Article Citation: Karounis H, Gouin S, Eisman H, Chalut D, 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 Jul;11(7):730-5. PMID: 15231459

What we already know about the topic: Traumatic lacerations are one of the most common causes leading children to the ED. Laceration repair using sutures can be traumatic to children, especially when they have to return for suture removal. Nonabsorbable sutures have been used as the material of choice for closing the outermost layer of any laceration. However, recently surgeons have been using absorbable suture material for pediatric operative wounds.

Why this study is important: The advantage of using absorbable sutures is that patients do not have to return for suture removal, and ultimately reduce healthcare cost. The objective of the study was to compare the outcomes of absorbable sutures vs. nonabsorbable sutures.

Brief overview of the study:

The study design was a randomized clinical trial that evaluated patients < 18 years with lacerations < 12 hours. Exclusion: wounds that could be approximated by tissue adhesives, animal/human bites, gross contamination, puncture/crush wounds, wounds crossing joints, lacerations of tendon/nerve/cartilage, collagen vascular disease, immunodeficiency, diabetes mellitus, bleeding disorder, and scalp lacerations.

Patients were randomized into two groups: absorbable plain gut sutures vs. nonabsorbable nylon sutures. Laceration repairs were performed by board-eligible/certified pediatric emergency physicians or fellows.

There were two scoring systems: Wound evaluation score(WES) and Visual analog scale of cosmesis (VAS). WES was composed of six items (presence of step-off, contour irregularities, margin separation, edge inversion, extensive distortion, and overall cosmetic appearance. The optimal score of WES was 6/6. VAS ranged from 0 to 100 with 0 representing the worst possible cosmetic outcome and 100 the best possible cosmetic outcome. The wound was evaluated by a nurse for infection, dehiscence and WES at the short-term follow-up (within 10 days) and later by a plastic surgeon using the WES and VAS at the long-term follow-up (4-5 months).

Short-term follow-up  

  • Of the 147 eligible patients, 50 were in the absorbable group, 45 were in the nonabsorbable group, and 52 declined participation.
  • There was no difference in the proportion of optimal WES (6/6) between the two groups.
    • Absorbable group: 63% of patients
    • Nonabsorbable group: 49% of patients
    • relative risk = 0.73; 95% confidence interval [95% CI] = 0.45 to 1.17
  • There was no difference in the rates of infection between the two groups (absorbable 2% vs. nonabsorbable  11%; 0.07) at the short-term follow-up.
  • There was no difference in the rates of dehiscence between the two groups (absorbable 0% vs. nonabsorbable  2%; 0.3) at the short-term follow-up.

Long-term follow-up

  • 32 patients withdrew after the short-term follow up. Of the 95 patients who were enrolled, 34 remained in the absorbable group, and 29 remained in the nonabsorbable group.
  • The absorbable group had a VAS of 79 (95% CI = 73 to 85) and the nonabsorbable group had a VAS of 66 (95% CI = 55 to 76) .
  • There was no difference in the proportion of optimal WES (6/6) between the two groups
    • Absorbable group: 36% of patients
    • Nonabsorbable group: 28% of patients
    • relative risk = 0.88; 95% CI = 0.62 to 1.26
  • Surgical scar revision was recommend for 2 patients in the absorbable group and 1 patient in the nonabsorbable group, but no patients chose to have their scars revised.

Limitations:

  • In the paper, board-eligible/certified pediatric emergency physicians or fellows repaired the lacerations, which may not be generalizable to other institutions.
  • In the paper, absorbable plain gut sutures and nonabsorbable nylon sutures were used, which may not be generalizable to other absorbable and nonabsorbable sutures.
  • A large number of patients (32/95) withdrew after the short-term follow up. Per paper, “Our sample size was calculated based on the potential long-term follow-up of our patients. Sample size was calculated based on a power of 90% (a = 0.05; b = 0.90) to detect a difference of 12 mm on the previously validated scale of cosmesis. We calculated that at least 43 patients were required per group (a = 0.05; b = 0.90).” However, due to the high withdrawal rate, the long-term follow-up did not have at least 43 patients per group, resulting in a decrease in statistical power.
  • For the short-term follow-up, the proportion of optimal WES (6/6) is 63% in the absorbable group and 49% in the nonabsorbable group. For the long-term follow-up, the proportion of optimal WES (6/6) is 36% in the absorbable group and 28% in the nonabsorbable group. Although there is no difference comparing the absorbable group and nonabsorbable group, there seems to be a discrepancy between the short-term follow-up and long-term follow-up. The high withdrawal rate may have attributed to this discrepancy.

Take home points:

The paper shows that the short and long-term cosmetic outcomes of absorbable plain gut sutures and nonabsorbable nylon sutures are similar in pediatric patients. Children may benefit from absorbable sutures, because they reduce return visits for suture removal. This article is a foundation of switching to absorbable sutures in our clinical practice.