Impact of Skin Suture Pattern on Incision Perfusion Using Intraoperative Laser Angiography: A Randomized Clinical Trial of Patients With Ankle Fractures

Abstract

Objectives: To assess which skin suture pattern—simple, vertical mattress, horizontal mattress, Allgöwer–Donati (AD), or running subcuticular—enables the greatest degree of perfusion as measured by indocyanine green laser angiography after ankle fracture surgery. Design: Prospective, randomized. Setting: Level 1 Academic Trauma Center. Patients/Participants: Seventy-five patients undergoing ankle fracture surgery were prospectively randomized to 1 of 5 skin suture patterns (n = 15 per cohort). Patient demographics and operative parameters were similar between groups. Main Outcome Measurements: Skin perfusion was assessed intraoperatively after skin closure using indocyanine green laser angiography and quantified in fluorescence units. Two perfusion values were collected: (1) mean incision perfusion was the mean of 10 points along the incision and (2) mean perfusion impairment was the perfusion difference between the incision and the skin adjacent to it. We also collected a postoperative patient scar assessment score. Results: Running subcuticular closure had significantly better mean incision perfusion than all other closure patterns. Mean perfusion impairment also favored running subcuticular closure, which was significantly lower than all other suture patterns except AD. We found no patient perceived cosmetic differences between the 5 suture pattern types. Conclusions: Running subcuticular suture pattern resulted in the greatest incision perfusion than simple, horizontal mattress, vertical mattress, and AD techniques after ankle fracture fixation. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Routine Use of Running Subcuticular Closures in Orthopaedic Trauma Patients Does Not Increase Wound Complications

“…RSC resulted in the most robust perfusion, VM closure resulted in intermediate perfusion, and staple closure yielded the poorest perfusion. Shorten et al 16 reported similar results in a RCT of patients undergoing ankle fracture ORIF with RSC resulting in superior perfusion compared with simple, horizontal mattress, VM, and Allgöwer-Donati techniques. These studies were motivated by previous studies that had demonstrated perfusion to be one of the most physiologically important factors in wound healing with increased oxygen tension resulting in increased deposition of collagen.…”

“…26 Although RSC has been shown to have superior wound perfusion and cosmesis across multiple surgical subspecialties, its effect on postoperative wound complications in orthopaedic surgery is scarce and conflicting. [13][14][15][16][17][18][19][20][21] A meta-analysis of 6 studies by Smith et al 4 found that the risk of postoperative wound complications was 3.8 times greater for patients who received staples compared with those who received sutures. A subsequent systematic review and meta-analysis of 12 studies by Krishnan et al 5 found no differences in the rate of wound complications between these groups.…”

“…[4][5][6][7][8][9][10][11][12][13][14] More recently, studies in multiple surgical subspecialities have demonstrated that running subcuticular closures (RSC) result in improved wound perfusion and cosmesis when compared with staples or cutaneous mattress suture closures (CMC). [15][16][17][18][19][20][21] However, the use of RSC in orthopaedic trauma remains poorly studied and rarely used because of concern for increased risk of wound complications. 1,9,11,13,22 The purpose of this study was to compare the rate of postoperative wound complications and wound-related reoperations before and after the implementation of an RSC protocol for orthopaedic trauma procedures.…”

Effect of Modified Allgöwer–Donati Suture Technique on Wound Cosmetics in Spinal Surgery

“…The Allgöwer-Donati suture technique has been used for ankle wound closure and maintains control of skin tension in orthopaedic surgery 9 . This technique achieves some cosmetic results by means of unilateral intermittent embedding of the wound.…”

Soft Elastomeric Capacitor for Strain and Stress Monitoring on Sutured Skin Tissues

“…In the past decades, various methods have been studied analytically and experimentally to evaluate the mechanical properties of different suture patterns. For example, the strength of various suture patterns used for incision closure was characterized through tensile tests, the performance of conventional and new suture techniques used for the closure of the linea alba was evaluated clinically through wound examination and ultrasonic probing, and the impact of the skin suture pattern on incision perfusion was assessed by indocyanine green laser angiography imaging . However, detecting tensile stress through the measurement of localized strain in sutured skins remains challenging because of the unique and complex properties of each sutured skin specimen and the lack of compliant sensors capable of monitoring large levels of strain in vivo .…”