Wyles Cody C, Jacobson Steven R, Houdek Matthew T, Larson Dirk R, Taunton Michael J, Sim Franklin H, Sierra Rafael J, Trousdale Robert T
Mayo Medical School, Rochester, MN, USA.
Mayo Clinic Department of Plastic and Reconstructive Surgery, Rochester, MN, USA.
Clin Orthop Relat Res. 2016 Jan;474(1):47-56. doi: 10.1007/s11999-015-4209-x.
Maintaining robust perfusion is an important physiologic parameter in wound healing. The effect of different closure techniques on wound perfusion after total knee arthroplasty (TKA) has not been established previously and may have implications for wound healing.
QUESTIONS/PURPOSES: We asked whether a running subcuticular, vertical mattress, or skin staple closure technique enables the most robust wound perfusion after TKA as measured by laser-assisted indocyanine green angiography (LA-ICGA) in patients without specific risk factors for wound healing complications.
Forty-five patients undergoing primary TKA without comorbidities known to impact wound healing and perfusion were prospectively randomized to receive superficial skin closure with one of the following techniques: (1) running subcuticular (3-0 monofilament); (2) vertical mattress (2-0 nylon); or (3) skin staples. Twenty procedures were performed by RTT, 15 by RJS, and 10 by FHS. All surgeons used an anterior skin incision over the medial third of the patella in combination with a median parapatellar arthrotomy. Perfusion was assessed with a LA-ICGA device and software system immediately after closure to quantify fluorescence. Twenty-seven points were assessed immediately after closure in the operating room in each patient (nine along the incision and nine pairs medial and lateral to the incision). Mean incision perfusion was determined from the nine points along the incision with higher values indicating greater blood flow. Mean perfusion impairment was determined by calculating the difference between the nine pairs of surrounding skin and the nine points along the incision with smaller values indicating less perfusion impairment. These parameters were compared with analysis of variance (ANOVA) and subsequent pairwise comparisons with an unadjusted analysis as well as a multivariate analysis that adjusted for age, sex, and body mass index. Patients were followed for a mean of 7 months after surgery (range, 3-12 months) for possible incision-related complications. No patents were lost to followup.
Running subcuticular closure demonstrated the best overall perfusion. Mean incision perfusion in fluorescent units with SD was as follows: running subcuticular, 64 (16); vertical mattress, 32 (18); and staples, 19 (7) (ANOVA p < 0.001). The running subcuticular closure demonstrated the least impairment of perfusion among the closures compared. Mean perfusion impairment was as follows: running subcuticular, 21 (12); vertical mattress, 37 (24); and staples, 69 (27) (ANOVA p < 0.001). All Tukey-adjusted pairwise comparisons from both metrics likewise favored the subcuticular closure (p < 0.001) both before and after adjusting for age, sex, and body mass index. One patient in the vertical mattress cohort experienced a surgical site infection; no other wound-related complications were observed in this study.
The method of closure can influence skin and soft tissue perfusion after TKA. Running subcuticular closure enables the most physiologic robust blood flow, which may improve wound healing. However, the clinical importance of these findings remains uncertain, because patients in this study were selected because they lacked risk factors for wound healing complications. Studies with this modality in specific patient populations at higher risk for wound complications will be necessary to quantify the clinical advantage of using running subcuticular closure.
Level I, therapeutic study.
维持充足的灌注是伤口愈合中的一个重要生理参数。全膝关节置换术（TKA）后不同缝合技术对伤口灌注的影响此前尚未明确，且可能对伤口愈合有影响。
问题/目的：我们想了解对于没有伤口愈合并发症特定危险因素的患者，连续皮下缝合、垂直褥式缝合或皮肤钉合缝合技术在TKA后是否能实现最强的伤口灌注，通过激光辅助吲哚菁绿血管造影（LA - ICGA）进行测量。
45例接受初次TKA且无已知影响伤口愈合和灌注的合并症的患者被前瞻性随机分组，接受以下技术之一进行浅表皮肤缝合：（1）连续皮下缝合（3 - 0单丝缝线）；（2）垂直褥式缝合（2 - 0尼龙缝线）；或（3）皮肤钉合。20例手术由RTT完成，15例由RJS完成，10例由FHS完成。所有外科医生均采用髌骨内侧三分之一上方的前正中皮肤切口并结合髌旁正中关节切开术。缝合后立即使用LA - ICGA设备和软件系统评估灌注以量化荧光。在手术室中，每位患者缝合后立即评估27个点（沿切口9个点以及切口内侧和外侧各9对）。沿切口的9个点确定平均切口灌注，值越高表明血流越大。通过计算切口周围9对皮肤与沿切口的9个点之间的差值确定平均灌注损伤，值越小表明灌注损伤越小。这些参数通过方差分析（ANOVA）以及随后的未调整分析和调整年龄、性别和体重指数的多变量分析进行比较。患者术后平均随访7个月（范围3 - 12个月），观察是否有与切口相关的并发症。无患者失访。
连续皮下缝合显示出最佳的总体灌注。荧光单位下的平均切口灌注及标准差如下：连续皮下缝合，64（16）；垂直褥式缝合，32（18）；皮肤钉合，19（7）（ANOVA p < 0.001）。与其他缝合方式相比，连续皮下缝合在灌注损伤方面最小。平均灌注损伤如下：连续皮下缝合，21（12）；垂直褥式缝合，37（24）；皮肤钉合，69（27）（ANOVA p < 0.001）。在调整年龄、性别和体重指数前后，两种测量指标的所有Tukey调整后的两两比较同样都支持皮下缝合（p < 0.001）。垂直褥式缝合组有1例患者发生手术部位感染；本研究中未观察到其他与伤口相关的并发症。
缝合方法可影响TKA后的皮肤和软组织灌注。连续皮下缝合能实现最符合生理状态的充足血流，这可能改善伤口愈合。然而，这些发现的临床重要性仍不确定，因为本研究中的患者是因缺乏伤口愈合并发症的危险因素而入选。有必要对伤口并发症风险较高特定患者群体采用这种方式进行研究，以量化使用连续皮下缝合的临床优势。
I级，治疗性研究。
