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 Table of Contents  
ORIGINAL ARTICLE
Year : 2012  |  Volume : 1  |  Issue : 3  |  Page : 153-157

Comparative study of safety and efficacy of electrocautery blade with cold scalpel blade for skin opening during fixation of fracture of forearm bone with plate and screws


Department of Orthopedics, Adichunchanagiri Institute of Medical Sciences, BG Nagar, Mandya District, Karnataka, India

Date of Web Publication26-Dec-2012

Correspondence Address:
K T Madhukar
176, Sampada, Siddivinayaka Block, Teachers Layout, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.105065

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  Abstract 

Introduction: The art of performing surgeries have improved in recent years with the development of various electrosurgical devices assisting surgeons in performing safer surgeries with better outcomes. Skin incision has traditionally been made with a standard scalpel blade with good primary healing end results of the wound. The electrocautery has been used safely in performing deeper dissections. Use of electrocautery in skin incision has been discouraged in the past for the fear of cutaneous scarring, wound dehiscence, and infections particularly in orthopedic surgeries using internal implants. A review of the literature shows not many studies have been conducted to evaluate the safety and efficacy of electrocautery in skin incisions during orthopedic surgeries using internal implants. Aim: A prospective study was conducted in a tertiary care hospital with the aim to determine whether an electrocautery blade can be used safely for skin incisions. Materials and Methods: Sixty-two patients with single-bone fracture of the forearm undergoing open reduction and internal fixation received one-half of the incision with a standard scalpel blade and another half with electrocautery in pure cutting mode randomly. Analysis: Wounds were compared on operating day for any physical changes and on days 3, 5, and 12, and again on 3 rd and 6 weeks follow-up to know any difference in skin healing between the incised wounds of the two halves. Results: No evidence of any difference in healing of the two halves of skin incision was noted. There was also no increased risk of wound scarring, dehiscence, or infection with electrocautery incision when compared with standard scalpel incision. The time taken for skin incision with electrocautery was significantly less when compared with cold scalpel incision. Conclusion: We propose that electrocautery can be safely used for performing skin incision, with comparable results to that of a standard scalpel skin incision.

Keywords: Electrocautery vs standard scalpel, skin incision, wound healing


How to cite this article:
Madhukar K T, Ganesh M T. Comparative study of safety and efficacy of electrocautery blade with cold scalpel blade for skin opening during fixation of fracture of forearm bone with plate and screws. Int J Health Allied Sci 2012;1:153-7

How to cite this URL:
Madhukar K T, Ganesh M T. Comparative study of safety and efficacy of electrocautery blade with cold scalpel blade for skin opening during fixation of fracture of forearm bone with plate and screws. Int J Health Allied Sci [serial online] 2012 [cited 2019 Nov 12];1:153-7. Available from: http://www.ijhas.in/text.asp?2012/1/3/153/105065


  Introduction Top


Cutaneous scarring after elective surgery is a matter of concern for all surgeons. The cold scalpel blade been used since generations for performing skin incision in operative surgeries followed by use of electrocautery blade [1] to extend the incision into the subcutaneous and deeper layers. Use of electrocautery has been discouraged in the past for performing skin incision for the fear of cutaneous scarring, wound dehiscence, [2] and infections particularly in orthopedic surgeries using internal implants. A review of the literature revealed hardly any studies about the usefulness of electrocautery in performing skin incisions in orthopedics cases using internal implants. Few studies with favorable results of using electrocautery in skin incisions of abdominal surgeries, [3],[4],[5],[6] neurosurgery, [7],[8] and cancer [9] patients undergoing surgeries is well documented.

The purpose of this prospective study was to know the efficacy and safety of using electrocautery for performing skin incision in fixation of fracture of the forearm bone in our clinical setting. This study objectively, prospectively, and randomly compares the time taken by a standard cold scalpel and electrocautery blades, wound complications, and cosmetic result in performing skin incisions in patients undergoing internal fixation of fracture of forearm bones.


  Materials and Methods Top


The study was conducted as a prospective, randomized one in a tertiary care center in Mandya district of Karnataka. Sixty-two patients with single-bone fracture of the forearm admitted from January 2011 to March 2012 were included into the study. Patients with simple fracture of either the radius or ulna were selected for the study. Consent from patients and ethical committee clearance were obtained before the procedure.

The following patients were excluded from study:

  1. Patients below the age of 18 years,
  2. Fractures of both bones of the forearm,
  3. Comminuted or open fractures,
  4. Previous history of hypertrophic or keloid scarring,
  5. Patients suffering from chronic immunosuppressive disorders or wound healing problems,
  6. Patients on long-term medications, which interferes with wound healing, such as corticosteroids, anticancer drugs, or colchicines for gout,
  7. Patients using tobacco products.
Twenty-eight patients had fracture of the shaft of the radius and 34 had fracture of the shaft of the ulna. The patients were given numerical codes in sequence according to the date of admission separately for radius and ulna fractures. All surgeries were performed under general/regional anesthesia with use of tourniquets. The incision site was marked. Each incision was then divided into two halves, one to be opened by steel scalpel blades and the other by a micro-electrocautery blade. Radius and ulna fractures with even numbers underwent incision with a standard scalpel in the upper half of the incision and odd number cases in the lower half. The other half of the incision was performed using Schiller's Surgitron GD-400 electrocautery apparatus [Figure 1] with an electrocautery blade [Figure 2]. The electrocautery unit was set on cutting pure mode, at a power of 5 W and using a 390-kHz sinusoid waveform during the procedure.
Figure 1: Electrocautery machine used for coagulation and cutting purpose

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Figure 2: The micro‑electrocautery blade used for performing skin incision

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The incision depth included the epidermis, dermis, and the superficial part of the subcutaneous layer. During electrocautery incision, only the tip of the blade was allowed to come in contact with the proposed incision line and the sides of the electrocautery blade were not allowed to touch the skin edges at any time by applying mild traction on either sides of the skin incision as the cutting proceeded.

The floor nurse noted the time taken to complete the incision on each side separately using a stop clock. The length of each half of the incision was recorded. The speed of skin incision was calculated in mm/s from the start of incision until completion of the incision, including hemostasis. The speed of incision was calculated by dividing length in millimeters by time in seconds for each half separately. The time calculated for incision did not included deep fascia or periosteum opening.

On completing total skin incision, the wound edges were inspected for any physical differences between the parts performed by the electrocautery and cold scalpel. The incision wound with scalpel and electrocautery was inspected in each case immediately after completing the skin incision with respect to color, viability, presence of charring effect, and dermal peeling by naked eye examination.

Deeper dissection was continued as usual and fractures were fixed with a 3.5 mm low-contact dynamic compression plate in each case. The wounds were closed in layers using vicryl in deeper tissues and ethilion or staples for the skin. The wound was inspected on postoperative days 3, 5, and 12 for wound healing and complications, and at 6-week and 3-months follow-up.

The variables evaluated in this study were time taken for incision; differences with respect to physical inspection of the wound edges soon after incision; cosmetic appearance of the scar as good, poor, contracted; and formation of keloids and wound complications.


  Results Top


Sixty-two skins incisions were performed by or under direct supervision of a single orthopedic surgeon using a cold scalpel and an electrocautery blade in open reduction and internal fixation of the fracture of the shaft of the radius or ulna using a low-contact dynamic compression plate.

The speed of incision when a cold scalpel was used ranged between 0.15 mm/s and 0.4 mm/s, with an average of 0.2 mm/s. The speed of incision with electrocautery blade was between 1.3 mm/s and 2.8 mm/s, with an average of 1.8 mm/s. The average time taken by cold scalpel for performing a 12-cm skin incision was 7 min against 3 min by electrocautery. In comparison with the cold scalpel, the time taken for incision with electrocautery was much lower.

Macroscopic differences with respect to color, viability, presence of charring effect, and dermal peeling between cold and electrocautery scalpel incisions were found to be nil. Postoperative inspection on days 1, 3, 5, and 12 also did not yield any differences in the physical character of the wound [Figure 3].

Healing of skin wound incised with cold and electrocautery scalpel at the end of 6 weeks and 3 months were the same [Figure 4]. Palpation of the incised wound for any scar tenderness did not yield any difference.
Figure 3: A well‑healed skin incision site used for radius fixation at the end of 2 weeks. The proximal part of the incision was performed using electrocautery and the distal half by a cold scalpel, and no physical differences were seen between the two regarding healing

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Figure 4: Skin incisional area healed very well at 3 months. The proximal part was performed using a skin scalpel and the distal with electrocautery

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Blood loss with these two methods of incision could not be evaluated because of the use of exsanguination and tourniquet application.

One case of superficial stitch abscess was found involving the full length of the skin incision area involving the ulna fixation site, which was effectively managed with antibiotics and regular dressings [Figure 5].
Figure 5: Superficial skin infection involving the full length of the incisional area that healed well with continued dressings and antibiotics

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A case of neuropraxia of the superficial branch of the radial nerve was seen in radius fixation where electrocautery was used in the distal half of the incision, but recovered well at 3-month follow-up.

No evidences of scar tenderness, hypertrophy, or keloid formation of the scar, or wound dehiscence were found either in the radius/ulna side of the incision either with cold or electrocautery scalpel incision in 6-month follow-up of patients.


  Discussion Top


Maintaining hemostasis during surgical procedures is critical for favorable outcomes in the operating room. Historically, heated stones, boiled oil, forceps heated with spirit lamps have been used to achieve hemostasis. [1]

Use of electricity in electrocoagulation begins with the discovery of Galvanic current by Luigi Galvani accidentally in 1786. [1] He noted that muscle spasms were induced in frog's legs hanging from copper hooks as they brushed the iron balustrade at his home.

William T Bovie [1] has being credited as the father of electrosurgical devices. Today there are various numbers of applications for electrosurgery in the operating room, but cauterization is unquestionably the most common application of the technology.

On 1 October 1926, Dr Harvey Cushing [1] used electrocautery to remove an enlarging vascular myeloma from the head of a 64-year-old patient who had a failed surgery with traditional means several days prior.

The current output of electrosurgical generators is modulated to deliver different waveforms to the tissue. As the output waveform changes, so does the corresponding tissue effect. In general, electrosurgical generators provide two types of modes, continuous and interrupted. The continuous mode of current output is most often referred as the cut mode and the interrupted mode as the coagulation mode.

In the cutting mode, the electrode rapidly heats cells to the point of vaporization. The excess heat is disposed as commonly noted smoke and steam, but is not passed to the tissues adjacent to the incision site, which explains the lack of tissue char and minimal scarring on wound healing. [1]

The abscence of excessive scarring and well healing of the incision similar to cold scalpel supports the exclusive use of electrocautery in open fixation of fractures in this era of increased rates of surgical exposure to hepatitis C, hepatitis B, and HIV infection patients is evident.

The method of surgical diathermy incision was observed to be easy, safe, and highly effective in all the meta-analysis studies conducted comparing electrocautery skin incision with scalpel incision. [10],[11],[12]

In summary, various studies have established that an electrocautery scalpel can be used as safely as a cold scalpel in performing skin and deeper incision without the risk of excessive scarring of skin, wound dehiscence, or infection. [13],[14],[15]

The lack of scarring at the incisional area and the well healing of the incision similar to cold scalpel has been well recorded in the literature on laparotomy [2],[3],[4],[5] and neurosurgical incisions, [7],[8] but not enough studies have been performed about its use in orthopedic cases.

In the present study, it was noted that a micro-electrocautery blade could be safely used for skin incision without any increased risk of cutaneous scarring, wound infection, or wound dehiscence even in orthopedic surgeries using internal implants. The time taken for skin incision is also significantly less compared with a cold scalpel. There was no evidence of any scar tenderness or keloid formation in follow-up of the cases.


  Conclusion Top


This study supports safer use of micro-electrocautery in skin incisions without the added risk of wound scarring, dehiscence, or infection. The time required for skin incision is significantly lower with cautery incision when compared with scalpel incision. Scalpel-free surgeries can be conducted in some cases, potentially saving money and allowing a safer operating room environment. Further multilevel studies are required to identify the shortcomings and complications associated with it in orthopedic surgeries.


  Acknowledgment Top


Professor Gunnaiah K.G, Head of the Department, Department of Orthopedics, Adichunchanagiri Institute of Medical Sciences, Mandya District, Karnataka. Professor Manjappa C.N, Department of Orthopedics, Adichunchanagiri Institute of Medical Sciences, Mandya District, Karnataka.

 
  References Top

1.Fulton J. Harvey Cushing: The Story of a Great Medical Pioneer. Springfield: Charles C Thomas Publisher; 1946.  Back to cited text no. 1
    
2.Kearns SR, Connolly EM, McNally S, McNamara DA, Deasy J. Randomized clinical trial of diathermy versus scalpel incision in elective midline laparotomy. Br J Surg 2001;88:41-4.  Back to cited text no. 2
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3.Bovie WJ. New electrosurgical unit. Surg Gynecol Obstet 1928;47:751-2.  Back to cited text no. 3
    
4.Shamim M. Diathermy vs scalpel skin incisions in general surgery: Double-blind, randomized, clinical trial. World J Surg 2009;33:1594-9.  Back to cited text no. 4
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5.Ahmad NZ, Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in making abdominal skin incisions. Ann Surg 2011;253:8-13.  Back to cited text no. 5
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6.Kim H, Brunner E, Ritter E, Thompson D, Devereux D. Relevance of methods of skin incision technique on development of wound infection. Am Surg 1991;57:129-30.  Back to cited text no. 6
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7.Nitta N, Fukami T, Nozaki K. Electrocautery skin incision for neurosurgery procedures - technical note. Neurol Med Chir (Tokyo) 2011;51:88-91.  Back to cited text no. 7
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8.Sheikh B. Safety and efficacy of electrocautery utilization for skin opening in neurosurgery. Br J Neurosurg 2004;18:268-72.  Back to cited text no. 8
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9.Kumar V, Tewari M, Shukla HS. A comparative study of scalpel and surgical diathermy incision in elective operations of head and neck cancer. Indian J Cancer 2011;48:216-9.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.Arid LN, Brown CJ. Systematic review and meta-analysis of electrocautery versus scalpel for surgical skin incisions. Am J Surg 2012;204:216-21.  Back to cited text no. 10
    
11.Drew PJ. Systematic review and meta-analysis of cutting diathermy versus scalpel for skin incision. Br J Surg 2012;99:613-20.  Back to cited text no. 11
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12.Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of cutting diathermy versus scalpel for skin incision. Br J Surg 2012;99:613-20.  Back to cited text no. 12
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13.Pearlman NW, Stiegmann GV, Vance V, Norton LW, Bell RC, Staerkel R, et al. A prospective study of incisional time, blood loss, pain, and healing with carbon dioxide laser, scalpel, and electrosurgery. Arch Surg 1991;126:1018-20.  Back to cited text no. 13
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14.Groot G, Chappell EW. Electrocautery used to create incisions does not increase wound infection rates. Am J Surg 1994;167:601-3.  Back to cited text no. 14
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15.Malis LI. Electrosurgery. Technical note. J Neurosurg 1996;85:970-5.  Back to cited text no. 15
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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Introduction
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