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Barbed sutures more efficient in TKA wound closure compared to standard sutures

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Barbed sutures more efficient in TKA wound closure compared to standard sutures

Vol: 5| Issue: 1| Number:63| ISSN#: 2564-2537
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:1

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

Clin Orthop Relat Res. 2015 Jun;473(6):2019-27

Contributing Authors:
AP Sah

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50 patients undergoing bilateral total knee arthroplasty (TKA) were randomly assigned to undergo closure with knotless bidirectional barbed sutures in one knee and standard sutures in the other. The purpose of this study was to determine whether there is a superior technique in terms of clinical outcomes and cost-effectiveness. Findings of this study determined knotless bidirectional barbed sutures to be more effective for closure time and direct operative cost compared to standard sutures. However, Knee Society Scores, range of motion (ROM), and wound appearance were comparable between methods.

Publication Funding Details +
None disclosed

Risk of Bias


Reporting Criteria


Fragility Index


Was the allocation sequence adequately generated?

Was allocation adequately concealed?

Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?

Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?

Blinding Patients: Was knowledge of the allocated interventions adequately prevented?

Was loss to follow-up (missing outcome data) infrequent?

Are reports of the study free of suggestion of selective outcome reporting?

Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?

Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?

Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.




Outcome Measurements


Inclusion / Exclusion


Therapy Description



Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

In total knee arthroplasty, wound closure is necessary to minimize postoperative wound complications and to withstand forces in order to prevent reopening of the incision during early knee motion. Cadaver model trials and biomechanical testing have suggested that knotless bidirectional barbed sutures have greater efficacy in providing sufficient wound closure and a higher resistance to failure when compared with standard sutures. However, previous studies have reported more prevalent postoperative wound complications in this method, and therefore, the relevance of bidirectional barbed sutures is still under debate. Thus, the present study was designed to determine an optimal approach to wound closure in TKA by using bilateral TKA patients.

What was the principal research question?

Are knotless bidirectional barbed sutures superior to standard sutures in terms of wound closure and the resulting clinical and cost outcomes in bilateral total knee arthroplasty, when assessed up to 1 year postoperatively?

Study Characteristics -
50 patients diagnosed with osteoarthritis and scheduled to undergo bilateral TKA were included in this study between January 2011 and December 2012. A medial parapatellar approach was used in all patients. Patients with prior incisions to the area of operation were excluded from the study. Postoperative assessments of the wound sites were recorded daily until the patient was discharged and then re-evaluated at each postoperative visit by the same physician assistant and surgeon. All patients served as their own controls, with one knee randomized for intervention and the other for comparison (Mean age= 68.1 +/- 8.5 years; 21M/29F; 50 completed follow-up).
Knotless bidirectional barbed suture group: Number 2 Quill suture (Ethicon Inc) was used for a running retinaculum closure, four to six Number 2-0 Vicryl sutures (Ethicon Inc) were used to approximate the deep-intermediate layer, and a running knotless barbed 2-0 Monoderm suture (Angiotech; Surgical Specialties Corp; Reading, PA, USA) was used to close the subcutaneous and subcuticular layers.
Conventional suture group: Patients in this group received eight uninterrupted Number 1 Vicryl pop-off sutures (Ethicon Inc; Somerville, NJ, USA) for the retinaculum, four to six Number 2-0 Vicryl sutures (Ethicon Inc) to approximate the deep-intermediate layer, and a Number 2-0 and Number 3-0 Monocryl suture (Ethicon Inc) for a running subcutaneous and subcuticular closure, respectively.
Outcomes of this study were detailed operative and tourniquet time, knee range of motion (ROM), Knee Society scores, postoperative complications, use of antibiotics, and any subsequent surgical interventions. Suture type and size for each knee, total operative time, time for wound closure, and any intraoperative suture issues were noted in the surgical record. Cost benefits based one operating room time and suture material were also measured.
RCT; prospective, within-patient controlled, single-center
Outcomes were assessed at 2, 6, 12, weeks and 1 year postoperatively. Knee Society scores were only assessed at the 12-week and 1 year follow-up time periods.

What were the important findings?

  • Wound closure time was significantly faster in the barbed suture group (11.4 +/- 2.2 minutes) compared to the standard suture group (16.1 +/- 2.2 minutes) (Meantime diff: 4.7 +/- 2.8 minutes 95% CI -5.5 to -3.7; p<0.001)
  • No significant differences were found in overall tourniquet time between both groups (barbed: 78.7 +/- 11.1 minutes; standard: 74.9 +/- 10.1 minutes; p=0.11)
  • Wound complications were comparable between the two approaches
  • Number of suture handoffs were significantly less with barbed sutures (7 - 9) compared to standard sutures (14 - 16) (p<0.001)
  • Significantly more suture breakages and premature disengagements were seen using the standard approach compared to the barbed approach (3 suture breakages and 5 premature disengagements compared to none in the barbed approach; p<0.005)
  • No significant differences were seen between groups when assessing ROM before discharge (barbed mean: 100.2 +/- 7.59 deg., standard mean: 99.8 +/- 15.43 deg.; 95% CI -4.47 to 5.28; p=0.8) or at 1 year follow-up (barbed mean: 126.7 +/- 6.9 deg., standard mean: 125.6 +/- 7.0 deg.; 95% CI -3.77 to 1.73; p=0.4)
  • Knee Society knee scores were comparable between both barbed and standard groups at 3 months follow-up (barbed mean: 89.2 +/- 7.27, standard mean: 90.4 +/- 5.79; 95% CI, 23.84 to 1.43; p=0.37) and at 1-year follow-up (barbed mean: 92.8 +/- 6.69, standard mean: 93.3 +/- 6.2; 95% CI, 21.97 to 3.36; p = 0.6)
  • Material costs of barbed sutures were higher than standard sutures, however; barbed sutures were cost beneficial in faster wound closure and reduction in operating room time

What should I remember most?

Significantly faster wound closure time was seen in knotless bidirectional barbed sutures compared to standard sutures in bilateral total knee arthroplasty patients. Additionally, barbed sutures were found to be more efficient in direct cost. No differences in the range of motion or Knee Society knee scores were seen between wound closure approaches.

How will this affect the care of my patients?

Knotless bidirectional barbed sutures were determined to have greater efficacy with relation to wound closure time and lower direct operative costs compared to standard sutures in TKA. However, results were comparable between the two suture methods when measured for range of motion and Knee Society knee scores. Further studies with larger population sizes should be conducted to yield more conclusive results.

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