EBQ:A Randomized, Controlled Trial Comparing Long-term Cosmetic Outcomes of Traumatic Pediatric Lacerations Repaired with Absorbable Plain Gut versus Nonabsorbable Nylon Sutures

incomplete Journal Club Article

Helen Karounis, MDCM, Serge Gouin, MDCM, Harley Eisman, MDCM, Dominic Chalut, MDCM, Helene Pelletier, RN, BSc, Bruce Williams, MD. "A Randomized, Controlled Trial Comparing Long-term Cosmetic Outcomes of Traumatic Pediatric Lacerations Repaired with Absorbable Plain Gut versus Nonabsorbable Nylon Sutures". Academic Emergency Medicine. 2004. 11(7):730-736.
PubMed

Clinical Question

Do absorbable sutures compared to nonabsorbable sutures in pediatric traumatic lacerations cause good long-term cosmesis with no increase in complications?

Conclusion

• plain catgut absorbable sutures compared to nonabsorbable sutures results in no difference in rate of dehiscence or infection
• plain gut suture had better cosmesis
• no patients had surgical scar revision

Out of 95 enrolled patients

• 61% long term follow up

• Long term cosmesis was judged as
  • infection
  • dehiscence rates
  • need for surgical scar revision

Major Points

• Suture repair is traumatizing in kids
• Not all lacerations can be repaired with tissue adhesives secondary to location, size and depth
• Operative wounds have been closed with absorbable suture material and have no difference in cosmetic outcome or wound complications.

Study Design

• Randomized clinical trial in a tertiary pediatric referral center
• Patients recruited consecutively by full-time ED physicians and peds-emerg fellows
• Subjects randomized by blocks of 6
  • absorbable plain catgut sutures
  • nonabsorbable nylon sutures
• Prophylatic antibiotics, steri-strips at physician’s discretion
• 5.0 or 6.0 suture on facial lacerations
• 4.0 or 5.0 suture material for extremities or torso
• all received topical antibiotics and dry dressing applied to wound
• Follow-up with single research nurse who assigned wound evaluation score (WES)
  • Facial lacerations 5-7 days after repair
  • Extremities and torso lacerations 7-10 days after repair
  • WES score- 6 point tool to evaluate for cosmesis
    • Presence of step-off
    • Countour irregularities
    • Margin separation
    • Edge inversion
    • Extensive distortion
    • Overall cosmetic appearance
• Plastic surgery follow up 4-5 months blinded to patient group
  • Visual analog scale
  • WES repeated

Population

• all patients younger than 18 years of age who presented to the ED with lacerations <12 hours old

Patient Demographics

• age, gender, deep sutures, sedation, steri-strips, median wound length, median wound width and mechanism of injury had no statistically significant difference

Inclusion Criteria

• Must meet all the criteria
  • Age<18
  • Laceration<12 hours old
  • Required suture repair

Exclusion Criteria

• Wound caused by animal or human bites
• Heavily soiled wounds requiring debridement
• Stellate crush wounds
• Contaminated puncture wounds
• Wounds in patients with history of keloid formation
• Wounds crossing joins or in areas of high tension
• Lacerations involving tendon, nerve, cartilage or bony injuries
• History of collagen vascular disease
• Prolonged corticosteroid use
• Primary or secondary immunodeficiency
• Type 1 diabetes mellitus or clotting disorders
• Scalp lacerations (difficult-to-evaluate cosmesis)
• Wounds that could be approximated by tissue adhesives (<5 cm in length or <0.5 cm in width)

Interventions

• Suture repair with simple interrupted with absorbable plain catgut sutures or nonabsorbable nylon sutures

Outcomes

• Long term cosmesis was judged as
  • infection
  • dehiscence rates
  • need for surgical scar revision

Primary Outcome

• VAS at 4 months after repair
• 63/95 presented for long term follow
• VAS for absorbable suture (79mm 95%CI = 73-85)
• VAS for nonabsorbable suture (66mm 95%CI=55-76)

Secondary Outcomes

• WES of the wounds at 5-10 days
  • all patients showed up for short term follow up
  • no difference in WES between groups

• WES at 4 months
  • Optimal WES in absorbable versus nonabsorbable (36% versus 28%)
• Complication rates (infection and dehiscence)
  • No difference in absorbable and nonabsorbable sutures for the rate of dehiscence (2 % vs 11%) and infection (0% vs 2%)

• Need for surgical scar revision
  • Recommended to 3 patients: 2 patients in the absorbable group and1 patient in the nonabsorbable. All three declined.

Criticisms & Further Discussion

*suture repairs were performed by pediatric ED personnel who might have an elevated level of knowledge as to the management of pediatric lacerations

• 52 of 147 eligible patients declined
• participants insisted on absorbable sutures
• only tried one type of absorbable suture unknown if this is generalizable to other rapidly dissolving absorbable suture materials