Staples Linked to Higher Risk for Infection After Joint Surgery

Laurie Barclay, MD

March 23, 2010

March 23, 2010 — The risk for infection after joint surgery is higher with staples vs traditional stitches, according to the results of a meta-analysis reported in the March 16 issue of the BMJ.

"With the development of accelerated rehabilitation and the pressures placed on surgeons to reduce lengths of stay in hospital, the method of skin closure has become increasingly important in orthopaedic surgery," write Toby O. Smith, BSc, from Norfolk and Norwich University Hospital in Norwich, United Kingdom, and colleagues. "Wound complications are one of the major sources of morbidity after orthopaedic procedures and can prolong the inpatient stay or lead to re-admission. The objective of good wound closure is rapid skin healing and an acceptable cosmetic result while minimising the risks of complications such as wound dehiscence or infection."

The goal of this meta-analysis was to compare the clinical outcomes after orthopaedic surgery using wound closure with staples vs sutures. The reviewers searched Medline, CINAHL, AMED, Embase, Scopus, and the Cochrane Library databases in all languages from 1950 to September 2009. They also searched bibliographies of identified articles for additional studies.

Selection criteria were randomized and nonrandomized controlled trials that compared the use of staples vs suture material for wound closure after orthopaedic surgery, including studies of poor methodologic quality. Two review authors independently determined eligibility, reviewed studies for methodologic quality, and extracted data. Consensus opinion allowed collation of final data to be analyzed.

The main study endpoint was superficial wound infection after wound closure with staples vs sutures. The reviewers calculated relative risk (RR) and mean difference with 95% confidence intervals (CIs), pooled data using a random-effects model, and evaluated heterogeneity with I2 and χ2 statistical tests.

In 6 publications reporting on a total of 683 wounds, 332 patients underwent wound closure with sutures, and 351 underwent closure with staples. Compared with suture closure, staple closure was associated with more than triple the risk for the development of a superficial wound infection after orthopaedic surgery (RR, 3.83; 95% CI, 1.38 - 10.68; P = .01).

When hip surgery was analyzed as a separate subgroup, the risk for the development of a wound infection was 4 times greater with use of staples vs use of sutures (RR, 4.79, 95% CI, 1.24 - 18.47; P = .02). Suture closure and staple closure did not differ significantly in development of inflammation, discharge, dehiscence, necrosis, or allergic reaction.

"After orthopaedic surgery, there is a significantly higher risk of developing a wound infection when the wound is closed with staples rather than sutures," the review authors write. "This risk is specifically greater in patients who undergo hip surgery. The use of staples for closing hip or knee surgery wounds after orthopaedic procedures cannot be recommended, though the evidence comes from studies with substantial methodological limitations."

Limitations of this meta-analysis include those inherent in the included studies, such as small sample size, poor randomization methods, and lack of blinding to the allocated methods of wound closure.

"Though we advise orthopaedic surgeons to reconsider their use of staples for wound closure, definitive randomised trials are still needed to assess this research question," the review authors conclude.

In an accompanying editorial, Bijayendra I. Singh, FRCS, and C. McGarvey, FRCS, from Medway Foundation National Health Service Trust in Gillingham, United Kingdom, note that the time saved using staples seldom exceeds 2 to 3 minutes.

"The Medical Journal of Australia has recently updated its guidelines for skin closure in the treatment of hip fractures, and they state that superficial wound complication rates are higher for wounds closed with metallic staples than for wounds closed with subcuticular vicryl," Drs. Singh and McGarvey write. "The British Orthopaedic Association's "blue book" for best practice in fragility fractures states that no strong evidence exists to support or condemn the use of either sutures or staples, but that patients should be made aware of which will be used. On the best available evidence, it may be more difficult to justify the use of staples in these patients."

This meta-analysis has received no external funding. The study authors and editorialists have disclosed no relevant financial relationships.

BMJ. 2010;340:c403, c1199. Abstract