238 THE JOURNAL OF BONE AND JOINT SURGERY A comparison of three methods of wound closure following arthroplasty A PROSPECTIVE, RANDOMISED, CONTROLLED TRIAL R. J. K. Khan, D. Fick, F. Yao, K. Tang, M. Hurworth, B. Nivbrant, D. Wood From Sir Charles Gairdner Hospital, Perth, Western Australia " R. J. K. Khan, FRCS(Tr & Orth), Orthopaedic Surgeon " D. Fick, MBBS, Registrar " K. Tang, MBBS, Registrar " F. Yao, MBBS, Registrar " B. Nivbrant, PhD, Professor " D. Wood, MD, Professor " M. Hurworth, FRACS, Registrar Perth Orthopaedic Institute, Hollywood Private Hospital, Nedlands, Perth 6009, Western Australia. Correspondence should be sent to Mr R. J. K. Khan at 1/ 14-16 Hamersley Street, Cottesloe, Western Australia; e-mail: riazkhan@aol.com ©2006 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.88B2. 16923 $2.00 J Bone Joint Surg [Br] 2006;88-B:238-42. Received 4 July 2005; Accepted after revision 25 October 2005 We carried out a blinded prospective randomised controlled trial comparing 2- octylcyanoacrylate (OCA), subcuticular suture (monocryl) and skin staples for skin closure following total hip and total knee arthroplasty. We included 102 hip replacements and 85 of the knee. OCA was associated with less wound discharge in the first 24 hours for both the hip and the knee. However, with total knee replacement there was a trend for a more prolonged wound discharge with OCA. With total hip replacement there was no significant difference between the groups for either early or late complications. Closure of the wound with skin staples was significantly faster than with OCA or suture. There was no significant difference in the length of stay in hospital, Hollander wound evaluation score (cosmesis) or patient satisfaction between the groups at six weeks for either hips or knees. We consider that skin staples are the skin closure of choice for both hip and knee replacements. Randomised, controlled trials in orthopaedics are uncommon, 1 and none has studied differ- ent techniques of wound closure. The advent of more rapid rehabilitation and quicker dis- charge of patients from hospital following arthroplasty 2 increases the need for a safe tech- nique of wound closure which permits rapid healing without complication. Since cyanoacrylate adhesive or ‘superglue’ was first introduced, it has been refined to 2- butylcyanoacrylate and more recently to 2- octylcyanoacrylate (OCA), 3 with improvement in its strength and flexibility. 4 Animal studies have confirmed that OCA does not interfere with wound healing, 5 has minimal toxicity 6 and may reduce the incidence of wound infec- tion. 7-9 The United States’ Food and Drug Administration has granted approval for its use in man. The potential advantages of tissue adhesive include ease of use, painless application, rapid closure, cosmesis, avoidance of needlestick injuries and removal of the suture or staples. 10 OCA is now widely used for wound closure. 11-29 In orthopaedic surgery, the use of tissue adhe- sives has not been described and the most com- mon skin closure remains staples or subcuticu- lar suture. We have compared skin closure using staples, subcuticular suture and OCA in patients undergoing total hip (THR) and total knee replacement (TKR). We have studied the rate of healing, the complications and their influence on early discharge from hospital. Our hypothesis was that OCA would be superior to skin staples or subcuticular suture and there- fore be more appropriate for the closure of wounds following hip and knee arthroplasty. Patients and Methods A pilot study was carried out in 2003 to assess the efficacy of OCA on wounds following hip and knee arthroplasty, and to familiarise sur- geons with its use. Approval for the study was obtained from the local ethics committee. The protocol described in the CONSORT state- ment was used as a template for design of the study. 30 Between January and July 2004 all patients admitted to the Perth Orthopaedic Institute and the Sir Charles Gairdner Hospital under the care of two surgeons (BN and DW) for a primary THR or TKR were considered for inclusion. Those who were having a revision or with a previous incision in the operative field, a history of keloid formation, allergy to super- glue, regular anticoagulation therapy or had an underlying malignancy were excluded. All sur- geons performed wound closures in all three groups. The patients were randomised using a com- puter-generated method stored in sealed identi- Arthroplasty