When kids present with lacerations, we have choices as to how to stitch them up. This journal club reviews the literature on the appropriate selection of sutures in children, and pits tissue adhesive head-to-head against adhesive strips.
After evaluating this article, participants will be able to:
1. Incorporate strategies into practice for effective wound closure in pediatric patients
2. Apply an evidence-based approach to the use of various wound closure products and techniques
We often see lacerations and wounds in the emergency department, and I am always surprised by how many physicians are still using non-absorbable sutures in children. Taking small stitches out of a child’s facial laceration can be extremely difficult. At times it may even require sedation if the child is unable to cooperate with suture removal – especially if the stitches are close to the periorbital region. In addition, I have seen several instances of wound infection from the inappropriate use of tissue adhesive for wounds that are at high risk for contamination, such as dog bites to the face.
Q: Can we use absorbable sutures for facial lacerations in children?
A: The first two studies confirm that absorbable sutures are a practical solution for facial laceration repair.
Citation_1: Luck RP, Flood R, Eyal D, Saludades J, Hayes C, Gaughan J. Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care. 2008 Mar;24(3):137-42.
OBJECTIVES: This study sought to compare the long-term cosmetic outcomes of absorbable versus non-absorbable sutures for facial lacerations in children and to compare the complication rates and parental satisfaction in the 2 groups.
DESIGN/METHODS: Healthy patients presenting to a pediatric emergency department with facial lacerations were randomized to repair using fast-absorbing catgut or nylon suture. Patients were followed up at 5 to 7 days and at 3 months. Three blinded observers, using a previously validated 100-mm cosmesis visual analogue scale (VAS) as the primary instrument, rated photographs of the wound taken at 3 months. For this noninferiority study, a VAS score of 15 mm or greater was considered to be the minimal clinically important difference. Parents also rated the wound using the VAS and completed a satisfaction survey.
RESULTS: Of the 88 patients initially enrolled, 47 patients completed the study: 23 in the catgut group and 24 in the nylon group. There were no significant differences in age, race, sex, wound length, number of sutures, and layered repair rates in the 2 groups. The observers’ mean VAS for the catgut group was 92.3 (95% confidence interval [CI], 89.1-95.4) and that for the nylon group was 93.7 (95% CI, 91.4-96.0), with a difference of the means of 1.4 (95% CI, -5.31 to 8.15), which was less than the minimal clinically important difference of 15 mm (power, >90%). The mean parental VAS score for the catgut group was 86.3 (95% CI, 78.4-94.1) and that for the nylon group was 91.2 (95% CI, 86.9-95.4), with a difference of the means of 4.9 (95% CI, 2.41-7.41), also less than 15 mm. There were no significant differences in the rates of infection, wound dehiscence, keloid formation, and parental satisfaction.
CONCLUSIONS: The use of fast-absorbing catgut suture is a viable alternative to nonabsorbable suture in the repair of facial lacerations in children
Citation_2: Karounis H, Gouin S, Eisman H, Chalut D, Pelletier H, Williams B. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med. 2004 Jul;11(7):730-5.
OBJECTIVES: To show that the use of absorbable sutures in pediatric traumatic lacerations affords good long-term cosmesis and no increase in complications (infection, dehiscence rates, and need for surgical scar revision) when compared with wounds sutured with nonabsorbable sutures.
METHODS: This was a randomized clinical trial conducted in a pediatric emergency department. Patients 1-18 years of age who presented to the emergency department with lacerations < 12 hours old were recruited between January 1999 and December 2001. Exclusion criteria were the following: wounds that could be approximated by tissue adhesives, animal/human bites, gross contamination, puncture/crush wounds, wounds crossing joints, lacerations of tendon/nerve/cartilage, collagen vascular disease, immunodeficiency, diabetes mellitus, bleeding disorder, and scalp lacerations.
Patients were randomized into one of two groups: those receiving absorbable plain gut sutures (group A) and those receiving nonabsorbable nylon sutures (group NA). Board-eligible/certified pediatric emergency physicians or clinical fellows performed laceration repair in a standardized approach. All wounds were reevaluated within ten days by a single research nurse who assessed the wounds using a previously validated wound evaluation score (WES) composed of six items (presence of step-off, contour irregularities, margin separation, edge inversion, extensive distortion, and overall cosmetic appearance). A score of 6/6 was considered optimal. The study nurse also noted the presence of infection and dehiscence. The patients were then seen by a single blinded plastic surgeon at four or five months who evaluated the wound using a previously validated visual analog scale of cosmesis (VAS). In addition, the surgeon repeated the WES and assessed the need for surgical scar revision.
RESULTS: A total of 147 patients were eligible, and 52 patients declined to participate. Of the 95 patients enrolled, 50 were randomized to group A and 45 to group NA. The two groups had similar ages, gender distributions, rates of use of sedation or steri-strips, wound lengths and widths, mechanisms of injury, and wound locations. At the short-term follow-up, no difference was found in the proportion of optimal WES scores between group A (63% of patients) and group NA (49% of patients) (relative risk = 0.73; 95% confidence interval [95% CI] = 0.45 to 1.17). No difference was found in the rates of infection and dehiscence between the two groups. Sixty-three of the 95 patients presented for long-term follow-up. The groups remained similar with respect to patient and wound characteristics as well as wound location. The average VAS score at four months was 79 (95% CI = 73 to 85) for group A and 66 (95% CI = 55 to 76) for group NA. In addition, no differences were found in the proportion of optimal WES between group A (36% of patients) and group NA (28% of patients) at four months (relative risk = 0.88; 95% CI = 0.62 to 1.26). Surgical scar revision was recommended for only three patients, of whom two were in group A. No patients chose to have their scars revised. No differences were found between group A and group NA for the rates of dehiscence (2% vs. 11%; p = 0.07) and infection (0 vs. 2; p = 0.3).
CONCLUSIONS: The use of plain catgut absorbable sutures in the repair of traumatic lacerations in children appears to be an acceptable alternative to non-absorbable sutures because the long-term cosmetic outcome seems to be at least as good. In this study, plain gut suture material seemed to provide slightly better cosmesis. In addition, no difference was found in the rate of dehiscence or infection between the groups
COMMENTS: Absorbable sutures are a useful adjunct for laceration repair as there is no reported cosmetic difference between absorbab
le and nonabsorbable sutures. One caveat from personal experience, for absorbable sutures around the eye, ask the parents to return if the sutures do not fall out in 5 days. I have seen several cases when children did not return in this time frame only to require sedation for suture removal when there is now granulation tissue at 2 weeks post suture date. A 48-hour wound check is also a good medico-legal defense.
Q: Have there been any reported cases of infection after tissue adhesive use?
A: Yes. In addition to this study, I have seen several cases of infected dog bites to the face in children who have had tissue adhesive placed instead of loose stitches. The tissue adhesive does not allow for drainage in these high risk patients.
Citation_3: Yeilding RH, O’Day DM, Li C, Alexander PT, Mawn LA. Periorbital infections after Dermabond closure of traumatic lacerations in three children. J AAPOS. 2012 Apr;16(2):168-72.
PURPOSE: To report the occurrence of periorbital infections in 3 children treated with the tissue adhesive 2-octyl cyanoacrylate (Dermabond) after traumatic periorbital laceration.
METHODS: We retrospectively reviewed the records of consecutive patients referred to Vanderbilt Children’s Hospital for the treatment of periorbital infections to identify cases associated with the use of Dermabond. The clinical features and outcomes of each case were reviewed. We performed a meta-analysis of published cases to identify any association of tissue adhesive with wound infection rate.
RESULTS: The review identified 3 patients, all of whom were younger than 3 years of age and developed cellulitis within 24 hours of wound closure. Broad-spectrum intravenous antibiotic therapy was started in less than 3 hours in all cases. Cultures were obtained in 2 of the 3 cases; both grew Streptococcus pyogenes. Two cases required surgical intervention, including one with necrotizing fasciitis. In the meta-analysis, the wound infection rate was 1.8% in tissue adhesive closure and 0.3% in standard wound closure (odds ratio 6.0; 95% confidence interval 0.7-50.3, P = 0.06).
CONCLUSIONS: The development of periorbital cellulitis after the closure of periorbital lacerations with Dermabond should alert the physician to the possibility of periorbital infection, including necrotizing fasciitis. The literature reviewed suggests a trend toward an increased infection rate with tissue adhesive closure. We propose that ineffective wound sterilization before tissue adhesive wound closure may be a contributing factor
Q: Is Tissue Adhesive better than Adhesive
A: Not necessarily. This study revealed that adhesive strips were a cheaper alternative and had similar cosmetic outcomes.
Citation_4: Zempsky WT, Parrotti D, Grem C, Nichols J.Randomized controlled comparison of cosmetic outcomes of simple facial lacerations closed with Steri Strip Skin Closures or Dermabond tissue adhesive. Pediatr Emerg Care. 2004 Aug;20(8):519-24.
OBJECTIVE: To compare the short-term complications and long-term cosmetic outcomes of simple facial lacerations closed with 3M Steri Strip Skin Closures or Dermabond.
METHODS: Prospective, randomized controlled trial of children ages 1 to 18 presenting to a pediatric emergency department with simple low-tension lacerations of the face. After standard wound care, patients received wound closure with either Steri Strip Skin Closure or Dermabond. Pain associated with closure was evaluated on a 100-mm visual analogue scale (0 = no pain, 100 = worst pain). A follow-up telephone call was made a week after enrollment to determine short-term complications. Patients returned 2 months after would closure for wound photography. Cosmetic outcomes were evaluated by 2 plastic surgeons blinded to the method of wound closure on a 100-mm visual analogue scale (0 = best scar, 100 = worst scar).
RESULTS: One hundred children aged 1 to 18 were enrolled. Ninety-seven patients had results analyzed. Forty-eight received Steri Strip Skin Closures and 49 received Dermabond. Patient demographics and wound characteristics were similar between groups. Pain scores on a 100-mm visual analogue scale were 9.0 mm for the Steri Strip group and 6.2 mm for the Dermabond group (P = ns). At short-term follow-up, there was one wound complication in the Steri Strip group and 7 complications in the Dermabond group (P = 0.06). Eighty-nine patients received 2-month evaluation (41 Steri Strip, 45 Dermabond). There was no difference in the mean visual analogue scale cosmesis scores: 37.2 mm (95% CI = 30.8-43.7) versus 43.8 mm (95% CI = 38.4-49.2) (P = 0.12).
CONCLUSIONS: Steri Strip Skin Closures and Dermabond provide similar cosmetic outcomes for closure of simple facial lacerations. Steri Strip Skin Closure may represent a low-cost alternative.
Citation_5: Eur J Ped Surg. 2011 May;21(3):159-62. Epub 2011 Jan 31.)
METHODS: In 2011, Romero et al studied the use of tissue adhesive (Dermabond™) versus adhesive strips (Steri-Strip™) for the closure of laparoscopic trocar wounds after appendectomies in children. Forty-nine patients undergoing laparoscopic appendectomy were enrolled in this prospective randomized trial. In every patient, two 5-mm and one 10-mm port-site incision was closed either with Dermabond™ or Steri-Strip™ after placing subcuticular absorbable sutures (4-0 Vicryl™). Postoperative complications, pain, and patient satisfaction with scars were evaluated at follow-up on day 10 and day 90 after the operation using a questionnaire and a visual analogue scale (VAS). Photographs of scars taken on day 90 were evaluated on a VAS by 2 pediatric surgeons blinded to the closure method used.
CONCLUSIONS: Absorbable sutures are a useful adjunct for laceration repair as there is no reported cosmetic difference between absorbable and nonabsorbable sutures. One caveat from personal experience, for absorbable sutures around the eye, ask the parents to return if the sutures do not fall out in 5 days. I have seen several cases when children did not return in this timeframe only to require sedation for suture removal when there is now granulation tissue at 2 weeks post suture date. A 48-hour wound check is also a good medico-legal defense.
Comments: Both tissue adhesives and adhesive strips were found to be excellent “no needle” alternatives for the closure of laparoscopic port-site incisions in children. As regards to cosmetic outcome, the authors concluded that Steri-Strip™ wound closure seemed to be the most suitable and less expensive technique.