Original Article
151
Barbed Sutures in Total Knee Arthroplasty: Are These Safe, Efficacious, and Cost-Effective? Aditya V. Maheshwari, MD1 Qais Naziri, MD1,2 Andy Wong, MD1 Michael A. Mont, MD2 Vijay J. Rasquinha, MD1 1 Department of Orthopaedic Surgery and Rehabilitation, SUNY
Downstate Medical Center, New York, New York 2 Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
Ivan Burko, MD1
Address for correspondence Aditya V. Maheshwari, MD, Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY 11203 (e-mail: [email protected]).
Abstract
Keywords
► TKA ► wound closure ► bidirectional barbed suture
The use of barbed sutures has become increasingly popular; however, their efficacy and safety continues to be debated. We review the records of 333 primary total knee arthroplasties (TKAs) to determine the difference in wound closure and total operative time between patients closed with a barbed versus standard sutures. We also evaluated complication rates and cost differences between the two groups. Overall, we saw no significant difference in either wound closure time (31 vs. 30 minutes) or total operative time (115 vs. 114 minutes). No significant differences were observed in the complication rate. Material costs were lower overall in the barbed suture group ($66.78 vs. 82.59). Further studies will be required to determine the role of barbed sutures in TKA.
As increased focus is placed on cost containment in health care, the importance of controlling costs in total knee arthroplasty (TKA) is becoming more important. As the life expectancy of U.S. population increases, the number of primary TKAs performed is expected to increase by 673% to 3.48 million cases in the year 2030.1,2 One such potential area of cost reduction in TKA is the closure of the wound.3 Conventionally, TKA wounds have been closed with absorbable, monofilament sutures that are secured with interrupted knots, but, recently, barbed sutures have been used with increasing frequency in several other surgical fields.4–8 It has been shown in cosmetic skin closures that barbed sutures are as safe and efficacious as conventional, knotted sutures, and may provide greater tension distribution.9 Furthermore, they performed as well as conventional, interrupted sutures when subjected to cyclical loading and are less likely to fail when sutures are damaged.10 However, their role in closure of TKA wounds is still evolving.3,8,11–13 The purpose of our study is to evaluate the safety, efficacy, and cost-effectiveness of using knotless, barbed sutures compared with conventional, interrupted sutures for the closure
received January 14, 2014 accepted February 11, 2014 published online April 24, 2014
of TKA. We asked the following questions: (1) is there a difference in operative time; (2) is there a difference in postoperative wound complications; and (3) is there a difference in overall cost?
Methods After institutional board review approval, we retrospectively reviewed the surgical database of the senior surgeon (V.J.R.) at a teaching hospital between January 2006 and December 2011. We started using knotless barbed sutures (Quill, Angiotech, Reading, PA) in January 2009 and all consecutive primary TKA procedures since then were considered for our study group. Before 2009, all procedures were closed by conventional knotted sutures and all consecutive primary TKA procedures from 2006 to 2008 were considered the control group. A total of 343 TKAs in 316 patients were considered for this study with a minimum of 6 months follow-up. Ten patients were lost to follow-up, leaving 333 TKAs in 306 patients for final analysis (►Fig. 1). There was no
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1373741. ISSN 1538-8506.
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J Knee Surg 2015;28:151–156.
Barbed Sutures in Total Knee Arthroplasty
Maheshwari et al.
Fig. 1 Flow diagram of patients included in the present study.
difference in the surgical technique between the two groups, except for the wound closure.
Surgical Technique All patients in this study underwent a TKA using a medial parapatellar approach. The closure of the barbed suture group was performed using one interrupted no. 1 Ethibond (Ethicon, Somerville, NJ) and one continuous no. 2 Quill (Angiotech, Reading, PA) for the arthrotomy, one continuous no. 0 Quill (Angiotech) for the subcutaneous tissue, and one continuous 4–0 Monocryl (Ethicon, Somerville, NJ) subcutaneous suture and staples for the skin. The closure, using the bidirectional quill suture, started in the midpoint of the incision. Both ends of the quill barbed suture are tipped with needles allowing simultaneous repair of the tissues both proximally and distally. The senior surgeon opts to close the subcutaneous tissue in a “zig-zag” fashion which acts essentially as a zipper to provide a watertight close of that layer as described previously.12 The closure in the conventional group was performed using one interrupted no. 1 Ethibond (Ethicon), one interrupted 0-Vicryl (Ethicon), and one continuous 0-Vicryl (Ethicon) for the arthrotomy; one pack of interrupted 0-Vicryl (Ethicon) (n ¼ 8 pop-off sutures/pack), two 2–0 Vicryl (Ethicon) (n ¼ 2) subcutaneously; and three 3–0 Ethilon (Ethicon) for the skin. Following the skin closure, all wounds were covered in Xeroform (Covidien, Mansfield, MA) dressing and a light Jones compression dressing held with elastic bandages. In addition to operative data, patient demographics including body mass index (BMI), diagnosis, preoperative Knee Society objective and function scores, and medical were also collected (►Table 1). The tourniquet inflation and deflation times were recorded for each patient from the operative records. The tourniquet was inflated and deflated two times in yielding two separate tourniquet times, and their sum was considered the total tourniquet time or the surrogate for the operative time. It was inflated once just before the incision and deflated when the prosthesis was in and after the cement was cured (first tourniquet time). Hemostasis was then achieved and wound irrigated. The tourniquet was then again The Journal of Knee Surgery
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inflated for wound closure and was deflated after the dressings were on (second tourniquet time). The second tourniquet time, which is more reflective of the true closure time, was not correctly recorded in a subgroup of patients, thus leaving only a single tourniquet time which is reflective of the total operative time. All patients who had a first and second tourniquet time recorded were placed in a single group, while the remaining patient data that had only a single tourniquet time were excluded from the primary analysis. However, to minimize bias, a secondary analysis was performed with the patient who had only a single tourniquet time recorded to ensure that the total operative time was similar to our main group of patients. The second tourniquet time was not recorded separately in 143 TKAs (133 patients) and thus these patients had only one total tourniquet time (although this was the sum of first and second tourniquet time). In the remaining 190 TKAs (143 patients), data were recorded separately for both first and second tourniquet time. To perform a cost analysis, material costs were obtained from the purchasing department of our hospital. All patients were followed up for at least 6 months (due to the resorption time of this suture) and any return to the operating room for wound issues was considered a wound complication for this study. Data were collected, recorded, and analyzed using Microsoft Excel 2010 (Redmond, Washington, DC) and SPSS (SPSS v18.0, IBM, Chicago, IL). A Student t-test was performed for continuous data including closure time, age, BMI, and KSS scores.14 Fischer exact test was used for categorical data including gender, comorbidities, and wound complication rates. A Mann–Whitney test was used to determine if both groups had comparable American Society of Anesthesiologists (ASA) scores. A p value of < 0.05 was considered to be statistically significant for this study.
Results In the main study group, there were equal proportions of men and women between patients who did and did not receive closure with a barbed suture (p ¼ 0.7). A slight difference was
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Table 1 Summary of patient demographics Factor
Barbed (n ¼ 115)
Standard (n ¼ 75)
p Value
Gender
93 F (81%) 22 M (19%)
59 F (79%) 16 M (21%)
0.715
Age
65 (9)
61 (8)
0.007
Body mass index (kg/m2)
34.0 (6.4)
34.3 (7.1)
0.686
Type I diabetes
4
4
0.714
Type 2 diabetes
21
16
0.708
Thyroid disease
7
5
0.755
Rheumatoid arthritis
5
5
0.520
Smoking
20
17
0.454
ASA 1
11
8
0.82
ASA 2
68
33
ASA 3
36
34
ASA 4
0
0
Abbreviations: ASA, American Society of Anesthesiologists; F, female; M, male. Note: Patient data shown as means with standard deviation in parentheses.
observed in the mean age of the two groups (65 vs. 61 years); however, there was no difference in the BMI between the two groups (34.0 vs. 34.3 kg/m2), the incidence of major medical comorbidities, ASA scores, or the incidence of cigarette smoking (►Table 1). Assessment of total operative time and wound closure time demonstrated no significant difference between patients closed with a barbed suture and those with a standard suture (►Table 2). The wound closure time with a barbed suture was measured to be 31 minutes compared with 30 minutes in the standard suture closure (p ¼ 0.26). Similarly, no significant difference was observed in the total operative time between the two groups (115 minutes vs. 114 minutes, respectively; p ¼ 0.71). In patients who had only a single tourniquet time recorded, no significant difference was observed in the total operative time which was quantitatively similar for both patients closed with a barbed or a standard suture technique (112 minutes vs. 108 minutes; p ¼ 0.08). Assessment of wound complications demonstrated that there were five total complications for a total complication rate of 2.6% (►Table 3). Four complications occurred in the standard suture group and one occurred in the barbed suture group. All of the complications were superficial wound
complications, four of which required a return to the operating room for a washout of the superficial tissues, while one wound dehiscence was treated conservatively. None of the patients had deep infections that required early irrigation and debridement with component retention or an antibiotic spacer. Assessment of cost demonstrated that there was a higher cost associated with the conventional suture group compared with the barbed suture group ($82.59 vs. $66.78; ►Table 4). When calculating the cost of closing the same tissue plane with barbed suture compared with conventional suture, there were higher costs associated with the barbed suture than the standard braided suture ($50.65 vs. $43.95). There were no cases of glove perforation or other accidents in either of the barbed suture group or the conventional suture group.
Discussion The desire to improve the effectiveness and the cost of surgical procedures has opened the door to various new technologies, and one of these is the introduction of a barbed suture into orthopedic procedures. The arthrotomy in a TKA procedure has historically been closed with sutures in an
Table 2 Outcomes of two suture techniques as measures by closure time and total operative time Complete data group (1st and 2nd Tourniquet time recorded)
Incomplete data group (only one tourniquet time recorded)
Barbed (n ¼ 115)
Standard (n ¼ 75)
p-Value
Barbed (n ¼ 25)
Standard (n ¼ 118)
p-Value
Closure time
31
30
0.26
–
–
–
Total operative time
115
114
0.71
112
105
0.08
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ASA score
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Table 3 Overall wound complications Patient no.
Age (gender)
BMI
Conventional/Barbed
Comorbid conditions
Complication
1
59 (female)
29.9
2
72 (female)
32
Conventional
HTN, RA
I&D
Conventional
HTN, renal failure, DM
Wound dehiscence
3
54 (male)
35.2
Conventional
None
I&D
4
64 (female
34.9
5
64 (female)
35.9
Conventional
HTN, hypercholesterolemia
I&D
Barbed
HTN
I&D
Abbreviations: DM, diabetes mellitus; HTN, hypertension; I & D, incision and drainage (superficial); RA, rheumatoid arthritis.
interrupted knot fashion. Our study looked at the cost– benefit, if any, of using knotless, barbed sutures that run in a continuous fashion. We determined if there was a difference in (1) closing time and total operative time, (2) postoperative wound complications, and (3) overall cost between those who underwent arthrotomy closure with barbed versus traditional suture. There were several limitations in the study, the first of which being its retrospective nature that limits complete data recording. The second tourniquet time that we used for closure time in the study was not routinely recorded separately in all cases, thus resulting in smaller subgroups. However, we believe that this second tourniquet time is a far more accurate way of measuring closing time than can be measured by operative time alone and thus provides more meaningful comparison between the two groups as compared with other studies that reported only total operative time. With the number of patients in our study, the low wound complication rates in each group may not provide adequate power for comparison. We analyzed our data based on our technique of closure, which may vary from other institutes. Similarly, the suture cost will also vary based on the institutional negotiation power. Thus, our results may not be uniformly valid for all settings. However, the strength of this study includes a single surgeon study in the same setting with a standardized technique, thus making the study more uniform and comparable. Only few comparative studies investigating barbed sutures have been reported in the literature (►Table 5). Ting et al15 performed a prospective, randomized clinical trial evaluating the use of bidirectional barbed sutures versus traditional sutures for arthroplasty closures of 25 total hip arthroplasties
and 35 TKAs with 14 hips and 17 knees, respectively, in the barbed suture group. In the hip group, the barbed closure time was 9.6 minutes compared with 15.0 minutes for the traditional suture group (p ¼ 0.0218). In the knee group, the barbed closure time was 9.2 minutes and the traditional suture closure time was 12.7 minutes (p ¼ 0.0172). Although both closure times were significantly shorter in their studies, it is important to note that their total operative time for the two procedures was not significantly shorter. The barbed suture groups had an operative duration mean of 85.10 minutes compared with 96.45 minutes for the traditional group showing a trend but not reaching statistical significance (p ¼ 0.0507). A recent prospective, randomized, controlled trial by Smith et al of 34 patients undergoing total hip or knee arthroplasty observed a shorter wound closure time (9.7 minutes saved; p < 0.05).16 Several retrospective studies have also evaluated the efficacy of using barbed sutures.10–12 Eickmann and Quane found that surgeries with barbed sutures were significantly faster compared with conventional sutures.11 They reported on 178 knees (90 using barbed sutures and 88 using conventional sutures) and observed a significantly shorter total surgical time (74.3 minutes vs. 85.8 minutes; p < 0.001). Similarly, Gililland et al, who in a report of 104 knees closed with barbed sutures and 87 closed with standard sutures, concluded that barbed sutures are associated with a slightly shorter estimated closure time (19.6 vs. 22.2 minutes, respectively; p ¼ 0.009).17 Our study concluded that there was no statistical difference in closing time or total operative time when using knotless, barbed sutures versus conventional interrupted sutures. This agrees with a prospective, randomized study
Table 4 Summary of suture material costs Barbed group
Conventional group
Suture
Price
Quantity
Suture
Price
Quantity
1 Ethibond
$1.70
1
1 Ethibond
$1.70
1
Quill no. 2
$27.45
1
0 Vicryl pop-off (8 per pack)
$15.02
2
Quill no. 0
$26.20
1
0 Vicryl
$13.91
1
4–0 Monocryl
$4.50
1
2–0 Vicryl (8 per pack)
$11.43
2
Staples
$9.93
1
3–0 Ethilon
$3.52
4
Total cost
$66.78
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$82.59
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Maheshwari et al.
with 183 patients performed by Murtha et al analyzing the use of barbed sutures in the closure of the Pfannenstiel incision and observed a similar barbed suture closure time (9.5 minutes) and control group closure time (8.9 minutes; p ¼ 0.183).6 Likewise, de Blacam et al concluded there was no significant difference in total length of operation when using barbed sutures for reconstructive abdominal closure in 142 patients compared with standard sutures (7 hours 17 minutes vs. 7 hours 4 minutes, respectively; p ¼ 0.549).4 The material costs associated with barbed sutures were observed to be lower than with the standard closure. This is consistent with the cost analysis done by Gililland et al who in a report of 104 knees closed with barbed sutures and 87 closed with standard sutures concluded that closure cost was equivalent between the two groups.17 In their study, the mean total closure cost was $595 USD (564–626) for barbed sutures and $627 USD (590–663) for standard sutures (p ¼ 0.259), leading the authors to conclude that overall closure cost was equivalent for the two techniques when suture cost and cost of operating room time was combined. Smith et al similarly observed that barbed sutures were costeffective and when time savings were taken into account, the authors reported an overall cost saving of $549.59 per case when barbed sutures were used.16 In our study, there was no statistically significant difference in complication rates between the conventional and barbed suture group (p ¼ 0.0803). This is consistent with a retrospective study by Stephens et al of 500 patients who underwent TKA and showed no significant increase in complications in the barbed suture group. They did, however, show a significantly lower total operative time of 4 minutes in the barbed suture group (p < 0.001).13 This is also similar to a study by Patel et al on 278 consecutive cases, where a unidirectional barbed suture was compared with conventional subcuticular sutures and stainless steel staples for the closure of the skin in total hip and knee arthroplasty procedures and found to have a higher complication rate in the unidirectional barbed suture (13, 7.8, and 10.3% in the barbed, standard, and staples groups, respectively), but this difference was not statistically significant.18 Similarly, Gililland et al showed no significant difference in wound complication rates in patients with barbed sutures (7%) compared with the standard group (13%; p ¼ 0.197).17 However, in contrast, both Smith et al16 and Campbell et al19 observed higher complication rates with barbed sutures. In particular, Campbell et al in a study of 416 TKAs observed higher rates of superficial infections in barbed sutures (11.8 vs. 3.2%; p ¼ 0.001) as well as deep infections (4.7 vs. 0.8%; p ¼ 0.018).19 The literature regarding the use of continuous, bidirectional barbed sutures remains controversial. While there have been some studies that have shown significant differences in wound closure times or total operative times, other studies have found no significant difference.10–12 Furthermore, although some studies may have found statistically significant differences in operative times, it remains to be determined if these, often modest (5–10 minutes), time savings are clinically or fiscally relevant. Furthermore, some studies have The Journal of Knee Surgery
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Abbreviations: NR, not reported; THA, total hip arthroplasty; TKA, total knee arthroplasty. Note: Data shown as means with range in parentheses.
Level III Current study
TKA
115
31 (13–46)
75
30 (15–51)
0.263
16.6/6.3 < 0.001 26.50 16 16.78 18 Prospective, randomized Smith et al16
TKA THA
9.7/10.3 0.0172 0.0218 0.0507 12.7 (7.0–19.3) 15.0 (9.5–26.2) 96.45 (62–172) (total operative time) 18 11 29 9.2 (6.3–13.8) 9.6 (5.4–13.5) 85.10 (47–146) ( total operative time) 17 14 31 Prospective, randomized Ting et al15
TKA THA Overall
6.7/9.1 < 0.001 85.8 (NR) (total operative time) 88 74.3 (NR) ( total operative time) 90 Retrospective review Eickmann and Quane11
TKA
7/13 0.009 22.0 (20.7–23.3) 87 19.6 (18.5–20.7) 104 Retrospective review Gililland et al17
TKA
Barbed suture closure time (min) No. of patients in barbed suture group Type of surgery Level of study Author
Table 5 Studies comparing barbed knotless sutures with conventional sutures in total knee arthroplasty
No. of subjects in standard group
Standard suture closure time (min)
p-Value
Wound complication rate, % (barbed/standard)
Barbed Sutures in Total Knee Arthroplasty
Barbed Sutures in Total Knee Arthroplasty
Maheshwari et al.
reported substantially higher wound complication rates with barbed sutures, while others such as ours have seen no substantial difference. Finally, the cost differences between the use of barbed compared with conventional sutures may not be of large clinical importance due to the modest price differences (approximately $15) seen between the two groups. Further larger studies are necessary to determine the proper role of barbed sutures in the setting of TKA.
9 Zaruby J, Gingras K, Taylor J, Maul D. An in vivo comparison of
10
11 12
References 1 Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young
2
3
4
5
6
7 8
patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res 2009;467(10):2606–2612 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89(4):780–785 Eggers MD, Fang L, Lionberger DR. A comparison of wound closure techniques for total knee arthroplasty. J Arthroplasty 2011;26(8): 1251–1258, e1–e4 de Blacam C, Colakoglu S, Momoh AO, Lin SJ, Tobias AM, Lee BT. Early experience with barbed sutures for abdominal closure in deep inferior epigastric perforator flap breast reconstruction. Eplasty 2012;12:e24 McKenzie AR. An experimental multiple barbed suture for the long flexor tendons of the palm and fingers. Preliminary report. J Bone Joint Surg Br 1967;49(3):440–447 Murtha AP, Kaplan AL, Paglia MJ, Mills BB, Feldstein ML, Ruff GL. Evaluation of a novel technique for wound closure using a barbed suture. Plast Reconstr Surg 2006;117(6):1769–1780 Paul MD. Barbed sutures for aesthetic facial plastic surgery: indications and techniques. Clin Plast Surg 2008;35(3):451–461 Sulamanidze M. Evaluation of a novel technique for wound closure using a barbed suture. Plast Reconstr Surg 2007;120(1):349–350, author reply 350
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13
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barbed suture devices and conventional monofilament sutures for cosmetic skin closure: biomechanical wound strength and histology. Aesthet Surg J 2011;31(2):232–240 Vakil JJ, O’Reilly MP, Sutter EG, Mears SC, Belkoff SM, Khanuja HS. Knee arthrotomy repair with a continuous barbed suture: a biomechanical study. J Arthroplasty 2011;26(5):710–713 Eickmann T, Quane E. Total knee arthroplasty closure with barbed sutures. J Knee Surg 2010;23(3):163–167 Nett M, Avelar R, Sheehan M, Cushner F. Water-tight knee arthrotomy closure: comparison of a novel single bidirectional barbed self-retaining running suture versus conventional interrupted sutures. J Knee Surg 2011;24(1):55–59 Stephens S, Politi J, Taylor BC. Evaluation of primary total knee arthroplasty incision closure with the use of continuous bidirectional barbed suture. Surg Technol Int 2011;XXI:199–203 Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott WN. The new Knee Society Knee Scoring System. Clin Orthop Relat Res 2012;470(1):3–19 Ting NT, Moric MM, Della Valle CJ, Levine BR. Use of knotless suture for closure of total hip and knee arthroplasties: a prospective, randomized clinical trial. J Arthroplasty 2012;27(10): 1783–1788 Smith EL, Disegna ST, Shukla PY, Matzkin EG. Barbed versus traditional sutures: closure time, cost, and wound related outcomes in total joint arthroplasty. J Arthroplasty 2014;29(2): 283–287 Gililland JM, Anderson LA, Sun G, Erickson JA, Peters CL. Perioperative closure-related complication rates and cost analysis of barbed suture for closure in TKA. Clin Orthop Relat Res 2012; 470(1):125–129 Patel RM, Cayo M, Patel A, Albarillo M, Puri L. Wound complications in joint arthroplasty: comparing traditional and modern methods of skin closure. Orthopedics 2012;35(5):e641–e646 Campbell AL, Patrick DA Jr, Liabaud B, Geller JA. Superficial wound closure complications with barbed sutures following knee arthroplasty. J Arthroplasty 2014;29(5):966–969
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151
Barbed Sutures in Total Knee Arthroplasty: Are These Safe, Efficacious, and Cost-Effective? Aditya V. Maheshwari, MD1 Qais Naziri, MD1,2 Andy Wong, MD1 Michael A. Mont, MD2 Vijay J. Rasquinha, MD1 1 Department of Orthopaedic Surgery and Rehabilitation, SUNY
Downstate Medical Center, New York, New York 2 Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
Ivan Burko, MD1
Address for correspondence Aditya V. Maheshwari, MD, Department of Orthopaedic Surgery and Rehabilitation, SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 30, Brooklyn, NY 11203 (e-mail: [email protected]).
Abstract
Keywords
► TKA ► wound closure ► bidirectional barbed suture
The use of barbed sutures has become increasingly popular; however, their efficacy and safety continues to be debated. We review the records of 333 primary total knee arthroplasties (TKAs) to determine the difference in wound closure and total operative time between patients closed with a barbed versus standard sutures. We also evaluated complication rates and cost differences between the two groups. Overall, we saw no significant difference in either wound closure time (31 vs. 30 minutes) or total operative time (115 vs. 114 minutes). No significant differences were observed in the complication rate. Material costs were lower overall in the barbed suture group ($66.78 vs. 82.59). Further studies will be required to determine the role of barbed sutures in TKA.
As increased focus is placed on cost containment in health care, the importance of controlling costs in total knee arthroplasty (TKA) is becoming more important. As the life expectancy of U.S. population increases, the number of primary TKAs performed is expected to increase by 673% to 3.48 million cases in the year 2030.1,2 One such potential area of cost reduction in TKA is the closure of the wound.3 Conventionally, TKA wounds have been closed with absorbable, monofilament sutures that are secured with interrupted knots, but, recently, barbed sutures have been used with increasing frequency in several other surgical fields.4–8 It has been shown in cosmetic skin closures that barbed sutures are as safe and efficacious as conventional, knotted sutures, and may provide greater tension distribution.9 Furthermore, they performed as well as conventional, interrupted sutures when subjected to cyclical loading and are less likely to fail when sutures are damaged.10 However, their role in closure of TKA wounds is still evolving.3,8,11–13 The purpose of our study is to evaluate the safety, efficacy, and cost-effectiveness of using knotless, barbed sutures compared with conventional, interrupted sutures for the closure
received January 14, 2014 accepted February 11, 2014 published online April 24, 2014
of TKA. We asked the following questions: (1) is there a difference in operative time; (2) is there a difference in postoperative wound complications; and (3) is there a difference in overall cost?
Methods After institutional board review approval, we retrospectively reviewed the surgical database of the senior surgeon (V.J.R.) at a teaching hospital between January 2006 and December 2011. We started using knotless barbed sutures (Quill, Angiotech, Reading, PA) in January 2009 and all consecutive primary TKA procedures since then were considered for our study group. Before 2009, all procedures were closed by conventional knotted sutures and all consecutive primary TKA procedures from 2006 to 2008 were considered the control group. A total of 343 TKAs in 316 patients were considered for this study with a minimum of 6 months follow-up. Ten patients were lost to follow-up, leaving 333 TKAs in 306 patients for final analysis (►Fig. 1). There was no
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1373741. ISSN 1538-8506.
Downloaded by: WEST VIRGINIA UNIVERSITY. Copyrighted material.
J Knee Surg 2015;28:151–156.
Barbed Sutures in Total Knee Arthroplasty
Maheshwari et al.
Fig. 1 Flow diagram of patients included in the present study.
difference in the surgical technique between the two groups, except for the wound closure.
Surgical Technique All patients in this study underwent a TKA using a medial parapatellar approach. The closure of the barbed suture group was performed using one interrupted no. 1 Ethibond (Ethicon, Somerville, NJ) and one continuous no. 2 Quill (Angiotech, Reading, PA) for the arthrotomy, one continuous no. 0 Quill (Angiotech) for the subcutaneous tissue, and one continuous 4–0 Monocryl (Ethicon, Somerville, NJ) subcutaneous suture and staples for the skin. The closure, using the bidirectional quill suture, started in the midpoint of the incision. Both ends of the quill barbed suture are tipped with needles allowing simultaneous repair of the tissues both proximally and distally. The senior surgeon opts to close the subcutaneous tissue in a “zig-zag” fashion which acts essentially as a zipper to provide a watertight close of that layer as described previously.12 The closure in the conventional group was performed using one interrupted no. 1 Ethibond (Ethicon), one interrupted 0-Vicryl (Ethicon), and one continuous 0-Vicryl (Ethicon) for the arthrotomy; one pack of interrupted 0-Vicryl (Ethicon) (n ¼ 8 pop-off sutures/pack), two 2–0 Vicryl (Ethicon) (n ¼ 2) subcutaneously; and three 3–0 Ethilon (Ethicon) for the skin. Following the skin closure, all wounds were covered in Xeroform (Covidien, Mansfield, MA) dressing and a light Jones compression dressing held with elastic bandages. In addition to operative data, patient demographics including body mass index (BMI), diagnosis, preoperative Knee Society objective and function scores, and medical were also collected (►Table 1). The tourniquet inflation and deflation times were recorded for each patient from the operative records. The tourniquet was inflated and deflated two times in yielding two separate tourniquet times, and their sum was considered the total tourniquet time or the surrogate for the operative time. It was inflated once just before the incision and deflated when the prosthesis was in and after the cement was cured (first tourniquet time). Hemostasis was then achieved and wound irrigated. The tourniquet was then again The Journal of Knee Surgery
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inflated for wound closure and was deflated after the dressings were on (second tourniquet time). The second tourniquet time, which is more reflective of the true closure time, was not correctly recorded in a subgroup of patients, thus leaving only a single tourniquet time which is reflective of the total operative time. All patients who had a first and second tourniquet time recorded were placed in a single group, while the remaining patient data that had only a single tourniquet time were excluded from the primary analysis. However, to minimize bias, a secondary analysis was performed with the patient who had only a single tourniquet time recorded to ensure that the total operative time was similar to our main group of patients. The second tourniquet time was not recorded separately in 143 TKAs (133 patients) and thus these patients had only one total tourniquet time (although this was the sum of first and second tourniquet time). In the remaining 190 TKAs (143 patients), data were recorded separately for both first and second tourniquet time. To perform a cost analysis, material costs were obtained from the purchasing department of our hospital. All patients were followed up for at least 6 months (due to the resorption time of this suture) and any return to the operating room for wound issues was considered a wound complication for this study. Data were collected, recorded, and analyzed using Microsoft Excel 2010 (Redmond, Washington, DC) and SPSS (SPSS v18.0, IBM, Chicago, IL). A Student t-test was performed for continuous data including closure time, age, BMI, and KSS scores.14 Fischer exact test was used for categorical data including gender, comorbidities, and wound complication rates. A Mann–Whitney test was used to determine if both groups had comparable American Society of Anesthesiologists (ASA) scores. A p value of < 0.05 was considered to be statistically significant for this study.
Results In the main study group, there were equal proportions of men and women between patients who did and did not receive closure with a barbed suture (p ¼ 0.7). A slight difference was
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Table 1 Summary of patient demographics Factor
Barbed (n ¼ 115)
Standard (n ¼ 75)
p Value
Gender
93 F (81%) 22 M (19%)
59 F (79%) 16 M (21%)
0.715
Age
65 (9)
61 (8)
0.007
Body mass index (kg/m2)
34.0 (6.4)
34.3 (7.1)
0.686
Type I diabetes
4
4
0.714
Type 2 diabetes
21
16
0.708
Thyroid disease
7
5
0.755
Rheumatoid arthritis
5
5
0.520
Smoking
20
17
0.454
ASA 1
11
8
0.82
ASA 2
68
33
ASA 3
36
34
ASA 4
0
0
Abbreviations: ASA, American Society of Anesthesiologists; F, female; M, male. Note: Patient data shown as means with standard deviation in parentheses.
observed in the mean age of the two groups (65 vs. 61 years); however, there was no difference in the BMI between the two groups (34.0 vs. 34.3 kg/m2), the incidence of major medical comorbidities, ASA scores, or the incidence of cigarette smoking (►Table 1). Assessment of total operative time and wound closure time demonstrated no significant difference between patients closed with a barbed suture and those with a standard suture (►Table 2). The wound closure time with a barbed suture was measured to be 31 minutes compared with 30 minutes in the standard suture closure (p ¼ 0.26). Similarly, no significant difference was observed in the total operative time between the two groups (115 minutes vs. 114 minutes, respectively; p ¼ 0.71). In patients who had only a single tourniquet time recorded, no significant difference was observed in the total operative time which was quantitatively similar for both patients closed with a barbed or a standard suture technique (112 minutes vs. 108 minutes; p ¼ 0.08). Assessment of wound complications demonstrated that there were five total complications for a total complication rate of 2.6% (►Table 3). Four complications occurred in the standard suture group and one occurred in the barbed suture group. All of the complications were superficial wound
complications, four of which required a return to the operating room for a washout of the superficial tissues, while one wound dehiscence was treated conservatively. None of the patients had deep infections that required early irrigation and debridement with component retention or an antibiotic spacer. Assessment of cost demonstrated that there was a higher cost associated with the conventional suture group compared with the barbed suture group ($82.59 vs. $66.78; ►Table 4). When calculating the cost of closing the same tissue plane with barbed suture compared with conventional suture, there were higher costs associated with the barbed suture than the standard braided suture ($50.65 vs. $43.95). There were no cases of glove perforation or other accidents in either of the barbed suture group or the conventional suture group.
Discussion The desire to improve the effectiveness and the cost of surgical procedures has opened the door to various new technologies, and one of these is the introduction of a barbed suture into orthopedic procedures. The arthrotomy in a TKA procedure has historically been closed with sutures in an
Table 2 Outcomes of two suture techniques as measures by closure time and total operative time Complete data group (1st and 2nd Tourniquet time recorded)
Incomplete data group (only one tourniquet time recorded)
Barbed (n ¼ 115)
Standard (n ¼ 75)
p-Value
Barbed (n ¼ 25)
Standard (n ¼ 118)
p-Value
Closure time
31
30
0.26
–
–
–
Total operative time
115
114
0.71
112
105
0.08
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ASA score
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Table 3 Overall wound complications Patient no.
Age (gender)
BMI
Conventional/Barbed
Comorbid conditions
Complication
1
59 (female)
29.9
2
72 (female)
32
Conventional
HTN, RA
I&D
Conventional
HTN, renal failure, DM
Wound dehiscence
3
54 (male)
35.2
Conventional
None
I&D
4
64 (female
34.9
5
64 (female)
35.9
Conventional
HTN, hypercholesterolemia
I&D
Barbed
HTN
I&D
Abbreviations: DM, diabetes mellitus; HTN, hypertension; I & D, incision and drainage (superficial); RA, rheumatoid arthritis.
interrupted knot fashion. Our study looked at the cost– benefit, if any, of using knotless, barbed sutures that run in a continuous fashion. We determined if there was a difference in (1) closing time and total operative time, (2) postoperative wound complications, and (3) overall cost between those who underwent arthrotomy closure with barbed versus traditional suture. There were several limitations in the study, the first of which being its retrospective nature that limits complete data recording. The second tourniquet time that we used for closure time in the study was not routinely recorded separately in all cases, thus resulting in smaller subgroups. However, we believe that this second tourniquet time is a far more accurate way of measuring closing time than can be measured by operative time alone and thus provides more meaningful comparison between the two groups as compared with other studies that reported only total operative time. With the number of patients in our study, the low wound complication rates in each group may not provide adequate power for comparison. We analyzed our data based on our technique of closure, which may vary from other institutes. Similarly, the suture cost will also vary based on the institutional negotiation power. Thus, our results may not be uniformly valid for all settings. However, the strength of this study includes a single surgeon study in the same setting with a standardized technique, thus making the study more uniform and comparable. Only few comparative studies investigating barbed sutures have been reported in the literature (►Table 5). Ting et al15 performed a prospective, randomized clinical trial evaluating the use of bidirectional barbed sutures versus traditional sutures for arthroplasty closures of 25 total hip arthroplasties
and 35 TKAs with 14 hips and 17 knees, respectively, in the barbed suture group. In the hip group, the barbed closure time was 9.6 minutes compared with 15.0 minutes for the traditional suture group (p ¼ 0.0218). In the knee group, the barbed closure time was 9.2 minutes and the traditional suture closure time was 12.7 minutes (p ¼ 0.0172). Although both closure times were significantly shorter in their studies, it is important to note that their total operative time for the two procedures was not significantly shorter. The barbed suture groups had an operative duration mean of 85.10 minutes compared with 96.45 minutes for the traditional group showing a trend but not reaching statistical significance (p ¼ 0.0507). A recent prospective, randomized, controlled trial by Smith et al of 34 patients undergoing total hip or knee arthroplasty observed a shorter wound closure time (9.7 minutes saved; p < 0.05).16 Several retrospective studies have also evaluated the efficacy of using barbed sutures.10–12 Eickmann and Quane found that surgeries with barbed sutures were significantly faster compared with conventional sutures.11 They reported on 178 knees (90 using barbed sutures and 88 using conventional sutures) and observed a significantly shorter total surgical time (74.3 minutes vs. 85.8 minutes; p < 0.001). Similarly, Gililland et al, who in a report of 104 knees closed with barbed sutures and 87 closed with standard sutures, concluded that barbed sutures are associated with a slightly shorter estimated closure time (19.6 vs. 22.2 minutes, respectively; p ¼ 0.009).17 Our study concluded that there was no statistical difference in closing time or total operative time when using knotless, barbed sutures versus conventional interrupted sutures. This agrees with a prospective, randomized study
Table 4 Summary of suture material costs Barbed group
Conventional group
Suture
Price
Quantity
Suture
Price
Quantity
1 Ethibond
$1.70
1
1 Ethibond
$1.70
1
Quill no. 2
$27.45
1
0 Vicryl pop-off (8 per pack)
$15.02
2
Quill no. 0
$26.20
1
0 Vicryl
$13.91
1
4–0 Monocryl
$4.50
1
2–0 Vicryl (8 per pack)
$11.43
2
Staples
$9.93
1
3–0 Ethilon
$3.52
4
Total cost
$66.78
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$82.59
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with 183 patients performed by Murtha et al analyzing the use of barbed sutures in the closure of the Pfannenstiel incision and observed a similar barbed suture closure time (9.5 minutes) and control group closure time (8.9 minutes; p ¼ 0.183).6 Likewise, de Blacam et al concluded there was no significant difference in total length of operation when using barbed sutures for reconstructive abdominal closure in 142 patients compared with standard sutures (7 hours 17 minutes vs. 7 hours 4 minutes, respectively; p ¼ 0.549).4 The material costs associated with barbed sutures were observed to be lower than with the standard closure. This is consistent with the cost analysis done by Gililland et al who in a report of 104 knees closed with barbed sutures and 87 closed with standard sutures concluded that closure cost was equivalent between the two groups.17 In their study, the mean total closure cost was $595 USD (564–626) for barbed sutures and $627 USD (590–663) for standard sutures (p ¼ 0.259), leading the authors to conclude that overall closure cost was equivalent for the two techniques when suture cost and cost of operating room time was combined. Smith et al similarly observed that barbed sutures were costeffective and when time savings were taken into account, the authors reported an overall cost saving of $549.59 per case when barbed sutures were used.16 In our study, there was no statistically significant difference in complication rates between the conventional and barbed suture group (p ¼ 0.0803). This is consistent with a retrospective study by Stephens et al of 500 patients who underwent TKA and showed no significant increase in complications in the barbed suture group. They did, however, show a significantly lower total operative time of 4 minutes in the barbed suture group (p < 0.001).13 This is also similar to a study by Patel et al on 278 consecutive cases, where a unidirectional barbed suture was compared with conventional subcuticular sutures and stainless steel staples for the closure of the skin in total hip and knee arthroplasty procedures and found to have a higher complication rate in the unidirectional barbed suture (13, 7.8, and 10.3% in the barbed, standard, and staples groups, respectively), but this difference was not statistically significant.18 Similarly, Gililland et al showed no significant difference in wound complication rates in patients with barbed sutures (7%) compared with the standard group (13%; p ¼ 0.197).17 However, in contrast, both Smith et al16 and Campbell et al19 observed higher complication rates with barbed sutures. In particular, Campbell et al in a study of 416 TKAs observed higher rates of superficial infections in barbed sutures (11.8 vs. 3.2%; p ¼ 0.001) as well as deep infections (4.7 vs. 0.8%; p ¼ 0.018).19 The literature regarding the use of continuous, bidirectional barbed sutures remains controversial. While there have been some studies that have shown significant differences in wound closure times or total operative times, other studies have found no significant difference.10–12 Furthermore, although some studies may have found statistically significant differences in operative times, it remains to be determined if these, often modest (5–10 minutes), time savings are clinically or fiscally relevant. Furthermore, some studies have The Journal of Knee Surgery
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Abbreviations: NR, not reported; THA, total hip arthroplasty; TKA, total knee arthroplasty. Note: Data shown as means with range in parentheses.
Level III Current study
TKA
115
31 (13–46)
75
30 (15–51)
0.263
16.6/6.3 < 0.001 26.50 16 16.78 18 Prospective, randomized Smith et al16
TKA THA
9.7/10.3 0.0172 0.0218 0.0507 12.7 (7.0–19.3) 15.0 (9.5–26.2) 96.45 (62–172) (total operative time) 18 11 29 9.2 (6.3–13.8) 9.6 (5.4–13.5) 85.10 (47–146) ( total operative time) 17 14 31 Prospective, randomized Ting et al15
TKA THA Overall
6.7/9.1 < 0.001 85.8 (NR) (total operative time) 88 74.3 (NR) ( total operative time) 90 Retrospective review Eickmann and Quane11
TKA
7/13 0.009 22.0 (20.7–23.3) 87 19.6 (18.5–20.7) 104 Retrospective review Gililland et al17
TKA
Barbed suture closure time (min) No. of patients in barbed suture group Type of surgery Level of study Author
Table 5 Studies comparing barbed knotless sutures with conventional sutures in total knee arthroplasty
No. of subjects in standard group
Standard suture closure time (min)
p-Value
Wound complication rate, % (barbed/standard)
Barbed Sutures in Total Knee Arthroplasty
Barbed Sutures in Total Knee Arthroplasty
Maheshwari et al.
reported substantially higher wound complication rates with barbed sutures, while others such as ours have seen no substantial difference. Finally, the cost differences between the use of barbed compared with conventional sutures may not be of large clinical importance due to the modest price differences (approximately $15) seen between the two groups. Further larger studies are necessary to determine the proper role of barbed sutures in the setting of TKA.
9 Zaruby J, Gingras K, Taylor J, Maul D. An in vivo comparison of
10
11 12
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