Elsevier

The Journal of Arthroplasty

Volume 33, Issue 2, February 2018, Pages 633-638
The Journal of Arthroplasty

Review
Wound Closure Techniques for Total Knee Arthroplasty: An Evidence-Based Review of the Literature

https://doi.org/10.1016/j.arth.2017.09.032Get rights and content

Abstract

Background

This literature review is aimed at identifying the different methods for superficial and deep wound closure in total knee arthroplasty and evaluating their outcomes. We evaluated (1) closure time, (2) infection and other complication rates, and (3) local wound-related outcomes.

Methods

A thorough search of the literature was performed using 3 electronic databases. Inclusion criteria included manuscripts that were written in English and available in full-text format. Reports were stratified into those that describe deep closure (7) and those that describe superficial closure (11).

Results

In superficial closure, staples may provide the fastest closure, adhesives, lower incidence of superficial complications, and subcuticular suture closures, greatest blood flow. In deep closure, barbed sutures may allow for faster closure time while providing similar postoperative complication rates and outcomes when compared to traditional sutures. The use of barbed sutures has been shown to utilize fewer resources and may potentially lead to a slight reduction in costs.

Conclusion

Ultimately, no optimal closure technique has been developed, and current studies do not provide a clear evidence-based answer. This field needs much more evidence-based studies before one can draw conclusions. Even though some of these studies are prospective and randomized, they may not be generalizable. Also, many of the studies have small numbers and are subject to type II errors and fragility. Certainly, more studies are needed to truly understand the advantages and disadvantages of these new methods. Nevertheless, this review allows orthopedists to evaluate the differences between closure methods.

Section snippets

Methods

A literature search was conducted using 3 electronic databases: PubMed, EBSCO Host, and SCOPUS. All available studies between 1989 and 2017 were evaluated. Searches were performed using the following terms: arthroplas*[title], knee [title], post-operative outcome [title], complication [title], wound closure [title], suture [title], deep [title], superficial [title], barbed suture [title], staple [title]; adhesive [title]; arthrotomy closure [title], function [title] and closure technique

Deep Closure

Deep or capsular closures are typically performed using either interrupted knotted sutures or more recently continuous barbed sutures. More traditionally, deep closure has been performed using interrupted, knotted sutures. Synthetic, absorbable, braided sutures are often used for deep or arthrotomy closures. In addition, polydioxanone suture is an alternative synthetic absorbable suture that has been used for deep closure. More recently, synthetic absorbable barbed sutures have been developed

Closure Time

Five level I or II studies evaluated the use of barbed sutures in deep and arthrotomy closure in TKA patients [4], [6], [7], [8], [9] (Table 1). Results have been shown to be superior or comparable to standard sutures. When specifically evaluating studies that assess time efficiency, all 5 studies have demonstrated faster closure time with barbed sutures when compared to conventional sutures.

Many studies have shown that barbed sutures allow for faster closure. Gililland et al [6] compared the

Superficial Closure Materials

The superficial layer is defined as the subcuticular and skin tissue. Closure methods for this layer can be broadly divided into 3 materials: sutures (braided, barbed, etc.), staples (traditional and novel), and various types of adhesives. Orthopedists have used these materials individually, as well as in various combinations.

Closure Time

Some studies have demonstrated that when compared to sutures, staples led to a faster mean closure time. Eggers et al [3] conducted a prospective, randomized controlled trial comparing the use of 2 cutaneous adhesives, staples, and sutures in 90 TKA patients. All cohorts had interrupted sutures used for the capsule and subcutaneous layers. Closure time rate was measured by dividing the closure time (in seconds) by the wound length (in centimeters) to control for varying wound sizes. The authors

Newer Closure Techniques

A novel closure system has been recently developed, which uses ultrasonic welding of polymer sutures (Axyaloop; Axya Medical Inc, Beverly, MA) for wound closure. It has been studied in rotator cuff repair and has potential future applications in knee surgery [25]. Similarly, various types of laser welding for wound closure have been developed. These systems utilize wavelength-specific dye absorbers and adhesive proteins such as albumin under temperature control for a fast and efficient wound

Conclusion

Optimal wound closure after TKA would allow for low complication rates, excellent wound healing, acceptable cosmesis, and high postoperative functional scores. Multiple wound closure materials are available for both superficial and deep closure, each with its advantages and disadvantages. In deep closure, barbed sutures have been shown to lead to the fastest closure while providing similar postoperative complications rates to more conventional sutures. In combination with faster surgical time,

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    The preparation of this manuscript was partially funded by an educational grant from Ethicon Inc.

    One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2017.09.032.

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