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Staples Linked to Higher Risk for Infection After Joint Surgery

My View

Don’t just “go with the flow” – getting back on your feet after your operation is hard enough without complications.

Make sure you understand your surgeon’s choice of techniques and the associated risks – we are not just another procedure adding to the surgeon’s bank account. It is our body, our life and we have a right to the best possible outcome; we are not just there to be another experiment in faster hospital throughput on the back of inadequate funding.

Why should we be chased through the hospital system faster to keep some accounting department happy – and take on 3 to 4 times the risk of increased infection, especially when infection of any sort is a major issue for those having joint replacements – the whole joint is immuno-compromised and there is a real risk that a skin infection could jeopardize the recovery of the hip – and your health.

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 2010 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.
  • “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.”

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.”


Laurie Barclay, MD

BMJ. 2010;340:c403, c1199. Abstract

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