Skip to main content

Advertisement

SpringerLink
Log in

Expert Consensus on Best Practices for Optimal Wound Closure in Total Knee Arthroplasty: A STRIDE Initiative for Orthopedic Surgeons of India

  • Original Article
  • Published:
Indian Journal of Orthopaedics Aims and scope Submit manuscript

Abstract

Background

Wound closure in joint replacement surgeries is crucial for postoperative rehabilitation. Despite substantial advances in total knee arthroplasty (TKA), no guidelines/recommendation or consensus practice statement available internationally or nationally around the optimal method of wound closure. The study aimed to develop evidence-based consensus on current practices, and proposed adoption of advanced wound closure initiatives.

Methods

From Nov 2020 to Jan 2021, a group of 12 leading orthopedic surgeons from India met virtually under the Success in Total joint replacement through Recommendation In wounD closure (STRIDE) initiative. Expert committee used Delphi method to evaluate definitional statements that were identified through a comprehensive review of the published literature. Over three rounds of iterative voting, revision, and exclusion, the expert panel provided recommendations based on their clinical expertise and scientific evidence. Statements that reached ≥ 80% agreement was considered as “consensus”. A survey poll was conducted following each round to add or suggest changes to the statements.

Results

General recommendations include marking the arthrotomy before incision, placing the knee in flexion (less than 90°) for re-approximation during arthrotomy closure. The barbed suture can be a good alternative to traditional sutures for providing water-tight capsule closure and topical skin adhesives (TSAs) to staples for minimizing hospital visits and improving patient satisfaction.

Conclusion

This consensus provides interim guidance and practical references to orthopedic surgeons of India enabling easy access to evidence-based healthcare solutions for TKA wound closure. These recommendations need to be periodically reviewed in light of emerging evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data Availability

Not applicable.

References

  1. Ghosh, A., & Chatterji, U. (2019). An evidence-based review of enhanced recovery after surgery in total knee replacement surgery. Journal of Perioperative Practice, 29(9), 281–290.

    Article  PubMed  Google Scholar 

  2. Bourne, R. B., Chesworth, B. M., Davis, A. M., Mahomed, N. N., & Charron, K. D. (2010). Patient satisfaction after total knee arthroplasty: Who is satisfied and who is not? Clinical Orthopaedics and Related Research, 468(1), 57–63.

    Article  PubMed  Google Scholar 

  3. Kahlenberg, C. A., Nwachukwu, B. U., McLawhorn, A. S., Cross, M. B., Cornell, C. N., & Padgett, D. E. (2018). Patient satisfaction after total knee replacement: A systematic review. HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery, 14(2), 192–201.

    Article  PubMed  Google Scholar 

  4. Galat, D. D., McGovern, S. C., Larson, D. R., Harrington, J. R., Hanssen, A. D., & Clarke, H. D. (2009). Surgical treatment of early wound complications following primary total knee arthroplasty. The Journal of Bone and Joint Surgery, 91(1), 48–54.

    Article  PubMed  Google Scholar 

  5. Mahomed, N. N., Barrett, J., Katz, J. N., Baron, J. A., Wright, J., & Losina, E. (2005). Epidemiology of total knee replacement in the United States Medicare population. The Journal of Bone and Joint Surgery, 87(6), 1222–1228.

    PubMed  Google Scholar 

  6. Beal, M. D., Delagramaticas, D., & Fitz, D. (2016). Improving outcomes in total knee arthroplasty-do navigation or customized implants have a role? Journal of Orthopaedic Surgery and Research, 11(1), 60.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Lawrie, C. M., & Nunley, R. M. (2018). Advances in closure technology and technique for total joint arthroplasty: Stitches in time. In Seminars in Arthroplasty, 29(1), 14–19.

    Article  Google Scholar 

  8. Lyons, M., Nunley, R. M., Amran, B. A. S., Doneley, T., Han, H. S., Harato, K., & Seno, A. (2019). PSU28 goals, challenges and solutions for wound closure and bleeding management in total knee arthroplasty: A modified Delphi panel. Value in Health, 22, S370.

    Article  Google Scholar 

  9. Fu, X., Tian, P., Li, Z. J., Sun, X. L., & Ma, X. L. (2016). Postoperative leg position following total knee arthroplasty influences blood loss and range of motion: A meta-analysis of randomized controlled trials. Current Medical Research and Opinion, 32(4), 771–778.

    Article  PubMed  Google Scholar 

  10. Jiang, C., Lou, J., Qian, W., Ye, C., & Zhu, S. (2017). Impact of flexion versus extension of knee position on outcomes after total knee arthroplasty: A meta-analysis. Archives of Orthopaedic and Trauma Surgery, 137(2), 257–265.

    Article  PubMed  Google Scholar 

  11. King, T. V., Kish, G., Eberhart, R. E., & Holzaepfel, J. L. (1992). The “genuflex” skin closure for total knee arthroplasty. Orthopedics, 15(9), 1057–1058.

    Article  CAS  PubMed  Google Scholar 

  12. Cerciello, S., Morris, B. J., Lustig, S., Corona, K., Visonà, E., Maccauro, G., & Neyret, P. (2016). The role of wound closure in total knee arthroplasty: A systematic review on knee position. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA, 24(10), 3306–3312.

    Article  PubMed  Google Scholar 

  13. Greenberg, J. A., & Goldman, R. H. (2013). Barbed suture: A review of the technology and clinical uses in obstetrics and gynecology. Reviews in Obstetrics & Gynecology, 6(3–4), 107–115.

    Google Scholar 

  14. Sutton, N., Schmitz, N. D., & Johnston, S. S. (2018). Comparing outcomes between barbed and conventional sutures in patients undergoing knee or hip arthroplasty. Journal of Comparative Effectiveness Research, 7(10), 975–987.

    Article  PubMed  Google Scholar 

  15. Xin, M., Wenhui, Z., Yuping, Y., et al. (2020). Meta-analysis of barbed suture versus traditional suture in primary total knee arthroplasty. Chinese Journal of Tissue Engineering Research, 24(21), 3430–3437.

    Google Scholar 

  16. Ray, J. A., Doddi, N., Regula, D., Williams, J. A., & Melveger, A. (1981). Polydioxanone (PDS), a novel monofilament synthetic absorbable suture. Surgery, Gynecology & Obstetrics, 153(4), 497–507.

    CAS  Google Scholar 

  17. Sprowson, A. P., Jensen, C., Parsons, N., Partington, P., Emmerson, K., Carluke, I., Asaad, S., Pratt, R., Muller, S., Ahmed, I., & Reed, M. R. (2018). The effect of triclosan-coated sutures on the rate of surgical site infection after hip and knee arthroplasty: a double-blind randomized controlled trial of 2546 patients. The Bone & Joint Journal, 100-B(3), 296–302.

    Article  CAS  Google Scholar 

  18. Ahmed, I., Boulton, A. J., Rizvi, S., Carlos, W., Dickenson, E., Smith, N. A., & Reed, M. (2019). The use of triclosan-coated sutures to prevent surgical site infections: A systematic review and meta-analysis of the literature. British Medical Journal Open, 9(9), e029727.

    Google Scholar 

  19. de Jonge, S. W., Atema, J. J., Solomkin, J. S., & Boermeester, M. A. (2017). Meta-analysis and trial sequential analysis of triclosan-coated sutures for the prevention of surgical-site infection. British Journal of Surgery, 104(2), e118–e133.

    Article  PubMed  Google Scholar 

  20. Wang, Y., Li, H., Lian, Y., Lu, D., Dong, F., Zhang, Z., Liao, Y., & Liu, H. (2018). Application of interrupted suture at exercise position in total knee arthroplasty. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Chinese Journal of Reparative and Reconstructive Surgery, 32(4), 400–405.

    PubMed  Google Scholar 

  21. Li, P., Zhang, W., Wang, Y., Li, J., Yan, P., Guo, S., Liu, J., Yang, K., He, Z., & Qian, Y. (2020). Barbed suture versus traditional suture in primary total knee arthroplasty: A systematic review and meta-analysis of randomized controlled studies. Medicine, 99(21), e19945.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Snyder, M. A., Chen, B. P., Hogan, A., & Wright, G. W. J. (2021). Multilayer watertight closure to address adverse events from primary total knee and hip arthroplasty: A systematic review of wound closure methods by tissue layer. Arthroplasty Today, 10, 180-189.e7.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Aho, J. M., Nickerson, T. P., Thiels, C. A., Saint-Cyr, M., & Farley, D. R. (2016). Prevention of postoperative seromas with dead space obliteration: A case-control study. International Journal of Surgery, 29, 70–73.

    Article  PubMed  Google Scholar 

  24. Borzio, R. W., Pivec, R., Kapadia, B. H., Jauregui, J. J., & Maheshwari, A. V. (2016). Barbed sutures in total hip and knee arthroplasty: What is the evidence? A meta-analysis. International Orthopaedics, 40(2), 225–231.

    Article  PubMed  Google Scholar 

  25. Chan, V. W. K., Chan, P. K., Chiu, K. Y., Yan, C. H., & Ng, F. Y. (2017). Does Barbed suture lower cost and improve outcome in total knee arthroplasty? A Randomized Controlled Trial. Journal of Arthroplasty, 32(5), 1474–1477.

    Article  PubMed  Google Scholar 

  26. Sundaram, K., Piuzzi, N. S., Patterson, B. M., Stearns, K. L., Krebs, V. E., & Mont, M. A. (2020). Skin closure with 2-octyl cyanoacrylate and polyester mesh after primary total knee arthroplasty offers superior cosmetic outcomes and patient satisfaction compared to staples: A prospective trial. European Journal of Orthopaedic Surgery & Traumatology: Orthopedie Traumatologie, 30(3), 447–453.

    Article  Google Scholar 

  27. Nett, M. (2011). Water-tight knee arthrotomy closure; comparison of a novel single bidirectional barbed self-retaining running suture versus conventional interrupted sutures. Journal of Knee Surgery, 24, 55–60.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We thank all the participants for their invaluable support in assisting the consensus process by providing their active advice from which the ideas for this consensus statement were generated.

Funding

Supported by Ethicon, a part of Johnson & Johnson Private Limited.

Author information

Authors and Affiliations

  1. Department of Orthopedics, Lilavati Hospital, Bandra West, Mumbai, Maharashtra, 400050, India

    Rajesh N. Maniar

  2. Welcare Hospital, Vadodara, Gujarat, India

    Bharat Mody

  3. Department of Joint Replacement & Reconstruction, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India

    Hemant M. Wakankar

  4. Department of Orthopedics, Nightingale Hospital, Kolkata, West Bengal, India

    Indrajit Sardar

  5. Department of Orthopedics, SaiShree Hospital for Special Surgery, Pune, Maharashtra, India

    Neeraj Adkar

  6. Department of Orthopedics, Ganga Hospital, Coimbatore, Tamil Nadu, India

    Rajkumar Natesan

  7. Centre for Bone, Joint and Spine, Meitra Hospital, Calicut, Kerala, India

    Sameer Ali Paravath

  8. Department of Orthopedics, Apollo Specialty Hospital, Bangalore, Karnataka, India

    Sanjay Pai

  9. Department of Orthopedics, Mahajan Ortho and Surgical Hospital, Nagpur, Maharashtra, India

    Unmesh S. Mahajan

Authors
  1. Rajesh N. Maniar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bharat Mody
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hemant M. Wakankar
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Indrajit Sardar
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Neeraj Adkar
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rajkumar Natesan
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sameer Ali Paravath
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Sanjay Pai
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Unmesh S. Mahajan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rajesh N. Maniar.

Ethics declarations

Conflict of interest

Rajesh N. Maniar, Bharat Mody, Hemant M. Wakankar, Indrajit Sardar, Neeraj Adkar, Rajkumar Natesan, Sameer Ali Paravath, Sanjay Pai, Unmesh S. Mahajan declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical approval

The views and opinions expressed in the article are solely of the authors as named above, and are based on their independent professional judgement.

Ethical standard statement

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Formal consent is not required for this type of study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Maniar, R.N., Mody, B., Wakankar, H.M. et al. Expert Consensus on Best Practices for Optimal Wound Closure in Total Knee Arthroplasty: A STRIDE Initiative for Orthopedic Surgeons of India. JOIO 57, 2066–2072 (2023). https://doi.org/10.1007/s43465-023-00922-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s43465-023-00922-6

Keywords

Search

Navigation