5th July 2013: Comparison of cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations

5th July 2013

Where can I find this paper?

http://www.ncbi.nlm.nih.gov/pubmed/23714755

What is this paper about (what is the research question)?

Do non-absorbable and absorbable sutures give comparable cosmetic results for repair of simple facial wounds in kids?

Summary of the Paper

Design: multicentre, randomised controlled, single blinded trial with allocation concealment

Objective: to compare long-term cosmetic outcomes of absorbable versus non-absorbable sutures based on physician scoring of facial lacerations in the paediatric population

Outcomes: primary – visual analogue scale assessment of wound acceptability made by physicians, blinded to suture material, at 3 months. Secondary – caregiver completion of same visual analogue scale plus completion of satisfaction questionnaire

Intervention: closure of wound by standard approach using 5.0 fast-absorbing surgical gut (FAC) without removal of sutures

Reference Standard: closure of wound by standard approach using 5.0 non-absorbable suture (NYL) with removal of sutures at 4-7 days

Participants: patients presenting to two urban paediatric EDs in Philadelphia April 2008-April 2010

Inclusion – English speaking patients aged 1-18 years with isolated, non-contaminated linear facial wounds between 1-5cm in length assessed by clinicians as requiring closure by suture

Exclusion – irregular or contaminated wounds/bites, wounds>8h old, patients with complex wounds, immunodeficiency, bleeding/clotting disorder, pregnancy, diabetes, renal dysfunction, or allergy to local anaesthetic

Results: 98 patients were recruited of whom 49 had closure with FAC and 49 with NYL. 85 were followed-up at 4-7 days (42 FAC,43 NYL) and 76 at 3months in person or by telephone (FAC 37, NYL 39). Telephone follow up did not include VAS score.

61 patients had completed VAS scores at 3/12 (FAC 29, NYL 32)

Mean VAS scores by physicians:

FAC 57.6, NYL 67.6

Difference in means -10 (95% CI for difference in means -19.6 to -0.4) 

Authors’  conclusions

We are not yet able to conclude that absorbable sutures are equivalent to nonabsorbable sutures with respect to cosmetic outcomes of facial lacerations in children.

On the study design

There is little information on how patients were recruited, but other than the restriction of English-speaking patients inclusion and exclusion criteria seem sensible.

The allocation concealment and blinding is helpful in reducing bias, but I would question whether leaving absorbable sutures until completely absorbed is standard practice – it isn’t mine, and therefore this impacts the external validity of the study.

The plan for follow-up at 3/12 seems sensible and is rationalised by the authors but this seems early to fully assess the “long-term” impact of wound closure.

While the exact suture material does not necessarily replicate standard UK practice it is reasonable to assume little difference between non-absorbable and absorbable suture material around the globe.

What were the results and what does this mean?

The trial is a non-inferiority trial – the aim is to show that using absorbable suture material does not give a perceptibly inferior cosmetic result. The visual analogue scoring undertaken by blinded physicians (and averaged between three scorers) showed not only lower VAS satisfaction scores for the absorbable suture group but a 95% confidence interval which did not cross zero, suggesting the study was unable to demonstrate non-inferiority. The validity of the VAS has been assessed elsewhere but there is a considerable difference between physician and caregiver scores.

It is also important to remember that despite sample size calculations which predicted attrition of 40%, only 61/98 recruited patients actually completed the full study protocol and had photographs for assessment by VAS – so the study was insufficiently powered.

What can we take from this paper into clinical practice?

It appears that if we use absorbable sutures and don’t remove them, there are noticable differences in wound healing at 3/12; there’s insufficient evidence in this paper to convince us that not removing sutures provides a comparable cosmetic result in the first three months.

More questions to ask

  • Are there benefits to using absorbable sutures and then removing them (in the same timeframe as we would normally remove non-absorbable sutures)?
  • Would we see non-inferiority at a later review – 18 months after closure perhaps?
  • Would we see non-inferiority in an appropriately powered study?

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