Staple versus suture closure for ankle fracture fixation: Retrospective chart review for safety and outcomes

Recent comparisons of suture versus metal staple skin closure on the rates of wound complications in orthopaedic surgeries have yielded conflicting results. Several studies have since started to approach this question based on anatomic location, comparing suture versus staple closure in total hip and knee arthroplasty and acetabulum fracture surgery. Ankle fractures are one of the most commonly treated fractures by orthopaedic surgeons with unique challenges to skin closure due to the lack of subcutaneous support. However, to date there are no studies comparing superficial skin closure methods specifically in ankle surgery. The objective of this study was to evaluate the safety of staple versus suture closure for open fixation of acute traumatic ankle fractures.

The medical records of patients treated at one institution by a single surgeon with open surgical fixation of an acute traumatic ankle fracture between 2011 and 2017 were retrospectively reviewed. Patients with less than 6 months of follow-up, polytrauma patients, diabetic patients, and patients with more than 3 medical comorbidities were excluded. Skin closure technique was determined by the presence or absence of metallic staples on postoperative imaging. Demographic variables, surgical characteristics, and postoperative outcomes up to one year were compared between patients who received superficial skin closure using staple versus suture techniques. Statistical analysis was performed using chi-squared tests and Fisher's exact tests, with p=0.05 used to denote statistical significance.

This study included 94 patients aged 18 to 75: two groups of 47 patients (Staple group and Suture group) that were demographically similar at baseline. Overweight and obese patients constituted the majority of the sample, 34% and 46% of patients, respectively. Current tobacco use was reported by 45% of patients. Fractures tended to be right-sided (63%), low energy (64%), and closed (98%), and the most common fracture types were bimalleolar (30%), lateral malleolar (24%), and pilon (19%) fractures. Ten patients (10.6%) developed local wound related complications within 4 months postoperatively, including five incidences of wound dehiscence, four superficial wound infections, and one deep infection. Eight patients (8.5%) required revision surgery due to wound related complications. There was no difference in the incidence of surgical site infections (p=0.361), local wound related complications (p=0.316), or revision surgeries (p=0.267) between wound closure techniques. Suture group patients required more staff in the operating room compared with staple group patients (p=0.001).

These results suggest that staples are a safe alternative to sutures for superficial skin closure in healthy, non-diabetic patients following open surgical fixation of acute traumatic ankle fractures. However, this retrospective, single-institution study was limited by the low number of available patients relative to the rare outcomes of interest. Larger, prospective studies are needed to validate the accuracy and generalizability of these results.