SLR - March 2021 - Zinnia M. Rocha

Skin Closure with Surgical Staples in Ankle Fractures: A Safe and Reliable Method

Reference: Prabhakar, G., Bullock, T.S., Martin, C.W. et al. Skin Closure with Surgical Staples in Ankle Fractures: A Safe and Reliable Method. International Orthopaedics (SICOT) 45, 275–280 (2021).

Level of Evidence: III

Scientific Literature Review

Reviewed By: Zinnia M. Rocha, DPM
Residency Program: Medstar Health Podiatric Surgery Residency – Washington DC

Podiatric Relevance: Soft tissue complications following ankle fracture repair are relatively common and can result in increased rates of infections and delayed healing. In turn, orthopedic infections have been correlated with increased length of stay, healthcare costs, post-operative mortality, and re-hospitalization rates. While existing orthopedic literature comparing suture closure with staple closure is somewhat confounding, studies looking specifically at outcomes in ankle fracture patients are limited to smaller patient series.

Methods: The study team conducted a retrospective review of closed ankle fractures that underwent open reduction and internal fixation at a level 1 trauma center between 2014-2016. The sample excluded pediatric patients and those who did not complete 12 weeks of follow up. Closure approach was dictated by the performing surgeon and all patients followed up at similar postoperative intervals. Surgical site complications were classified as either superficial infection, deep surgical site infection or other wound complication. The primary outcome measure was defined as the presence of one of the above complications and the secondary outcome measure was the classification of that complication into either superficial, deep or other.

Results: A total of 545 patients underwent ORIF during the study period and 360 patients went on to meet the inclusion criteria. The study population consisted of 119 patients who underwent closure with nonabsorbable suture and 241 patients who underwent closure with staples. Demographic data gathered from the medical record revealed 30.6 percent were current smokers, 48.9 percent were obese and 16 percent had diabetes. There were no statistically significant differences in demographic variables, comorbidities, nor injury characteristics.

The overall rate of surgical site complication was 15.6 percent. While there was a higher rate amongst patients who underwent suture closure (20.2 percent versus 13.3 percent), this did not reach statistical significance. Superficial site infection was the most common type of complication at 6.7 percent. There was a slightly higher incidence of these superficial infections in the suture group (10.1 percent versus 5 percent), but again this difference did not reach significance. Deep infection and other wound complication rates in both groups were comparable.

Conclusions: The authors conclude that the use of surgical staples for skin closure as part of ankle ORIF is a relatively safe and reliable technique. The authors also acknowledge that the retrospective nature of their study presents limitations and comment on the potential for selection bias given the choice of skin closure modality was at the individual surgeon’s discretion. While the patient population is described by BMI, gender, comorbidities, ASA classification, polytrauma, mechanism of injury, ankle fracture dislocation, AO classification and operative time, how these parameters may have specifically influenced study outcomes is not discussed in the present study. With such a large sample size, additional data to this effect would certainly prove useful in guiding surgeons when they are selecting closure technique to optimize healing outcomes for their individual patients.

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