SLR - February 2020 - Daniel L. Wu
Reference: Mullens C, Messa C, Kozak G, Rhemtulla I, Fischer J. To Glue or Not to Glue? Analysis of Fibrin Glue for Split-thickness Skin Graft Fixation. J Plastic and Reconstructive Surg Am. 2019 May 16; 7(5), e2187.Scientific Literature Review
Reviewed By: Daniel L. Wu, DPM
Residency Program: Scripps Mercy Hospital – San Diego, CA
Podiatric Relevance: Wound care is a hallmark for today’s foot and ankle surgeon, especially in the diabetic population. Split thickness skin grafts (STSGs) remain one of the best options in assisting in closure of partial thickness ulcerations that are non-infected with a healthy vascular and granular wound base. Hematoma and seroma remain the most common complications of STSGs. Various techniques to reduce shear and ensure robust fixation of the STSGs have been described to reduce these post op complications. Recently, fibrin glue, consisting of thrombin and clotting proteins, has shown to be a viable option for fixation of STSGs by mimicking the end stage of the clotting cascade, promoting hemostasis and adherence. This study compares clinical outcomes of traditional suture fixation with negative pressure wound therapy (NPWT) vs. fibrin glue fixation of STSGs. It is hypothesized that fibrin glue is easier and quicker to apply and more cost effective compared to traditional suture and NPWT.
Methods: A level III retrospective comparative study was performed with patients either receiving suture fixation with NPWT (n = 10) or fibrin glue alone (n = 10) for fixation of STSGs to their wound recipient sites. Twenty patients were chosen and matched accordingly to similar wound location and size. The fibrin glue was sprayed topically on the wound base prior to application of the STSG followed by a second layer applied over the graft. Primary outcome measures were 180 days post-STSG placement and any related complications defined as graft failure, seroma, or surgical site infection. Secondary outcomes included OR operation time, hospital length of stay, cost associated with each skin graft procedure, post op wound vac use, and time for 100 percent graft take.
Results: The primary outcome results showed no significant differences in complications between both groups 180 days status post STSG application with only one complication noted in the fibrin glue group although unspecified. In patients with fibrin glue fixation, results showed decreased OR time (34.9 vs. 49.4 minutes, p = 0.612), no need for use of NPWT (0 vs. 10 wounds, p < 0.0001), decreased cost ($16,542 vs. $24, 266, p = 0.545), and decreased time for 100 percent graft take (20.2 vs. 29.4 days, p = 0.405) compared to suture fixation with NPWT. Both groups had similar length of hospital stay (2.8 FG vs. 3.5 days).
Conclusions: Fibrin glue for STSG fixation compared to traditional suture and NPWT showed no significant differences in clinical outcomes. Fibrin glue offers the potential benefit of decreased OR time, decreased cost, no need for NPWT, and decreased time for 100% graft take. Limitations of this study include but are not limited to the retrospective comparative non randomized study design, low n value, and variability of demographic and wounds in each group. Larger prospective randomized controlled trials comparing fibrin glue to traditional STSG fixation are needed to further confirm its utility and ease of use without complications.