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Abstract & Commentary
Source: Karounis H et al. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med 2004;11: 730-735.
This prospective, randomized clinical trial attempted to determine if there was any difference in outcome between lacerations closed with traditional nonabsorbable sutures vs. those closed with fast-absorbing gut. This Canadian study was performed at a single site during a period of two years, and all patients aged younger than 18 years with lacerations that met clinical criteria were offered enrollment. Both groups predominantly contained patients who had wounds on the face; patients with wounds to the arms, torso, hands, legs, and feet were included also. Wound closure was randomized to either of the two study materials. Patients were followed-up initially within 5-10 days, and subsequently at 4-5 months by a plastic surgeon blinded to the closure technique. At the first follow-up, wounds were evaluated using a validated scoring system for wound appearance (e.g., step-off and edge inversion), as well as overall cosmesis and evidence for infection (nylon sutures also were removed at this time). The plastic surgeon who evaluated the patients at 4-5 months used a previously validated visual analog scale (VAS) to score wound cosmesis and assessed the need for surgical scar revision.
A total of 147 patients were eligible for the study, and 95 ultimately consented to be enrolled in the randomization process. Fifty were randomized to absorbable and 45 to non-absorbable sutures. The groups were matched in age, location of wounds, and wound characteristics.
At the short-term follow-up, no difference was found in the visual wound scores, infection rates, or overall cosmesis. Sixty-three of the original 95 patients presented for their 4-5 month follow-up visit. The average VAS score for the absorbable group was 79 (95%, CI 73-85), and 66 for the non-absorbable group (95%, CI 55-76). Surgical scar revision was recommended to three patients at the long-term follow-up visit: two in the absorbable group, and one in the non-absorbable group. No patients chose to have their scars revised.
Commentary by Andrew Perron, MD, FACEP, FACSM
"You’re going to close the skin with what?!" When a resident first proposed closing a pediatric laceration with absorbable suture, I responded with the above phrase, and certainly with a look on my face that let him know that was a ridiculous plan. I remember the reply was that it was done all the time on his plastic surgery rotation, but it would be fine to practice old-fashioned medicine and close with nylon. Frightened that I was becoming one of those attending physicians who hadn’t bothered to keep up with the latest developments in my specialty, I went to the literature and found a total of five articles on the topic, none of which were published in the emergency medicine literature. I went back to the resident and said I would reserve judgment until I saw a well done prospective study in emergency medicine literature to support the practice. I now have that study.
This prospective study, although not overwhelming in numbers, was conceived carefully, applied appropriately, and followed up adequately. It provides the answers I need to incorporate this technique into my practice. Can I use it on a pediatric ED population? Yes. Is there an increased risk of infection? No. Is there a short- or long-term cosmetic disadvantage to the patient? No.
If I could improve anything in this study, it would be two areas. First, the large number of patient refusals (52 of 147 eligible patients): More than a third of patients approached were not enrolled. A limited post-hoc analysis of that group by the authors did not detect any sample bias, but it remains a concern. Second, only 63 of the 95 total patients enrolled were re-examined at the four-month follow-up visit. One can play the what-if game by asking: What if the group with absorbable sutures who were lost to follow-up did so because the patients all had such horrendous cosmetic results that they sought their own plastic surgeons, and those with nonabsorbable sutures did not? That question is unanswerable. Overall, I plan to use this article to change my practice in the ED starting with the next pediatric laceration I see. And if anyone asks, I’ll cite this article as my justification.
Dr. Perron, Residency Program Director, Department of Emergency Medicine, Maine Medical Center,Portland, ME, is on the Editorial Board of Emergency Medicine Alert.