Wound Closure in Orthopedics
Surgical wound complications are a significant problem in orthopaedic surgery with wound infection, dehiscence, and poor cosmesis contributing significantly to patient morbidity. Surgical techniques and adjunctive modalities continue to be introduced with the goals of avoiding these issues, and an increasing number of research studies have been undertaken to characterize clinical outcomes. A thorough understanding of surgical wound closure strategies and the efficacy of available techniques and treatment options should help decrease complication rates and improve patient outcomes.
Skin Staples Or Sutures
Staples are a favorite among the surgeons as it reduces the time for closure and easy to apply. But metallic staples cause lot more inflammatory response and scarring compared to sutures. Various meta analysis have concluded Staples are associated with greater infection rates. From a patient perspective staples produces more unsightly rail track scars compared to sutures.
Skin sutures are better than staples in term of cosmesis and complication rates. Level 1 Evidence
With greater complications with external metallic staples a subcuticular staples was introduced called Insorb though the cosmetic outcome is better than external staples cost is a limiting factor.
Barbed suture vs Traditional sutures
Barbed sutures are created by machining the suture to create tiny excrescences or barbs. This results in a roughened surface that does not slip within the tissue and acts like a ratcheting device, gathering tissue and holding tension imparted by the surgeon while eliminating the need for knots. It does allow you to use fewer sutures per case, which means fewer needles on the field and less handling of needles during closure. It is relatively easy to adopt while compared to standard suture and is associated with comparable efficacy and complication rate and reduction in the time required for closure. Several disadvantages can be attributed to suture knots in wound closure: they are tedious to tie, may be a nidus for infection and can strangulate tissue. They may extrude through skin weeks after surgery. Additional needle manipulations during knot-tying may predispose to glove perforation. .This type of suture has demonstrated improved “water tightness” in knee arthrotomy closure compared to a standard interrupted suture technique in a cadaver model, has demonstrated reduced time for total surgery by 10% and time for closure by 33%. Use of this suture has been shown to be safe and effective in many other surgical specialties, while proving easier and faster than traditional suturing technique. Its use is highly recommended
There have been various studies conducted using barbed sutures in Knee and Hip replacement surgeries and uniformly concluded that operative time and overall cost comes down with barbed suture compared to traditional sutures.
All Meta analysis have consistently shown benefit of barbed sutures over traditional sutures. Except one review where infection rates were reported higher. From personal experience we have found that this may be related to surgical technique of closure. When barbed sutures are placed very superficially in the dermis there is greater transaction of sebaceous glands and sweat glands which harbor around 20% bacteria inspite of through skin asepsis. The subcuticular closure must be placed at mid or lower dermis and steri strips used for additional security this can reduce infective complications.
Barbed suture technique
Arthroplasty wound closure guide.
Capsule closure with barbed suture 2-0 PDS/PDO
Subcutaneous closure with barbed suture 1-0 PDS/PDO
Subcuticular closure with barbed suture 3-0 Monoderm/Monocryl
Arthroplasty wound closure with barbed sutures have varied advantages like watertight closure, decreased operative time and reduced overall cost.
Level of Evidence 1
The Future of wound closure