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Is Subcutaneous Suture Necessary?
Orthopedic & Muscular System: Current Research

Orthopedic & Muscular System: Current Research
Open Access

ISSN: 2161-0533

+44-20-4587-4809

Research Article - (2012) Volume 1, Issue 1

Is Subcutaneous Suture Necessary?

Babak Siavashi1*, Ehsan Pendar2, Mohammad Reza Golbakhsh1, Mir Mostafa Sadat3, Mohammad Javad Zehtab3 and Dariush Gouran Savad Kouhi3
1Assistant Professor of Orthopedics, Sina Hospital, Tehran University of Medical Sciences, Iran
2Resident of Orthopedics, Sina Hospital, Tehran University of Medical Sciences, Iran
3Associate Professor of Orthopedics, Sina Hospital, Tehran University of Medical Sciences, Iran
*Corresponding Author: Babak Siavashi, Sina Hospital, Tehran University of Medical Sciences, Imam Khomeini St., Tehran, Iran, Tel: 9821-66348543, Fax: 9821-66348543 Email:

Abstract

Introduction: It is most often advised to repair subcutaneous soft tissue using absorbable sutures at the end of surgery before skin closure. We purposed to evaluate the outcome of post operative wound in the instances of avoiding subcutaneous suturs.
Materials and methods: We conducted a single blind randomized clinical trial during 1382-88 on all patients who attended for orthopedic surgeries in Sina hospital. Patients with secondary closure or cutaneous or myocutaneous graft/flap are axcluded from study. After categorizing patients based on upper/lower limb and fascia repair, the patients were divided into two groups with or without subcutaneous repair using computerized random numbers chart. The patients were assessed for probable complications (wound dehiscence, infection, fluid collection, inflammation and skin necrosis) at 1st, and 2nd weeks as well as the 1st and 3rd months postoperatively.
Results: After administering inclusion and exclusion criteria, 14953 patients (1662 female, 13291 male; mean age 40.6±4.9 years) were enrolled in the study 6120 had subcutaneous repair. The observed complications in patients without subcutaneous sutures in comparison to the others with subcutaneous sutures besides other parameters (upper or lower extremity and fascia repair) were not statistically significant regarding wound inflammation, infection, fluid collection, necrosis and dehiscence.
Discussion: It seems that omitting subcutaneous soft tissue repair will not lead to major complications in several cases of orthopedic surgery. It shortens the time of surgery and may also reduce the costs because of suture materials.

Keywords: Suture; Subcutaneous; Complications

Introduction

Most surgery descriptions in books suggest that subcutaneous soft tissue is repaired using absorbable sutures at the end of surgery and after closing the fascia; then, the skin is repaired by non-absorbable sutures [1]. Subcutaneous absorbable sutures are known to have several advantages like omitting the subcutaneous for avoiding seroma collection [2], reducing tension in wound edges for bringing the sides together and having a softer scar after suturing. However, some outcomes of subcutaneous sutures may be a longer operation time, reaction to absorption stages of subcutaneous absorbable sutures [3-5] (Table 1) and an increase in final costs of surgeries. Since few studies have been conducted on the possibility of avoiding subcutaneous sutures around the world and no similar studies have been carried out in Iran, we decided to conduct a comparative study on using and avoiding subcutaneous sutures before final repair.

Surgery site Subcutaneous suture
Done Undone
Number Percentage Number Percentage
Upper extremity
With fascia repair
Without fascia repair
72
1080
1.0
18.0
49
2952
1.0
33.0
Lower extremity
With fascia repair
Without fascia repair
3096
1872
51.0
30.0
1584
4248
18.0
48.0
Total 6120 100.0 8833 100.0

Table 1: Distribution of patients in studied groups.

Materials and Methods

This single blind randomized clinical trial was conducted on all eligible orthopedic surgery candidates who referred to Sina Hospital during six years from 2003 to 2009. Since no similar study has been conducted on orthopedic patients and as maximizing power and minimizing type I and II was necessary, all eligible patients who had undergone surgery during the mentioned time were enrolled for the study. The proposal and the methodology of the study were approved by the Research and Medical Ethics Committee of the hospital. This was a single blind study; i.e. the patients were not aware of their classification but the surgeons were informed of their grouping and the required information of the patients in both groups (upper/lower extremity, repairing or not repairing fascia).

Inclusion criteria

All orthopedic surgery candidates with the possibility of primary wound repair who signed the informed consent form and returned for follow ups every three months postoperatively, entered the study. The surgical operations include all elective surgeries with clean wounds, traumas and fractures without the need for leaving the wound open or performing secondary wound repair as well as cases in which cutaneous graft, cutaneous and myocutaneous flap was not required.

Exclusion criteria

Patients with at least one of the following conditions were excluded from the study:

1. Patients whose wound had to be left open or required secondary repair
2. Patients requiring cutaneous graft, cutaneous and myocutaneous flap
3. Incisions<2cm
4. Patient who did not participate in 3-month follow up sessions due to travel, death or uncooperativeness

Method

After executing the inclusion and exclusion criteria, the cases signed an informed consent and were divided into the two major groups of upper and lower extremities. Then, they were assigned to subgroups with and without fascia repair and were randomly classified into with/without subcutaneous repair classes. Simple randomization was carried out using computerized random numbers chart (Table 2). It is to be noted that the basis of the classification was the difference in the repair power of upper and lower extremities and the point that upper and lower limb fascia repair surgeries are conducted above the elbow and knee, respectively. The difference in sample sizes is the result of simple randomization.

Extremity Repair Complication Subcutaneous suture probability
Yes No
Upper With fascia repair Wound edge necrosis
Subcutaneous fluid collection
Dehiscence
Wound infection
Cutaneous reaction (Inflammation)
0
1
0
2
2
1
1
0
0
2
0.405
0.648
----
0.352
0.642
Without fascia repair Wound edge necrosis
Subcutaneous fluid collection
Dehiscence
Wound infection
Cutaneous reaction (Inflammation)
1
0
0
4
6
4
1
1
9
13
0.595
0.732
0.732
0.476
0.401
Lower With fascia repair Wound edge necrosis
Subcutaneous fluid collection
Dehiscence
Wound infection
Cutaneous reaction (Inflammation)
3
17
0
38
12
1
9
0
22
8
0.583
0.541
----
0.367
0.357
Without fascia repair Wound edge necrosis
Subcutaneous fluid collection
Dehiscence
Wound infection
Cutaneous reaction (Inflammation)
12
6
5
31
15
41
16
12
70
37
0.132
0.470
0.576
0.529
0.459

Table 2: Comparing complications in studied groups.

In the subcutaneous suture group, absorbable Vicryl was used for repair and each 3 cm of the tissue was sutured; however, non-absorbable nylon braid was used for skin repair. Subcutaneous drain was not used in any of the groups but sub-fascia drain was inserted for all fascia repair cases. The initial wound dressing was changed on the second day, postoperatively. Next dressings were changed every day and on 10th-14th day, the sutures were pulled. The patients were examined for skin edge necrosis, cutaneous and dermal reaction (inflammation), infection, dehiscence, fluid and seroma collection in 1st and 2nd weeks and 1st and 3rd months. The follow up period was three months because Vicryl is completely absorbed within 3 months and soft tissue repair complications usually represent before that. Therefore, the wound status and tensity reaches a plateau during the said time [6].

Dehiscence is defined as an opening of wound edges due to weak sutures without any sign of infection and inflammation. Infection can be determined by pus secreted from the wound and necrosis refers to the discoloration of wound edges into dark blue or black so that the skin is not alive and requires repair. Subcutaneous fluid collection was considered as a case with a clear representation requiring sutures opening and fluid discharge. Cutaneous reaction was only defined as wound edge redness without secretions. It is noteworthy that in some cases where the wound was slightly red and inflamed but was represented in form of infection and pus in subsequent examinations, the latter was considered as the final complication.

Statistical analysis

All the data were entered in SPSS ver. 15 and descriptive statistics were provided for qualitative and quantitative variables (Table 3). The frequency of complications resulting from not having subcutaneous sutures was separately determined; its association with the repair method was obtained in form of sub-group analysis using Chi-square test. The significance of the tests was considered 0.05.

Complication Upper extremity Lower extremity
With fascia repair Without fascia repair With fascia repair Without fascia repair
Subcutaneous suture p Value Subcutaneous suture p Value Subcutaneous suture p Value Subcutaneous suture p Value
With Without With Without With Without With Without
Wound edge necrosis 0 1 0.405 1 4 0.595 3 1 0.583 12 41 0.132
Subcutaneous fluid collection 1 1 0.648 0 1 0.732 17 9 0.541 6 16 0.470
Dehiscence 0 0 1 0 1 0.732 0 0 1 5 12 0.576
Wound infection 2 0 0.352 4 9 0.476 38 22 0.367 31 70 0.529
Cutaneous reaction (Inflammation) 2 1 0.642 6 13 0.401 12 8 0.357 15 37 0.459

Table 3: Statastical Analysis of Qualitative and Quantitative variables.

Results

After administering the inclusion and exclusion criteria, 14953 patients (1662 females and 1329 males; mean age: 40.6±4.9 yrs.) were enrolled for the study; then, 4153 patients were assigned to the upper extremity and the other 10800 cases were categorized as the lower extremity group. The age range of the former and the latter groups was 4-86 (mean age: 32.3±8.6 yrs.) and 1-103 (mean age: 45.7±8.5 yrs.), respectively. The distribution of the patients and their classification according to having/not having fascia repair and then subcutaneous sutures is presented in Figure 1. The complications were mostly observed in the lower extremity group (355 vs. 47), among the cases without fascia repair (284 vs 118) and in the no-suture group (247 vs 145). The significant difference between the complications in upper and lower extremities was observed in both early (like inflammation) and delayed complications (like infection).

orthopedic-muscular-system-vicryl-braids-skin

Figure 1: Vicryl braids on the skin surface.

Of the total 176 wound infections, 160 cases were observed during the 2nd and 3rd examinations and the rest were detected in the first examination. All complications due to subcutaneous fluid collection or wound edges inflammation were observed during the first examination and the ones resulting from dehiscence and skin edge necrosis were seen in the first and the second examinations.

There was a significant relationship between subcutaneous suturing and complications like skin edge necrosis, coetaneous and dermal reaction (inflammation), infection, dehiscence and subcutaneous seroma and fluid collection, though they were not generally or individually observed in follow up sessions (Figure 2).

orthopedic-muscular-system-patients-fascia-suture

Figure 2: Classifying patients into different groups based on upper/lower limb, fascia repair and subcutaneous suture.

Discussion and Conclusion

Subcutaneous suturing is often recommended at the end of operation and before skin closure [1]. In this study, it is tried to compare the incidence of complications resulting from using or not using subcutaneous sutures in orthopedic surgery candidates.

According to the findings of the study, soft tissue complications were more prevalent in the lower extremity. This phenomenon can be associated with better perfusion in the upper extremity and the point that lower extremity traumas occur with more energy and this can be the reason for more severe soft tissue damage and the relevant complications.

Moreover, some complications like subcutaneous fluid collection, inflammation around the wound and dehiscence are more frequently observed in 1st and 2nd weeks while infection usually represents in 2nd and 4th weeks, preoperatively. In most cases, dehiscence represents up to the 2nd week and since the wound tissue has a better consolidation, the incidence of the complication decreases. The case is the same with subcutaneous fluid collection and after the 2nd week, the fluid is either absorbed or becomes infectious.

Based on the existing studies, the only case in which subcutaneous suturing is preferred is the use of subcuticular suture (plastic) or staple for skin repair [7-9]. In such conditions, subcutaneous suturing before skin repair leads to a more convenient, delicate and faster repair of the skin. In the study of Kore et al, the rate of complications due to not using subcutaneous suturing following abdominal hysterectomy of obese women is reported to be high. However, further investigations were not carried out to compare complications with the other group (with subcutaneous suturing) and to find the statistical significance [10]. In another study, the difference between two-layer and threelayer suturing in laparotomy was not significant [11]. Furthermore, following the study conducted on pilonidal sinus surgery candidates, simple skin suturing is an effective, inexpensive method [12].

Findings of the present study asserts that as no significant difference was observed in soft tissue complications of patients with and without subcutaneous suturing, it can be confidently said that the use of subcutaneous sutures did not have a specific effect on reducing complications like wound edge necrosis, a sign of the excessive tensin of skin; subcutaneous fluid collection, a sign of subcutaneous virtual space and other complications like dehiscence, wound infection and cutaneous reaction (inflammation). On the other hand, since subcutaneous suturing requires sufficient time, eliminating this technique can save the operation time and anesthesia and avoiding Vicryl can reduce the costs.

References

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  2. Tan PC, Mubarak S, Omar SZ (2008) Absorbable sutures for subcuticular skin closure of a transverse suprapubic incision. Int J Gynaecol Obstet 103: 179- 181.
  3. Van Rijssel EJ, Brand R, Admiraal C, Smit I, Trimbos JB (1989 )Tissue reaction and surgical knots: the effect of suture size, knot configuration, and knot volume. Obstet Gynecol 74: 64-68.
  4. Smit IB, Witte E, Brand R,Trimbos JB (1991) Tissue reaction to suture materials revisited: is there argument to change our views? Eur Surg Res 23: 347-354.
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  6. Esenyel CZ, Demirhan M, KiliƧoglu O, Adanir O, BilgiƧ B et al. (2009) Evaluation of soft tissue reactions to three nonabsorbable suture materials in a rabbit model. Acta Orthop Traumatol Turc 43: 366-372.
  7. Gaertner I, Burkhardt T, Beinder E (2008) Scar appearance of different skin and subcutaneous tissue closure techniques in caesarean section: a randomized study. Eur J Obstet Gynecol Reprod Biol 138: 29-33.
  8. Guyuron B, Vaughan C (1992) A comparison of absorbable and nonabsorbable suture materials for skin repair. Plast Reconstr Surg 89: 234-236.
  9. Kore S, Vyavaharkar M, Akolekar R, Toke A, Ambiye V (2000) Comparison of closure of subcutaneous tissue versus non-closure in relation to wound disruption after abdominal hysterectomy in obese patients. J Postgrad Med 46: 26-28.
  10. Coomer RPC, Mair TS, Edwards GB, Proudman CJ (2007) Do subcutaneous sutures increase risk of laparotomy wound suppuration? Equine Vet J 39: 396- 399.
  11. Yigit T, Yigitler C, Gulec B, Ihsan Uzar, Ozer T, et al. (2005) Do we Need to Use Subcutaneous Suture for Pilonidal Sinus Treated with Excision and Simple Primary Closure? Acta chir belg 105: 635-638.
Citation: Siavashi B, Pendar E, Golbakhsh MR, Sadat MM, Zehtab MJ, et al. (2012) Is Subcutaneous Suture Necessary? Orthopedic Muscul Sys 1: 107.

Copyright: © 2012 Siavashi B, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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