Barbed versus traditional sutures for wound closure in knee arthroplasty: a systematic review and meta-analysis

Allergic Contact Dermatitis to Octyl Cyanoacrylate Skin Glue After Surgical Wound Closure: A Systematic Review

The rising incidence of allergic contact dermatitis (ACD) after cyanoacrylate adhesive use necessitates a comprehensive understanding of its clinical presentations, risk factors, and management. In this systematic review, we conducted an exhaustive search following PRISMA guidelines within Medline and PubMed databases to identify studies reporting cases of ACD resulting from cyanoacrylate adhesive application in wound closure. A total of 47 studies, covering 193 ACD cases, were included in our analysis. These cases involved 35 male, 120 female patients, and 38 cases without gender information (M:F ratio = 1:3.43), with ages ranging from 7 to 92 years (mean age 43.9 years). The majority of cases (n = 140) were part of 6 orthopedic studies, focusing on joint replacements (n = 68), orthopedic surgeries (n = 38), and breast surgeries (n = 29). The remaining 58 cases encompassed various surgical procedures. Common clinical manifestations included swelling, pruritic rash, erythema, vesicles, and itching around the surgical sites, typically appearing around 10 days post-adhesive application (within a range of 6 hours to 6 weeks). Patients with prior exposure to 2-octyl cyanoacrylate tended to exhibit earlier symptoms. Similar rates of dermatitis were observed across different adhesive brands, suggesting brand independence. Treatment strategies involved adhesive removal, administration of steroids and antihistamines, meticulous wound care, and, in some cases, surgical intervention. Notably, 3.1% of the 193 cases required surgical intervention. Risk factors, including a history of atopic dermatitis, high body mass index, diabetes, prior adhesive exposure, and surgical history, were identified in the studies. Patch tests confirmed 2-octyl cyanoacrylate as the allergen in 21 studies. Our review aims to enhance health care professionals' understanding of ACD resulting from the use of cyanoacrylate adhesive, facilitating improved postsurgical management and prevention strategies. Recognizing diverse risk factors, understanding varying clinical presentations, distinguishing ACD from infection, and employing appropriate treatment approaches are essential for achieving optimal outcomes in such cases.

Comparison of incisional bursting strength of a bidirectional absorbable knotless suture material versus a standard continuous absorbable suture material for closure of the equine linea alba

OBJECTIVE

To evaluate the use of bidirectional knotless barbed suture material for closure of the equine linea alba.

STUDY DESIGN

Laboratory study.

ANIMAL OR SAMPLE POPULATION

Adult light horse cadavers (n = 24).

METHODS

A 25 cm incision was made through the linea alba, and a 200 L polyurethane bladder was positioned within the abdomen. The linea alba was closed either using USP2/EP5 bidirectional polydioxanone barbed suture or USP2/EP5 standard polydioxanone suture in a simple continuous pattern. Closure time was recorded for each suture type. The bladder was air-insufflated at 40 L/min, and the pressure at body wall failure recorded. The length of suture used for wound closure and wound failure modes were recorded. Suture length, closure time, bursting pressure, and failure modes were compared using Welch-Aspin t-tests.

RESULTS

The incisional bursting pressure was comparable between the two groups (p > .05). Less suture material (p < .01) was required with the barbed suture than the standard suture. Closure time was less for the barbed suture than the standard suture (p < .01). Suture failure was the main failure mode in both groups (83% cases).

CONCLUSIONS

Closure of the equine linea alba using bidirectional barbed suture material reduced the amount of foreign material in the wound and decreased closure time without compromising incisional strength.

CLINICAL RELEVANCE

Bidirectional barbed suture material could be considered as an alternative to standard suture materials for closure of the equine line alba.

The Examination of the Benefits of the Usage of Barbed, Knotless Suture in Capsule Repair During Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study

Introduction

In today's world, high-cost procedures are being examined, and alternative procedures are being developed. In this context, one frequently examined procedure is total knee replacement.

Purpose

This study aims to examine the three different closure techniques used in total knee replacement.

Methods

This study is a prospective randomized controlled study. Two hundred participants who underwent total knee replacement surgery, were included in the study. Participants were randomly divided into three groups. Arthrotomy was performed using a medial parapatellar approach with a midline incision. Standard femoral and tibial cuts were followed by the implantation of a Smith and Nephew genesis II implant for all participants. Complications, joint range of motion, pain scores, certain movement degrees, and functional scores were investigated.

Results

Pre-op and post-op range of motion, knee society score, oxford knee score, certain movement degree values have shown no significant difference. Visual analogue scale values were different significantly between the groups. There is a statistical difference between the range of motion, knee society score, oxford knee score, certain movement degree and visual analogue scale values in repeated measurements. The most common complication was a hematoma. This was observed most frequently in the continuous vicryl suture group. The closure time in the Barbed group was significantly lower than in the other groups.

Discussion

Treatment for total knee replacement is a heavy economic burden. Health systems and hospitals are under pressure. The results obtained in our study show that there is no superiority of one closure technique over the other.

[Surgical suture material-fundamentals]

At the end of surgical therapy, the access is closed with sutures. Surgical sutures are thus used to adapt wound edges and tissues. The task of the suture material is to hold the tissues together until healing. For patients, a cosmetically good suture is often the sign of good surgery. Different tissues and layers have different requirements regarding the suture material. The different types from monofil to polyfil, braided, from absorbable to nonabsorbable are presented. The classification of suture strengths is compared. The areas of application of different strengths and the duration until removal of the sutures for the different body regions are presented. The one-hand and two-hand techniques of surgical knots are explained in detail. The technique of suture removal is presented. In the online material, the suture materials of different composition and manufacturers can be compared.

Occlusive wound closure prevents prolonged wound discharge-A randomised controlled trial in patients undergoing tumour resection and endoprosthetic reconstruction of the proximal femur because of metastatic bone disease

Prolonged wound discharge is a common postoperative complication of orthopaedic procedures and a risk factor for implant-related infection. Occlusive wound closure methods have previously been suggested to reduce or even prevent this complication. We performed a randomised controlled trial on 70 patients who underwent surgical treatment for metastatic bone disease involving the proximal femur at our centre between January 2017 and August 2018. At conclusion of the tumour resection and endoprosthetic reconstruction procedure, patients were randomised to either occlusive wound closure (n = 35), using the Dermabond Prineo-22 skin closure system, or routine wound closure with conventional skin staples (n = 35). Skin closure with occlusive wound closure resulted in a lesser degree (P < .0001) and shorter duration of postoperative wound discharge (HR 2.89 [95% CI 1.6-5.05], P < .0018). Compared with staples, surgical wounds were already dry after a mean of 3.5 days [95% CI 3.2-3.9] versus 6.1 days [95% CI 4.8-7.3] (P < .0001). Prolonged wound discharge for 7 days or more was observed in 23% of patients (n = 8) in the Staples-group but was entirely absent in the occlusive wound closure group (P < .003). This study provides strong evidence that occlusive wound closure reduces frequency, degree, and duration of wound discharge in a patient population at particularly high risk for this complication.

Arthrotomy Dehiscence After Total Knee Arthroplasty With a Barbed Suture

INTRODUCTION

Meticulous arthrotomy closure during total knee arthroplasty (TKA) is essential to preserve quadriceps strength and maintain proper patellar tracking. We recently encountered a subset of patients referred with anterior knee pain, a palpable retinaculum defect, and quadriceps weakness. Each patient was found to have an arthrotomy dehiscence. This study highlights arthrotomy dehiscence as a failure mechanism after TKA.

METHODS

A retrospective case series of patients who underwent primary TKA followed by subsequent capsular dehiscence was reviewed. We investigated whether the dehiscence was related to trauma, the presence of a palpable arthrotomy defect, patellar tracking, quadriceps strength, and the type of closure technique.

RESULTS

All patients had an atraumatic disruption and presented with anterior knee pain and quadriceps weakness. Fourteen of 18 patients (78%) had a palpable defect along the medial retinaculum. Nine of 18 patients (50%) had patellar subluxation or tilting. Barbed sutures were used in 13 of 18 (72%) patients. A simple arthrotomy repair (44%) or a vastus medialis obliquus advancement (56%) was used successfully in all patients.

DISCUSSION

Atraumatic arthrotomy dehiscence as a cause of TKA failure historically has been a rare event. Recently, we have noticed a disturbing number of patients presenting with this failure mechanism. With this study, we call attention to this unique atraumatic failure mechanism in patients presenting with anterior knee pain after TKA. Surgeons should be aware of this risk when using barbed sutures alone and should consider routinely reinforcing the arthrotomy with interrupted sutures.

LEVEL OF EVIDENCE

Level IV, Retrospective Case Series.

EFFICACY AND SAFETY OF KNOTLESS BARBED SUTURES IN CAPSULAR CLOSURE FOLLOWING DISTAL FEMUR FRACTURE FIXATION

Introduction

Good wound closure is an important step in management of distal femur fracture to prevent infection and faster rehabilitation. Knotless barbed sutures can save time and distribute wound tension evenly. However, its role in terms of functional outcome, closure time, and postoperative complications has not been studied in a distal femur fracture.

Material and methods

A total of 47 patients aged more than 18 years of distal femur fracture treated with distal femur locking plate were randomized either into either barbed or traditional suture groups. in the barbed group, capsular wound closure was carried out with 2-0 bidirectional barbed knotless sutures (Quill SRS^® PDO, Angiotech, Vancouver, BC, Canada). In patients assigned to group B, capsular closure was done with 1-0 Vicryl^® (Ethicon inc. Somerville, NJ) and 5-0 Ethibond^® alternatively.

Results

The mean flexion at the knee joint was 105.7±15.6 degrees in the study group while it was 110.4±13.7 in the control group (p= 0.2133). Mean estimated closure time was significantly shorter in the study group as compared to the control group (p<0.05). Cases of needle prick injury were higher in traditional suture group. Patients developed stitch abscess and superficial infection in both groups. However, the difference in incidence between the two was not statistically significant.

Conclusion

Barbed suture is an efficient method of wound closure. It reduces wound closure time with similar complication rate as with use of conventional sutures. Evidence Level II; Randomized Clinical Trial.

Barbed Suture versus Interrupted Suture in Posterior Cervical Spine Surgery: Are They Equivalent?

Introduction

Posterior cervical spine approaches have been associated with increased rates of wound complications compared to anterior approaches. While barbed suture wound closure for lumbar spine surgery has been shown to be safe and efficacious, there is no literature regarding its use in posterior cervical spine surgery. In a cohort of patients undergoing elective posterior cervical spine surgery, we sought to compare postoperative complication rates between barbed and traditional interrupted suture closure.

Methods

A retrospective review of demographics, past medical history, and operative and postoperative variables collected from a prospective registry between July 1, 2016, and June 30, 2020 was undertaken. All patients 18 years old and above undergoing elective posterior cervical fusion were included. The primary outcome of interest was wound complications, including surgical site infection (SSI), dehiscence, or hematoma. In addition, numerical rating scale (NRS) neck pain (NP), NRS arm pain (AP), Neck Disability Index (NDI), and operative time were collected. A variety of statistical tests were used to compare the two suture groups.

Results

Of 117 patients undergoing posterior cervical fusion, 89 (76%) were closed with interrupted suture and 28 (24%) with barbed suture. The interrupted cohort were more likely to have >1 comorbidity (p<0.001), diabetes mellitus (p=0.013), and coronary artery disease (p=0.002). No difference in postoperative wound complications between interrupted/barbed sutures was observed after univariate (OR 1.07, 95% CI: 0.27-4.25, p=0.927) and multivariable logistic regression analysis (OR 0.77, 95% CI: 0.15-4.00, p=0.756). Univariate logistic regression revealed no differences in achieving minimal clinically important difference (MCID) NRS-NP (OR 0.73, 95% CI: 0.28-1.88, p=0.508) or NRS-AP (OR 0.68, 95% CI: 0.25-1.90, p=0.464) at 3 months between suture groups. The interrupted suture group was less likely to achieve MCID NDI at 3 months (OR 0.29, 95% CI: 0.11-0.80, p=0.016).

Conclusions

Barbed suture closure in posterior cervical spine surgery does not lead to higher rates of postoperative wound complications/SSI compared to traditional interrupted fascial closure.

The use of novel knotless barbed sutures in posterior long-segment lumbar surgery: a randomized controlled trial

Background

The study carries the aim to compare the clinical efficacy and economic outcomes of using barbed suture closure versus conventional closure for wounds after posterior long-segment lumbar surgery.

Methods

One hundred and eighty-one patients undertaking posterior long-segment lumbar surgery participated in the prospective randomized controlled trial study to receive either barbed suture wound closure (n = 91) or conventional suture closure (n = 90). Outcome measures included operating room time (ORT), wound closure time, length of incision, length of hospital stay (LOS), 90-day readmission rates, wound complications of dehiscence and infection, and costs.

Results

Barbed suture group was related with significantly lower ORT (P = 0.036), wound closure time (P < 0.001) and average wound closure time (P < 0.001), and significantly lower wound complication rates (dehiscence and infection) (P = 0.031). No significant differences were found when compared with conventional suture group in terms of length of incision (P = 0.086), length of hospital stay (P = 0.174), readmission rates up to 90 days after the surgical procedure (P = 0.232) and costs (P = 0.205).

Conclusion

The study suggested the knotless barbed suture technique outperformed the conventional suture in shortening operating room time, wound closure time and average wound closure time, and reducing wound complication rates.

Barbed Sutures for Total Hip and Knee Arthroplasty Have Shorter Wound Closure Time and are Cost-Effective in Comparison to Traditional Sutures: A Systematic Review and Meta-analysis of 16 Randomized Controlled Trials

PURPOSE

Surgical wound closure is of paramount importance, especially in total joint replacement surgeries wherein correct closure technique not only aids in rapid healing, but with lesser complications, we would be looking at a quicker rehabilitation of the patients. Bidirectional barbed sutures appear to reduce the wound closure time in all the planes and are cost-effective in comparison with traditional sutures. This study is aimed at evaluating the efficacy and superiority of bidirectional barbed sutures in comparison to traditional suturing techniques.

METHODS

Electronic databases like Embase, PubMed, Cochrane Library, Lilacs were searched up to February 2021. 16 high-quality randomized-controlled trials (RCT) were selected in this study. The search method identified 2168 total knee replacements (TKR) and 229 total hip replacements (THR) among 2397 patients. All the studies compared barbed sutures with traditional wound closure techniques. Data of wound closure time, overall cost, length of hospital stay, overall wound complications, suture-related complications, range of motion data, and knee society scores were collected and further analyzed.

RESULTS

The baseline patient characteristics were identical among all the included studies. Compared to traditional sutures a significantly decreased wound closure time in both THR and TKRs (p < 0.00001) and cost (p < 0.00001) was noted, although no statistically significant difference was found in overall complications in THRs (p = 0.95) and TKRs (p = 0.69). ROM (p = 0.54-6 weeks after surgery and p = 0.68-3 months after surgery) and Knee society scores (p = 0.92) in both the groups of patients undergoing TKR. However, the length of hospital stay was prolonged in the barbed suture group (p = 0.01), pinpricks (p = 0.02), and broken sutures (p = 0.02).

CONCLUSIONS

Novel methods of wound closure such as barbed sutures achieve satisfactory surgical implementation being more efficient in the form of decreasing the overall wound closure time, with comparable wound complication rates and being cost-effective. But the drawbacks like the incidence of broken sutures and pinpricks are more. Overall using barbed sutures in place of traditional sutures may be considered safe and a viable alternative choice for suturing in total joint replacements.

LEVEL OF EVIDENCE

Level I, Systematic review and Meta-analysis of RCT.

Barbed Sutures in Total Knee Arthroplasty: A Meta-analysis of Randomized-Controlled Trials

Newer methods of wound closure such as barbed sutures hold the potential to reduce closure time and equivalent wound complications in various surgeries. However, few studies have compared barbed suture and conventional wound closure techniques in total knee arthroplasty (TKA). The purpose of this review was to appraise the efficacy and safety of the barbed suture in closure of TKA. We conducted a meta-analysis to identify relevant randomized-controlled trials involving barbed sutures and conventional sutures in TKA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI, VIP, Wanfang database, up to August 2019. Finally, we identified 1,472 TKAs (1,270 patients) assessed in 13 randomized-controlled trials. Compared with conventional wound closure techniques, barbed sutures resulted in shorter total wound closure time (p < 0.001), fewer needle puncture injuries to members of the surgical team (p = 0.02). There were no significant differences in terms of blister formation (p = 1.0), superficial infection (p = 0.82), range of motion (p = 0.94), incisional exudate (p = 0.75), suture abscess (p = 0.26), or suture breakage (p = 0.11), wound-related complications (p = 0.10), ecchymosis (p = 0.08) between barbed and conventional wound closure. Based on the available level I evidence, we thus conclude that a knotless barbed suture is a safe and effective approach for wound closure in TKA. Given the relevant possible biases in our meta-analysis, more adequately powered and better-designed randomized-controlled trials studies with long-term follow-up are required to recommend barbed sutures for routine administration in TKA.

A Prospective, Randomized Evaluation of the Quality of Wound Closure With Barbed Versus Standard Suture After Total Joint Arthroplasty

Complications such as joint infection or delayed wound healing can lead to morbidity and elevated health care costs after total joint arthroplasty. The purpose of this study was to compare the quality of running knotless barbed suture vs standard monofilament suture wound closure with respect to wound drainage and healing complications after total joint arthroplasty. For this study, 1000 joint arthroplasty patients were prospectively randomized to have fascial, soft tissue, and skin closure with knotless barbed suture vs standard suture during the period 2016 to 2018. An absorptive dressing was used for 1 week postoperatively. Each dressing was weighed and the saturated surface area of the dressing measured. A total of 939 dressings were available for evaluation. Incisions were evaluated for wound healing at each postoperative visit. Of the 1000 joint arthroplasties performed, suture breakage or needle disengagement occurred similarly with the standard monofilament suture and the running barbed suture (13 times vs 6 times; P=.17). Dressings were weighed, and when standard monofilament sutures were used, an average of 1.2 g more postoperative bandage weight was recorded (P<.002). Postoperative wound complications including stitch abscess or wound irritation occurred more often with standard monofilament sutures than with running barbed sutures (16 times vs 5 times; P<.025). Optimal wound closure after joint replacement is critical to enhance soft tissue healing and minimize infection risk, which can be caused by excessive wound drainage. The positive results shown for the running barbed suture of this prospective study indicate the difference in quality of closure between the standard monofilament suture and the running barbed suture in hip and knee arthroplasty surgical sites. [Orthopedics. 2021;44(4):216-222.].

A symmetric anchor designed barbed suture versus conventional interrupted sutures in total knee arthroplasty: A multicenter, randomized controlled trial

OBJECTIVE

This randomized controlled study was designed to compare the wound closure efficacy and safety of barbed suture in comparison to the conventional interrupted suture for total knee arthroplasty (TKA).

METHODS

This multicenter, single-blind, randomized controlled trial enrolled 184 patients who underwent elective TKA between June 2017 and April 2018. The subjects were randomized between two groups. Surgical incision closure time was considered as the primary end point.

RESULTS

A total of 184 patients participated in this randomized controlled trial; 91 patients had wound closure that involved barbed suture and 93 patients underwent conventional treatment-that is interrupted suturing with nonbarbed sutures. The surgical incision closure time was shorter (p < 0.0001) in the barbed suture group compared with the control group (15.5 ± 4.88 vs. 20.9 ± 6.30 min). However, both groups were found to be equal in terms of the rate of postoperative complications.

CONCLUSION

Usage of the symmetric anchor designed barbed suture is safe, efficacious, and demonstrates a decrease in surgical incision closure time in patients undergoing TKA compared to interrupted closure using conventional sutures. Future studies are warranted to demonstrate clinical and economic benefits of barbed sutures.

Subcuticular sutures versus staples for skin closure after primary hip arthroplasty

High-quality and cost-effective health care are highly recommended especially in joint replacement surgeries, particularly in total hip arthroplasty. Therefore, it is indispensable for orthopaedic surgeons to spot the potential areas of quality improvement. Evaluating the efficacy of the different ways of skin closure is an unacknowledged topic. We performed this study following both the Preferred Reporting Items for Systematic Reviews and Meta- analyses Statement (PRISMA) and the Cochrane Handbook for systematic reviews and meta-analysis. Articles were from any country, written in any language. We included all randomised control trials and retrospective cohort studies undergoing primary total hip arthroplasty who either received staples or subcuticular sutures for skin closure. The primary outcome was the incidence of wound infection. Secondary outcomes included length of stay (LOS), time to skin closure, total cost, and patient’s satisfaction. We included five studies in our cumulative meta- analysis. We conducted them using Review Manager V.5.0. We computed the risk ratio as a measure of the treatment effect, taking into account heterogeneity. We used Random-effect models. Primary skin closure with subcuticular sutures had insignificant marginal advantages for wound infections, LOS, and wound oozing. On the contrary, staples were more cost- effective and had less time for closure with higher patient’s satisfaction. Except for closure time and patient satisfaction , no significant difference between the two groups. The use of staples after THA may have several slight clinical advantages over the subcuticular sutures. However, owing to the complexities associated with wound closure, future clinical and laboratory studies assessing their complication outlines must be examined before an optimum technique can be determined.

New Perspective for Soft Tissue Closure in Medication-Related Osteonecrosis of the Jaw (MRONJ) Using Barbed Sutures

The aim of this study was to compare the effectiveness of barbed versus smooth sutures for soft tissue closure of exposed jawbone sites in medication-related osteonecrosis of the jaw (MRONJ) patients. Exposed necrotic jawbone sites surgically managed by intraoral soft tissue closure were evaluated. Either barbed sutures (Stratafix™ or V-Loc™) together with Prolene^® or Vicryl^® sutures were used. We estimated the effect of barbed sutures (BS) with Prolene^® compared to smooth sutures (Vicryl^®) on the hazard rate of intraoral soft tissue dehiscence using a multivariate Cox regression model within a target trial framework, adjusting for relevant confounders. In total, 306 operations were performed in 188 sites. In the primary analysis 182 sites without prior surgery were included. Of these, 113 sites developed a dehiscence during follow-up. 84 sites were operated using BS and Prolene^®. A total of 222 sites were operated with Vicryl^® (control group). In the BS group, the median time to event (i.e., dehiscence) was 148 days (interquartile range (IQR), 42–449 days) compared to 15 days (IQR, 12–52 days) in the control group. The hazard rate of developing intraoral dehiscence was 0.03 times (95%-confidence interval (CI): 0.01; 0.14, p < 0.001) lower for BS patients compared to the control group. Within the limits of a retrospective study, BS showed a high success rate and are therefore recommended for soft tissue closure of exposed jawbone sites in MRONJ patients. Additional studies are warranted to further evaluate this novel application of BS.

Is continuous locking suture with braided suture sufficient for arthrotomy repair in the conventional TKR? A randomized controlled trial study

Introduction

Medial-parapatellar-arthrotomy is the standard approach for total knee replacement(TKR). No studies have clarified the outcomes as quadriceps-strength-recovery (QS) and safety of Continuous-locking-suture-technique(CLS) for the arthrotomy-repair.

Methods

Patients were randomly assigned into a CLS(n = 40) and an interrupted-horizontal-mattress(IHM, n = 40). QS, visual-analog-scale(VAS), modified-timed-up-and-go(TUGT) test, Western-Ontario-and McMasters-Universities-Osteoarthritis-Index[WOMAC] and Knee-Society-Score[KSS] were followed for 6 months’.

Results

A significantly-shorter capsular-closure-time in CLS(233 ± 40 VS 388 ± 47 sec)(p < 0.0001). There were insignificant difference in QS, VAS, TUGT, WOMAC and KSS during the 6-month follow-up period(p > 0.05 all). No wound complications were found.

Conclusion

CLS with braided-suture is safe and effective as demonstrated a recovery of the QS and knee function outcome comparable to IHM.

Trial registration

This study was registered in Thai Clinical Trials Registry on December 2015 (https://www.clinicaltrials.in.th). The registration number was TCTR20151208003.

Barbed vs conventional suture at cesarean delivery: A systematic review and meta-analysis

INTRODUCTION

Barbed sutures are used in cesarean delivery with the intended benefits of better tissue approximation, hemostasis, and strength, as well as reduced operative time. A systematic review and meta-analysis was undertaken to assess the safety and efficacy of the use of barbed suture compared with conventional sutures in cesarean delivery.

MATERIAL AND METHODS

MEDLINE, EMBASE, PubMed, Scopus, Cochrane CENTRAL, and three clinical trial registries, were searched from inception to December 2019, without restriction by language or publication year. Randomized controlled trials comparing the use of barbed suture with conventional sutures in closure of any layer (uterine/fascial/skin) during cesarean delivery were included. The safety outcomes included estimated blood loss, pain, mortality, and other morbidity including infection, re-operation or re-admission. Effectiveness outcomes included closure time, need for additional suture and scar integrity. Study selection, data extraction, risk-of-bias, and quality assessment were independently performed by two authors. Primary analysis compared outcomes for all layers of surgical closure, whereas subgroup analysis was performed by individual layer. Pooled mean differences (MD) and risk ratios (RR) with 95% CI were calculated using a random effects model. Level of evidence was assessed using GRADE criteria. PROSPERO registration number: CRD42020168859.

RESULTS

The review included four trials (three comparing uterine closure and one comparing skin closure), at high risk of bias, representing 460 participants. Primary analysis showed no morbidity differences between two groups. The use of barbed suture for uterine closure was associated with shorter incision closure time (MD 110.58 seconds, 95% CI 93.79-127.36 seconds), shorter total surgical time (MD 1.92 minutes, 95% CI 0.03-3.80 minutes), and a reduced need for additional hemostatic sutures (RR 0.39, 95% CI 0.28-0.54), with no difference in estimated blood loss (MD 46.17 mL, 95% CI 13.55 to -105.89 mL) or postoperative morbidity (RR 0.96, 95% CI 0.46-2.01). The level of evidence was deemed to be low to very low, based on inconsistency and imprecision of results.

CONCLUSIONS

Barbed sutures may be a suitable alternative to conventional sutures for uterine closure because they reduce uterine repair time, total surgical time, and the need for additional hemostatic sutures, without an increase in blood loss or maternal morbidity.

Barbed Sutures in Total Knee Arthroplasty: Are They Really Useful? A Randomized Controlled Trial

Bidirectional barbed sutures (BBSs) have recently been investigated in total knee arthroplasty (TKA). The contrasting results from the scarce literature suggest that BBSs are safe, save time and money, and give results comparable to traditional sutures. The purpose of the study is to test the real effect of BBSs on closure time in TKA and assess the functional results as well as the complications related to them. It was a randomized controlled trial. Eighty-five patients undergoing primary TKA were assigned to receive traditional closure with Vicryl (V-group) or with BBSs (Q-group). The exclusion criteria were significant coronal deformity, flexion contracture, or the need for stem and/or augmentation. The closure time for the capsule and that for the subcutaneous layer were registered separately. Intraoperative incidences were recorded. The follow-up was up to 1 month, during which the range of motion (ROM), superficial or deep infection, and wound dehiscence were assessed. There was a significant reduction in the capsule layer (27 seconds; p = 0.02) and global time closure (51 seconds; p = 0.01) in the Q-group. No differences were found in the subcutaneous layer (24 seconds; p = 0.055). There were more intraoperative suture breakages in the Q-group, mainly in the subcutaneous layer (p < 0.001). No differences in terms of dehiscence, infection, and ROM were observed at the 1-month follow-up. BBSs allow for slightly faster wound closure than Vicryl during a TKA. However, the differences observed have minimal clinical repercussions. Moreover, no differences in the infection rate (deep or superficial), dehiscence, or ROM were found.

Bidirectional knotless barbed versus conventional smooth suture for closure of surgical wounds in inguinal castration in horses

Background

Castration of the stallion is one of the most frequently performed surgical procedures in the horse. Recently barbed suture materials for surgical wound closure were introduced to the market with manufacturers claiming that these sutures enhance speed and security as they eliminate the need to tie knots. Recently, it has been suggested that this type of suture may increase postoperative complications. This study aimed at investigating and comparing a bidirectional absorbable knotless barbed suture (KBS) to a conventional smooth suture (SS) for wound closure of inguinal castrations in the horse. This was done by evaluating short-term and post-discharge complications and by comparing the time spent on suturing the surgical wounds after bilateral inguinal castration, which was performed on 45 horses undergoing castration at The Large Animal Teaching Hospital at University of Copenhagen from September 2017 to May 2019.

Results

Short-term complications were few; at 24 h minor swelling occurred in 29 and 33% of horses sutured with KBS and SS respectively and cutaneous dehiscence during recovery occurred in two horses of each group. Post-discharge follow-up revealed that three horses needed veterinary attention for treatment of complications (scrotal swelling (n = 1, KBS); wound exudation (n = 1, SS) and wound dehiscence after return to pasture (n = 1, SS)). Wound closure was achieved 6 min faster with KBS than with SS (P < 0.0001).

Conclusions

Use of the KBS suture did not result in increased occurrence of postoperative complications. Wound closure was faster with KBS than with SS in equine bilateral inguinal castration. Our results show that KBS can safely be used in the horse following bilateral inguinal castrations without adverse effects and with a reduction in suturing time.

Polyester Mesh Dressings Reduce Delayed Wound Healing and Reoperations Compared with Silver-Impregnated Occlusive Dressings after Knee Arthroplasty

Background

New dressings aimed at reducing surgical wound complications after knee arthroplasty continue to evolve. We compared wound complications and reoperations between 2 dressings: 2-octyl cyanoacrylate adhesive and polyester mesh (Dermabond® Prineo®, “mesh”) and silver-impregnated occlusive dressings and n-butyl-2-cyancacrylate adhesive (AQUACEL® Ag SURGICAL cover dressing with SwiftSet™, “standard").

Methods

This retrospective cohort study reviewed 353 consecutive partial and total knee arthroplasties performed by a single surgeon; 6 were excluded for not using either dressing type. Thus, 347 cases were separated into 2 cohorts: mesh (n = 176) and standard dressing (n = 171). Demographics and risk factors were similar, except for age. Surgical and closure techniques were consistent in all patients. Delayed wound healing was assessed by the surgeon at the 2-week office visit for drainage, suture abscess, or wound edge separation. Secondary outcome measures include infection, office-based closure, and return to the operating room for reclosure.

Results

There were 2 instances of delayed wound healing in the mesh group and 16 in the standard dressing group (1.14% vs 9.36%, P ≤ .0001). There were significantly fewer reoperations in the mesh group than in the standard group (0 vs 2.33%, P = .04). There were no infections or office-based closures.

Conclusion

Mesh dressings were associated with fewer episodes of delayed wound healing and reoperations than the standard dressing. A possible mechanism may be that this brand of mesh distributes wound tension more evenly. In addition, because it remains in place longer during the immediate postoperative period, it may work via prolonged wound edge support.

Barbed and conventional sutures in spinal surgery patients: an economic and clinical outcomes comparison

Objective:

To compare economic and clinical outcomes of barbed sutures versus conventional sutures alone in wound closure for patients undergoing spinal surgery.

Method:

A retrospective study using the Premier Healthcare Database. The database was searched for patients who underwent elective inpatient spinal surgery (fusion or laminectomy) for a spinal disorder between 1 January 2014 and 30 June 2018 (first=index admission). Using billing records for medical supplies used during the index admission, patients were classified into mutually-exclusive groups: patients with any use of STRATAFIX (Ethicon, US) knotless tissue control devices (barbed sutures group); or patients with use of conventional sutures alone (conventional sutures group). Outcomes included the index admission's length of stay, total and subcategories of hospital costs, non-home discharge, operating room time (ORT, minutes), wound complications and readmissions within ≤90 days. Propensity score matching and generalised estimating equations were used to compare outcomes between the study groups.

Results:

After matching, 3705 patients were allocated to each group (mean age=61.5 years [standard deviation, SD±12.9]; 54% were females). Compared with the conventional suture group, the barbed suture group had significantly lower mean ORT (239±117 minutes, versus 263±79 minutes conventional sutures, p=0.015). Operating room costs were also siginificantly lower in the barbed suture group ($6673±$3976 versus $7100±$2700 conventional sutures, p=0.020). Differences were statistically insignificant for other outcomes (all p>0.05). Subanalysis of patients undergoing fusions of ≥2 vertebral joints yielded consistent results.

Conclusion:

In this study, wound closure incorporating barbed sutures was associated with lower ORT and operating room costs, with no significant difference in wound complications or readmissions, when compared with conventional sutures alone.

Polyester mesh dressings reduce delayed wound healing rates after total hip arthroplasty compared with silver-impregnated occlusive dressings

Background

New dressings purport to reduce surgical wound complications after total hip arthroplasty (THA). This study compared delayed wound healing rates and reoperations between 2 increasingly popular dressings: a silver-impregnated occlusive (standard) dressing and a 2-octyl cyanoacrylate adhesive with polyester mesh.

Methods

This retrospective cohort study reviewed 431 consecutive THAs performed by 2 surgeons between January 2017 and May 2019. One hundred and eight were excluded for not using standard or mesh dressings. A final 323 cases were separated into 2 cohorts: mesh (n = 186) and standard dressings (n = 137). Standard dressings were removed at 1 week. Mesh persisted until nonadherent, approximately 3-4 weeks. The surgeon assessed delayed wound healing at the 2-week postoperative visit. Secondary outcomes include deep infection and return to the operating room for a wound-related diagnosis. Differences were determined using the chi-square test.

Results

There were no demographic, comorbidity, or surgical differences between groups. There were 22 total cases of delayed wound healing with 7 (3.8%) in the mesh group and 15 (10.9%) in the standard dressing group (P = .01). There were no significant differences in reoperations (2 [1.1%] vs 2 [1.5%], P = .76) or deep infections (2 [1.1%] vs 1 [0.7%], P = .75).

Conclusions

Mesh dressings are a safe and reliable dressing type for THA and were associated with a decrease in early wound healing complications when compared with standard, silver-impregnated occlusive dressings in this retrospective series. The mesh tension sharing properties and longer duration of occlusive protection may explain this difference.

Level of Evidence

Level III.

Reduced Seroma Risk in Drainless Abdominoplasty Using Running Barbed Sutures: A 10-Year, Multicenter Retrospective Analysis

BACKGROUND

Drains are still commonly inserted during abdominoplasties despite extensive evidence documenting the benefits of drainless procedures. Continued improvements in progressive tension suturing (PTS) techniques and suture technologies have consistently shown a reduced seroma risk profile that outperforms procedures involving surgical drains.

OBJECTIVES

The aim of this report was to assess the authors' combined patient series, which represents the largest and longest-running, retrospective, multicenter set of abdominoplasty patients treated with a PTS technique involving running barbed sutures.

METHODS

Two surgical groups, each at different surgical centers, have for the past decade performed drainless abdominoplasties in which running barbed sutures were used. The results for all 445 patients in this series are reported by surgical center and pooled across centers.

RESULTS

The majority of the 445 patients underwent drainless abdominoplasty alone (n = 368; 82.7%); most of the remaining patients did so as part of a circumferential body lift (n = 55; 12.4%). Overall, 33 (7.4%) patients experienced a postoperative complication. The overall seroma rate was 4.7% (21 of 445 patients), but this dropped to 2.3% after surgical technique modifications were made to decrease upper abdominal dead space. The seroma incidence in this series is markedly lower than the 13% seroma rate with drains reported during the same time period and comparable to those seen in drainless abdominoplasties with interrupted suture techniques.

CONCLUSIONS

Drainless abdominoplasty involving PTS with running barbed sutures shows long-term reproducibility in lowering seroma risk compared to techniques in which drains are inserted, supporting results from published series of drainless abdominoplasty procedures that use interrupted suture techniques.

LEVEL OF EVIDENCE: 4

Barbed sutures reduce arthrotomy closure duration compared to interrupted conventional sutures for total knee arthroplasty: a randomized controlled trial

BACKGROUND

The broad aim of this study was to compare the safety and efficacy of using barbed sutures versus standard-of-care sutures for closure of arthrotomy during total knee arthroplasty. Specifically, we compared the duration of arthrotomy closure, the number of sutures utilized for arthrotomy closure, and 90-day outcomes, including wound-related readmission, reoperation, and complications.

MATERIALS AND METHODS

A total of 60 patients undergoing primary total knee arthroplasty were enrolled in a prospective, blinded trial and randomized to receive either running closure of the arthrotomy with barbed sutures (n = 30) or interrupted closure with standard-of-care sutures (n = 30).

RESULTS

Arthrotomy closure time was significantly shorter in the barbed suture group (3 min ± 2 min) versus the standard-of-care group (13 min ± 5 min, p < 0.001). The average suture utilization for arthrotomy closure was 1 suture (range 1-2) versus 3 sutures (range 2-4) in the standard-of-care group (p < 0.001). The overall number of wound-related complications in the barbed suture group was 3/30 (10%) versus 3/30 (10%) in the standard-of-care group (p = 1.00). There was one dehiscence 1/30 (3%) in the standard-of-care group versus zero in the barbed suture group (p = 1.00). The rate of superficial surgical site infection was 1/30 (3%) in barbed suture versus zero in the standard-of-care groups (p = 1.00).

CONCLUSION

These results suggest barbed suture utilization may be faster and more resource-efficient than the use of standard-of-care sutures for arthrotomy closure in primary total knee arthroplasty without increased complications. CLINICALTRIALS.

GOV IDENTIFIER

NCT03285529.

Skin Closure Tape and Surgical Staples in Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Background

Staples closure technology has been widely used in total knee arthroplasty (TKA) and achieved good results. In recent years, a new type of material called skin closure tape (SCT) has been applied to TKA which also showed good treatment results. However, since it is still not clear yet which one is better, this paper collects literatures for statistical analysis so as to provide evidence for the use of SCT in TKA.

Methods

The comparative study on effects between SCT and staples is reviewed after the primary release of TKA in PubMed, the Cochrane library, and the EMBASE database up to March 2019. The two researchers independently screened the literature and evaluated the quality of the literature using bias risk tools.

Results

A total of four studies (3330 knees) have been included in our meta-analysis. For the main point, the results show that the SCT can reduce readmission rates compared to staples (RR 0.68, 95% CI 0.49–0.95, P=0.03), with no significant difference in complications (RR 0.85, 95% CI 0.27–2.64, P=0.77). Secondly, the results suggest that although there is no significant difference in removal time between the two groups, the SCT can reduce pains, save time and costs, and have a better cosmetic effect.

Conclusions

Our study indicates SCT as a closure method with fewer complications and faster speed compared with staples. Nevertheless, the cost and pain need to be further confirmed because of the small sample size included in this study.

Controversial Topics in Total Knee Arthroplasty: A Five-Year Update (Part 2)

This review article examines updates to the literature during the past 5 years on numerous topics which were felt to have ongoing controversy. These topics include venous thromboprophylaxis, tranexamic acid usage, tourniquet usage, and wound closure techniques.

A better strategy using barbed sutures for wound closure in total knee arthroplasty

Aim: The purpose of this study was to conduct a meta-analysis to systematically compare the clinical outcomes between knee barbed sutures (KBS) and knee traditional sutures (KTS) for wound closure in total knee arthroplasty (TKA). Method: This study retrieved potential academic articles comparing the clinical outcomes between KBS and KTS in TKA from the MEDLINE database, the PubMed database, the EMBASE database and the Cochrane Library. The reference articles for the identified studies were carefully reviewed to ensure that all available documents were represented in the study. Results: A total of 14 articles (eight randomized controlled trials [RCTs], six non-RCTs) were involved in our study. The overall participants of barbed Sutures group were 1255, whereas it was 1247 in the traditional sutures. Our meta-analysis showed that KBS is preferable for wound closure of TKA as its shorter lower total cost (weighted mean difference [WMD] = -276.281, 95% CI = -480.281 to -72.280; p = 0.008) and wound closure time (WMD = -4.895,95% CI = -6.105 to -3.685; p < 0.001). However, there was no difference in any complications (p = 0.572), wound complications (p = 0.550), superficial infection (p = 0.918), deep infection (p = 0.654), wound dehiscence (p = 0.649), suture abscess (p = 0.939), arthrofibrosis (p = 0.970), needle sticks (p = 0.158), suture breakage (p = 0.371) and knee society scores (KSS; p = 0.073). Conclusion: The use of KBS in TKA is associated with significantly shortened wound closure times and total closure cost without increased risk of intraoperative needle sticks and suture breakage and postoperative incision complications. Given the relevant possible biases in our study, adequately powered and more RCTs with long-term follow-up are needed to compare the efficacy and safety between KBS and KTS.

The Implications of Barbed Sutures on Scar Aesthetics: A Systematic Review

BACKGROUND

Barbed sutures have become increasingly popular in the field of aesthetic plastic surgery, particularly in body contouring and breast operations, in which the use of barbed sutures may offer both time and cost savings. Scar aesthetics is an important outcome for both surgeons and patients in these procedures; however, there is a paucity of studies assessing the aesthetic outcome of barbed sutures with regard to scarring.

METHODS

A systematic review of the PubMed, EMBASE, and Cochrane databases was performed from the date of their inception through July of 2017 using the search terms "barbed suture" combined with "scar" or "wound." Studies were included if they were prospective, evaluator-blind, randomized, controlled trials; closed the dermal layer of incisions using barbed sutures; and included an evaluator-blind aesthetic assessment of scarring.

RESULTS

Six prospective, randomized, controlled trials met inclusion criteria. The cosmetic result of scars in 926 patients was evaluated after an average of 8.1 months. Five of the six controlled trials found the aesthetic results of wounds closed with barbed sutures to be equivalent to those closed with traditional sutures, and one study showed significantly superior aesthetic results with barbed sutures. Use of barbed sutures resulted in shorter operating times in four of the five studies that timed incision closure. Similar complication rates were observed in all evaluated studies.

CONCLUSION

Based on this systematic review, the majority of studies concluded that there were no differences in scarring aesthetics when dermal layers were closed using barbed sutures compared with traditional suturing techniques.

Concealed cosmetic closure in total knee replacement surgery - A prospective audit assessing appearance and patient satisfaction

OBJECTIVE

With the trend towards accelerated rehabilitation, the method of skin closure has become increasingly important in orthopedic surgery. It is imperative to evaluate a technique that provides superior clinical and cosmetic results specifically for TKA, due to relatively thin skin anterior to the knee making poor wound healing an issue of concern. We conducted a prospective, single-arm audit evaluating the patient assessments of incision cosmesis for a novel technique in TKA wound closure called Concealed Cosmetic Closure (CCC).

METHODS

570 knees were included in the study whose wound was closed with concealed cosmetic subcuticular interrupted sutures (CCCIS) between January 2014 and May 2016. A validated, ordinal questionnaire, Stony Brooks Scar Evaluation Scale (SBSES) designed to elicit a score evaluating scar satisfaction was interviewed by the investigators to patients 6 months to 3 years postoperatively.

RESULTS

CCC is a simple and relatively rapid single-operator technique that takes about 7-10 min to close 11-17 cm knee incision. In our study, the mean score for Stony Brook Scar Evaluation Scale (SBSES) was 4.4 (SD of 0.73) (range 3-5). The scar was rated highly in terms of cosmesis, patient satisfaction and appearance of the wound.

CONCLUSION

CCC is an effective modality for skin closure in total knee arthroplasty providing superior cosmetic healing with minimal complications leading to improved long term patient satisfaction.

A US hospital budget impact analysis of a skin closure system compared with standard of care in hip and knee arthroplasty

Background

Medicare’s mandatory bundle for hip and knee arthroplasty necessitates provider accountability for quality and cost of care to 90 days, and wound closure may be a key area of consideration. The DERMABOND^® PRINEO^® Skin Closure System (22 cm) combines a topical skin adhesive with a self-adhering mesh without the need for dressing changes or suture or staple removal. This study estimated the budget impact of the Skin Closure System compared to other wound closure methods for hip and knee arthroplasty.

Methods

A 90-day economic model was developed assuming 500 annual hip/knee arthroplasties for a typical US hospital setting. In current practice, wound closure methods for the final skin layer were set to 50% sutures and 50% staples. In future practice, this distribution shifted to 20% sutures, 20% staples, and 60% Skin Closure System. Health care resources included materials (eg, staplers, steri-strips, and traditional/barbed sutures), standard or premium dressings, outpatient visits, and home care visits. An Expert Panel, comprised of three orthopedic physician assistants, two orthopedic surgeons, and a home health representative, was used to inform several model parameters. Other inputs were informed by national data or literature. Unit costs were based on list prices in 2016 US dollars. Uncertainty in the model was explored through one-way sensitivity and alternative scenario analyses.

Results

The analysis predicted that use of Skin Closure System in the future practice could achieve cost savings of $56.70 to $79.62 per patient, when standard or premium wound dressings are used, respectively. This translated to an annual hospital budgetary savings ranging from $28,349 to $39,809 when assuming 500 arthroplasties. Dressing materials and postoperative health care visits were key model drivers.

Conclusions

Use of the Skin Closure System may provide cost savings within hip and knee arthroplasties due to decreases in resource utilization in the postacute care setting.

Comparison of Nonabsorbable and Absorbable Suture in Total Knee Arthroplasty

Background

Wound closure of KA is important for postoperative rehabilitation. At present there is still no consensus on the best wound closure technique for KA. We performed the present study to determine whether absorbable suture is better than nonabsorbable suture in total knee arthroplasty (TKA).

Material/Methods

A total of 180 patients who underwent TKA were divided into 3 groups: 80 cases of nonabsorbable suture, 50 cases of 2-0 absorbable suture, and 50 cases of 4-0 absorbable suture. The time required for closure, frequency of gauze change, length of stay in hospital, adverse events, range of motion (ROM) after 3 months postoperatively, and VAS score of wounds were calculated. Comparison was made to explore any significant differences between different groups.

Results

There were significant differences between the nonabsorbable group and the absorbable group with regards to closure time, frequency of gauze change, and hospital length of stay (LOS). Closure time was longer in the absorbable group than in the nonabsorbable group. Frequency of gauze change, hospital LOS, and adverse events were lower, and VAS was higher in the absorbable group. Closure time was longer in the 4-0 absorbable group than in the 2-0 group. There was no significant difference between the 4-0 group and 2-0 group in other variables. There was no significant difference in long-term ROM among all groups.

Conclusions

Absorbable suture in TKA reduces the incidence of fatty liquefaction, frequency of gauze change, and postoperative LOS. It improves the cosmetic appearance and overall reduces the economic cost. There was no significant effect on early and long-term functional ROM. In conclusion, absorbable suture can be used in TKA when appropriately indicated.

Failure of a Unidirectional Barbed-Suture Device at the Arthrotomy Repair Site Following Total and Unicondylar Knee Arthroplasty: A Case Report

CASE

We report the failure of a routine arthrotomy repair following knee arthroplasty. Five additional cases of arthrotomy failure occurred within a 14-month period during which a specific unidirectional knotless barbed suture device had been used for arthrotomy closure.

CONCLUSION

Additional study on larger cohorts may be useful to understand the effectiveness of barbed suture for arthrotomy closure in knee arthroplasty.

Comparing outcomes between barbed and conventional sutures in patients undergoing knee or hip arthroplasty

AIM

To compare outcomes between barbed sutures and conventional sutures among patients undergoing knee or hip arthroplasty.

MATERIALS & METHODS

Retrospective study of patients (aged ≥18 years) undergoing elective knee/hip arthroplasty for osteoarthritis between 1 January 2013 and 1 September 2015. Patients were classified as: any Stratafix™ Knotless Tissue Control Devices (barbed suture group) used for closure vs. conventional sutures only (conventional suture group).

RESULTS

Compared with the conventional suture group, the barbed suture group had statistically significant: shorter length of stay, knee = 0.2 d; hip = 0.3 d and operating room time, knee = 7 min; hip = 22 min and lower rate of discharge to skilled nursing facility/nonhome setting (knee = 3.0%; hip = 6.8%).

CONCLUSION

Use of barbed sutures was associated with shorter length of stay, operating room time and less resource intensive discharge status as compared with conventional sutures alone.

The efficacy and safety of knotless barbed sutures in total joint arthroplasty: a meta-analysis of randomized-controlled trials

BACKGROUND

The knotless barbed sutures (KBS) are an innovative type of suture that can accelerate the placement of sutures and eliminate knot tying. Whether the KBS are safe and efficient in total joint arthroplasty (TJA) remains controversial. Therefore, we conducted a meta-analysis to evaluate its efficacy and safety.

METHODS

Randomized-controlled trials (RCTs) were identified from the PubMed, Embase, and Cochrane Library databases up to October 2017. The Cochrane risk of bias tool was used to assess methodological quality. The statistical analysis was performed with RevMan 5.3.5 software.

RESULTS

A total of five RCTs (600 participants) were included in our meta-analysis. The results showed that KBS reduced wound suture time (MD - 4.51, 95% CI - 5.37 to - 3.66, P < 0.00001) and the wound suture cost (MD - 282.63, 95% CI - 445.32 to - 119.95, P < 0.00001), and did not significantly increase the rate of complications (OR 0.77, 95% CI 0.42-1.39, P = 0.13) or intraoperative events (OR 0.86, 95% CI 0.04-17.28, P = 0.92). There were no significant differences in ROM at postoperative 6 weeks and 3 months (MD - 0.74, 95% CI - 4.19 to 2.71, P = 0.67; MD - 0.30, 95% CI - 2.62 to 2.02, P = 0.80; respectively).

CONCLUSION

Our findings suggest that KBS are a safe and effective method for TJA. Given the possible biases, adequately powered and better designed studies with longer follow-up are required to reach a firmer conclusion.

[Bidirectional knotless barbed sutures during primary total knee arthroplasty: effective solution or new problem?]

THE HYPOTHESIS OF THE STUDY

The use of bidirectional knotless barbed sutures for closure of capsule and subcutaneous fat tissue in primary total knee arthroplasty (TKA) is safe and time-saving.

MATERIAL AND METHODS

302 patients with end-stage osteoarthritis scheduled for primary non-complex TKA were randomly divided into two prospective groups: in group I (N=102) the capsule of the knee joint and subcutaneous fat tissues were closed by continuous braided suture while in group II (N=200) by bidirectional knotless barbed sutures. The skin in both groups was closed by non-absorbable monofilament polycaproamide uninterrupted suture.

RESULTS

The time of the surgery was significantly shorter in group II (65,25±11,9 min) than in group I (72,5±14,7 min) (p<0.05). The volume of hidden blood loss was similar in both groups. The number of patients with superficial infection during the first two week after surgery did not differ significantly (1,9% (I) and 1% (II)): they all healed successfully after skin debridement and additional closure. There were no cases of deep periprosthetic infection (PPI). At 3-month follow-up no difference found regarding pain level and knee function (Knee Society Score).

CONCLUSION

The use of bidirectional knotless barbed sutures in TKA reduces the time of surgery, does not affect the volume of hidden blood loss or PPI occurrence.

Economic evaluation of different suture closure methods: barbed versus traditional interrupted sutures

Healthcare systems are receiving increasing pressures from payers, such as the Centers for Medicare and Medicaid (CMS), to reduce the costs associated with procedures, and with the implementation of the Affordable Care Act, high costs are addressed through pay-for-performance programs. Thus, multiple areas of total knee arthroplasty (TKA) surgery are under scrutiny, including surgical times, material costs, and the costs of associated complications and readmissions. Suture type has been determined to be a factor that may influence closure times, as well as direct material costs. Therefore, the purpose of this review was to compare: (I) the cost of using barbed vs. conventional interrupted sutures; (II) the additional cost of differences in complications, if any; (III) to extrapolate cost savings on a hospital and national level; and (IV) to discuss the role of these findings on hospital savings and the effect on bundled payments. It was found that the main factors affecting differences in overall costs between barbed and standard interrupted suture were material cost and closure time. Many studies have demonstrated greater cost savings with the barbed suture due to shorter operative times, despite the higher material costs. The majority of studies also demonstrated similar complication rates between the suture types, and thus these are unlikely to affect the cost difference. However, to the best of our knowledge, there are no TKA studies in the literature evaluating the effect of suture type and associated complications on lengths of stay and readmission rates. Thus, it is unclear how these cost savings will translate to reimbursements rates and the role that they might play in bundled payments. Several studies in other specialties demonstrate decreased infection rates with the use of barbed sutures, which, if found to be true for TKA can be extrapolated to 3 million dollars of savings in revision TKA costs. Further studies on this topic are needed to define these relationships.

Characterizing the Diagnosis and Treatment of Allergic Contact Dermatitis to 2-Octyl Cyanoacrylate Used for Skin Closure in Elective Orthopedic Surgery

BACKGROUND

While studies have shown that postoperative wound complications can predispose to deep infection following orthopedic surgery, the best form of skin closure has not been elucidated. Furthermore, the unique risks and benefits of each type of wound closure have not been studied. The goal of this study is to present the diagnosis and treatment of patients with allergic contact dermatitis (ACD) from 2-octyl cyanoacrylate, a skin adhesive commonly used in wound closure.

METHODS

Twenty-nine patients with ACD to 2-octyl cyanoacrylate (Prineo, Ethicon, NJ) following elective orthopedic surgeries from 2013 to 2016 were retrospectively reviewed; this occurred in 29 of 6088 units of Prineo used at our institution, for an estimated incidence of 0.5%. Nineteen patients (66%) had knee operations. Mean age was 55 years (range, 15-92 years). We classified patients by symptom severity and treatment requirements into mild, moderate, and severe reactions.

RESULTS

Most reactions were moderate (48%) or severe (38%) reactions. Mean time from surgery to diagnosis was 11.8 days (range, 2-42 days). All patients underwent removal of the Prineo dressing and daily dressing changes with a specific protocol. Twenty patients (69%) received oral antihistamines, 16 patients (55%) required topical corticosteroids, and 5 patients (17%) required oral corticosteroids. All cases of ACD ultimately resolved at a mean of 22 days (range, 13-56 days) postoperatively.

CONCLUSION

2-Octyl cyanoacrylate skin adhesive occurs in an estimated 0.5% of cases and can lead to severe postoperative ACD when used following orthopedic operations. However, with early recognition and appropriate treatment, patients' symptoms resolve without a significant impact on wound healing.

Are Barbed Sutures Associated With 90-day Reoperation Rates After Primary TKA?

BACKGROUND

Studies have suggested that barbed sutures for wound closure in TKAs are an acceptable alternative to standard methods. However others have observed a higher risk of wound-related complications with barbed sutures.

QUESTIONS/PURPOSES

(1) Do 90-day TKA reoperation rates differ between patients undergoing a barbed suture arthrotomy closure compared with a traditional interrupted closure? (2) Do the 90-day reoperation rates of wound-related, deep infection, and arthrotomy failure complications differ between barbed suture and traditional closures?

METHODS

A retrospective analysis of a longitudinally maintained institutional primary TKA database was conducted on all TKAs performed between April 2011 and September 2015. We compared 884 primary TKAs, where the arthrotomy was closed with a barbed suture, with 1598 primary TKAs closed with the standard interrupted suture. After barbed sutures were introduced at our institution in 2012, the majority of surgeons gradually switched to barbed suture closures, with many using them exclusively by the end of the data collection period. We confirmed in-person followups and available data past 90 days for 97.4% (1556 of 1598) of the knees in patients with standard sutures and 94.8% (838 of 884) of the knees in patients with barbed sutures. Our primary endpoint was all-cause 90-day reoperation; our secondary endpoints considered: wound-related reoperation, as defined by previous studies; deep infection per Musculoskeletal Infection Society guidelines; and arthrotomy failure, defined intraoperatively as an opening or dehiscence through the previous arthrotomy closure. T tests and chi-square analyses were used to determine differences between the suture cohorts, and bivariate logistic regression was used to determine associations with our 90-day reoperation outcomes.

RESULTS

With the numbers available, there was no association between suture type and 90-day all-cause reoperation (odds ratio [OR], 1.70; 95% CI, 0.82-3.53; p = 0.156). Suture type was not associated with wound-related reoperation (OR, 2.73; 95% CI, 0.97-7.69; p = 0.058). A 0.6% (five of 884) arthrotomy failure rate was observed in the barbed cohort while no (0 of 1598) arthrotomy failures were noted in the traditional group (p = 0.003). Deep infections were rare in both groups (two of 884 barbed sutures, 0 of 1598 standard sutures) and could not be compared.

CONCLUSIONS

Although we saw no difference in overall and wound-related 90-day reoperation rates by suture type with the numbers available, we observed a higher frequency in our secondary question of arthrotomy failures when barbed sutures are used for arthrotomy closure during TKA. Given the widespread use of this closure technique, our preliminary pilot results warrant further investigation in larger multicenter cohorts.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Use of 2-Octyl Cyanoacrylate Adhesive and Polyester Mesh for Wound Closure in Primary Knee Arthroplasty

Wound closure in primary knee arthroplasty is important both for surgical success, by minimizing the risk of wound complications and infection, and for patient satisfaction with wound care and cosmesis. This article reports the use of a topical self-adhering, pressure-sensitive polyester mesh combined with 2-octyl cyanoacrylate adhesive for final skin closure of primary knee arthroplasty without external staples or sutures. During a 2.5-year period, 360 consecutive primary knee arthroplasty procedures (321 total knee arthroplasty procedures and 39 partial knee arthroplasty procedures) performed by 1 surgeon at 1 institution were reviewed. For all primary arthroplasty procedures, closure was performed with a standardized method. Final skin closure was performed with 2-octyl cyanoacrylate adhesive and polyester mesh. Patients returned at 6 weeks and 1 year postoperatively. The study found a 0.8% rate of superficial wound complications, no cases of dehiscence, no wound complications requiring operative irrigation and debridement, and no prosthetic joint infections. One patient had a reaction consistent with previously reported localized contact dermatitis that was believed to be related to the 2-octyl cyanoacrylate adhesive. In 2 cases, treatment with cephalexin was required, in 1 case for 2 small suture abscesses and in the other case for periincisional cellulitis. All wound complications resolved by 6 weeks. The results showed that 2-octyl cyanoacrylate adhesive and polyester mesh can be used successfully in the setting of primary knee arthroplasty for closure of high-tension knee arthroplasty wounds. This series found a 0.8% rate of superficial wound complications, no cases of dehiscence, and no infections. [Orthopedics. 2017; 40(5):e784-e787.].

A Meta-Analysis and Systematic Review Evaluating Skin Closure After Total Knee Arthroplasty-What Is the Best Method?

BACKGROUND

Many cost drivers of total knee arthroplasty (TKA) have been critically evaluated to meet the heightened quality-associated expectations of performance-based care. However, assessing the efficacy of the different modalities of skin closure has been an underappreciated topic. The present study aims to provide further insight by conducting a meta-analysis and systematic review evaluating the rates of common complications and perioperative quality outcomes associated with different suture and staple skin closure techniques after TKA.

METHODS

The present study was conducted in accordance with both the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement and the Cochrane Handbook for meta-analyses and systematic reviews. Primary outcome measures evaluated rates of common complications associated with primary TKA. Secondary outcome measures evaluated wound closure time, direct surgical costs, and cosmetic and knee function outcomes.

RESULTS

Our meta-analysis demonstrated that skin sutures had a higher likelihood of superficial and deep infections, abscess formation, and wound dehiscence. Conversely, staples had a higher tendency for prolonged wound discharge. A systematic review of wound closure times and overall resource utilization demonstrated that wound closure was faster and more cost-effective with skin staples than sutures.

CONCLUSION

Primary skin incision closure with staples demonstrated lower wound complications, decreased wound closure times, and an overall reduction in resource utilization. Given these outcomes, the use of staples after TKA may have several subtle clinical advantages over sutures.

Does Barbed Suture Lower Cost and Improve Outcome in Total Knee Arthroplasty? A Randomized Controlled Trial

BACKGROUND

Wound closure is key to prevent infection, facilitate immediate rehabilitation, and improve efficiency of total knee arthroplasty (TKA). Continuous knotless suturing with barbed suture can potentially save time and distribute tension more evenly. However, its role in TKA in terms of cost-effectiveness and wound complications is not clear. This study aims at comparing barbed and traditional sutures' wound closure time and cost in primary TKA.

METHODS

One hundred nine knees were randomized into either barbed or traditional group. Synthetic absorbable sutures (Vicryl, Ethicon Inc) and bidirectional barbed sutures (Stratafix, Ethicon Inc) were used. Arthrotomy and subcutaneous wound closure time, wound complications, and rehabilitation parameters in terms of range of motion and Knee Society Score were compared. Patients were followed up to 3 months.

RESULTS

Traditional sutures had significantly more positive leak tests (10 vs 2, P value <.05) and wound complications (11 vs 2, P value <.05). No differences in range of motion and Knee Society Score were noted. Arthrotomy and subcutaneous closure time were significantly shorter with barbed sutures (arthrotomy 325 seconds vs 491 seconds; subcutaneous 306 seconds vs 381 seconds, P value <.05). Concerning cost of suture material and operation time, barbed suture on average saved USD 48.7 per TKA in our local institute.

CONCLUSION

Bidirectional barbed suture improves the cost-effectiveness of TKA through reducing wound closure time and wound complications.