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

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Complete 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?

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.

Conclusion

  • The use of plain gut absorbable suture in pediatric traumatic lacerations affords good long-term cosmesis and similar complication rates to wounds repaired with nonabsorbable, nylon.
  • suggests that there is in no difference in rate of dehiscence or infection between plain catgut absorbable sutures and nonabsorbable sutures
  • broad exclusion criteria
  • absorbable sutures might decrease repeat trauma to kids as they may not have to be sedated to remove the stitches
  • study is inadequately powered
  • plain gut suture had better cosmesis
  • no patients had surgical scar revision
  • 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.

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
  • need 43 patients per group to detect difference, there were less than this number in the primary outcome so study is inadequately powered


External Links

See Also

Funding

  • Supported by the Montreal Children's Research Institute and the Canadian Association of Emergency Physicians

References