Minor scrapes and cuts can be easily treated with proper cleansing and bandaging. But when they are more serious, such as a laceration, gash or another type of break in the skin, medical intervention may be required. If so, the doctor will likely use staples or sutures to stitch the wound. Let’s learn more about each of these techniques and how to know which one is appropriate.
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Sutures are the most commonly used choice for skin repair. A suture is simply a piece of thread, like sewing thread, attached to a needle. The needles are of various sizes and have a cutting or non-cutting edge. The doctor will “sew” your skin together just like sewing fabric.
Sutures are classified according to the structure of the thread and where the material comes from. Single-thread sutures are more delicate, making them easier to guide through tissue. Multi-thread or braided sutures make for a stronger closure but can also increase the chance of infection.
Sutures can be continuous, using one thread throughout, or interrupted, using several threads in case one comes out. They are made from natural or synthetic materials.
Finally, sutures will either be permanent and non-absorbable – that is, they remain in your skin until a doctor removes them – or will absorb into your skin and be dissolved by enzymes in your body. Permanent sutures are often used to close surgical incisions or lacerations or simply for wounds that cut through several layers of skin and will require a longer healing time.
Finally, there are many suture techniques. The doctor’s selection depends on the depth and severity of your wound, as well as whether it’s simple outpatient or surgical in nature.
Purse-string: continuous suture placed around the wounded area and tightened like a drawstring
Buried: internally placed permanent suture
Subcutaneous: suture placed just below the upper layer of skin in a line parallel to the wound
Deep: continuous or interrupted suture place under several layers of tissue
Nonabsorbable sutures
These sutures must be removed by a doctor, usually about two weeks after insertion. In rare cases, they are left in permanently. There are several types of nonabsorbable sutures. They include synthetic single-thread (polypropylene), natural braided thread (silk), natural single-thread (nylon) and synthetic braided thread (polyester). These are most appropriate for neurological and cardiovascular surgery.
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Absorbable sutures
These dissolving sutures are generally used for more delicate areas such as inside the mouth, as stitches removal is not required. They can be used for skin grafting, protecting lost or burned skin with healthy skin taken from elsewhere on the body. They are also used for lower layers of skin, connective tissue or muscle and any area with blood vessels just under the skin’s surface. Absorbable sutures come in the following types:
Polydioxanone (PDS): synthetic single-thread used best on soft tissue and in cardiac procedures for children
Gut: Natural single-thread that causes a strong reaction and scar; designed primarily for gynecological surgery
Polyglactin: synthetic braided suture best for hand or face injuries
Poliglecaprone: synthetic single-thread appropriate for soft tissue repair and to close skin without leaving a scar
Only PDS sutures should be used in neurological or cardiovascular procedures.
Surgery staples are an alternative to sutures; they are usually non-absorbable and must be removed after a maximum of 21 days. Some stay in permanently for especially damaged tissue or organs. The length of time they must stay in depends on what surgery you had, how severe your wound is and other factors.
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Staples are placed with a special wound stapler, which often resembles the larger construction stapler with a lever and handle. All the doctor has to do is correctly maneuver the stapler and push it down. The process is much faster than manually sewing with sutures. Always follow your doctor’s instructions for post-staple care.
Staple removal, which should not be painful, requires special tools and procedures only available through your doctor. For this reason, you should never try to take them out yourself. Here are the steps to removing staples after surgery:
Remove any bandages, clean the area
Make sure the wound looks healed and not infected
Slide part of the surgical staple remover tool under the staples on both ends of the wound, then wiggle it side to side until it comes out
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Repeat the above step on every second staple, then remove the others
Protect each incision with a steri strip
Surgical staples can be made from a variety of materials depending on the circumstances. Stainless steel can be helpful for patients with metal allergies; titanium if the doctor is concerned about an infection; plastic is readily available and can be good for scar healing, and a biodegradable polylactide-polyglycolide copolymer is great for plastic surgery as it greatly reduces cosmetic damage.
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Staples may be the best option when the wound is too big or surgery too complex for sutures. They can also speed up surgery time, lessen pain and reduce infection risk. If you have a C-section, for example, staples will leave less of a scar and shorten your recovery time.
One study comparing sutures v. staples found no satisfactory evidence that produced a clear winner. Researchers evaluated variables such as infection, readmission rate and pain. A physician’s preference is unique to the situation and their experience, but either choice has its pros and cons.
In general, surgical staples produce a faster healing time with less inflammation and easier removal. They are often best for difficult surgeries. Sutures can sometimes be more cosmetically pleasing and only need one doctor to perform, which is ideal for outpatient cases. But while surgical staples have slightly more advantages than sutures, they also carry higher risk.
Risks and Precautions
Regardless of your chosen method, it’s best to take precautions for the best chance at proper healing. Your physician should always keep a good blood supply running to the wound, align the stitches to natural edges in the skin, always use Band-Aids or other sterile wound covers, use the right size and material, and make sure not to over-tighten or over-staple. Failing to do these things can result in complications and injuries ranging from mild to serious, including:
Infection and early wound opening
Blood clots or
fistulas
Allergic reactions
Sepsis or internal bleeding
Organ damage
You may be surprised to learn that the U.S. Food and Drug Administration (FDA) categorizes surgical staplers with low-risk medical tools like bandages and tongue depressors. But there were 41,000 adverse medical events due to staplers between 2011-2018, and a quarter of those were serious injuries or death. The FDA was underreporting even more incidents and is now considering moving staplers to a higher-risk class.
If you or a loved one has suffered due to negligent surgical stapling, your best path to justice is to consult an attorney knowledgeable in dangerous product personal injury. It’s even better if that attorney has dealt specifically with medical devices and injuries. Take the time to do your research – your peace of mind will thank you.
After orthopaedic surgery, there is a greater risk of wound infection in patients whose wounds are closed with metallic staples than with sutures. Our meta-analysis showed no significant difference between the two closure methods with respect to wound discharge, inflammation, necrosis, dehiscence, or allergic reaction. We consider, however, that only one study had acceptable methodological quality.1 The remaining evidence base presented considerable methodological limitations, including not justifying sample sizes based on a power calculation, poorly blinding patients and assessors to the method of wound closure, not adequately following up patients over a reasonable period of time, and poorly detailing the allocation method to the two groups. While it might be difficult to blind assessors to the method of wound closure, particularly within the initial postoperative month, blinding of patients is logistically possible. Accordingly, such limitations should be considered in the design of future studies to improve the evidence base.
Factors that have been cited as important in the choice of wound closure after orthopaedic surgery have included the ease and speed of closure, the level of patients’ discomfort, the complication rate, the final cosmetic result, and the cost.2 Early studies had suggested that the incidence of wound infection might be reduced with staples because of the mechanism of fixation. Johnson et al19 and Stillman et al20 suggested that skin stapling might cause less damage to the wound’s defences than non-absorbable sutures. This was based on the principle that the presence of a foreign material might compromise the immune response. Furthermore, Pickford et al suggested that as staples do not penetrate the incision but cross the incision site, this might prevent the introduction of foreign material.21 Our findings, however, suggested the contrary—namely, that wounds closed with staples rather than sutures have four times the risk of infection. Whether this is a consequence of the clip being metallic rather than vicryl or nylon material or whether the tension developed through a mattress suture closure is superior to that of staples in reducing the incidence of opening the wound during mobilisation remains unclear. Our conclusion was reached, however, after application of the statistical method for the whole evidence base and was significant for hip surgery but not knee surgery. The rationale for this has been postulated by Khan et al,1 who pointed out that knee wounds are considerably longer than hip wounds and are subjected to more mobility as they are covered by less tissue. As only 88 patients have been assessed in relation to knee wound closure with staples compared with sutures, this observation remains underpowered at present.
It remains unclear as to whether there was a difference in cosmetic result between wounds closed with sutures or staples after orthopaedic surgery.1 17 As the present included studies did not analyse the results based on different comorbidities, age, or skin type, we do not know whether patients with difference skin types might present with differing outcomes—for example, Afro-Caribbean patients are more susceptible to hypertrophic and keloid scarring.22
Previous studies have examined the clinical outcomes of skin closure with continuous or subcuticular interrupted suture techniques for repair of episiotomy or second degree perineal tears23 24 25 and vascular surgery.26 27 Most orthopaedic studies used interrupted subcuticular suture techniques for wound closure, while only two studies adopted a continuous suture technique.9 10 There were no substantial differences in the trends in results between these two studies and the other studies included in this review As this has yet to be empirically studied, it is therefore unclear whether the method of suture closure is a confounding variable with respect to the rate of complications, the patients’ reported satisfaction for cosmetic results, and the discomfort reported through the removal of suture material.
Graham et al28 proposed that deposition of wound collagen is directly related to wound oxygenation and perfusion.29 30 They reported more favourable blood perfusion characteristics in wounds closed with staples rather than sutures, in addition to a significantly higher blood contact in the wound at seven days compared with the suture group (P=0.02).28 We found that the incidence of wound infection was greater with staples than with sutures. Therefore, our findings do not confirm those of Graham et al,28 as oxygen perfusion might be associated with wound infection and necrosis. The influence of oxygen perfusion in hip wounds and knee wounds, which was assessed in the study of Graham et al,28 remains unclear.
Murphy et al suggested that poor results with staples were attributable to poor technique in staple placement.9 The accuracy of suture or staple closure and choice of closure method can have an effect on the accuracy of coaptation of the dermal margins. Poor technique can lead to suboptimal healing.10 This might cause oozing wound edges and delay in healing and increase the potential for infection.8 9 Superficial infection in hip and knee arthroplasty is a worrying clinical sign because of the risk of the infection spreading through the dermal layers to the implant. With the increased pressure on surgical time, and the advances in non-medical staff taking extended roles in wound closure, such considerations might be important when considering outcomes within each institution.
Metal staples have been regarded as a more expensive option for wound closure,9 10 though costs could be reduced by reduced theatre time and ease of clip removal compared with suturing wounds. This might prove to be false economy, however, as the consequences of a deep infection for the patient are substantial through the increased costs associated with medical care and admission to hospital.31 Furthermore, as the number of dressing changes was greater in those who underwent skin stapling, and as a specific staple remover is required, the overall cost of the staples and applicator is mitigated by savings in dressing costs. Although Singh et al estimated the cost effectiveness of these two closure methods,2 no formal cost-benefit analysis has been undertaken.
One study assessed patients’ satisfaction1 and reported no significant difference between the groups.1 Stockley and Elson10 and Singh et al2 reported that staples were invariably more painful to remove than sutures. The relative discomfort of staple removal compared with suture removal has been previously cited in the non-orthopaedic literature.32 33 34 Secondly, some authors have suggested that there might be greater satisfaction for surgeons in using staples than sutures. The time saving benefits of staples might have a psychological effect on surgeons and theatre staff, particular after a long operation.9 10 35 Given the difference in the incidence of superficial wound infection, and the limited empirical evidence for patients’ or surgeons’ preference for staple closure, there is insufficient evidence to justify the use of staples over sutures.
Our findings can be directly generalised only to orthopaedic hip and knee arthroplasty surgery. Different methods of skin closure, however, have been assessed in other surgical procedures, such as scalp lacerations. While stapling has been shown to be faster and less expensive than suturing in the repair of uncomplicated scalp lacerations in children and adults, no differences in complication rates, including infection, have been shown.36 37 38 Similarly, there was no significant difference in complications after abdominal wound closure.39 In this specific population, however, stapling resulted in poorer cosmetic scores than suturing in transverse abdominal wounds.39 Ranaboldo and Rowe-Jones reported that wound pain and requirement for analgesia was significantly lower in patients whose laparotomy wounds were closed with sutures compared with staples.40 Finally, a systematic review of methods of skin closure in caesarean section reported that use of absorbable subcuticular sutures resulted in less postoperative pain and yielded a better cosmetic result than staples.41 While there seems to be consensus that staple closure is faster than suture closure, there remains some variation between studies for cosmetic results and pain outcomes. There seemed to be no significant difference in complication rates, including wound infection, between caesarean wounds closed with sutures compared with staples, contrary to our findings. By re-evaluating this issue with well designed randomised controlled trials it will be possible to compare the findings of orthopaedic to other surgical procedures.
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