Tissue adhesives for simple traumatic lacerations

Journal of Athletic Training, March-April, 2008 by Joel W. Beam

COMMENTARY

Cyanoacrylate derivative tissue adhesives were developed in 1949 and have had a long history of use in tissue bonding outside the United States. In 1998, the Food and Drug Administration approved octylcyanoacrylate for use and, currently, 2-octylcyanoacrylate in low-viscosity and high-viscosity formulas (Dermabond, Ethicon Inc, Somerville, NJ) is the only tissue adhesive approved and available commercially in the United States. (1) Tissue adhesives are commonly used to replace standard wound closure (SWC) (sutures, staples, adhesive strips) in the management of surgical and traumatic wounds. The literature investigating the use of tissue adhesives is vast, but the variability of interventions, wound sizes and locations, participant ages, and outcome measures has lessened comparisons among tissue adhesives and SWC. Perhaps most important in these investigations are the outcome measures of cosmetics, pain with and time to complete the procedure, and rate of complications such as infection, erythema, and dehiscence. Are tissue adhesives effective for closure of simple traumatic lacerations? Among athletic trainers, is their use appropriate with healthy individuals involved in athletic and work activities?

Farion et al (2) presented several clinical implications in the use of tissue adhesives for the management of simple traumatic lacerations. Several findings support the suggestion that tissue adhesives are an alternative to SWC. Overall, no significant differences were seen between tissue adhesives and SWC in short-term or long-term cosmetic outcomes, which may be the most important outcome among individuals who sustain facial and neck lacerations. However, a subgroup analysis significantly favored butylcyanoacrylate for cosmetic outcome at 1 to 3 months compared with SWC. Also, the use of tissue adhesives significantly lowered the incidence of erythema compared with SWC. Tissue adhesives significantly lowered both the time to complete the wound closure procedure (by an average of 4.7 minutes) and pain scores reported by parents, patients, physicians, and nurses. The authors suggested that these findings should be considered in the management of lacerations in children, as SWC can be emotionally traumatic for the patient and parent. (2)

The evidence provided in this review for the management of simple traumatic lacerations among healthy individuals applies directly to athletic trainers. Tissue adhesives appear to provide a rapid, reliable method of wound closure when an immediate return to athletic and work activities is necessary. (3) However, few groups have empirically studied the effects of environmental (heat, cold, and moisture) and physical (rigid equipment and surfaces, friction, and tension) stressors on tissue adhesives. (3) Two groups examined the use of a tissue adhesive (Dermabond) for the closure of traumatic lacerations sustained by ice hockey athletes during competition in a senior men's world championship (4) and professional season. (3) Thirty-six lacerations (length range = 0.8 cm to 8 cm) sustained to the eyebrow, eyelid, or general face were closed with a tissue adhesive. These authors (3,4) reported that all athletes returned immediately to competition after the procedure (1 laceration was sustained at the end of the match), cosmetic outcomes at the conclusion of competition and day 7 were either "acceptable" or "good/excellent," and no erythema, infection, discharge, or need for delayed closure occurred. In a study (3) of professional athletes, 1 wound demonstrated a small, superficial dehiscence after competition, but cosmetic assessment did not change at day 7.

Dehiscence may have the potential to be a limiting factor in the use of tissue adhesives for wound closure by athletic trainers. For most, the goal of using tissue adhesives is timely wound closure with an immediate return to sport or work activities for the healthy individual. In the review, Farion et al (2) revealed a significant increase in the risk of dehiscence when tissue adhesives were compared with SWC. The authors suggested that wound characteristics (length, width, and depth), patient characteristics (age), allied health care provider skill level/training, or different tissue adhesives may have affected these findings. (2) Additionally, tissue adhesives are not appropriate for use with all wounds, and proper wound cleansing, debridement, and dressing techniques should not be compromised to achieve a quick closure and return to activity. (3,5) The use of tissue adhesives is contraindicated in animal bites; stellate wounds; wounds with evidence of infection, gangrene or ulceration; mucosal surfaces or across mucocutaneous junctions; areas of high moisture or dense hair; and areas of high tension such as joints. (1,5) Further research is needed to examine the effects of environmental and physical stressors on the rate of dehiscence and the short-term and long-term effects on cosmetic outcome among various populations.