Dissertations, ClinicalTrials.gov, UK Clinical Trials Gateway, UK Clinical Research Network Study Portfolio, Open Grey, Grey Literature Report, and Web of Science.

Selection criteria: Articles were from any country, written in English and published after 1950. We included all randomised control trials and observational studies comparing adults (≥ 18 years) undergoing orthopaedic surgery who either received staples or sutures for skin closure. The primary outcome was the incidence of surgical site infection. Secondary outcomes included closure time, inflammation, length of stay, pain, abscess formation, necrosis, discharge, wound dehiscence, allergic reaction and health-related quality of life.

Results: 13 studies were included in our cumulative meta-analysis conducted using Review Manager V.5.0. The risk ratio was computed as a measure of the treatment effect taking into account heterogeneity. Random-effect models were applied. There was no significant difference in infection comparing sutures to staples. The cumulative relative risk was 1.06 (0.46 to 2.44). In addition, there was no difference in infection comparing sutures to staples in hip and knee surgery, respectively. Lastly, except for closure time, there was no significant difference in secondary outcomes comparing sutures to staples.

Conclusions: Except for closure time, there was no significant difference in superficial infection and secondary outcomes comparing sutures to staples was found. Given that there may in fact be no difference in effect between the two skin closure and the methodological limitations of included studies, authors should begin to consider the economic and logistic implications of using staples or sutures for skin closure.

Prospero registration number: CRD42015017481.

Figure 1

PRISMA flow diagram.

Figure 2

Forest plot of the cumulative risk ratio (95% CI) of wound infection comparing patients who received staples or sutures for wound closure after orthopaedic surgery. Analysis conducted with Mantel-Haenzel random-effects model.

Figure 3

Forest plot of the cumulative risk ratio (95% CI) of wound dehiscence comparing patients who received staples or sutures for wound closure after orthopaedic surgery. Analysis conducted with Mantel-Haenszel random effects model.

Figure 4

Forest plot indicating the adjusted relative risk (RR; 95% CI) of infection within scenario 1: all lost to follow-up had infection in the suture group, thus favouring staples. Original randomised treatment sizes were used for RR calculations. Cumulative effect was calculated using the Mantel-Haenzel random-effects model.

Figure 5

Forest plot indicating the adjusted relative risk (RR; 95% CI) of infection within scenario 2: all lost to follow-up had infection in the staple group, thus favouring sutures. Original randomised treatment sizes were used for RR calculations. Cumulative effect was calculated using the Mantel-Haenzel random-effects model.

Figure 6

Forest plot indicating relative risk (95% CI) within hip surgeries. Cumulative effect was calculated using the Mantel-Haenzel random-effects model.

Figure 7

Forest plot indicating relative risk (95% CI) within knee surgeries. Cumulative effect was calculated using the Mantel-Haenzel random-effects model.

Figure 8

Funnel plot examining potential publication bias for incidence of wound infection after orthopaedic surgery (RR, relative risk).