Knee Arthrotomy Repair With a Continuous Barbed Suture : A Biomechanical Study

We compared knee arthrotomy closures using interrupted biodegradable sutures and running bidirectionally barbed sutures in cadaveric specimens subjected to cyclic loading. During the initial 2000 flexion cycles, both groups maintained closure and no suture ruptured. Suture throws were then sequentially cut to weaken the repairs, and the knees were cyclically flexed after each cut. Both types of suture repairs survived the cutting of the first throw or stitch and subsequent cyclical testing. However, there was a significant difference in the repairs after multiple cuts (log-rank test, P < .003). None of the knees in the interrupted suture group survived more than 3 cuts, whereas in the barbed repair group, it took the severing of as many as 7 throws for failure to occur.     

The effects of barbed suture on watertightness after knee arthrotomy closure: a cadaveric study

Background

Wound closure is one of the crucial aspects of total knee arthroplasty (TKA) for patients who perform high-flexion activities of daily living, because the joint capsule is highly stretched and integrity of the arthrotomy closure must be maintained. Watertightness of the knee joint is a different aspect of the repair integrity of arthrotomy closure and is being noticed with increasing usage of the drain clamp method for blood management after TKA. Recently, the barbed knotless suture has been growing in popularity as a strong, secure closure appropriate for high-tension areas, such as the fascia and joint capsule. The purpose of this study was to compare the barbed knotless suture with simple interrupted suture in cadaveric knees.

Methods

Nine fresh-frozen cadaveric lower extremities were used. After placing a parapatellar incision and setting a closed suction drain, arthrotomies were closed randomly using three suture materials: simple interrupted absorbable suture (No. 0 PDS, group C); or a single running knotless barbed suture Stratafix with 8N (group BS-8N) or 15N (group BS-15N) of tension. After arthrotomy closure, saline was injected in a retrograde manner into the joint through a drain until saline started to leak from the joint. Peak values for intra-articular pressure and infusion volume in each group were recorded and compared.

Results

Mean infusion volumes were 13.0?±?7.2?ml, 38.6?±?10.7?ml, and 5.1?±?2.5?ml in groups BS-8N, BS-15N, and C, respectively. Mean intra-articular pressures were 0.67?±?0.47?kPa, 9.44?±?4.55?kPa, and 0.56?±?0.44?kPa in groups BS-8N, BS-15N, and C, respectively. Infusion volume and joint internal pressure were significantly higher in group BS-15N than in groups BS-8N (p =?0.008) or C (p =?0.04).

Conclusions

Barbed suture with 15N appears appropriate for maintaining maximal watertightness after knee joint capsule closure, offering successful drain clamping, higher resistance to early mobilization protocols, and subsequent achievement of early deep knee flexion after TKA.

     

Total knee arthroplasty closure with barbed sutures

Bidirectional barbed sutures, which do not require the tying of knots, have the potential to reduce closure times of total knee arthroplasty (TKA) wounds without adverse effect to wound security, cosmesis, or infection risk. In this retrospective study, data were reviewed from TKAs performed between January 2007 and September 2008. For 88 of these procedures, conventional absorbable sutures were used for interrupted closure of the retinacular and subcutaneous layers and for running closure of the subcuticular layer. For 90 procedures, bidirectional barbed absorbable sutures were used for running closure of the retinacular and subcutaneous layers. Surgeries performed with barbed sutures were significantly faster than those performed with conventional sutures (mean times of 74.3 minutes and 85.8 minutes, respectively, p < 0.001) with no detrimental clinical effects.     

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 a barbed suture in the closure of hip and knee arthroplasty wounds

Wound closure in primary and revision total hip and knee arthroplasty is an essential and critical component of the procedure. A well-performed closure may take up to 20 to 30 minutes for primary and revision surgeries, respectively. Traditionally, a layered closure is performed using various forms of absorbable and nonabsorbable sutures placed in an interrupted fashion, requiring the surgeon to tie knots to secure each stitch. Disadvantages of knot tying include increased operative time, prominence in subcutaneous layers, and local tissue ischemia. Recently, a bi-directional, barbed suture has been introduced that affords surgeons the ability to close soft tissue layers in a running fashion without the need for knot tying. The bi-directional nature of the barbs allows for simultaneous closure from the wound center, therefore offsetting the increased cost per suture by the decreased number of sutures used and the time saved in the operating room to close the incision. Additional potential advantages of using knotless sutures include enhanced biomechanical strength, increased resistance to catastrophic arthrotomy failure, and a more watertight closure. Our early data support the efficiency and safety of using this suture in total joint arthroplasty wound closure. This article reviews our experience and describes the technique for using barbed sutures during wound closure in 940 cases of primary and revision total joint arthroplasties.     

Is There an Advantage to Knotless Barbed Suture in TKA Wound Closure? A Randomized Trial in Simultaneous Bilateral TKAs

Background

Effective wound closure is critical to minimizing wound complications and withstanding the forces associated with early knee motion after TKA. Barbed sutures allow for knotless fixation, have been used successfully in other specialties, and may provide for more even distribution of tension along the length of the incision; however, data regarding unidirectional barbed sutures from randomized trials have raised important concerns about their use. Bidirectional barbed sutures offer a potential alternative, but have not been studied extensively in orthopaedic surgery.

Questions/purposes

Using a prospective, randomized, within-patient controlled study design I compared wound closure performed with bidirectional barbed sutures in one knee of bilateral TKAs performed under the same anesthetic with those performed with standard sutures in the other knee to determine whether the barbed suture was associated with (1) faster closure times; (2) fewer intraoperative suture issues, such as needle sticks or suture breakage, and fewer postoperative wound complications; (3) no detrimental effect on clinical outcomes, including knee ROM and Knee Society scores; and (4) lower total operative cost, considering suture material cost and operating room time savings.

Methods

Between 2011 and 2012, 50 consecutive patients meeting prespecified inclusion criteria with simultaneous bilateral TKAs had deep and superficial closures performed using interrupted and running standard sutures in one randomly assigned knee, and running knotless bidirectional barbed sutures in the other knee. The barbed suture is US FDA-approved for soft tissue approximation wherever absorbable sutures are appropriate. Intraoperative suture issues and the number of sutures used were recorded at the time of wound closure. Suture cost was compared between the standard and barbed sutures and measured against the operative time cost, as estimated per minute saved. Patients were followed postoperatively at 2, 6, and 12 weeks, and 1 year. Outcomes assessed included detailed operative and tourniquet time, knee ROM, Knee Society scores, postoperative complications, use of antibiotics, and any subsequent surgical interventions. These outcomes were assessed at each visit except for Knee Society scores which were collected at the 12-week and 1-year evaluations. All patients completed followups up to the final evaluation at 1 year.

Results

Mean wound closure time was 4.7 minutes less using barbed sutures (SD, ± 2.8; 95% CI, −5.5 to −3.7; p < 0.001), average 16.1 (SD, ± 2.2) versus 11.4 (SD, ± 2.2) minutes for the standard versus barbed suture types, respectively. Overall tourniquet time was not different at 78.7 minutes (SD, ± 11.1 minutes) versus 74.9 minutes (SD, ± 10.1 minutes), respectively (p > 0.1). There were no intraoperative clinical issues, such as provider or patient injury, using either suture. There were no needle disengagements or suture breakages with barbed-suture closure; five episodes of premature disengagement of the suture from the needle and three suture breakages were observed with standard closures (p < 0.005). There were no postoperative wound dehiscences or disruptions of the arthrotomy closure with either closure technique. Final ROM was not different with the numbers available (barbed-suture group mean, 126.7° ± 6.9° SD vs standard-suture group mean, 125.6° ± 7.0° SD; p = 0.4, 95% CI, −3.77 to 1.73) between patient groups at 1 year. There were no differences with the numbers available in 1-year Knee Society knee scores (barbed mean, 92.8 ± 6.69 SD vs standard mean, 93.3 ± 6.2 SD; p = 0.6, 95% CI, −1.97 to 3.36). Considering suture material cost against time savings in operating room time, there was a cost savings of mean USD 175 per case when using barbed suture.

Conclusions

In this randomized controlled trial, I found knotless bidirectional barbed suture to be more efficient in terms of closure time and lower in direct operative cost than conventional suture material, while showing no difference in terms of Knee Society knee scores, ROM, or wound appearance with the numbers available. Future studies with larger numbers will be needed to compare overall costs of care and to detect uncommon complications that might arise, although none were observed in this small series.

Level of Evidence

Level I, therapeutic study.     

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.

Wound Healing after Open Appendectomies in Adult Patients: A Prospective, Randomised Trial Comparing Two Methods of?Wound Closure

Background

The skin is closed in open appendectomy traditionally with few interrupted nonabsorbable sutures. The use of this old method is based on a suggestion that this technique decreases wound infections. In pediatric surgery, skin closure with running intradermal absorbable sutures has been found to be as safe as nonabsorbable sutures, even in complicated cases. Our purpose was to compare the safety of classic interrupted nonabsorbable skin closure to continuous intradermal absorbable sutures in appendectomy wounds in adult patients.

Methods

A total of 206 adult patients with clinically suspected appendicitis were allocated to the study and prospectively randomized into two groups of wound closure: the interrupted nonabsorbable (NA) suture and the intradermal continuous absorbable (A) suture group. Primary wound healing was controlled on the first postoperative day, at 1?week clinically and after 2?weeks by means of a telephone interview. Follow-up data were obtained from 185 patients (90 in group NA and 95 in group A).

Results

Continuous absorbable intradermal suturing was as safe as nonabsorbable sutures in regard to wound infections.

Conclusion

Continuous, absorbable sutures can be used safely even in complicated appendicectomies without increasing the risk of wound infection. Considering the benefits of absorbable suturing, we recommend this method in all open appendectomies.     

The use of sterile adhesive tape in the closure of arthroscopic puncture wounds: a comparison with a single layer nylon closure.

A prospective trial was undertaken comparing the wound healing and infection rates in arthroscopic arthrotomy wounds closed by sterile adhesive tapes on interrupted Nylon skin sutures. Two hundred and thirty consecutive arthroscopic procedures had arthrotomy wounds closed by a single layer skin closure of either interrupted Nylon (n = 62) or sterile adhesive tapes (n = 168). All wounds healed by primary intention. Only one wound developed a superficial infection around a Nylon suture and no patient developed a synovial herniation. It is concluded that closure of arthroscopic puncture wounds with sterile adhesive tape is effective and convenient for wound management.     

Knee Arthrotomy Closure With Barbed Suture in Flexion Versus Extension: A Porcine Study

The purpose of this biomechanical study was to evaluate knee arthrotomy closure with a barbed suture in flexion versus extension. 48 porcine knees were randomized into three groups: full extension, 30° flexion, and 60° flexion. Each knee was then flexed to 90° and then 120°, with failures recorded. Arthrotomy closure in extension had significantly higher failure rates (6/16) upon flexion to 90° compared to arthrotomy closure in either 30° or 60° flexion (0/32) (P = 0.032). Upon ranging from 0° to 120°, arthrotomy failure occurred in 50% (8/16) of arthrotomies in the extension group, 6.25% (1/16) in the 30° flexion group and 18.75% (3/16) in the 60° flexion group (P = 0.022). Knee arthrotomy closure in extension compared to flexion had significantly higher rates of failure.     

Influence of suture material and suture technique on collagen fibril diameters in midline laparotomies

BACKGROUND: Although laparotomy closure is associated with a cumulative 15% failure rate, the effect of different suture techniques and materials on the ultrastructural composition of the healing incision has not been investigated. METHOD: in 40 Wistar rats the collagen fibril diameters and the regenerative tissue were compared using electron microscopy 14 and 28 days after midline laparotomy. Wounds were closed with single and running sutures using either polypropylene or polyglactin 910. RESULTS: Closure with polypropylene led to significantly larger mean fibril diameters than closure with polyglactin. Regardless of time and suture material, running closure resulted in significantly smaller mean collagen fibril diameters than single sutures. Four weeks after laparotomy, inflammatory reactions, disorganization of collagen and irregularities of the vascular architecture were found after closure with absorbable suture material but not after closure with nonabsorbable material. CONCLUSION: Suture material and suture method significantly influence the ultrastructural composition of the healing incision. Persisting mechanical irritation around the suture threads after single sutures and severe persisting inflammatory reactions after the use of absorbable suture material are important influencing factors.     

Use of Knotless Suture for Closure of Total Hip and Knee Arthroplasties : A Prospective,Randomized Clinical Trial

We performed a prospective, randomized clinical trial to evaluate the efficacy of using a bidirectional barbed suture compared with traditional sutures in the deep closure of primary total hip (25) and knee (35) arthroplasties. Complications, time to closure, and length of surgery were evaluated. Closure was noted to be significantly faster (9.3 vs 13.6 minutes, P < .005) in the barbed suture group. Wound-related complications were similar (3 cases) in both groups at 3-month follow-up. Although this study supports the use of barbed technology as a functionally comparable and more efficient modality of wound closure with the potential for costs savings based on reduced operative time, the cost-effectiveness of its adoption is institution dependent and will rely on the optimization of all other perioperative factors.     

Extensor mechanism repair failure with use of bidirectional barbed suture in total knee arthroplasty

Total knee arthroplasty (TKA) continues to advance as innovative devices become available. #2 PDO Quill SRS (Angiotech, Reading, Pa) bidirectional barbed suture was used for 161 primary TKAs at our facility. We report on 3 separate cases of extensor mechanism repair failure after primary TKA in which a barbed suture was used for extensor mechanism closure. Before the implementation of this device, there were no reported failures in 385 primary TKAs. We recommend that surgeons who use this device for extensor mechanism repair of a medial parapatellar arthrotomy in TKA exercise caution when operating on patients with morbid obesity, diabetes, and rheumatoid arthritis. We have discontinued use of the bidirectional barbed suture until more definitive large orthopedic studies establish its efficacy and safety.     

单向倒刺线在腹腔镜胆总管探查一期连续缝合中的应用

【摘 要】 目的 探讨单向倒刺线连续缝合在腹腔镜胆总管探查一期缝合术中闭合胆总管的安全性和有效性。方法 对2016年6月至2017年12月西安交通大学第一附属医院进行腹腔镜胆总管探查一期缝合术治疗的81例胆总管结石患者进行前瞻性研究。按照随机数字表法,患者分为单向倒刺线连续缝合组（41例）和普通可吸收线连续缝合组（40例）。比较两组患者胆总管闭合缝合时间,术后并发症情况,术后住院时间及随访情况。结果 两组患者均手术成功,术中结石取净,无术中并发症。倒刺线组胆总管缝合时间明显少于普通线组[（11.4±2.0）min vs （15.6±3.5）min,t=-6.67,P < 0.05];两组胆漏发生率（2.4% vs 5.0%）,急性胆管炎发生率（4.9% vs 5.0%）,术后平均住院时间[（4.4±1.2）d vs（4.4±1.6）d]差异均无统计学意义（P > 0.05）。所有患者均获得随访,随访半年以上者倒刺线组18例,普通线组15例,尚未见结石残余、结石复发或胆管狭窄情况。结论 单向倒刺缝线连续缝合用于腹腔镜胆总管探查一期缝合术安全可行,可以降低腹腔镜下缝合难度,缩短缝合时间,并且不增加并发症风险.     

Meta-analysis of techniques for closure of midline abdominal incisions

BACKGROUND: Various randomized studies have evaluated techniques of abdominal fascia closure but controversy remains, leaving surgeons uncertain about the optimal method of preventing incisional hernia. METHOD: Medline and Embase databases were searched. All trials with a follow-up of at least 1 year that randomized patients with midline laparotomies to closure of the fascia by different suture techniques and/or suture materials were subjected to meta-analysis. Primary outcome was incisional hernia; secondary outcomes were wound dehiscence, wound infection, wound pain and suture sinus formation. RESULTS: Fifteen studies were identified with a total of 6566 patients. Closure by continuous rapidly absorbable suture was followed by significantly more incisional hernias than closure by continuous slowly absorbable suture (P < 0.009) or non-absorbable suture (P = 0.001). No difference in incisional hernia incidence was found between slowly absorbable and non-absorbable sutures (P = 0.75), but more wound pain (P < 0.005) and more suture sinuses (P = 0.02) occurred after the use of non-absorbable suture. Similar outcomes were observed with continuous and interrupted sutures, but continuous sutures took less time to insert. CONCLUSION: To reduce the incidence of incisional hernia without increasing wound pain or suture sinus frequency, slowly absorbable continuous sutures appear to be the optimal method of fascial closure.     

无需打结的后腹腔镜保留肾单位肾部分切除术——介绍一种快速简单的腹腔镜缝合术

目的：介绍近年来在后腹腔镜肾部分切除术（LPN）中应用的一种无需打结的缝合技术和经验.方法：术中应用＂哈巴狗＂动脉夹控制肾动脉后切除肿瘤,用4-0可吸收缝线＂8＂字形缝合肿瘤基底部明显的动脉出血部和集合系统,用1-0可吸收缝线连续缝合肾创面的缺损部,用Hem-o-lok夹夹持缝线以保持缝线的张力,因省去腔镜下打结操作,有效地缩短了热缺血时间.应用此项技术为30例肾肿瘤患者实施了LPN.结果：所有患者手术均获得成功,无中转开放手术者.平均肿瘤最大径（3.2±1.1）（0.8～7.5）cm,平均手术时间（134.3±26.4）（90～230）min,术中平均出血（97.3±67.4）（50～600）min,平均热缺血时间（24.8±6.2）（10～40）min.所有患者术后病理检查报告均切缘阴性.围手术期主要并发症为尿漏2例（6.67%）,术后肾周出血1例（3.33%）,经保守治疗后痊愈出院.结论：改进的无需打结的LPN缝合技术安全可靠,简便快速,能有效地减少热缺血时间,具有推广意义.     

Barbed sutures in total hip and knee arthroplasty: what is the evidence? A meta-analysis

Introduction

Newer methods of wound closure such as bidirectional barbed sutures hold the potential to reduce closure time and thus overall operating room costs during total joint arthroplasty (TJA), including total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, it is unclear whether these sutures have similar clinical outcomes or whether they place the patient at risk of developing wound complications that may outweigh the time-saving benefits of these sutures.

Methods

A systematic review of the literature was performed to identify all level I trials that reported the use of barbed suture during TJA. We analyzed the efficacy, safety, major and minor complications, and overall cost related to barbed sutures.

Results

Four studies met our criteria, and included 588 patients who were randomized either to barbed suture closure (n?=?290 TJAs, 268 TKAs, and 22 THAs) or to a matched conventional suture cohort (n?=?298 TJAs, 279 TKAs, and 19 THA). In terms of time savings with wound closure, the barbed suture was 6.3 minutes faster than the conventional cohort (p?<?0.05). The odds for developing a minor complication were nearly identical (odds ratio [OR] 1.04, p?=?0.95) and for major complication was not significantly different (OR 2.94, p?=?0.27). The overall mean savings including both THA and TKA was USD 298 per case.

Conclusions

In randomized controlled trials, barbed sutures are consistently associated with shorter wound closure time, which also corresponds to cost savings, even when the higher cost of these sutures is taken into account. There was no significant difference in the odds of experiencing either minor or major complications between patients in whom barbed sutures versus standard sutures were used for wound closure. Current evidence supports continued use of these sutures.Level of Evidence: Level I

     

单向倒刺线在腹腔镜胆总管探查术中的应用研究

[摘 要] 目的 研究单向倒刺线在腹腔镜胆总管探查手术中的应用效果。方法 选取江苏大学附属武进医院2016 年1 月至2017 年10 月期间行腹腔镜胆总管探查术并用单向倒刺线连续缝合胆总管的病例50例作为倒刺线组,选取同期50 例行常规可吸收线间断缝合胆总管的病例50 例作为常规组,比较两组胆总管缝合时间、术中出血量、术后肠功能恢复时间、胆漏发生率、伤口感染率、住院费用、住院时间等。结果 倒刺线组缝合时间（13.7±1.9）min,短于常规组（24.9±2.8）min（t=-16.113,P < 0.001）;倒刺线组胆漏发生率为0,而常规组12%,差异有统计学意义（P=0.027）;两组术中出血量、术后肠功能恢复时间、术后切口感染、住院时间、住院费用等无统计学差异（P > 0.05）。结论 单向倒刺线连续缝合应用于腹腔镜胆总管探查术简单、方便、安全,并减少胆漏发生率,可作为腹腔镜下胆总管缝合的常规术式。     

Superficial Wound Closure Complications with Barbed Sutures Following Knee Arthroplasty

As quality measures may be increasingly used in knee surgery reimbursement, an important focus in outcome assessment will shift toward minimizing complications and increasing efficiency in knee arthroplasty reconstruction. The purpose of this study was to evaluate the efficacy of barbed, absorbable sutures in closure of the longitudinal surgical incision following knee arthroplasty, using post-operative complication occurrences. In 416 operations, primary outcomes assessed were deep infection, superficial infection, dehiscence, or stitch abscesses. Secondary outcomes included self-limiting eschar, severe effusion, arthrofibrosis, and keloid formation. Evaluation of overall primary outcomes showed a higher rate of wound complications using barbed sutures (P < 0.001). With increased rates of infection and overall closure related complications, this study shows that barbed suture use for superficial closure after knee arthroplasty should be avoided.