SLR - June 2021 - Madison Ravine

Impact of Skin Suture Pattern on Incision Perfusion Using Intraoperative Laser Angiography: A Randomized Clinical Trial of Patients with Ankle Fractures

Reference: Shorten P, Haimes M, Nesbit R, Bartlett C, Schottel P. Impact of Skin Suture Pattern on Incision Perfusion Using Intraoperative Laser Angiography: A Randomized Clinical Trial of Patients with Ankle Fractures. J Orthop Trauma. 2020 Oct;34(10):547-552. doi: 10.1097/BOT.0000000000001787. PMID: 32947587.

Level of Evidence: Therapeutic Level I

Scientific Literature Review

Reviewed By: Madison Ravine, DPM
Residency Program: Cambridge Health Alliance – Cambridge, MA

Podiatric Relevance: When managing the acute ankle fracture, appreciating the degree of concomitant soft tissue injury is paramount in determining outcome. The principle post-operative complication for ankle ORIF remains incisional wound healing. As such, multiple surgeon-controlled variables have been investigated to mitigate these risks. In this study, the authors aimed to investigate which skin closure pattern—simple interrupted, vertical mattress, horizontal mattress, Allgöwer-Donati, or running subcuticular—allowed for the greatest incisional perfusion as measured by indocyanine green laser angiography (ICGLA) following ankle fracture ORIF.

Methods: All patients with OTA 44 A, B, or C ankle fractures requiring operative management presenting to a single Level 1 trauma center were enrolled in this prospective, randomized clinical trial. Exclusion criteria included previous surgery to the area and iodine allergy, which would preclude the use of ICGLA. All patients underwent ORIF using standard AO technique with lateral or posterolateral approach. In accordance with the authors’ common practice, layered closure was performed using #1 Vicryl and 2-0 Monocryl in simple interrupted fashions. All patients were then randomly allocated to one of five skin closure techniques (simple interrupted, vertical mattress, horizontal mattress, Allgöwer-Donati, or running subcuticular). Skin closure was performed using 3-0 Monocryl for running subcuticular and 3-0 Nylon for all others. Incision perfusion was then assessed using ICGLA. Measurements obtained included mean incision perfusion and mean perfusion impairment – a comparison of the incision perfusion to that of adjacent uninvolved tissue. Patients were matched as to age, body mass index, and medical comorbidities. Operative metrics were matched as to time to surgery, time from tourniquet deflation to ICGLA, and fracture classification between cohorts. All patients were followed for a minimum of three months post operatively. At the three-month post-operative visit, patient satisfaction of scar was assessed via the Modified Patient and Observer Scar Assessment Scale (POSAS).

Results: Of the 75 patients included in this study, 15 were allocated to each cohort. Across all cohorts, the running subcuticular pattern demonstrated statistically superior perfusion. Regarding mean incision perfusion, the running subcuticular pattern demonstrated greater perfusion than Allgöwer-Donati, vertical mattress, horizontal mattress, and simple interrupted (in descending order). In terms of mean perfusion impairment, the running subcuticular pattern demonstrated the lowest perfusion impairment equal only to the Allgöwer Donati, followed by vertical mattress, horizontal mattress, and finally simple interrupted. There was no statistically significant difference in POSAS score between cohorts.

Conclusions: This study demonstrates that the running subcuticular pattern had greater incision perfusion than all other suture patterns and lower perfusion impairment than all except the Allgöwer Donati, without any patient perceived difference in scar. Using running subcuticular closure in combination with standard principles of soft tissue handling, such as full thickness flaps and limited manipulation, may work synergistically to optimize outcomes. This data is particularly important in medically high-risk populations or high risk fracture patterns. This study further highlights the application and use of ICGLA in orthopedic trauma. Moving forward, ICGLA may prove a helpful tool in assessing and mitigating post traumatic soft tissue compromise. 

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