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Three Part Question

In [adults with scalp laceration] are [staples better than sutures] for [ease of application and patient comfort]?

Clinical Scenario

An elderly lady is admitted to the emergency department after collapsing in the street. She has a 3cm laceration in the left parietal area. Neurological examination and skull X-ray are normal. You have examined and cleaned the wound, but wonder if staples would be a better option than sutures for wound closure.

Search Strategy

Medline 1966-04/02 using the OVID interface, Cochrane Library 2002, Issue 1.
Medline: [(exp Sutures OR sutur$.mp OR exp Suture Techniques OR stitch$.mp) AND (exp Surgical Staplers OR exp Surgical Stapling OR stapl$.mp) AND (exp Scalp OR scalp.mp OR exp Craniocerebral Trauma OR head.mp OR head injur$.mp)] Cochrane: (SURGICAL-STAPLERS*:ME) AND (SUTURES*:ME)

Search Outcome

Medline: Altogether 42 papers found of which 40 were irrelevant. Cochrane: 29 papers, of which 1 additional relevant paper found. 1 additional paper identified from a reference.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ritchie AJ and Rocke LG, 1989, Northern Ireland	200 patients attending A&E over a 6 month period, with scalp lacerations	Prospective randomised study	Speed of repair	Average 49 sec to close stapled wound and 6 min 20 sec to close sutured wound	39% of patients missed the second wound review at 3 weeks Cost only takes into account price of material equipment
			Patient discomfort	Wound repair with staples was less painful than with sutures
			Cost	£4.25 per stapled wound, £2 per sutured wound
			Wound complications	No difference in wound complications
Brickman KR and Lambert RW, 1989, USA	76 emergency patients with scalp, trunk, and extremity lacerations	Observational study looking at stapled wounds	Time efficiency	Most wounds were closed within 30 secs	67% of wounds were scalp lacerations 17 patients lost at 7 day follow-up 37% also contacted 6 months later Paper does not use physicians time to calculate cost, nor does it include the cost of suture kits for stapling
			Cosmesis	One scalp wound and one leg wound dehisced
			Wound complications	Two stapled wounds dehisced
			Cost efficiency	Most wound closures with staples cost $5.11 compared to $9-$11 for suture closure
			Patient satisfaction	None were dissatisfied
			Physician satisfaction	As a new technique they found it easy and rapid
MacGregor FB et al, 1989, Scotland	100 consecutive patients presenting to A&E with superficial lacerations	Prospective randomised study	Speed of repair	Mean time per staple 18.6 sec, mean time per suture 124 sec	Not all lacerations involved the scalp Times included skin preparation Physicians time not used to calculate costs
			Cost	5 staples £4.14, 5 sutures £2.36
			Ease of removal	No difference
			Wound complications at time of removal	No difference
			Patient acceptability	More patients found staples acceptable. No local anaesthetic applied for stapling
Orlinsky M et al, 1995, USA	Patients presenting to the emergency department with linear lacerations of the scalp, extremities and trunk	Prospective randomised study	Time efficiency	Average speed of stapling 8.3 seconds per cm, and for suturing 63.2 seconds per cm.	Unable to report wound healing outcomes as follow-up poor
			Cost of repair	Average cost of wound repair by staple, $7.08 if no suture kit used, and $17.69 if kit used. Average cost suture repair was $21.58.

Comment(s)

There have been no large studies looking at the advantages of stapling wounds. It appears that stapling is cheaper than suturing, but the above studies have used a variety of different parameters to estimate cost. There are no large prospective, randomised studies targeting adults with scalp lacerations, addressing patient comfort, ease of application and risk of needlestick injury.

Clinical Bottom Line

Staples are a quicker and cheaper method of scalp wound closure.

References

1. Ritchie AJ, Rocke LG. Staples versus sutures in the closure of scalp wounds: a prospective, double-blind, randomized trial. Injury 1989;20(4):217-8.
2. Brickman KR, Lambert RW. Evaluation of skin stapling for wound closure in the emergency department. Ann Emerg Med 1989;18(10):1122-5.
3. MacGregor FB, McCombe AW, King PM, et al. Skin stapling of wounds in the accident department. Injury 1989;20(6):347-8.
4. Orlinsky M, Goldberg RM, Chan L, et al. Cost analysis of stapling versus suturing for skin closure. Am J Emerg Med 1995;13(1):77-81.