Closing Arguments

Dear Readers:

Wound closure would seem to have a rich evidence base of randomized controlled trials (RCTs), but new questions are leading to surprising answers. The first publication reviewed in this Evidence Corner explores the relative risks and benefits of closing pilonidal cyst excisions compared to open or secondary intention healing and offers conclusions that leave practicing clinicians with a choice between faster healing or reduced recurrence. The second review explores the relative merits of closing traumatic lacerations with tissue adhesive as compared to standard wound closure (SWC) using sutures, adhesive strips, or staples. These results also create a dilemma for clinicians: quick, low-pain closure but at a higher risk for dehiscence. Both reviews open the possibilities for improving wound closure techniques with important choices to make for more patient-oriented outcomes.

Optimizing Pilonidal Sinus Closure
Reference: McCallum IJ, King PM, Bruce J. Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis. BMJ. 2008;336(7649):868–871. Epub 2008 Apr 7.
Rationale: The pilonidal sinus can have a costly, complicated path to healing, associated with a prolonged hospital stay, comorbidities, and delayed return to activities of daily living.
Objective: Explore outcomes resulting from pilonidal sinus open healing compared with primary closure and effects of midline compared with off-midline primary closure.
Methods: Authors conducted a systematic review and metaanalysis of RCTs identified in a search of MEDLINE, EMBASE, CINAHL, and Cochrane databases for pilonidal sinus closure techniques.
Data were extracted independently by two reviewers and assessed for quality from studies evaluating surgical treatment of pilonidal sinus in patients aged at least 14 years or more. Fixed and random effects model meta-analyses compared clinical outcomes where appropriate. Dichotomous data were reported as relative risks or Peto odds ratios.Continuous data were reported as mean differences.
Results: Eighteen RCTs on 1573 patients were included in the review. Of these, 12 compared open second intention healing with primary closure. Primary closure was associated with faster mean healing time (14–7 days) than that reported for open healing (41–91 days) though these results were unsuitable for meta-analysis. Recurrence was less likely after open healing, with a relative risk ratio requiring 14 patients to heal by second intention to prevent one recurrence. Surgical infection rates did not differ for pilonidal cysts primarily closed or experiencing open healing.
Four studies reported healing after midline closure in a mean of 20–27 day and one study reported healing with off-midline Z-plasty in a mean of 15.4 days compared to 41 days for open healing (P < 0.001). The remaining 6 RCTs compared midline to off-midline surgical closure.Wounds receiving off-midline closure healed 5.4 days faster than midline-closed wounds with less likelihood of infection or recurrence. No consistent differences were reported in patientreported pain or length of hospital stay, owing to differences in outcome measures for these variables.
Authors’ Conclusions: Pilonidal sinus surgical excisions healed more quickly with primary closure, but with a higher risk of sinus recurrence than with open healing. Surgical site infections using open or closed healing did not differ. When considering surgical treatment, relative benefits and harms of the two approaches should be carefully assessed. Off-midline closure showed clear healing, infection, and recurrence benefits over midline closure.

Tissue Adhesives for Traumatic Lacerations

Reference: Beam JW. Tissue adhesives for simple traumatic lacerations. J Athl Train. 2008;43(2):222–224.
Rationale: Athletic trainers may need to quickly close lacerations so players can rapidly return to competition. Tissue adhesives offer a rapid closure alternative.
Objective: Evaluate the clinical evidence comparing traumatic laceration closure using tissue adhesives to that using SWC.
Methods: The author added a sports perspective on a 2001 Cochrane review of randomized controlled trials (RCTs) comparing wound closure using SWC to using a tissue adhesive.¹ MEDLINE, EMBASE, clinical trial registers, and Cochrane 2003 clinical trial databases were searched. Investigators and corporations were contacted to identify and retrieve additional studies addressing wounds, injury, lacerations, face or nose injury, and tissue adhesives or acrylates. Studies were included if cosmetic outcomes were measured on acute, linear lacerations less than 12 hours old when closed, and were of length, width, and depth sufficient for wound edge approximation with minimal tension after deep suture placement, if required. Studies on stellate, necrotic, or heavily contaminated wounds or those over joints or hirsute areas were excluded. Cosmetic result was the primary outcome. Secondary outcomes included pain, need for delayed closure, dehiscence, infection, erythema, and discharge. Studies comparing tissue adhesive to SWC were analyzed using a random effects model; studies comparing different tissue adhesives used a fixed effects model.
Results: Ten studies compared SWC to 1 or more tissue adhesives: butylcyanoacrylate or octylcyanoacrylate. One study compared the 2 tissue adhesives. Analysis of 8 studies on 565 lacerations found no significant difference between SWC and tissue adhesives on the Cosmetic Visual Analogue Scale (CVAS). A subgroup analysis of CVAS scores showed superior cosmetic outcomes 1 to 3 months after application of butylcyanoacrylate compared to SWC. Analysis of 4 studies on 364 lacerations found no significant difference between SWC or tissue adhesives for up to 1 year on cosmetic outcomes measured using the Wound Evaluation Score (WES). Analysis of 83 lacerations comparing butyl- with octylcyanoacrylate found no significant CVAS or WES score differences between wounds closed using the 2 tissue adhesives.
Secondary outcomes favored tissue adhesives on 3 measures: less pain (6 groups, 570 lacerations) shorter time to complete the procedure (8 groups, 584 lacerations), and a lower incidence of erythema (8 groups, 727 lacerations). Dehiscence outcomes significantly favored SWC with fewer dehiscence episodes compared to tissue-adhesive closure.

Author’s Conclusions:
Clinical evidence suggests that adhesives may offer a quick alternative method of closing simple traumatic lacerations for athletic trainers in situations with time restrictions. However dehiscence may be a “limiting factor in the use of tissue adhesives for wound closure by athletic trainers.”

Clinical Perspective
Both publications highlight methods of wound closure with clear benefits each counterbalanced by an important drawback. Evidence-based practice calls for using the best available evidence to meet individual patient needs. Such dilemmas highlight the importance of patient-oriented professional skills in decision-making informed by evidence-based principles.²
Pilonidal cysts heal faster when closed, especially with Z-plasty, but are more likely to recur than with open healing. Avoiding recurrence may be more important than rapid healing for some patients with a pilonidal cyst. The reverse may be true for others. Wise clinicians will communicate the risks and benefits of each procedure to patients, balancing patient preferences and clinical implications of recurrence against the need for rapid healing in selecting the method of closure.
The second review offers no new RCTs comparing SWC with tissue adhesives beyond those reviewed in 2001 concluding, “Clinical evidence suggests that tissue adhesives can replace SWC for the management of simple traumatic lacerations.” Further RCTs are recommended on complications such as dehiscence, which may seriously affect outcomes. One would hope that the studies comparing complication rates are performed before drawing the conclusion that tissue adhesives can replace SWC to close simple traumatic lacerations. While awaiting further evidence to answer these questions, the evidence-based practitioner should inform patients of the risks and benefits of each closure technique, so both can participate in evidence-informed closure selection.