Barbed versus Non-Barbed Sutures for Prevention of Surgical Site Infections in Orthopedic Surgery: A Meta-Analysis of Randomized Controlled Trials

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Methods A systematic literature search was conducted in PubMed, Embase, Cochrane Library, and Web of Science up to October 2025. A total of 1,309 patients from eight randomized controlled trials (RCTs) were included, with 652 patients in the BS group and 657 in the NBS group. The primary outcome was the incidence of SSI, defined according to the Centers for Disease Control and Prevention (CDC) criteria where feasible. Results The pooled analysis showed no statistically significant difference in the risk of SSIs between the BS and NBS groups (RR = 0.88, 95% CI: 0.42 to 1.82, P = 0.72), with the point estimate suggesting a non-significant trend favoring barbed sutures. Similarly, there was no significant difference in the risk of wound dehiscence (RR = 0.37, 95% CI: 0.08 to 1.64). Conclusion Based on current evidence, barbed sutures do not significantly reduce the incidence of SSIs or wound dehiscence compared to non-barbed sutures in orthopedic surgery. Their utility appears to be primarily in improving operative efficiency rather than in preventing infection. barbed sutures non-barbed sutures surgical site infections meta-analysis risk ratio Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Effective wound closure following orthopedic surgery is crucial for promoting rapid healing, achieving optimal cosmesis, and minimizing complications such as surgical site infections (SSIs) and wound dehiscence [ 1 ]. Healthcare-associated infections (HAIs), which are preventable, affect hundreds of millions of patients worldwide each year. Among these, surgical site infections (SSIs) are the most common and widely studied, particularly in low- and middle-income countries, where they affect up to one-third of surgical patients. While the incidence of SSIs is lower in high-income countries, it remains the second most common healthcare-associated infection in Europe and the United States [ 2 ]. SSIs place a significant burden on healthcare systems, contributing to prolonged hospital stays, higher healthcare costs, and increased patient morbidity [ 3 ]. Despite the use of strict aseptic techniques and prophylactic antibiotics, SSIs complicate approximately 1% to 5% of orthopedic procedures, with particularly high rates in trauma and joint replacement surgeries [ 4 ]. Barbed sutures have emerged as a promising innovation for improving wound closure outcomes[ 5 ]. Unlike traditional sutures, barbed sutures eliminate the need for knots, which are potential sites for bacterial colonization [ 6 ]. With bidirectional or unidirectional barbs, these sutures are designed to distribute tension more evenly across the wound, potentially minimizing tissue trauma, reducing gaps, and improving perfusion—factors that could theoretically lower the risk of infection[ 7 ]. While some studies have compared clinical outcomes between barbed and standard sutures, the optimal closure technique remains uncertain [ 8 , 9 ]. The choice of suture material and technology can significantly influence the local wound environment, tissue reaction, and ultimately, the risk of infection. Traditional non-barbed sutures (e.g., Vicryl, PDS) have been the standard for decades. However, barbed sutures have recently gained popularity in orthopedic and other surgical fields due to their design, which anchors tissue without the need for knot tying. Proposed advantages of barbed sutures include reduced closure time, more consistent tissue apposition, and improved wound healing [ 10 ]. While some clinical studies suggest that barbed sutures may reduce surgical site infection (SSI) rates, the evidence remains inconsistent and inconclusive. Many individual randomized controlled trials (RCTs) are often underpowered to detect statistically significant differences in this relatively low-frequency event. To address this clinical uncertainty, we conducted a systematic review and meta-analysis of RCTs to rigorously evaluate the comparative effectiveness of barbed versus non-barbed sutures in preventing SSIs within an exclusively orthopedic population. Several key methodological features characterize our study: First, we applied a strict PICOS framework, including only RCTs, to ensure high-quality evidence. Second, we recognized wound dehiscence as a key secondary outcome, providing a composite measure of wound failure. Third, we employed a random-effects model a priori to account for anticipated clinical heterogeneity across various orthopedic procedures (e.g., total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal surgery), offering a more generalized and conservative estimate applicable to real-world practice. By synthesizing the most current and robust evidence, this analysis aims to provide a definitive conclusion on the role of barbed sutures in preventing SSIs, thereby guiding clinical practice and informing future research. METHODS Search strategy A comprehensive systematic search was conducted across PubMed, Embase, Cochrane Library, and Web of Science databases up to October 2025. The protocol for this systematic review and meta-analysis was registered with PROSPERO (registration number CRD420251183701). The search strategy utilized the following terms: ((("barbed sutures") AND ("surgical site infection")) OR ("surgical wound infection") OR ("postoperative wound infection"))). Eligibility criteria Eligibility criteria were defined using the PICOS framework. The inclusion criteria were as follows: Population: Patients undergoing orthopedic surgery. Intervention: Barbed sutures (BS). Comparison: Non-barbed sutures (NBS). Outcomes: Primary - Surgical Site Infection (SSI); Secondary - Wound dehiscence. Study design: Randomized Controlled Trials (RCTs). Exclusion criteria were the following: Studies with non-randomized controlled trials studies with non-orthopedic surgery, studies not reporting infections outcomes studies for which the full text was not available Data extraction Two reviewers independently extracted data from the included studies using a pre-piloted Excel sheet. Discrepancies were resolved by consensus, or when necessary, by a third reviewer. The extracted data included the first author, publication year, country, number of patients in each group, age characteristics per group, incidence of SSI in both barbed and non-barbed sutures, and the type of procedure. Quality assessment The same two reviewers independently assessed the included studies for the risk of bias using the Cochrane Collaboration’s risk of Bias Tool (RoB2) [ 11 ]. This tool consists of seven bias domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases. Each domain was rated as having a low, unclear, or high risk of bias. Any discrepancies were resolved through discussion. Primary and secondary outcomes The primary outcome of this study is the incidence of surgical site infections (SSIs), which are defined by the Centers for Disease Control and Prevention (CDC) as infections occurring up to 30 days after surgery (or up to one year if an implant is placed). While SSIs are typically categorized as either superficial (affecting the skin and subcutaneous tissue) or deep (involving the fascia and muscle), our data did not include this sub classification. The secondary outcome measured was the incidence of wound dehiscence, a serious complication characterized by the partial or complete separation of the deep wound layers, which can occur even if the skin remains closed. Statistical analysis A meta-analysis was conducted using RevMan 5.4 software. Risk ratios (RRs) were chosen as the effect measure for dichotomous outcomes, as they are more intuitive for clinicians than odds ratios. A random-effects model was used for all meta-analyses, as it provides a more conservative estimate by accounting for both within-study and between-study variability. A fixed-effect model would only be appropriate if the studies were functionally identical, which is uncommon. The random-effects model was selected a priori due to anticipated clinical heterogeneity (e.g., varying types of orthopedic surgeries), a decision further supported by the I² statistic[ 12 ]. RESULTS Study selection Our systematic search identified 4,709 potentially relevant records. After removing 106 duplicates, 4,603 titles and abstracts were screened. Fifteen studies underwent full-text review, of which eight randomized controlled trials involving a total of 1,309 patients met all inclusion criteria and were included in the meta-analysis. The study selection process is outlined in the PRISMA flow diagram. Seven studies were excluded at the full-text stage, primarily due to missing data (n = 6) or non-English language (n = 1) (Fig. 1 ). Baseline study characteristics The eight included RCTs enrolled a total of 1,309 patients, with 652 allocated to the barbed suture (BS) group and 657 to the non-barbed suture (NBS) group. The mean age of participants was 63.6 years in the BS group and 62.4 years in the NBS group. The studies, published between 2012 and 2024, involved patients undergoing various orthopedic procedures, including total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal surgery. The baseline characteristics of the included studies are summarized in Table 1 . Table 1 distribution characteristics of the selected studies used for meta-analysis study year country BS age SSI Deh NBS age SSI Deh Type of surgery Nicholas.T [ 13 ] 2012 Chicago 31 64.4 (41–86) 6 - 29 63.5 (30–80) 3 - THA and TKA Jeremy [ 14 ] 2014 America 191 64 ± 10 3 - 203 63 ± 10 4 - TKA Vincent [ 15 ] 2016 China 55 70.5 ± 8.2 0 1 54 70.4 ± 8.9 1 1 TKA Sundaram [ 16 ] 2020 New York 30 68 ± 7 1 0 30 66 ± 7 0 3 TKA wei [ 17 ] 2020 China 90 66.6 ± 6.1 0 - 89 67.4 ± 5.7 1 - TKA Kevin [ 18 ] 2022 India 37 63.5 ± 4.6 1 - 35 62.3 ± 5.2 0 - TKA Shi [ 19 ] 2022 China 91 55.85 ± 17.1 1 1 90 52.97 ± 19.92 4 3 SPINE SURGERY Song [ 20 ] 2024 Korea 127 56.57 ± 16.01 1 - 127 53.67 ± 16.85 3 - THA and TKA Abbreviation: BS: barbed suture; NBS: non-barbed suture; SSI: surgical site infection Risk of bias The risk of bias assessment is summarized in Figure 2. The majority of the included studies showed a low risk of bias for random sequence generation. However, allocation concealment was inadequately described in most studies, resulting in an "unclear" risk of bias for this domain. Performance bias was a common concern, as blinding of surgeons to the suture type is challenging, leading to a high or unclear risk of bias for the blinding of participants and personnel in most studies. All studies were assessed as having a low risk of bias for incomplete outcome data, selective reporting, and other potential sources of bias. Primary Outcome: Surgical Site Infection All eight included studies reported data on surgical site infections[ 13-20 ]. The pooled analysis revealed no statistically significant difference in the risk of SSIs between the barbed suture (BS) and non-barbed suture (NBS) groups (RR = 0.88, 95% CI: 0.42 to 1.82; p = 0.72) (Figure 4). Secondary Outcome: Wound Dehiscence Three of the eight studies reported on wound dehiscence. Similarly, no statistically significant difference was found between the two groups (RR = 0.37, 95% CI: 0.08 to 1.64; p = 0.63) (Figure 5). Subgroup Analysis A planned subgroup analysis based on the type of orthopedic procedure (e.g., total knee arthroplasty [TKA] vs. total hip arthroplasty [THA] vs. spinal surgery) could not be performed for the outcomes of SSI or wound dehiscence due to the limited number of studies available for each specific procedure. Sensitivity Analysis a sensitivity analysis was performed by sequentially excluding each study to assess the robustness of the pooled results for the primary outcome of SSI. The findings remained consistent and non-significant with the exclusion of any single study, confirming the robustness of the overall conclusion. Publication bias Funnel plots were generated to assess publication bias for outcomes where 10 or more studies were available; however, as fewer than 10 studies were included in each analysis, the power of this assessment is limited. The funnel plots for both SSI and wound dehiscence showed a roughly symmetrical distribution of studies, suggesting no obvious publication bias (Figures 6 & 7). Egger's test was not performed due to the insufficient number of studies, as it is known to be unreliable with fewer than 10 trials [ 21 ]. GRADE Assessment we performed a GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) assessment for the critical outcomes. The certainty of the evidence for both the primary outcome of SSI and the secondary outcome of wound dehiscence was rated as low. This rating was due to imprecision (wide confidence intervals crossing the line of no effect and a low event rate) and risk of bias (unclear or high risk related to allocation concealment and blinding). Discussion This meta-analysis, encompassing eight randomized controlled trials with 1,309 patients, provides a quantitative synthesis of the highest available evidence regarding the role of barbed sutures in preventing surgical site infections (SSIs) in orthopedic surgery. The pooled results revealed no statistically significant difference in the risk of SSIs between the barbed suture (BS) and non-barbed suture (NBS) groups (RR = 0.88). Although the point estimate suggests a non-significant trend favoring barbed sutures, the wide confidence interval—spanning from appreciable harm to considerable benefit—indicates substantial imprecision. Similarly, no significant advantage was observed for barbed sutures in the clinically relevant outcome of wound dehiscence (RR = 0.37). These findings imply that, based on current evidence, the adoption of barbed sutures for the primary purpose of infection prevention in orthopedic surgery is not sufficiently supported. The overall certainty of this evidence, considering risk of bias and inconsistency, should be regarded as moderate to low, indicating substantial imprecision and necessitating cautious interpretation. The absence of a statistically significant reduction in SSI rates with barbed sutures requires careful interpretation from both biological and clinical perspectives. Theoretically, the knotless design and even tension distribution of barbed sutures are intended to minimize tissue strangulation, reduce dead space, and enhance perfusion—all key factors believed to lower infection risk [ 10 ]. Several factors may explain the discrepancy between the theoretical benefits and the lack of measurable clinical effects in our combined analysis. First, the baseline risk of SSI in elective orthopedic procedures performed under modern sterile conditions is approximately 1%-2%, making it exceptionally challenging for individual trials, or even a meta-analysis of this scale, to detect anything other than a very large protective effect. This highlights the issue of statistical power [ 22 ]. Second, the predominant mechanism of infection in clean orthopedic surgeries involving implants may involve hematogenous seeding or contamination during the procedure itself—factors largely unaffected by the final layer of wound closure [ 23 ]. Additionally, subtle variations in surgical technique, subcutaneous handling, and postoperative care may have a more profound impact on SSI rates than the choice of suture material for fascial or subcuticular layers [ 24 ]. The presence of barbed material, while avoiding knots, could potentially provoke a minor foreign body reaction in some patients, offsetting the benefits of knot elimination [ 25 ]. The observed trend toward reduced wound dehiscence, while not statistically significant, suggests a potential mechanical advantage in wound strength that warrants further investigation [ 26 ]. Our findings align with several prior systematic reviews while adding crucial nuance and scope. For instance, the meta-analysis by of Wang et al. (2023) [ 12 ], Feng et al. (2020) [ 27 ], Chen et al. (2018)[ 28 ], Mun et al.(2023) [ 29 ] and others, focused solely on Total Knee Arthroplasty (TKA), also concluded no significant difference in SSI rates, reinforcing the specificity of our conclusion within the orthopedic domain. Crucially, our analysis diverges from reviews that combined diverse surgical specialties surgical specialties (e.g., bariatric, gynecological), where tissue characteristics and infection pathophysiology differ significantly from musculoskeletal surgery [30] . His bariatric surgery meta-analysis, for example, highlighted operational efficiencies but similarly found no significant difference in overall postoperative complications, supporting the idea that the primary impact of suture technology may not be on infection outcomes. Importantly, no major international orthopedic or surgical infection guideline currently recommends barbed over non-barbed sutures for SSI prevention [ 31 ]. Our review strengthens this position by providing an updated, procedure-focused synthesis that explicitly refutes the infection-prevention hypothesis, clarifying that the proven advantage of barbed sutures in reducing operative time in procedures like laparoscopic bariatric surgery [ 32 ] does not extend to orthopedic SSI prevention. While not statistically significant, the substantial point estimate for wound dehiscence (RR = 0.37) warrants further consideration (Figure 5). Our results align with findings reported by Pustilnik et al. [ 33 ]. From a clinical and public health perspective, the implication is clear: the decision to use barbed sutures in orthopedic surgery should not be based on the expectation of reducing infection rates [6, 31] . Instead, their value proposition lies in potentially improving operative efficiency, such as reducing wound closure time, a benefit demonstrated in other fields and hinted at in some orthopedic studies [8] . Surgeons may opt for barbed sutures for convenience, speed, and possibly improved cosmetic outcomes in subcuticular closures, but they should remain vigilant in preventing SSIs through multifaceted, evidence-based approaches [34] . Future research should pivot away from simply comparing infection rates and focus on several targeted areas. Well-powered, multi-center RCTs are needed, specifically designed with SSI as the primary endpoint, although these would require very large sample sizes [ 12 ]. Additionally, pragmatic studies investigating long-term patient-reported outcomes, scar cosmesis, and cost-effectiveness analyses would be valuable, particularly in weighing the higher material cost of barbed sutures against potential savings from reduced operating room time [35 ]. Investigating specific high-risk subgroups, such as obese patients or those undergoing revision surgery, may reveal nuanced benefits not apparent in broader populations[ 36 ]. Furthermore, future trials should standardize the monitoring and reporting of complications linked to barbed sutures, such as soft-tissue irritation or suture extrusion[ 37 ]. Strengths and Limitations The principal strengths of this meta-analysis lie in its adherence to rigorous methodological standards: a pre-registered protocol, a comprehensive and systematic literature search, the strict inclusion of only randomized controlled trials (RCTs) to maximize internal validity, dual independent processes for study selection and data extraction, and the use of appropriate random-effects models to account for clinical heterogeneity. It represents the most contemporary synthesis on this topic, incorporating recent trials up to 2024. The study’s exclusive focus on orthopedic surgery distinguishes it from earlier, more generalized reviews, providing clinically actionable conclusions for orthopedic surgeons. However, several limitations must be acknowledged. The modest number of included trials and the relatively low event rate for SSIs resulted in imprecise effect estimates, as reflected in the wide confidence intervals. Considerable clinical heterogeneity existed among the included studies, which encompassed various procedures, including total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal surgery—each with distinct risk profiles. Methodologically, while random sequence generation was often well described, allocation concealment and blinding of personnel were frequently unclear, introducing the potential for performance bias. Although our search was extensive, the possibility of unpublished data or publication bias cannot be entirely ruled out, even though funnel plots did not show obvious asymmetry. Conceptually, the follow-up periods in the included trials were typically consistent with standard SSI surveillance (30 days), but longer-term outcomes related to the suture material itself remain unexplored. Finally, the generalizability of the findings to all orthopedic contexts may be somewhat limited, as the evidence base is heavily weighted toward elective joint arthroplasty procedures. Conclusion This meta-analysis of high-quality RCTs provides robust evidence that barbed sutures do not lead to a statistically significant or clinically meaningful reduction in the risk of surgical site infections (SSIs) or wound dehiscence compared to non-barbed sutures in orthopedic surgery. Therefore, their utility appears to be primarily in improving operational efficiency rather than in preventing infection when compared to non-barbed sutures. Clinicians are encouraged to prioritize proven SSI prevention strategies—such as meticulous antisepsis, appropriate antibiotic prophylaxis, and glycemic control—while recognizing that the choice of suture material for wound closure plays a neutral role in this specific outcome. For orthopedic practice, the "knotless" feature of barbed sutures offers a technical refinement but does not represent a paradigm shift in infection prevention. Declarations Author’s contribution Juvenal : Conceptualization, Methodology, Writing – Original Draft. Patrick: Investigation, Data Curation, Formal Analysis. Meng and Liu : Software, Validation, Visualization, supervision. Simon and Abdul: Formal Analysis, Writing – Review & Editing. GAO: Supervision, Project Administration, Writing – Review & Editing, Funding Acquisition. Funding Not applicable Data availability All the data generated or analyzed during this study are available in this article. Ethics approval and consent to participate Not applicable Consent for publication Not applicable Registration The study protocol was registered on PROSPERO (CRD420251183701). Conflict of interest The authors declare no conflict of interest. Clinical trial number : not applicable. References Meena S, et al. 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The efficacy and safety of knotless barbed sutures in total joint arthroplasty: a meta-analysis of randomized-controlled trials. Arch Orthop Trauma Surg. 2018;138(10):1335–45. Berríos-Torres SI, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–91. Daley BJ, et al. How slow is too slow? Correlation of operative time to complications: an analysis from the Tennessee Surgical Quality Collaborative. J Am Coll Surg. 2015;220(4):550–8. Pustilnik HN, et al. Barbed Versus Conventional Suture for Spinal Surgery: A Systematic Review and Meta-Analysis. World Neurosurg. 2025;193:241–55. Allegranzi B, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16(12):e288–303. Gililland JM, et al. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8611370","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578297044,"identity":"590ca846-f30c-4209-991c-8d9117df0015","order_by":0,"name":"Juvenal Nshimirimana","email":"","orcid":"","institution":"Central South University","correspondingAuthor":false,"prefix":"","firstName":"Juvenal","middleName":"","lastName":"Nshimirimana","suffix":""},{"id":578297045,"identity":"0bcdc0c4-77ce-4bd7-81bb-7de04bf01738","order_by":1,"name":"Abayo Remy Patrick","email":"","orcid":"","institution":"Central South 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00:41:14","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96779,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8611370/v1/e3f455ea422dddcfe15643ea.html"},{"id":100930572,"identity":"2a829b41-dded-46dc-b258-297f23bd9617","added_by":"auto","created_at":"2026-01-23 00:41:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29158,"visible":true,"origin":"","legend":"\u003cp\u003ePrisma flow chart of included studies\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8611370/v1/37b7859bebee97da75c5fa3a.png"},{"id":100930576,"identity":"895b32cd-f7c0-4e71-84dd-605fb979de3f","added_by":"auto","created_at":"2026-01-23 00:41:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":195706,"visible":true,"origin":"","legend":"\u003cp\u003e(A\u0026amp;B): risk of bias summary\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8611370/v1/4c5cc05c6741f96f88d0264a.png"},{"id":100930573,"identity":"3935177c-3d13-44d3-af6a-a27f1974c2f0","added_by":"auto","created_at":"2026-01-23 00:41:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":11339,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot of postoperative wound infection.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8611370/v1/a91e12b2d9220946012821eb.png"},{"id":100930574,"identity":"11e5f810-2659-402e-bd1a-5d48ccab07a1","added_by":"auto","created_at":"2026-01-23 00:41:14","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":52791,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot of postoperative wound dehiscence.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8611370/v1/564450b334de2d1b8328ad45.png"},{"id":100930577,"identity":"a4055926-d8de-46ce-9b37-d5365dd67dd0","added_by":"auto","created_at":"2026-01-23 00:41:14","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":80966,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel plot (\u003cstrong\u003eA\u003c/strong\u003e: infection, \u003cstrong\u003eB\u003c/strong\u003e: dehiscence)\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8611370/v1/cfa95dc751409f10d7ae068a.jpeg"},{"id":100953093,"identity":"bb1e8d21-c704-4a2e-a474-0ca1b9ea6084","added_by":"auto","created_at":"2026-01-23 07:19:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1159209,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8611370/v1/af1ba746-77db-4431-8b2c-b2aeb5c94e67.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barbed versus Non-Barbed Sutures for Prevention of Surgical Site Infections in Orthopedic Surgery: A Meta-Analysis of Randomized Controlled Trials","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEffective wound closure following orthopedic surgery is crucial for promoting rapid healing, achieving optimal cosmesis, and minimizing complications such as surgical site infections (SSIs) and wound dehiscence [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Healthcare-associated infections (HAIs), which are preventable, affect hundreds of millions of patients worldwide each year. Among these, surgical site infections (SSIs) are the most common and widely studied, particularly in low- and middle-income countries, where they affect up to one-third of surgical patients. While the incidence of SSIs is lower in high-income countries, it remains the second most common healthcare-associated infection in Europe and the United States [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. SSIs place a significant burden on healthcare systems, contributing to prolonged hospital stays, higher healthcare costs, and increased patient morbidity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite the use of strict aseptic techniques and prophylactic antibiotics, SSIs complicate approximately 1% to 5% of orthopedic procedures, with particularly high rates in trauma and joint replacement surgeries [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBarbed sutures have emerged as a promising innovation for improving wound closure outcomes[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Unlike traditional sutures, barbed sutures eliminate the need for knots, which are potential sites for bacterial colonization [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. With bidirectional or unidirectional barbs, these sutures are designed to distribute tension more evenly across the wound, potentially minimizing tissue trauma, reducing gaps, and improving perfusion\u0026mdash;factors that could theoretically lower the risk of infection[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. While some studies have compared clinical outcomes between barbed and standard sutures, the optimal closure technique remains uncertain [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The choice of suture material and technology can significantly influence the local wound environment, tissue reaction, and ultimately, the risk of infection. Traditional non-barbed sutures (e.g., Vicryl, PDS) have been the standard for decades. However, barbed sutures have recently gained popularity in orthopedic and other surgical fields due to their design, which anchors tissue without the need for knot tying. Proposed advantages of barbed sutures include reduced closure time, more consistent tissue apposition, and improved wound healing [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While some clinical studies suggest that barbed sutures may reduce surgical site infection (SSI) rates, the evidence remains inconsistent and inconclusive. Many individual randomized controlled trials (RCTs) are often underpowered to detect statistically significant differences in this relatively low-frequency event.\u003c/p\u003e \u003cp\u003eTo address this clinical uncertainty, we conducted a systematic review and meta-analysis of RCTs to rigorously evaluate the comparative effectiveness of barbed versus non-barbed sutures in preventing SSIs within an exclusively orthopedic population. Several key methodological features characterize our study: First, we applied a strict PICOS framework, including only RCTs, to ensure high-quality evidence. Second, we recognized wound dehiscence as a key secondary outcome, providing a composite measure of wound failure. Third, we employed a random-effects model a priori to account for anticipated clinical heterogeneity across various orthopedic procedures (e.g., total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal surgery), offering a more generalized and conservative estimate applicable to real-world practice. By synthesizing the most current and robust evidence, this analysis aims to provide a definitive conclusion on the role of barbed sutures in preventing SSIs, thereby guiding clinical practice and informing future research.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch strategy\u003c/h2\u003e \u003cp\u003eA comprehensive systematic search was conducted across PubMed, Embase, Cochrane Library, and Web of Science databases up to October 2025. The protocol for this systematic review and meta-analysis was registered with PROSPERO (registration number CRD420251183701). The search strategy utilized the following terms: (((\"barbed sutures\") AND (\"surgical site infection\")) OR (\"surgical wound infection\") OR (\"postoperative wound infection\"))).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cp\u003eEligibility criteria were defined using the PICOS framework.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePopulation: Patients undergoing orthopedic surgery.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIntervention: Barbed sutures (BS).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eComparison: Non-barbed sutures (NBS).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOutcomes: Primary - Surgical Site Infection (SSI); Secondary - Wound dehiscence.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStudy design: Randomized Controlled Trials (RCTs).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eExclusion criteria were the following:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eStudies with non-randomized controlled trials\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003estudies with non-orthopedic surgery,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003estudies not reporting infections outcomes\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003estudies for which the full text was not available\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eData extraction\u003c/h3\u003e\n\u003cp\u003eTwo reviewers independently extracted data from the included studies using a pre-piloted Excel sheet. Discrepancies were resolved by consensus, or when necessary, by a third reviewer. The extracted data included the first author, publication year, country, number of patients in each group, age characteristics per group, incidence of SSI in both barbed and non-barbed sutures, and the type of procedure.\u003c/p\u003e\n\u003ch3\u003eQuality assessment\u003c/h3\u003e\n\u003cp\u003eThe same two reviewers independently assessed the included studies for the risk of bias using the Cochrane Collaboration\u0026rsquo;s risk of Bias Tool (RoB2) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This tool consists of seven bias domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases. Each domain was rated as having a low, unclear, or high risk of bias. Any discrepancies were resolved through discussion.\u003c/p\u003e\n\u003ch3\u003ePrimary and secondary outcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome of this study is the incidence of surgical site infections (SSIs), which are defined by the Centers for Disease Control and Prevention (CDC) as infections occurring up to 30 days after surgery (or up to one year if an implant is placed). While SSIs are typically categorized as either superficial (affecting the skin and subcutaneous tissue) or deep (involving the fascia and muscle), our data did not include this sub classification. The secondary outcome measured was the incidence of wound dehiscence, a serious complication characterized by the partial or complete separation of the deep wound layers, which can occur even if the skin remains closed.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eA meta-analysis was conducted using RevMan 5.4 software. Risk ratios (RRs) were chosen as the effect measure for dichotomous outcomes, as they are more intuitive for clinicians than odds ratios. A random-effects model was used for all meta-analyses, as it provides a more conservative estimate by accounting for both within-study and between-study variability. A fixed-effect model would only be appropriate if the studies were functionally identical, which is uncommon. The random-effects model was selected a priori due to anticipated clinical heterogeneity (e.g., varying types of orthopedic surgeries), a decision further supported by the I\u0026sup2; statistic[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStudy selection\u003c/h2\u003e \u003cp\u003eOur systematic search identified 4,709 potentially relevant records. After removing 106 duplicates, 4,603 titles and abstracts were screened. Fifteen studies underwent full-text review, of which eight randomized controlled trials involving a total of 1,309 patients met all inclusion criteria and were included in the meta-analysis. The study selection process is outlined in the PRISMA flow diagram. Seven studies were excluded at the full-text stage, primarily due to missing data (n\u0026thinsp;=\u0026thinsp;6) or non-English language (n\u0026thinsp;=\u0026thinsp;1) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBaseline study characteristics\u003c/h2\u003e \u003cp\u003eThe eight included RCTs enrolled a total of 1,309 patients, with 652 allocated to the barbed suture (BS) group and 657 to the non-barbed suture (NBS) group. The mean age of participants was 63.6 years in the BS group and 62.4 years in the NBS group. The studies, published between 2012 and 2024, involved patients undergoing various orthopedic procedures, including total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal surgery. The baseline characteristics of the included studies are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003edistribution characteristics of the selected studies used for meta-analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003estudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSSI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDeh\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNBS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSSI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDeh\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eType of surgery\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNicholas.T [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChicago\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64.4\u003c/p\u003e \u003cp\u003e(41\u0026ndash;86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e63.5\u003c/p\u003e \u003cp\u003e(30\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eTHA and TKA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJeremy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAmerica\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64\u0026thinsp;\u0026plusmn;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e63\u0026thinsp;\u0026plusmn;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eTKA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVincent [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e70.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eTKA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSundaram [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNew York\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eTKA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewei [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e67.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eTKA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKevin [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e62.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eTKA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShi [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.85\u0026thinsp;\u0026plusmn;\u0026thinsp;17.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e52.97\u0026thinsp;\u0026plusmn;\u0026thinsp;19.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eSPINE SURGERY\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSong [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKorea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56.57\u0026thinsp;\u0026plusmn;\u0026thinsp;16.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e53.67\u0026thinsp;\u0026plusmn;\u0026thinsp;16.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eTHA and TKA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\u003cp\u003eAbbreviation: BS: barbed suture; NBS: non-barbed suture; SSI: surgical site infection\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk of bias\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe risk of bias assessment is summarized in Figure 2. The majority of the included studies showed a low risk of bias for random sequence generation. However, allocation concealment was inadequately described in most studies, resulting in an \u0026quot;unclear\u0026quot; risk of bias for this domain. Performance bias was a common concern, as blinding of surgeons to the suture type is challenging, leading to a high or unclear risk of bias for the blinding of participants and personnel in most studies. All studies were assessed as having a low risk of bias for incomplete outcome data, selective reporting, and other potential sources of bias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Outcome: Surgical Site Infection\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eAll eight included studies reported data on surgical site infections[\u003cstrong\u003e13-20\u003c/strong\u003e].\u0026nbsp;The pooled analysis revealed no statistically significant difference in the risk of SSIs between the barbed suture (BS) and non-barbed suture (NBS) groups (RR = 0.88, 95% CI: 0.42 to 1.82; p = 0.72) (Figure 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Outcome: Wound Dehiscence\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Three of the eight studies reported on wound dehiscence. Similarly, no statistically significant difference was found between the two groups (RR = 0.37, 95% CI: 0.08 to 1.64; p = 0.63) (Figure 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubgroup Analysis\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A planned subgroup analysis based on the type of orthopedic procedure (e.g., total knee arthroplasty [TKA] vs. total hip arthroplasty [THA] vs. spinal surgery) could not be performed for the outcomes of SSI or wound dehiscence due to the limited number of studies available for each specific procedure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSensitivity Analysis\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;a sensitivity analysis was performed by sequentially excluding each study to assess the robustness of the pooled results for the primary outcome of SSI. The findings remained consistent and non-significant with the exclusion of any single study, confirming the robustness of the overall conclusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Publication bias\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunnel plots were generated to assess publication bias for outcomes where 10 or more studies were available; however, as fewer than 10 studies were included in each analysis, the power of this assessment is limited. The funnel plots for both SSI and wound dehiscence showed a roughly symmetrical distribution of studies, suggesting no obvious publication bias (Figures 6 \u0026amp; 7). Egger\u0026apos;s test was not performed due to the insufficient number of studies, as it is known to be unreliable with fewer than 10 trials [\u003cstrong\u003e21\u003c/strong\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGRADE Assessment\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;we performed a GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) assessment for the critical outcomes. The certainty of the evidence for both the primary outcome of SSI and the secondary outcome of wound dehiscence was rated as low. This rating was due to imprecision (wide confidence intervals crossing the line of no effect and a low event rate) and risk of bias (unclear or high risk related to allocation concealment and blinding).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis meta-analysis, encompassing eight randomized controlled trials with 1,309 patients, provides a quantitative synthesis of the highest available evidence regarding the role of barbed sutures in preventing surgical site infections (SSIs) in orthopedic surgery. The pooled results revealed no statistically significant difference in the risk of SSIs between the barbed suture (BS) and non-barbed suture (NBS) groups (RR = 0.88). Although the point estimate suggests a non-significant trend favoring barbed sutures, the wide confidence interval—spanning from appreciable harm to considerable benefit—indicates substantial imprecision. Similarly, no significant advantage was observed for barbed sutures in the clinically relevant outcome of wound dehiscence (RR = 0.37). These findings imply that, based on current evidence, the adoption of barbed sutures for the primary purpose of infection prevention in orthopedic surgery is not sufficiently supported. The overall certainty of this evidence, considering risk of bias and inconsistency, should be regarded as moderate to low, indicating substantial imprecision and necessitating cautious interpretation.\u003c/p\u003e\n\u003cp\u003eThe absence of a statistically significant reduction in SSI rates with barbed sutures requires careful interpretation from both biological and clinical perspectives. Theoretically, the knotless design and even tension distribution of barbed sutures are intended to minimize tissue strangulation, reduce dead space, and enhance perfusion—all key factors believed to lower infection risk [\u003cstrong\u003e10\u003c/strong\u003e].\u0026nbsp;Several factors may explain the discrepancy between the theoretical benefits and the lack of measurable clinical effects in our combined analysis. First, the baseline risk of SSI in elective orthopedic procedures performed under modern sterile conditions is approximately 1%-2%, making it exceptionally challenging for individual trials, or even a meta-analysis of this scale, to detect anything other than a very large protective effect. This highlights the issue of statistical power\u0026nbsp;[\u003cstrong\u003e22\u003c/strong\u003e]. Second, the predominant mechanism of infection in clean orthopedic surgeries involving implants may involve hematogenous seeding or contamination during the procedure itself—factors largely unaffected by the final layer of wound closure\u0026nbsp;[\u003cstrong\u003e23\u003c/strong\u003e]. Additionally, subtle variations in surgical technique, subcutaneous handling, and postoperative care may have a more profound impact on SSI rates than the choice of suture material for fascial or subcuticular layers\u0026nbsp;[\u003cstrong\u003e24\u003c/strong\u003e]. The presence of barbed material, while avoiding knots, could potentially provoke a minor foreign body reaction in some patients, offsetting the benefits of knot elimination\u0026nbsp;[\u003cstrong\u003e25\u003c/strong\u003e]. The observed trend toward reduced wound dehiscence, while not statistically significant, suggests a potential mechanical advantage in wound strength that warrants further investigation\u0026nbsp;[\u003cstrong\u003e26\u003c/strong\u003e].\u003c/p\u003e\n\u003cp\u003eOur findings align with several prior systematic reviews while adding crucial nuance and scope. For instance, the meta-analysis by of Wang et al. (2023) [\u003cstrong\u003e12\u003c/strong\u003e], Feng et al. (2020) [\u003cstrong\u003e27\u003c/strong\u003e], Chen et al. (2018)[\u003cstrong\u003e28\u003c/strong\u003e], \u0026nbsp;Mun et al.(2023) [\u003cstrong\u003e29\u003c/strong\u003e] and others, focused solely on Total Knee Arthroplasty (TKA), also concluded no significant difference in SSI rates, reinforcing the specificity of our conclusion within the orthopedic domain.\u0026nbsp;Crucially, our analysis diverges from reviews that combined diverse surgical specialties surgical specialties (e.g., bariatric, gynecological), where tissue characteristics and infection pathophysiology differ significantly from musculoskeletal surgery\u0026nbsp;\u003cstrong\u003e[30]\u003c/strong\u003e.\u0026nbsp;His bariatric surgery meta-analysis, for example, highlighted operational efficiencies but similarly found no significant difference in overall postoperative complications, supporting the idea that the primary impact of suture technology may not be on infection outcomes. Importantly, no major international orthopedic or surgical infection guideline currently recommends barbed over non-barbed sutures for SSI prevention\u0026nbsp;[\u003cstrong\u003e31\u003c/strong\u003e]. Our review strengthens this position by providing an updated, procedure-focused synthesis that explicitly refutes the infection-prevention hypothesis, clarifying that the proven advantage of barbed sutures in reducing operative time in procedures like laparoscopic bariatric surgery [\u003cstrong\u003e32\u003c/strong\u003e] does not extend to orthopedic SSI prevention.\u003c/p\u003e\n\u003cp\u003eWhile not statistically significant, the substantial point estimate for wound dehiscence (RR = 0.37) warrants further consideration (Figure 5). Our results align with findings reported by Pustilnik et al. [\u003cstrong\u003e33\u003c/strong\u003e].\u003c/p\u003e\n\u003cp\u003eFrom a clinical and public health perspective, the implication is clear: the decision to use barbed sutures in orthopedic surgery should not be based on the expectation of reducing infection rates\u003cstrong\u003e[6, 31]\u003c/strong\u003e. Instead, their value proposition lies in potentially improving operative efficiency, such as reducing wound closure time, a benefit demonstrated in other fields and hinted at in some orthopedic studies\u003cstrong\u003e[8]\u003c/strong\u003e. Surgeons may opt for barbed sutures for convenience, speed, and possibly improved cosmetic outcomes in subcuticular closures, but they should remain vigilant in preventing SSIs through multifaceted, evidence-based approaches\u003cstrong\u003e[34]\u003c/strong\u003e. Future research should pivot away from simply comparing infection rates and focus on several targeted areas. Well-powered, multi-center RCTs are needed, specifically designed with SSI as the primary endpoint, although these would require very large sample sizes [\u003cstrong\u003e12\u003c/strong\u003e]. Additionally, pragmatic studies investigating long-term patient-reported outcomes, scar cosmesis, and cost-effectiveness analyses would be valuable, particularly in weighing the higher material cost of barbed sutures against potential savings from reduced operating room time \u003cstrong\u003e[35\u003c/strong\u003e].\u0026nbsp;Investigating specific high-risk subgroups, such as obese patients or those undergoing revision surgery, may reveal nuanced benefits not apparent in broader populations[\u003cstrong\u003e36\u003c/strong\u003e]. Furthermore, future trials should standardize the monitoring and reporting of complications linked to barbed sutures, such as soft-tissue irritation or suture extrusion[\u003cstrong\u003e37\u003c/strong\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe principal strengths of this meta-analysis lie in its adherence to rigorous methodological standards: a pre-registered protocol, a comprehensive and systematic literature search, the strict inclusion of only randomized controlled trials (RCTs) to maximize internal validity, dual independent processes for study selection and data extraction, and the use of appropriate random-effects models to account for clinical heterogeneity. It represents the most contemporary synthesis on this topic, incorporating recent trials up to 2024. The study’s exclusive focus on orthopedic surgery distinguishes it from earlier, more generalized reviews, providing clinically actionable conclusions for orthopedic surgeons.\u003c/p\u003e\n\u003cp\u003eHowever, several limitations must be acknowledged. The modest number of included trials and the relatively low event rate for SSIs resulted in imprecise effect estimates, as reflected in the wide confidence intervals. Considerable clinical heterogeneity existed among the included studies, which encompassed various procedures, including total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal surgery—each with distinct risk profiles. Methodologically, while random sequence generation was often well described, allocation concealment and blinding of personnel were frequently unclear, introducing the potential for performance bias. Although our search was extensive, the possibility of unpublished data or publication bias cannot be entirely ruled out, even though funnel plots did not show obvious asymmetry. Conceptually, the follow-up periods in the included trials were typically consistent with standard SSI surveillance (30 days), but longer-term outcomes related to the suture material itself remain unexplored. Finally, the generalizability of the findings to all orthopedic contexts may be somewhat limited, as the evidence base is heavily weighted toward elective joint arthroplasty procedures.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis meta-analysis of high-quality RCTs provides robust evidence that barbed sutures do not lead to a statistically significant or clinically meaningful reduction in the risk of surgical site infections (SSIs) or wound dehiscence compared to non-barbed sutures in orthopedic surgery. Therefore, their utility appears to be primarily in improving operational efficiency rather than in preventing infection when compared to non-barbed sutures. Clinicians are encouraged to prioritize proven SSI prevention strategies\u0026mdash;such as meticulous antisepsis, appropriate antibiotic prophylaxis, and glycemic control\u0026mdash;while recognizing that the choice of suture material for wound closure plays a neutral role in this specific outcome. For orthopedic practice, the \u0026quot;knotless\u0026quot; feature of barbed sutures offers a technical refinement but does not represent a paradigm shift in infection prevention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJuvenal\u003cstrong\u003e:\u003c/strong\u003e Conceptualization, Methodology, Writing \u0026ndash; Original Draft. Patrick: Investigation, Data Curation, Formal Analysis. Meng and Liu\u003cstrong\u003e:\u003c/strong\u003e Software, Validation, Visualization, supervision. Simon and Abdul: Formal Analysis, Writing \u0026ndash; Review \u0026amp; Editing. GAO: Supervision, Project Administration, Writing \u0026ndash; Review \u0026amp; Editing, Funding Acquisition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All the data generated or analyzed during this study are available in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was registered on PROSPERO (CRD420251183701).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMeena S, et al. Barbed versus standard sutures in total knee arthroplasty: a meta-analysis. Eur J Orthop Surg Traumatol. 2015;25(6):1105\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllegranzi B, et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16(12):e276\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRasouli MR, et al. Risk factors for surgical site infection following total joint arthroplasty. J Bone Joint Surg Am. 2014;96(18):e158.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParvizi J, et al. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. J Arthroplasty. 2018;33(5):1309\u0026ndash;e13142.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGililland JM, et al. Barbed versus standard sutures for closure in total knee arthroplasty: a multicenter prospective randomized trial. J Arthroplasty. 2014;29(9 Suppl):135\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang W, et al. Barbed versus traditional sutures for wound closure in knee arthroplasty: a systematic review and meta-analysis. Sci Rep. 2016;6:19764.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParikh PM, Davison SP, Higgins JP. Barbed suture tenorrhaphy: an ex vivo biomechanical analysis. Plast Reconstr Surg. 2009;124(5):1551\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEickmann T, Quane E. Total knee arthroplasty closure with barbed sutures. J Knee Surg. 2010;23(3):163\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStephens 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;21:199\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenberg JA, Goldman RH. Barbed suture: a review of the technology and clinical uses in obstetrics and gynecology. Rev Obstet Gynecol. 2013;6(3\u0026ndash;4):107\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSterne JAC, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, et al. Effect of barbed versus standard sutures on wound complications in total knee arthroplasty: A meta-analysis. Int Wound J. 2023;20(10):4130\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTing NT, et al. Use of knotless suture for closure of total hip and knee arthroplasties: a prospective, randomized clinical trial. J Arthroplasty. 2012;27(10):1783\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGililland JM et al. \u003cem\u003eBarbed versus standard sutures for closure in total knee arthroplasty: A multicenter prospective randomized trial.\u003c/em\u003e Journal of Arthroplasty, 2014. 29(9 SUPPL.): pp. 135\u0026ndash;138.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan VWK, et al. Does Barbed Suture Lower Cost and Improve Outcome in Total Knee Arthroplasty? A Randomized Controlled Trial. J Arthroplasty. 2017;32(5):1474\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSundaram K, et al. Barbed sutures reduce arthrotomy closure duration compared to interrupted conventional sutures for total knee arthroplasty: a randomized controlled trial. Musculoskelet Surg. 2021;105(3):275\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang W, et al. A symmetric anchor designed barbed suture versus conventional interrupted sutures in total knee arthroplasty: A multicenter, randomized controlled trial. J Orthop Surg (Hong Kong). 2020;28(3):2309499020965681.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhatri K et al. \u003cem\u003eComparison of Three Suture Materials in Capsular Closure Closure Time and Wound Complications Following Knee Arthroplasty.\u003c/em\u003e Bull Hosp Jt Dis (2013), 2022. 80(4): pp. 246\u0026ndash;251.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShi K, et al. The use of novel knotless barbed sutures in posterior long-segment lumbar surgery: a randomized controlled trial. J Orthop Surg Res. 2022;17(1):279.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong M, Cho Y. A Prospective Randomized Controlled Study of Stratafix versus Standard-of-Care for Deep Tissue Closure in Orthopedic Surgery. Clin Orthop Surg. 2024;16(5):820\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfonso J, et al. The Perils of Misinterpreting and Misusing Publication Bias in Meta-analyses: An Education Review on Funnel Plot-Based Methods. Sports Med. 2024;54(2):257\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlanagan ME, et al. A national collaborative for reducing health care\u0026ndash;associated infections: current initiatives, challenges, and opportunities. Am J Infect Control. 2011;39(8):685\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimmerli W, Sendi P. Orthopaedic biofilm infections. Apmis. 2017;125(4):353\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson DJ, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(6):605\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBogliolo S, et al. Barbed suture in minimally invasive hysterectomy: a systematic review and meta-analysis. Arch Gynecol Obstet. 2015;292(3):489\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemyttenaere SV, et al. Barbed suture for gastrointestinal closure: a randomized control trial. Surg Innov. 2009;16(3):237\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng S, et al. Are There Lower Complication Rates with Bidirectional Barbed Suture in Total Knee Arthroplasty Incision Closure? A Randomized Clinical Trial. Med Sci Monit. 2020;26:e922783.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen J, et al. A Novel Knotless Barbed Suture Technique for Traumatic Thoracolumbar Fracture in Posterior Surgery. World Neurosurg. 2018;114:e1031\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMun J, et al. Surgical and Clinical Outcomes Associated With the Use of Barbed Sutures and Self-Adhering Mesh System and Polymeric Glue for Wound Closure in Multilevel or Revision Spinal Surgery: A Matched Cohort Comparative Study With Conventional Wound Closure Procedure. Neurospine. 2023;20(3):981\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan Y, et al. The efficacy and safety of knotless barbed sutures in total joint arthroplasty: a meta-analysis of randomized-controlled trials. Arch Orthop Trauma Surg. 2018;138(10):1335\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerr\u0026iacute;os-Torres SI, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaley BJ, et al. How slow is too slow? Correlation of operative time to complications: an analysis from the Tennessee Surgical Quality Collaborative. J Am Coll Surg. 2015;220(4):550\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePustilnik HN, et al. Barbed Versus Conventional Suture for Spinal Surgery: A Systematic Review and Meta-Analysis. World Neurosurg. 2025;193:241\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllegranzi B, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16(12):e288\u0026ndash;303.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGililland JM, et al. Perioperative closure-related complication rates and cost analysis of barbed suture for closure in TKA. Clin Orthop Relat Res. 2012;470(1):125\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin Y, et al. The Efficacy and Safety of Knotless Barbed Sutures in the Surgical Field: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Sci Rep. 2016;6:23425.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaruby J, et al. An in vivo comparison of barbed suture devices and conventional monofilament sutures for cosmetic skin closure: biomechanical wound strength and histology. Aesthet Surg J. 2011;31(2):232\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"barbed sutures, non-barbed sutures, surgical site infections, meta-analysis, risk ratio","lastPublishedDoi":"10.21203/rs.3.rs-8611370/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8611370/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis meta-analysis aims to assess whether barbed sutures (BS) are superior to non-barbed sutures (NBS) in reducing surgical site infections (SSIs) in orthopedic surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA systematic literature search was conducted in PubMed, Embase, Cochrane Library, and Web of Science up to October 2025. A total of 1,309 patients from eight randomized controlled trials (RCTs) were included, with 652 patients in the BS group and 657 in the NBS group. The primary outcome was the incidence of SSI, defined according to the Centers for Disease Control and Prevention (CDC) criteria where feasible.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe pooled analysis showed no statistically significant difference in the risk of SSIs between the BS and NBS groups (RR\u0026thinsp;=\u0026thinsp;0.88, 95% CI: 0.42 to 1.82, P\u0026thinsp;=\u0026thinsp;0.72), with the point estimate suggesting a non-significant trend favoring barbed sutures. Similarly, there was no significant difference in the risk of wound dehiscence (RR\u0026thinsp;=\u0026thinsp;0.37, 95% CI: 0.08 to 1.64).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBased on current evidence, barbed sutures do not significantly reduce the incidence of SSIs or wound dehiscence compared to non-barbed sutures in orthopedic surgery. Their utility appears to be primarily in improving operative efficiency rather than in preventing infection.\u003c/p\u003e","manuscriptTitle":"Barbed versus Non-Barbed Sutures for Prevention of Surgical Site Infections in Orthopedic Surgery: A Meta-Analysis of Randomized Controlled Trials","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 00:41:09","doi":"10.21203/rs.3.rs-8611370/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-29T10:36:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-28T05:16:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-25T00:16:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"251529543738842867153586561632846398041","date":"2026-01-24T16:01:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165458705210378108095166733794272403174","date":"2026-01-23T23:59:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108303439942185802222998640598941120100","date":"2026-01-22T22:03:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"303197246013570484156029668167813864308","date":"2026-01-21T13:49:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242893461166404984332796741598255387260","date":"2026-01-21T08:59:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81769591257381884623415736977336456244","date":"2026-01-21T08:24:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-21T08:07:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-19T17:00:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-17T05:44:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-17T05:43:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-01-15T14:05:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d84931d-124c-4803-9cf1-25a7f114a347","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T16:08:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 00:41:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8611370","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8611370","identity":"rs-8611370","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}