The Effect of Absorbable Knotless Barbed Suture on Total Knee Arthroplasty Incision Closure: A Retrospective Cohort Study

The Effect of Absorbable Knotless Barbed Suture on Total Knee Arthroplasty Incision Closure: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Absorbable Knotless Barbed Suture on Total Knee Arthroplasty Incision Closure: A Retrospective Cohort Study Zhifa Huang, Yili Pan, Jianchao Ma, Qiangning Li, Jinzhi Meng, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8561219/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Numerous studies have investigated the utilization of absorbable knotless barbed sutures in total knee arthroplasty (TKA) and compared various techniques and materials; however, the efficacy of full-thickness closure remains inconsistent. This retrospective study aimed to evaluate whether full-thickness wound closure in TKA using absorbable knotless barbed sutures, compared with running-coated Vicryl Plus antibacterial sutures, was associated with a reduction in complication rates. Methods Patients who underwent primary unilateral TKA with incision closure using either absorbable knotless barbed sutures or coated Vicryl Plus antibacterial sutures between January 2020 and September 2023 were retrospectively enrolled. Demographics, comorbidities, perioperative data, postoperative complications, Knee Society Scores (KSS), knee range of motion (ROM), and scar appearance were systematically collected and analyzed over a 24-month follow-up. Perioperative risk factors associated with superficial wound infection were also evaluated. Results At the 24-month postoperative follow-up, no statistically significant differences were observed in major complication rates among the four groups ( P > 0.05), including periprosthetic joint infection ( P > 0.05) and revision surgery ( P > 0.05). However, a statistically significant difference was observed in the overall incidence of minor superficial wound complications among the groups ( P 0.05), Groups A, B, and C exhibited lower incidence rates than Group D. The use of barbed sutures was associated with significantly shorter suture time and operative duration (all P 0.05). Conclusion The results of this study indicate that the use of barbed sutures for incision closure in TKA was not associated with an increased risk of major or minor wound complications. These findings suggest that barbed sutures may be considered a viable alternative for incision closure in TKA; however, careful application is advised when involving subcutaneous or adipose tissue. Clinical trial number: Not applicable. Total knee arthroplasty barbed sutures incision closure wound complications Introduction Closure techniques following total joint arthroplasty (TJA) exert both immediate and long-term effects on surgical efficiency, wound healing, morbidity, and patient satisfaction [ 1 ]. Meticulous incision closure in total knee arthroplasty (TKA) is essential for withstanding incision tension, promoting optimal cutaneous healing, achieving cosmetically favorable scars, and reducing postoperative complications [ 2 , 3 ]. However, inadequate suturing techniques can compromise wound healing and elevate the risk of surgical site infection (SSI) or periprosthetic joint infection (PJI) [ 4 ], which remains the most destructive and feared complication following TKA [ 5 ]. Interrupted sutures have traditionally been the standard technique for incision closure in TKA. However, tying multiple knots is time-consuming and may adversely affect tissue healing by causing tissue overlap and impeding fibroblast proliferation [ 6 ]. Furthermore, the resulting bulky suture knots may serve as potential niduses for infection [ 7 ], provoking inflammatory responses and resulting in SSI. Barbed sutures, characterized by their knotless and self-anchoring properties, demonstrate superior elasticity and high tensile strength, facilitating tissue tension distribution and enhancing wound closure efficiency [ 8 , 9 ]. Previous studies have reported that barbed sutures in TKA can significantly reduce costs, shorten suture time, and do not increase the rate of wound complications [ 10 – 18 ]. In most of these reports, barbed sutures were employed for the closure of the arthrotomy and/or subcutaneous layers or were restricted to the subcuticular layer only. However, few have applied barbed sutures for full-thickness closure without adjuncts, such as staples or advanced closure systems, and the reported outcomes regarding wound complications remain inconsistent [ 19 , 20 ]. This inconsistency complicates the assessment of their efficacy in full-thickness wound closure during TKA. Therefore, we conducted a single-center retrospective study to investigate whether the application of barbed sutures for full-thickness incision closure in TKA results in comparable or lower rates of postoperative complications than running coated Vicryl Plus antibacterial sutures without the application of staples and skin adhesive. Patients and Methods Study design and participants This retrospective cohort study was conducted following approval from the Ethics Committee of the Fourth Affiliated Hospital of Guangxi Medical University (ethics approval number: KY2025661), and informed consent was obtained from all enrolled patients. All procedures adhered to the ethical standards set forth in the Declaration of Helsinki and its subsequent amendments. Consecutive patients diagnosed with knee osteoarthritis (KOA) who underwent primary unilateral TKA at the same medical institution between January 2020 and September 2023 were enrolled. The inclusion criteria consisted of (1) patients aged 18 to 79 years who underwent primary unilateral total knee arthroplasty, with incision closure performed using either barbed sutures or coated Vicryl Plus antibacterial sutures; (2) completion of a 24-month follow-up period. The exclusion criteria were revision or unicompartmental knee arthroplasty, bilateral procedures, and insufficient follow-up or incomplete medical records. During the reporting period, 426 cases involving primary unilateral TKA were reviewed. Among them, 20 patients were excluded due to inadequate follow-up, 8 due to undergoing bilateral TKA, and 9 due to incomplete medical records. Ultimately, 389 patients meeting the inclusion criteria were enrolled and stratified into four groups. Group A (n = 105): The joint capsule (Stratafix 1 − 0), subcutaneous tissue (Stratafix 2 − 0), and intradermal tissue (Stratafix 4 − 0) were sutured using an absorbable, knotless barbed suture (Ethicon Stratafix symmetric PDS plus knotless tissue control device). Four to five additional sutures were placed to prevent suture slippage and wound dehiscence. Group B (n = 90): The joint capsule (Stratafix 1 − 0) and subcutaneous tissue (Stratafix 2 − 0) were closed with a barbed suture, and the intradermal tissue (Ethicon VICRYL plus 4 − 0) was closed using an absorbable suture. Group C (n = 88): The joint capsule was sutured with a barbed suture (Stratafix 1 − 0), and the subcutaneous (Ethicon VICRYL plus 2 − 0) and intradermal (Ethicon VICRYL plus 4 − 0) were sutured with an absorbable suture. Group D (n = 106): The joint capsule (Ethicon VICRYL plus 1 − 0), subcutaneous tissue (Ethicon VICRYL plus 2 − 0), and intradermal tissue (Ethicon VICRYL plus 4 − 0) were approximated using a coated Vicryl Plus antibacterial suture. This specific grouping was selected to investigate the impact of barbed sutures at varying tissue depths, facilitating a detailed analysis of their safety and efficacy when applied to Group A (full-thickness closure), Group B (capsular and subcutaneous closure), and Group C (capsular closure only) in comparison to conventional closure (Group D). Surgical procedure The medial parapatellar approach [ 21 ] was employed in every instance. A tourniquet was applied during each procedure, inflated at incision, and deflated prior to closure. Following the implantation of all prosthetic components, a solution of tranexamic acid (1.0 g tranexamic acid mixed with 100 ml normal saline) was administered intravenously before the release of the tourniquet to facilitate hemostasis. Incision closure was conducted with the knee flexed at 45° to 90° [ 1 , 4 , 14 ]. Additionally, in all cases, an intra-articular injection of tranexamic acid (1.0 g in 10 ml normal saline) was systematically administered after arthrotomy closure for leakage testing and hemostatic purposes [ 14 ]. Postoperative treatment All patients received standardized postoperative management. Prophylactic antibiotics were administered intravenously before surgery and for 24 h postoperatively, including 1.5 g of cefuroxime, 1.0 g of cefazolin, or 0.6 g of clindamycin, depending on the patient’s allergy profile. Subcutaneous low-molecular-weight heparin (4000 IU) was administered daily for 14 days post-procedure. The incision was covered with sterile gauze, and the dressings were changed every two days during hospitalization. Postoperative analgesia was administered through patient-controlled analgesia (PCA) pumps, supplemented with non-steroidal anti-inflammatory drugs and/or opioid analgesics. Physiotherapy, which comprised ambulation and range of motion (ROM) exercises, commenced on the second postoperative day. Data collection Detailed demographic and perioperative data were obtained for all patients, encompassing age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status, operative duration, tourniquet time, closure time (defined as the duration from tourniquet deflation to the completion of skin closure, approximated as operative duration minus tourniquet time) [ 10 ], and length of hospital stay (LOS). Additionally, we recorded comorbidities associated with the risk of wound complications, including diabetes mellitus (DM), current smoking, chronic steroid use, cardiovascular disease, cerebrovascular disease, rheumatoid arthritis (RA), and post-transplant status [ 22 , 23 ]. We also measured the C-reactive protein to albumin ratio (CAR, calculated as [serum CPR (mg/L)/serum albumin (g/dL)]) [ 24 , 25 ] and the prognostic nutritional index (PNI, calculated as [10 × serum albumin (g/dL) + 0.005 × TCL (/mm 3 )]) [ 26 , 27 ]. Postoperative wound complications were reviewed and meticulously documented, including major complications such as periprosthetic joint infection (PJI) and revision, and minor complications such as wound dehiscence, effusion, superficial infection, cellulitis, or suture abscess. Knee Range of Motion (ROM) and Knee Society Score (KSS) [ 28 ] were assessed preoperatively and at 24 months postoperatively. Scar cosmesis was assessed with the Stone Brooks Scar Scale (SBSES) [ 29 ], which quantifies scar quality across five parameters: width (scores 0 for > 2 mm and 1 for ≤ 2 mm), height (scores 0 for raised or depressed relative to surrounding skin and 1 for flush with skin), color (scores 0 for darker than surrounding skin and 1 for same as or lighter than surrounding skin), presence of hatch or suture marks (scores 0 for present and 1 for absent), and overall appearance (scores 0 for poor and 1 for good). Statistical analysis Statistical analyses were conducted using SPSS software (version 25.0; IBM Corp., Armonk, NY, USA). The distribution of data was evaluated with the Shapiro–Wilk test. Continuous variables were compared using independent samples t-tests, analysis of variance, or the corresponding nonparametric tests (Mann–Whitney U or Kruskal–Wallis test), depending on their normality. Categorical variables were analyzed using the chi-square test or Fisher’s exact test, as appropriate. To identify risk factors for postoperative complications, univariate logistic regression was first performed. All variables associated with an increased risk of wound complications (p < 0.10) were subsequently entered stepwise into a multivariate logistic regression model. Statistical significance was defined as a two-tailed p-value < 0.05. Results The demographic characteristics and overall incidence of comorbidities were comparable across all four groups, with no statistically significant differences observed in age, sex, BMI, BMI ≥ 30 kg/mm², CAR, PNI, and comorbidities of patients (all P > 0.05) (Table 1 ). However, statistically significant differences were identified in ASA status, operative, tourniquet, and closure times, and length of stay (LOS) among the groups (all P < 0.05) (Table 1 ). Notably, the operative and closure times were significantly shorter in the barbed suture group compared to the other three groups ( P < 0.05) (Table 1 ). Table 1 Patient data for both groups. Patient factors Group A Group B Group C Group D P Demographics Total patients, n (%) 105 (26.99%) 90 (23.13%) 88 (22.62%) 106 (27.25%) - Age, y (SD) 67.44 ± 7.67 66.16 ± 7.47 66.85 ± 8.36 67.88 ± 7.41 0.440 a Gender Female, n (%) Male, n (%) 87 (82.86%) 18 (17.14%) 82 (91.11%) 8 (8.89%) 74 (84.09%) 14 (15.91%) 87 (82.08%) 19 (17.92%) 0.298 c BMI (SD) 26.22 ± 4.04 25.88 ± 3.52 25.57 ± 3.24 25.57 ± 3.73 0.782 b BMI ≥ 30 kg/mm² 13 (12.38%) 9 (10.00%) 10 (11.36%) 10 (9.43%) 0.926 c ASA, n (%) 1–2 3–4 48 (45.71%) 57 (54.29%) 41 (45.56%) 49 (54.44%) 55 (62.5%) 33 (37.5%) 76 (71.7%) 30 (28.3%) < 0.001 c CAR 1.36 ± 3.63 2.42 ± 5.14 1.62 ± 3.57 1.75 ± 3.23 0.068 b PNI 48.92 ± 5.12 48.35 ± 5.70 48.36 ± 4.42 48.38 ± 4.62 0.815 a Operative time, m (SD) 106.31 ± 9.41 * &$ 110.31 ± 17.01 #£ 117.36 ± 21.53 119.60 ± 25.94 < 0.001 b Tourniquet time, m (SD) 88.26 ± 8.98 &$ 90.79 ± 16.84 93.35 ± 21.28 94.65 ± 25.90 0.014 b Closure time, m (SD) 17.85 ± 3.08 * &$ 19.52 ± 1.60 #£ 23.99 ± 1.44 ð 24.95 ± 2.01 < 0.001 b LOS, d (SD) 14.48 ± 3.4120 &$ 14.27 ± 3.43 #£ 17.28 ± 4.33 ð 15.60 ± 4.42 < 0.001 b Comorbidities Diabetes mellitus, n (%) 18 (17.14%) 24 (26.67%) 14 (15.91%) 20 (18.87%) 0.255 c Current smoker, n (%) 9 (8.57%) 6 (6.67%) 7 (7.95%) 6 (5.66%) 0.843 c Chronic steroid use, n (%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) - Cardiovascular disease, n (%) 69 (65.71%) 60 (66.67%) 51 (57.95%) 65 (61.32%) 0.591 c Cerebrovascular disease, n (%) 7 (6.67%) 7 (7.78%) 8 (9.09%) 11 (10.38%) 0.788 c Table 1 (continue) Patient factors Group A Group B Group C Group D P Rheumatoid arthritis, n (%) 3 (2.86%) 4 (4.44%) 3 (3.41%) 3 (2.83%) 0.927 d Post-transplant, n (%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) - BIM, body mass index; ASA, American Society of Anesthesiologists; CAR, C-reactive protein to albumin ratio; PNI, prognostic nutritional index; LOS, length of hospital stay; PVD, peripheral vascular disease. a ANOVA; b Kruskal-Wallis test; c Chi-square test; d Fisher’s exact test. Mann-Whitney U test: * Group A vs. Group B, P < 0.05; & Group A vs. Group C, P < 0.01; $ Group A vs. Group D, P < 0.05; # Group B vs. Group C, P < 0.05; £ Group B vs. Group D, P < 0.05; ð Group C vs. Group D, P < 0.05. No statistically significant difference was noted in the overall incidence of major wound complications following TKA among the four groups ( P = 0.441) (Table 2 ). Four cases of periprosthetic joint infection (PJI) were identified, with one case each in Groups A and D and two cases in Group B. The incidence of PJI was comparable across the groups ( P = 0.686). All four affected patients required reoperation, which included irrigation, debridement, and revision arthroplasty (Table 2 ). The overall revision surgery rates among the groups were similar (Group A: 0.95%; Group B: 1.11%; Group C: 0%; Group D: 0.94%) ( P = 1.0) (Table 2 ). Table 2 Wound complications of study groups. Complications Group A Group B Group C Group D P Minor complications total, n (%) 4 (4.76%) * 6 (6.66%) $ 8 (9.09%) & 21 (19.81%) 0.001 a Dehiscence, n (%) 1 (0.95%) 2 (2.22%) 3 (3.41%) 5 (4.72%) 0.373 b Effusion, n (%) 2 (1.9%) 2 (2.22%) 3 (3.41%) 7 (6.6%) 0.294 b Superficial infection (combined), n (%) 1 (0.95%) 2 (2.22%) 2 (2.27%) 7 (6.6%) 0.140 b Cellulitis, n (%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) - Suture abscess, n (%) 1 (0.95%) 0 (0%) 0 (0%) 2 (1.89%) 0.625 a Major complications total, n (%) 2 (1.9%) 3 (3.33%) 0 (0%) 2 (1.89%) 0.441 a PJI, n (%) 1 (0.95%) 2 (2.22%) 0 (0%) 1 (0.94%) 0.686 a Revisions, n (%) 1 (0.95%) 1 (1.11%) 0 (0%) 1 (0.94%) 1.0 a PJI, periprosthetic joint infection; a Chi-square test; b Fisher’s exact test; * Group A vs. Group D, Chi-square test, P < 0.001; $ Group B vs. Group D, Chi-square test, P < 0.05; & Group C vs. Group D, Chi-square test, P < 0.05. In terms of minor wound complications, a statistically significant difference was observed in the overall rates between the groups ( P = 0.001). Although the overall incidence rates were comparable across Groups A (4.76%), B (6.66%), and C (9.09%), these groups demonstrated superiority over Group D (19.81%, all P 0.05); however, Groups A, B, and C exhibited lower incidence rates compared to Group D (Table 2 ). All cases were managed with local wound care and antibiotic therapy, with no patients requiring revision surgery. A comparison of the KSS scores, knee ROM, and cosmetic scores among the groups is presented in Table 3 . No significant differences were observed among the four groups in the preoperative and postoperative assessments of KSS and ROM; however, both groups exhibited significant improvements at 24 months postoperatively when compared to baseline ( P < 0.001). Furthermore, the four groups demonstrated clinically comparable cosmetic results, and the observed differences were not statistically significant ( P = 0.653). Table 3 Comparison of ROM, KSS, and cosmesis score between groups. Variable Group A Group B Group C Group D P KSS (SD) Per-operation 112.70 ± 4.99 112.40 ± 3.19 112.94 ± 3.48 112.32 ± 3.49 0.452 a Post-operation 158.29 ± 3.97* 157.89 ± 4.56* 157.24 ± 4.34* 157.24 ± 4.14* 0.185 a Total score improvement 45.58 ± 6.19 45.49 ± 5.31 44.30 ± 4.77 44.91 ± 5.78 0.491 a ROM (SD) Per-operation 93.67 ± 6.77 94.33 ± 5.91 94.43 ± 4.18 94.29 ± 5.09 0.642 a Post-operation 114.24 ± 5.32* 114.61 ± 5.96* 115.85 ± 4.10* 114.72 ± 6.17* 0.173 a Total range improvement 19.62 ± 11.96 20.28 ± 5.68 21.42 ± 4.54 20.43 ± 6.44 0.677 a Cosmesis score (SD) 3.14 ± 0.45 3.2 ± 0.67 3.19 ± 0.66 3.08 ± 0.76 0.653 a KSS, Knee Society Scores; ROM, range of motion; a Kruskal-Wallis test; * post-operation vs. pre-operation, Wilcoxon signed-rank test, P < 0.001. Univariate logistic regression analysis revealed several significant predictors of postoperative incision complications, including rheumatoid arthritis (RA) (0.030, 0.008–0.116, P < 0.001), cerebrovascular disease (0.259, 0.067–1.009, P = 0.052), operative time (1.047, 1.017–1.078, P = 0.002), tourniquet time (1.049, 1.016–1.082, P = 0.003), length of stay (LOS) (1.151, 1.003–1.320, P = 0.045), CAR (1.138, 1.059–1.223, P < 0.001), and PNI (0.882, 0.791–0.984, P = 0.025) (Table 4 ). Subsequently, multivariate analysis was conducted to further evaluate the impact of these seven risk factors on superficial wound infections. The results indicated that RA (0.021, 0.003–0.129, P < 0.001) and CAR (1.112, 1.011–1.222, P = 0.029) were identified as two significant independent predictors of the outcome (Table 4 ). Table 4 Logistic Regression Analysis for potential risk factors for incision complication in TKA. Risk factors Univariate Logistic Regression Multiple Logistic Regression Odds Ratio (95% CI) P-value Odds Ratio (95% CI) P-value Age 0.958 (0.889, 1.033) 0.263 Sex (male gender) 2.000 (0.253, 15.789) 0.511 BIM ≥ 30 kg/mm² 1.342 (0.169, 10.665) 0.781 ASA score ≥ 3 1.557 (0.461, 5.259) 0.476 Diabetes mellitus 1.221 (0.262, 5.692) 0.799 Current smoker 1.919 (0.243, 15.158) 0.536 Chronic steroid use Reference 0.999 Cardiovascular disease 2.453 (0.764, 7.876) 0.132 Cerebrovascular disease 0.259 (0.067, 1.009) 0.052 0.206 (0.036, 1.186) 0.077 Rheumatoid arthritis 0.030 (0.008, 0.116) < 0.001 0.021 (0.003, 0.129) < 0.001 Post-transplant Reference - Operative time 1.047 (1.017, 1.078) 0.002 1.227 (0.935, 1.610) 0.141 Tourniquet time 1.049 (1.016, 1.082) 0.003 0.848 (0.639, 1.127) 0.256 LOS 1.151 (1.003, 1.320) 0.045 1.099(0.938, 1.287) 0.242 Drain tube 0.326 (0.085, 1.259) 0.104 Blood transfusion Reference 0.999 CAR 1.138 (1.059, 1.223) < 0.001 1.112 (1.011, 1.222) 0.029 PNI 0.882 (0.791, 0.984) 0.025 1.010 (0.865, 1.180) 0.896 BIM, body mass index; ASA, American Society of Anesthesiologists; LOS, length of hospital stay; CAR, C-reactive protein to albumin ratio; PNI, prognostic nutritional index. Discussion Successful outcomes of knee arthroplasty are contingent upon the quality of wound closure [ 1 ], necessitating the optimization of suture techniques. Barbed sutures, a widely used method for expeditious wound closure, are distinguished by fine barbs evenly distributed along their surface. This self-anchoring design maintains tissue tension, prevents retraction, and eliminates the need for knotting once the suture is placed [ 30 , 31 ]. Additionally, it exhibits enhanced stability [ 32 ] and waterproof properties [ 33 , 34 ], while improving the approximation of the soft tissue edge. These features reduce the risk of knotless wound dehiscence and contribute to improved scar outcomes [ 35 ]. However, the utility of barbed sutures for full-thickness closure without staples or an advanced closure system in total knee arthroplasty has been scarcely investigated, with only two studies available, and their findings remain inconsistent [ 19 , 20 ]. Further validation of the safety of using barbed sutures for full-thickness closure in TKA is warranted. The present study suggests that barbed sutures may represent a viable alternative to conventional sutures for incision closure in TKA. The use of barbed suture was not associated with an increase incidence of major or minor wound complications (Table 2 ), which aligns with findings from previously published literature [ 11 , 13 – 18 , 20 ]. Notably, a statistically significant difference was observed in the overall incidence of minor wound complications among the groups ( P = 0.001). When superficial complications were classified by type, superficial infection, wound dehiscence, and effusion were found to be comparable between the groups (all P > 0.05). However, Groups A, B, and C exhibited lower incidence rates than Group D (Table 2 ). These findings align with those of prior studies [ 14 , 36 ]. In terms of major complications, no statistically significant differences were observed between the groups in the incidence of major wound complications, including PJI ( P = 0.686) and revision procedures ( P = 1.0). In this study, only four patients developed PJI: one in Group A, two in Group B, and one in Group D (Table 2 ). These rates are comparable to the previously reported incidence of PJI following TKA (0.72%) [ 37 ]. Furthermore, the frequency of revision procedures performed for PJI is consistent with, or slightly lower than, the incidences documented in the literature, which range from 0.97% to 5% [ 38 , 39 ]. These findings indicate that barbed sutures can be safely employed for full-thickness closure during TKA. We hypothesized that these differences may be attributed to the characteristics of the sutures used in this study. Barbed sutures employ barbs to grasp and secure tissues together, maintaining approximation and tension at the tissue edges, which helps prevent dehiscence and reduce fluid exudation. Moreover, the use of barbed sutures facilitates efficient incision closure, decreases operative duration and intraoperative blood loss, and shortens tourniquet duration. These advantages contribute to alleviating periarticular ischemia and hypoxia, improving soft tissue immunity, and thereby lowering the risk of wound infections [ 4 , 11 , 40 – 42 ]. In contrast, Vicryl sutures used in the running suture technique cause the entire suture line to function as a cohesive unit. With this closure method, the structural integrity of the entire wound may be compromised in the event of suture failure or knot loosening, potentially leading to dehiscence [ 19 , 36 ]. Furthermore, inadequate suturing may result in insufficient tissue approximation, leading to an imbalance in soft tissue tension, formation of dead space, and accumulation of hematomas and seromas, which can ultimately culminate in wound dehiscence and effusion [ 43 , 44 ]. Additionally, an inflammatory reaction triggered by the absorption of the knot may further increase the risk of SSI [ 4 ]. Notably, our findings indicated that Group C, which utilized barbed sutures for joint capsule closure, was observed to have a lower major complication rate (0%) and a significantly reduced incidence of minor complications (9.09%, P < 0.05) than Group D. These results align with previously published studies [ 1 , 4 , 10 , 11 ], indicating that barbed sutures for joint capsule closure are not associated with higher complication rates than conventional sutures. However, Group B (subcutaneous closure with barbed sutures) showed a higher incidence of major complications (3.33%) than Group C, while maintaining comparable rates to Group D (1.89%, P > 0.05). Furthermore, despite the similar overall wound complication rates observed in Groups C and A, Group A (full-thickness closure) demonstrated a higher major complication rate (1.9%), which was comparable to Group B (3.33%, P > 0.05). These findings suggest that employing barbed sutures for the closure of subcutaneous or adipose tissue may increase the risk of infectious complications, consistent with the existing literature [ 4 , 19 ]. The underlying mechanism may involve excessive tension and cutting action of barbed sutures during postoperative joint mobilization, potentially leading to ischemic necrosis of the subcutaneous tissues and subsequent infection [ 19 , 45 ]. Further research is necessary to clarify the safety profile of barbed sutures in subcutaneous and adipose tissue layers. Previous studies have identified the duration of surgery as a potential risk factor for SSI following total knee arthroplasty [ 46 – 48 ]. Similarly, Namba et al. [ 37 ] demonstrated that longer operative times correlate with an elevated risk of deep SSI in TKA, with each 15-minute increment corresponding to a 9% rise in risk. Extended surgical time is associated with prolonged exposure of the operative field [ 49 ] and the application of a tourniquet, which may result in local hypoxia, vascular damage, and subsequent adipocyte necrosis, thereby increasing the risk of infection [ 4 , 23 , 50 ]. Of note, most studies have reported that the use of barbed sutures is associated with a reduction in wound closure time by approximately 3 to 12 minutes [ 4 , 10 , 11 , 13 , 14 , 17 – 20 , 51 ]. Theoretically, their use simplifies surgical procedures, improves blood flow, and consequently reduces the risk of infection. Consistent with previous studies, we observed that barbed sutures were associated with a significant reduction in suture, operative, and tourniquet times (Table 1 ), along with a decreased incidence of superficial wound infections (Table 2 ). However, related studies have indicated that the use of barbed sutures for full-thickness closure may elevate the risk of superficial infections [ 4 , 19 ]. It has been hypothesized that these sutures might strangulate the vascular supply, compromise adequate tissue repair, and potentially lead to necrosis and chronic wound infection. Furthermore, the design of sutures may increase their susceptibility to infection. Nevertheless, these mechanisms remain unvalidated in vivo. Our study conducted a comprehensive investigation into risk factors for superficial wound infections, focusing on comorbidities and perioperative indices previously linked to wound complications. These factors included elevated BMI, DM, RA, higher ASA scores [ 22 , 23 , 37 , 52 – 54 ], as well as prolonged operative duration [ 46 – 48 ] and tourniquet time [ 23 , 55 , 56 ]. Additionally, we incorporated CAR [ 24 , 25 ] and PNI [ 57 ], which are predictive markers for PJI or postoperative wound complications in TKA, into our analysis. Univariate analysis indicated that RA, cerebrovascular disease, operative duration, tourniquet time, length of stay (LOS), CAR, and PNI were significantly correlated with an increased risk of superficial wound infection (Table 4 ). In the multivariate logistic regression analysis, only RA and CAR emerged as independent predictors of infection (Table 4 ), consistent with previous reports [ 23 , 39 , 57 ]. It is worth noting that the broad confidence intervals observed for several patient factors suggest a potential limitation in the statistical power to detect associations. Additionally, the baseline prevalence of certain comorbidities conventionally associated with infection was relatively low in this cohort. This lower prevalence may explain the lack of statistical significance observed for specific established risk factors, such as smoking and DM, within our model. Furthermore, among obese patients undergoing TKA, factors such as prolonged incisions, extended operative duration, procedural complexity, and compromised subcutaneous vascularization may contribute to the risk of complications [ 22 , 58 ]. In the present study, a higher percentage of patients in the barbed suture group (12.38%) had a BMI ≥ 30 kg/m² [ 53 , 59 ], which might theoretically elevate the risk of complications within this cohort. Additionally, the proportion of patients classified as ASA ≥ 3 was greater in the barbed group (54.29%), a classification conventionally linked to an increased risk of complications [ 52 ]. While these observations might theoretically imply a heightened risk of complications, the lack of a corresponding increase in actual complication rates supports the safety profile of barbed sutures in TKA. Moreover, rigorous preoperative glycemic management for diabetic patients in this cohort may mitigate their increased risk of infection. In terms of functional outcomes, although no statistically significant differences were noted between the groups in preoperative or postoperative assessments ( P > 0.05), both the Knee Society Score (KSS) and knee ROM demonstrated significant improvements in both groups at 24 months postoperatively compared to baseline (all P 0.05) (Table 3 ). Consistent with our findings, Gililland et al. [ 10 ] reported no significant difference in cosmetic outcomes between barbed and traditional sutures. Similarly, Ting et al. [ 1 ] found that the cosmetic effect of barbed sutures was equivalent to that of conventional sutures. This result may be explained by the practice of performing skin closure with the knee flexed at 90°. By minimizing suture tension during postoperative rehabilitation, this technique likely helped to mitigate the risk of infection secondary to ischemia. Furthermore, continuous subcuticular closure facilitates optimal physiological blood flow, promoting wound healing [ 60 ] and achieving an aesthetically pleasing result. There are several limitations to this study that should be noted. First, the retrospective nature of the design inherently implies a potential for selection bias. Second, although our dataset was larger than those in many previous studies, the statistical power to detect rare adverse events remained constrained. Specifically, the overall low incidence of infections, coupled with the low prevalence of certain comorbidities, resulted in wide confidence intervals, which suggests that caution is warranted regarding the precision of these estimates. Third, our use of unidirectional barbed sutures differs from the bidirectional sutures employed in other studies [ 4 , 19 ]; this divergence may limit the direct comparability of our results. Finally, the currently available data did not permit the differentiation of infectious mechanisms based on the specific level of wound closure. In conclusion, the results of this study indicated that barbed sutures were associated with comparable rates of major wound complications and a significantly lower incidence of minor wound complications compared to Vicryl sutures in TKA incision closure. When used for full-thickness wound closure, barbed sutures appeared to correlate with fewer superficial wound complications, reduced closure time, and cosmetic outcomes equivalent to those achieved with conventional methods. These findings suggest that barbed sutures may represent a viable alternative for incision closure in TKA. However, caution is advised when considering their use in subcutaneous and adipose tissue, and further research is necessary to clarify their safety profile within these anatomical layers. For superficial skin closure, the adjunctive use of staples or skin adhesives alongside conventional sutures may be considered. Additionally, it is advisable to conduct​ a comprehensive preoperative assessment of inflammatory markers and comorbidities to help mitigate potential surgical risks. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the Fourth Affiliated Hospital of Guangxi Medical University (ethics approval number: KY2025651). Written informed consent was obtained from all patients. This retrospective cohort study involving human participants was conducted in strict accordance with the ethical principles outlined in the World Medical Association (WMA) Declaration of Helsinki (adopted at the 18th WMA General Assembly, Helsinki, Finland, June 1964, and amended at the 75th WMA General Assembly, Helsinki, Finland, October 2024). Consent for publication Not applicable. Competing interests The authors declare no conflicts of interest. Funding The authors thank the study funded by the First Affiliated Hospital of Guangxi Medical University Innovation Team Cultivation Program (Grant Number: YYZS2023004), the Guangxi Natural Science Foundation (Grant Number: 2025GXNSFAA069791), the Key Project of the Guangxi Science and Technology Department (Grant Number: AB22080096), the Liuzhou Science and Technology Project (Grant Number: 2024RA0102A001, 2024SB0104E001). Author Contribution ZH, YP, JM and QL gathered the data. ZH, JM, HL and GL performed data analyses. ZH and JY drafted the manuscript. HL, GL, and JY critically revised the manuscript for intellectual content. All the authors have reviewed the manuscript. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Ting NT, Moric MM, Della Valle CJ, Levine BR. Use of knotless suture for closure of total hip and knee arthroplasties. J Arthroplasty. 2012;27:1783–8. https://doi.org/10.1016/j.arth.2012.05.022 . Krebs VE, Elmallah RK, Khlopas A, Chughtai M, Bonutti PM, Roche M, et al. Wound closure techniques for total knee arthroplasty: An evidence-based review of the literature. J Arthroplast. 2018;33:633–8. https://doi.org/10.1016/j.arth.2017.09.032 . Campbell AL, Patrick DA, Liabaud B, Geller JA. Superficial wound closure complications with barbed sutures following knee arthroplasty. J Arthroplast. 2014;29:966–9. https://doi.org/10.1016/j.arth.2013.09.045 . 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J Bone Joint Surg Am. 2012;94:e101. https://doi.org/10.2106/JBJS.J.01935 . Butt U, Ahmad R, Aspros D, Bannister GC. Factors affecting wound ooze in total knee replacement. Ann R Coll Surg Engl. 2011;93:54–6. https://doi.org/10.1308/003588410X12771863937124 . Olivecrona C, Lapidus LJ, Benson L, Blomfeldt R. Tourniquet time affects postoperative complications after knee arthroplasty. Int Orthop. 2013;37:827–32. https://doi.org/10.1007/s00264-013-1826-4 . Karlidag T, Bingol O, Keskin OH, Durgal A, Yagbasan B, Ozdemir G. C-reactive protein to albumin ratio and prognostic nutrition index as a predictor of periprosthetic joint infection and early postoperative wound complications in patients undergoing primary total hip and knee arthroplasty. Diagnostics. 2025;15:2230. https://doi.org/10.3390/diagnostics15172230 . Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. 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15:02:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1088703,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8561219/v1/8e22404a-e917-456a-8fa5-4ae6af6d31c0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effect of Absorbable Knotless Barbed Suture on Total Knee Arthroplasty Incision Closure: A Retrospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClosure techniques following total joint arthroplasty (TJA) exert both immediate and long-term effects on surgical efficiency, wound healing, morbidity, and patient satisfaction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Meticulous incision closure in total knee arthroplasty (TKA) is essential for withstanding incision tension, promoting optimal cutaneous healing, achieving cosmetically favorable scars, and reducing postoperative complications [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, inadequate suturing techniques can compromise wound healing and elevate the risk of surgical site infection (SSI) or periprosthetic joint infection (PJI) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], which remains the most destructive and feared complication following TKA [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterrupted sutures have traditionally been the standard technique for incision closure in TKA. However, tying multiple knots is time-consuming and may adversely affect tissue healing by causing tissue overlap and impeding fibroblast proliferation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Furthermore, the resulting bulky suture knots may serve as potential niduses for infection [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], provoking inflammatory responses and resulting in SSI. Barbed sutures, characterized by their knotless and self-anchoring properties, demonstrate superior elasticity and high tensile strength, facilitating tissue tension distribution and enhancing wound closure efficiency [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Previous studies have reported that barbed sutures in TKA can significantly reduce costs, shorten suture time, and do not increase the rate of wound complications [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In most of these reports, barbed sutures were employed for the closure of the arthrotomy and/or subcutaneous layers or were restricted to the subcuticular layer only. However, few have applied barbed sutures for full-thickness closure without adjuncts, such as staples or advanced closure systems, and the reported outcomes regarding wound complications remain inconsistent [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This inconsistency complicates the assessment of their efficacy in full-thickness wound closure during TKA.\u003c/p\u003e \u003cp\u003eTherefore, we conducted a single-center retrospective study to investigate whether the application of barbed sutures for full-thickness incision closure in TKA results in comparable or lower rates of postoperative complications than running coated Vicryl Plus antibacterial sutures without the application of staples and skin adhesive.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003e This retrospective cohort study was conducted following approval from the Ethics Committee of the Fourth Affiliated Hospital of Guangxi Medical University (ethics approval number: KY2025661), and informed consent was obtained from all enrolled patients. All procedures adhered to the ethical standards set forth in the Declaration of Helsinki and its subsequent amendments. Consecutive patients diagnosed with knee osteoarthritis (KOA) who underwent primary unilateral TKA at the same medical institution between January 2020 and September 2023 were enrolled.\u003c/p\u003e \u003cp\u003eThe inclusion criteria consisted of (1) patients aged 18 to 79 years who underwent primary unilateral total knee arthroplasty, with incision closure performed using either barbed sutures or coated Vicryl Plus antibacterial sutures; (2) completion of a 24-month follow-up period. The exclusion criteria were revision or unicompartmental knee arthroplasty, bilateral procedures, and insufficient follow-up or incomplete medical records.\u003c/p\u003e \u003cp\u003eDuring the reporting period, 426 cases involving primary unilateral TKA were reviewed. Among them, 20 patients were excluded due to inadequate follow-up, 8 due to undergoing bilateral TKA, and 9 due to incomplete medical records. Ultimately, 389 patients meeting the inclusion criteria were enrolled and stratified into four groups.\u003c/p\u003e \u003cp\u003eGroup A (n\u0026thinsp;=\u0026thinsp;105): The joint capsule (Stratafix 1\u0026thinsp;\u0026minus;\u0026thinsp;0), subcutaneous tissue (Stratafix 2\u0026thinsp;\u0026minus;\u0026thinsp;0), and intradermal tissue (Stratafix 4\u0026thinsp;\u0026minus;\u0026thinsp;0) were sutured using an absorbable, knotless barbed suture (Ethicon Stratafix symmetric PDS plus knotless tissue control device). Four to five additional sutures were placed to prevent suture slippage and wound dehiscence.\u003c/p\u003e \u003cp\u003eGroup B (n\u0026thinsp;=\u0026thinsp;90): The joint capsule (Stratafix 1\u0026thinsp;\u0026minus;\u0026thinsp;0) and subcutaneous tissue (Stratafix 2\u0026thinsp;\u0026minus;\u0026thinsp;0) were closed with a barbed suture, and the intradermal tissue (Ethicon VICRYL plus 4\u0026thinsp;\u0026minus;\u0026thinsp;0) was closed using an absorbable suture.\u003c/p\u003e \u003cp\u003eGroup C (n\u0026thinsp;=\u0026thinsp;88): The joint capsule was sutured with a barbed suture (Stratafix 1\u0026thinsp;\u0026minus;\u0026thinsp;0), and the subcutaneous (Ethicon VICRYL plus 2\u0026thinsp;\u0026minus;\u0026thinsp;0) and intradermal (Ethicon VICRYL plus 4\u0026thinsp;\u0026minus;\u0026thinsp;0) were sutured with an absorbable suture.\u003c/p\u003e \u003cp\u003eGroup D (n\u0026thinsp;=\u0026thinsp;106): The joint capsule (Ethicon VICRYL plus 1\u0026thinsp;\u0026minus;\u0026thinsp;0), subcutaneous tissue (Ethicon VICRYL plus 2\u0026thinsp;\u0026minus;\u0026thinsp;0), and intradermal tissue (Ethicon VICRYL plus 4\u0026thinsp;\u0026minus;\u0026thinsp;0) were approximated using a coated Vicryl Plus antibacterial suture.\u003c/p\u003e \u003cp\u003eThis specific grouping was selected to investigate the impact of barbed sutures at varying tissue depths, facilitating a detailed analysis of their safety and efficacy when applied to Group A (full-thickness closure), Group B (capsular and subcutaneous closure), and Group C (capsular closure only) in comparison to conventional closure (Group D).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical procedure\u003c/h3\u003e\n\u003cp\u003eThe medial parapatellar approach [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] was employed in every instance. A tourniquet was applied during each procedure, inflated at incision, and deflated prior to closure. Following the implantation of all prosthetic components, a solution of tranexamic acid (1.0 g tranexamic acid mixed with 100 ml normal saline) was administered intravenously before the release of the tourniquet to facilitate hemostasis. Incision closure was conducted with the knee flexed at 45\u0026deg; to 90\u0026deg; [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, in all cases, an intra-articular injection of tranexamic acid (1.0 g in 10 ml normal saline) was systematically administered after arthrotomy closure for leakage testing and hemostatic purposes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003ePostoperative treatment\u003c/h3\u003e\n\u003cp\u003eAll patients received standardized postoperative management. Prophylactic antibiotics were administered intravenously before surgery and for 24 h postoperatively, including 1.5 g of cefuroxime, 1.0 g of cefazolin, or 0.6 g of clindamycin, depending on the patient\u0026rsquo;s allergy profile. Subcutaneous low-molecular-weight heparin (4000 IU) was administered daily for 14 days post-procedure. The incision was covered with sterile gauze, and the dressings were changed every two days during hospitalization. Postoperative analgesia was administered through patient-controlled analgesia (PCA) pumps, supplemented with non-steroidal anti-inflammatory drugs and/or opioid analgesics. Physiotherapy, which comprised ambulation and range of motion (ROM) exercises, commenced on the second postoperative day.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eDetailed demographic and perioperative data were obtained for all patients, encompassing age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status, operative duration, tourniquet time, closure time (defined as the duration from tourniquet deflation to the completion of skin closure, approximated as operative duration minus tourniquet time) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and length of hospital stay (LOS). Additionally, we recorded comorbidities associated with the risk of wound complications, including diabetes mellitus (DM), current smoking, chronic steroid use, cardiovascular disease, cerebrovascular disease, rheumatoid arthritis (RA), and post-transplant status [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. We also measured the C-reactive protein to albumin ratio (CAR, calculated as [serum CPR (mg/L)/serum albumin (g/dL)]) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and the prognostic nutritional index (PNI, calculated as [10 \u0026times; serum albumin (g/dL)\u0026thinsp;+\u0026thinsp;0.005 \u0026times; TCL (/mm\u003csup\u003e3\u003c/sup\u003e)]) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePostoperative wound complications were reviewed and meticulously documented, including major complications such as periprosthetic joint infection (PJI) and revision, and minor complications such as wound dehiscence, effusion, superficial infection, cellulitis, or suture abscess. Knee Range of Motion (ROM) and Knee Society Score (KSS) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] were assessed preoperatively and at 24 months postoperatively. Scar cosmesis was assessed with the Stone Brooks Scar Scale (SBSES) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], which quantifies scar quality across five parameters: width (scores 0 for \u0026gt;\u0026thinsp;2 mm and 1 for \u0026le;\u0026thinsp;2 mm), height (scores 0 for raised or depressed relative to surrounding skin and 1 for flush with skin), color (scores 0 for darker than surrounding skin and 1 for same as or lighter than surrounding skin), presence of hatch or suture marks (scores 0 for present and 1 for absent), and overall appearance (scores 0 for poor and 1 for good).\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were conducted using SPSS software (version 25.0; IBM Corp., Armonk, NY, USA). The distribution of data was evaluated with the Shapiro\u0026ndash;Wilk test. Continuous variables were compared using independent samples t-tests, analysis of variance, or the corresponding nonparametric tests (Mann\u0026ndash;Whitney U or Kruskal\u0026ndash;Wallis test), depending on their normality. Categorical variables were analyzed using the chi-square test or Fisher\u0026rsquo;s exact test, as appropriate. To identify risk factors for postoperative complications, univariate logistic regression was first performed. All variables associated with an increased risk of wound complications (p\u0026thinsp;\u0026lt;\u0026thinsp;0.10) were subsequently entered stepwise into a multivariate logistic regression model. Statistical significance was defined as a two-tailed p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographic characteristics and overall incidence of comorbidities were comparable across all four groups, with no statistically significant differences observed in age, sex, BMI, BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/mm\u0026sup2;, CAR, PNI, and comorbidities of patients (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). However, statistically significant differences were identified in ASA status, operative, tourniquet, and closure times, and length of stay (LOS) among the groups (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Notably, the operative and closure times were significantly shorter in the barbed suture group compared to the other three groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" 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\u003ePatient data for both groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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=\"left\" 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=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup D\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal patients, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (26.99%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90 (23.13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88 (22.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e106 (27.25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, y (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.44\u0026thinsp;\u0026plusmn;\u0026thinsp;7.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.16\u0026thinsp;\u0026plusmn;\u0026thinsp;7.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.85\u0026thinsp;\u0026plusmn;\u0026thinsp;8.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.88\u0026thinsp;\u0026plusmn;\u0026thinsp;7.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.440\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eFemale, n (%)\u003c/p\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (82.86%)\u003c/p\u003e \u003cp\u003e18 (17.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82 (91.11%)\u003c/p\u003e \u003cp\u003e8 (8.89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74 (84.09%)\u003c/p\u003e \u003cp\u003e14 (15.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87 (82.08%)\u003c/p\u003e \u003cp\u003e19 (17.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.298\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.88\u0026thinsp;\u0026plusmn;\u0026thinsp;3.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.57\u0026thinsp;\u0026plusmn;\u0026thinsp;3.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.57\u0026thinsp;\u0026plusmn;\u0026thinsp;3.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.782\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/mm\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (12.38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (10.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (11.36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (9.43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.926 \u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA, n (%)\u003c/p\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (45.71%)\u003c/p\u003e \u003cp\u003e57 (54.29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (45.56%)\u003c/p\u003e \u003cp\u003e49 (54.44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (62.5%)\u003c/p\u003e \u003cp\u003e33 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76 (71.7%)\u003c/p\u003e \u003cp\u003e30 (28.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.36\u0026thinsp;\u0026plusmn;\u0026thinsp;3.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.42\u0026thinsp;\u0026plusmn;\u0026thinsp;5.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.068\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.92\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.35\u0026thinsp;\u0026plusmn;\u0026thinsp;5.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.36\u0026thinsp;\u0026plusmn;\u0026thinsp;4.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.38\u0026thinsp;\u0026plusmn;\u0026thinsp;4.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.815\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time, m (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106.31\u0026thinsp;\u0026plusmn;\u0026thinsp;9.41\u003cb\u003e*\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026amp;$\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110.31\u0026thinsp;\u0026plusmn;\u0026thinsp;17.01\u003csup\u003e\u003cb\u003e#\u0026pound;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117.36\u0026thinsp;\u0026plusmn;\u0026thinsp;21.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e119.60\u0026thinsp;\u0026plusmn;\u0026thinsp;25.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTourniquet time, m (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.26\u0026thinsp;\u0026plusmn;\u0026thinsp;8.98\u003csup\u003e\u003cb\u003e\u0026amp;$\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.79\u0026thinsp;\u0026plusmn;\u0026thinsp;16.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93.35\u0026thinsp;\u0026plusmn;\u0026thinsp;21.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94.65\u0026thinsp;\u0026plusmn;\u0026thinsp;25.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.014\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClosure time, m (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08\u003cb\u003e*\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026amp;$\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60\u003csup\u003e\u003cb\u003e#\u0026pound;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.99\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003csup\u003e\u003cb\u003e\u0026eth;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.95\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLOS, d (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.48\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4120\u003csup\u003e\u003cb\u003e\u0026amp;$\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43\u003csup\u003e\u003cb\u003e#\u0026pound;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.28\u0026thinsp;\u0026plusmn;\u0026thinsp;4.33\u003csup\u003e\u003cb\u003e\u0026eth;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.60\u0026thinsp;\u0026plusmn;\u0026thinsp;4.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (17.14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (26.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (15.91%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 (18.87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.255\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smoker, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (8.57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (7.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (5.66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.843\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic steroid use, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular disease, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (65.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (66.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51 (57.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65 (61.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.591\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular disease, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7.78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (9.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (10.38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.788\u003csup\u003e\u003cb\u003ec\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e(continue)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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=\"left\" 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=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup D\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRheumatoid arthritis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (4.44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (2.83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.927\u003csup\u003e\u003cb\u003ed\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-transplant, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBIM, body mass index; ASA, American Society of Anesthesiologists; CAR, C-reactive protein to albumin ratio; PNI, prognostic nutritional index; LOS, length of hospital stay; PVD, peripheral vascular disease.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e ANOVA; \u003csup\u003eb\u003c/sup\u003e Kruskal-Wallis test; \u003csup\u003ec\u003c/sup\u003e Chi-square test; \u003csup\u003ed\u003c/sup\u003e Fisher\u0026rsquo;s exact test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eMann-Whitney U test: * Group A vs. Group B, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e\u0026amp;\u003c/sup\u003e Group A vs. Group C, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01; \u003csup\u003e$\u003c/sup\u003e Group A vs. Group D, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e\u003cb\u003e#\u003c/b\u003e\u003c/sup\u003e Group B vs. Group C, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e\u003cb\u003e\u0026pound;\u003c/b\u003e\u003c/sup\u003e Group B vs. Group D, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e\u003cb\u003e\u0026eth;\u003c/b\u003e\u003c/sup\u003e Group C vs. Group D, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNo statistically significant difference was noted in the overall incidence of major wound complications following TKA among the four groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.441) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Four cases of periprosthetic joint infection (PJI) were identified, with one case each in Groups A and D and two cases in Group B. The incidence of PJI was comparable across the groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.686). All four affected patients required reoperation, which included irrigation, debridement, and revision arthroplasty (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The overall revision surgery rates among the groups were similar (Group A: 0.95%; Group B: 1.11%; Group C: 0%; Group D: 0.94%) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.0) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWound complications of study groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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=\"left\" 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=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup D\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinor complications total, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4.76%) \u003cb\u003e*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6.66%) \u003csup\u003e\u003cb\u003e$\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (9.09%) \u003csup\u003e\u003cb\u003e\u0026amp;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (19.81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDehiscence, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (4.72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.373\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffusion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.294\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperficial infection (combined), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2.27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.140\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCellulitis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuture abscess, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (1.89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.625\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor complications total, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (1.89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.441\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePJI, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (0.94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.686\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevisions, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (0.94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0 \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003ePJI, periprosthetic joint infection; \u003csup\u003ea\u003c/sup\u003e Chi-square test; \u003csup\u003eb\u003c/sup\u003e Fisher\u0026rsquo;s exact test; * Group A vs. Group D, Chi-square test, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; \u003csup\u003e$\u003c/sup\u003e Group B vs. Group D, Chi-square test, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e\u0026amp;\u003c/sup\u003e Group C vs. Group D, Chi-square test, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn terms of minor wound complications, a statistically significant difference was observed in the overall rates between the groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). Although the overall incidence rates were comparable across Groups A (4.76%), B (6.66%), and C (9.09%), these groups demonstrated superiority over Group D (19.81%, all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). When minor complications were stratified by specific types, no significant differences were noted in superficial infection, effusion, and wound dehiscence among the groups (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05); however, Groups A, B, and C exhibited lower incidence rates compared to Group D (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). All cases were managed with local wound care and antibiotic therapy, with no patients requiring revision surgery.\u003c/p\u003e \u003cp\u003eA comparison of the KSS scores, knee ROM, and cosmetic scores among the groups is presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e. No significant differences were observed among the four groups in the preoperative and postoperative assessments of KSS and ROM; however, both groups exhibited significant improvements at 24 months postoperatively when compared to baseline (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, the four groups demonstrated clinically comparable cosmetic results, and the observed differences were not statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.653).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of ROM, KSS, and cosmesis score between groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" 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=\"left\" 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=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup C\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup D\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eKSS (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePer-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e112.70\u0026thinsp;\u0026plusmn;\u0026thinsp;4.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e112.32\u0026thinsp;\u0026plusmn;\u0026thinsp;3.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.452\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e158.29\u0026thinsp;\u0026plusmn;\u0026thinsp;3.97*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e157.89\u0026thinsp;\u0026plusmn;\u0026thinsp;4.56*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e157.24\u0026thinsp;\u0026plusmn;\u0026thinsp;4.34*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e157.24\u0026thinsp;\u0026plusmn;\u0026thinsp;4.14*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.185\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e45.58\u0026thinsp;\u0026plusmn;\u0026thinsp;6.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.49\u0026thinsp;\u0026plusmn;\u0026thinsp;5.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.30\u0026thinsp;\u0026plusmn;\u0026thinsp;4.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44.91\u0026thinsp;\u0026plusmn;\u0026thinsp;5.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.491\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eROM (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePer-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e93.67\u0026thinsp;\u0026plusmn;\u0026thinsp;6.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.43\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94.29\u0026thinsp;\u0026plusmn;\u0026thinsp;5.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.642\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e114.24\u0026thinsp;\u0026plusmn;\u0026thinsp;5.32*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114.61\u0026thinsp;\u0026plusmn;\u0026thinsp;5.96*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115.85\u0026thinsp;\u0026plusmn;\u0026thinsp;4.10*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e114.72\u0026thinsp;\u0026plusmn;\u0026thinsp;6.17*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.173\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal range improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e19.62\u0026thinsp;\u0026plusmn;\u0026thinsp;11.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.28\u0026thinsp;\u0026plusmn;\u0026thinsp;5.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.42\u0026thinsp;\u0026plusmn;\u0026thinsp;4.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.43\u0026thinsp;\u0026plusmn;\u0026thinsp;6.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.677\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCosmesis score (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.653\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eKSS, Knee Society Scores; ROM, range of motion; \u003csup\u003ea\u003c/sup\u003e Kruskal-Wallis test; * post-operation vs. pre-operation, Wilcoxon signed-rank test, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUnivariate logistic regression analysis revealed several significant predictors of postoperative incision complications, including rheumatoid arthritis (RA) (0.030, 0.008\u0026ndash;0.116, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), cerebrovascular disease (0.259, 0.067\u0026ndash;1.009, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.052), operative time (1.047, 1.017\u0026ndash;1.078, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), tourniquet time (1.049, 1.016\u0026ndash;1.082, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), length of stay (LOS) (1.151, 1.003\u0026ndash;1.320, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045), CAR (1.138, 1.059\u0026ndash;1.223, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and PNI (0.882, 0.791\u0026ndash;0.984, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Subsequently, multivariate analysis was conducted to further evaluate the impact of these seven risk factors on superficial wound infections. The results indicated that RA (0.021, 0.003\u0026ndash;0.129, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and CAR (1.112, 1.011\u0026ndash;1.222, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029) were identified as two significant independent predictors of the outcome (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic Regression Analysis for potential risk factors for incision complication in TKA.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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=\"left\" 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=\"left\" 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=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRisk factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariate Logistic Regression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003eMultiple Logistic Regression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds Ratio (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eOdds Ratio (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.958 (0.889, 1.033)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male gender)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.000 (0.253, 15.789)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.511\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"16\" rowspan=\"17\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBIM\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/mm\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.342 (0.169, 10.665)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.781\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA score\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.557 (0.461, 5.259)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.476\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.221 (0.262, 5.692)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.799\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.919 (0.243, 15.158)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.536\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic steroid use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.453 (0.764, 7.876)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.259 (0.067, 1.009)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.206 (0.036, 1.186)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRheumatoid arthritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.030 (0.008, 0.116)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.021 (0.003, 0.129)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-transplant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.047 (1.017, 1.078)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.227 (0.935, 1.610)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTourniquet time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.049 (1.016, 1.082)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.848 (0.639, 1.127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.151 (1.003, 1.320)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.099(0.938, 1.287)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrain tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.326 (0.085, 1.259)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.138 (1.059, 1.223)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.112 (1.011, 1.222)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.882 (0.791, 0.984)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.010 (0.865, 1.180)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.896\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eBIM, body mass index; ASA, American Society of Anesthesiologists; LOS, length of hospital stay; CAR, C-reactive protein to albumin ratio; PNI, prognostic nutritional index.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSuccessful outcomes of knee arthroplasty are contingent upon the quality of wound closure [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], necessitating the optimization of suture techniques. Barbed sutures, a widely used method for expeditious wound closure, are distinguished by fine barbs evenly distributed along their surface. This self-anchoring design maintains tissue tension, prevents retraction, and eliminates the need for knotting once the suture is placed [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Additionally, it exhibits enhanced stability [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and waterproof properties [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], while improving the approximation of the soft tissue edge. These features reduce the risk of knotless wound dehiscence and contribute to improved scar outcomes [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. However, the utility of barbed sutures for full-thickness closure without staples or an advanced closure system in total knee arthroplasty has been scarcely investigated, with only two studies available, and their findings remain inconsistent [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Further validation of the safety of using barbed sutures for full-thickness closure in TKA is warranted.\u003c/p\u003e \u003cp\u003eThe present study suggests that barbed sutures may represent a viable alternative to conventional sutures for incision closure in TKA. The use of barbed suture was not associated with an increase incidence of major or minor wound complications (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e), which aligns with findings from previously published literature [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Notably, a statistically significant difference was observed in the overall incidence of minor wound complications among the groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). When superficial complications were classified by type, superficial infection, wound dehiscence, and effusion were found to be comparable between the groups (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, Groups A, B, and C exhibited lower incidence rates than Group D (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These findings align with those of prior studies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In terms of major complications, no statistically significant differences were observed between the groups in the incidence of major wound complications, including PJI (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.686) and revision procedures (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.0). In this study, only four patients developed PJI: one in Group A, two in Group B, and one in Group D (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These rates are comparable to the previously reported incidence of PJI following TKA (0.72%) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Furthermore, the frequency of revision procedures performed for PJI is consistent with, or slightly lower than, the incidences documented in the literature, which range from 0.97% to 5% [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. These findings indicate that barbed sutures can be safely employed for full-thickness closure during TKA.\u003c/p\u003e \u003cp\u003eWe hypothesized that these differences may be attributed to the characteristics of the sutures used in this study. Barbed sutures employ barbs to grasp and secure tissues together, maintaining approximation and tension at the tissue edges, which helps prevent dehiscence and reduce fluid exudation. Moreover, the use of barbed sutures facilitates efficient incision closure, decreases operative duration and intraoperative blood loss, and shortens tourniquet duration. These advantages contribute to alleviating periarticular ischemia and hypoxia, improving soft tissue immunity, and thereby lowering the risk of wound infections [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In contrast, Vicryl sutures used in the running suture technique cause the entire suture line to function as a cohesive unit. With this closure method, the structural integrity of the entire wound may be compromised in the event of suture failure or knot loosening, potentially leading to dehiscence [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Furthermore, inadequate suturing may result in insufficient tissue approximation, leading to an imbalance in soft tissue tension, formation of dead space, and accumulation of hematomas and seromas, which can ultimately culminate in wound dehiscence and effusion [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Additionally, an inflammatory reaction triggered by the absorption of the knot may further increase the risk of SSI [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNotably, our findings indicated that Group C, which utilized barbed sutures for joint capsule closure, was observed to have a lower major complication rate (0%) and a significantly reduced incidence of minor complications (9.09%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) than Group D. These results align with previously published studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], indicating that barbed sutures for joint capsule closure are not associated with higher complication rates than conventional sutures. However, Group B (subcutaneous closure with barbed sutures) showed a higher incidence of major complications (3.33%) than Group C, while maintaining comparable rates to Group D (1.89%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Furthermore, despite the similar overall wound complication rates observed in Groups C and A, Group A (full-thickness closure) demonstrated a higher major complication rate (1.9%), which was comparable to Group B (3.33%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). These findings suggest that employing barbed sutures for the closure of subcutaneous or adipose tissue may increase the risk of infectious complications, consistent with the existing literature [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The underlying mechanism may involve excessive tension and cutting action of barbed sutures during postoperative joint mobilization, potentially leading to ischemic necrosis of the subcutaneous tissues and subsequent infection [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Further research is necessary to clarify the safety profile of barbed sutures in subcutaneous and adipose tissue layers.\u003c/p\u003e \u003cp\u003ePrevious studies have identified the duration of surgery as a potential risk factor for SSI following total knee arthroplasty [\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Similarly, Namba et al. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] demonstrated that longer operative times correlate with an elevated risk of deep SSI in TKA, with each 15-minute increment corresponding to a 9% rise in risk. Extended surgical time is associated with prolonged exposure of the operative field [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] and the application of a tourniquet, which may result in local hypoxia, vascular damage, and subsequent adipocyte necrosis, thereby increasing the risk of infection [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Of note, most studies have reported that the use of barbed sutures is associated with a reduction in wound closure time by approximately 3 to 12 minutes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Theoretically, their use simplifies surgical procedures, improves blood flow, and consequently reduces the risk of infection. Consistent with previous studies, we observed that barbed sutures were associated with a significant reduction in suture, operative, and tourniquet times (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e), along with a decreased incidence of superficial wound infections (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, related studies have indicated that the use of barbed sutures for full-thickness closure may elevate the risk of superficial infections [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. It has been hypothesized that these sutures might strangulate the vascular supply, compromise adequate tissue repair, and potentially lead to necrosis and chronic wound infection. Furthermore, the design of sutures may increase their susceptibility to infection. Nevertheless, these mechanisms remain unvalidated in vivo.\u003c/p\u003e \u003cp\u003eOur study conducted a comprehensive investigation into risk factors for superficial wound infections, focusing on comorbidities and perioperative indices previously linked to wound complications. These factors included elevated BMI, DM, RA, higher ASA scores [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], as well as prolonged operative duration [\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] and tourniquet time [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Additionally, we incorporated CAR [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and PNI [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], which are predictive markers for PJI or postoperative wound complications in TKA, into our analysis. Univariate analysis indicated that RA, cerebrovascular disease, operative duration, tourniquet time, length of stay (LOS), CAR, and PNI were significantly correlated with an increased risk of superficial wound infection (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In the multivariate logistic regression analysis, only RA and CAR emerged as independent predictors of infection (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e), consistent with previous reports [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. It is worth noting that the broad confidence intervals observed for several patient factors suggest a potential limitation in the statistical power to detect associations. Additionally, the baseline prevalence of certain comorbidities conventionally associated with infection was relatively low in this cohort. This lower prevalence may explain the lack of statistical significance observed for specific established risk factors, such as smoking and DM, within our model.\u003c/p\u003e \u003cp\u003eFurthermore, among obese patients undergoing TKA, factors such as prolonged incisions, extended operative duration, procedural complexity, and compromised subcutaneous vascularization may contribute to the risk of complications [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. In the present study, a higher percentage of patients in the barbed suture group (12.38%) had a BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 kg/m\u0026sup2; [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e], which might theoretically elevate the risk of complications within this cohort. Additionally, the proportion of patients classified as ASA\u0026thinsp;\u0026ge;\u0026thinsp;3 was greater in the barbed group (54.29%), a classification conventionally linked to an increased risk of complications [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. While these observations might theoretically imply a heightened risk of complications, the lack of a corresponding increase in actual complication rates supports the safety profile of barbed sutures in TKA. Moreover, rigorous preoperative glycemic management for diabetic patients in this cohort may mitigate their increased risk of infection.\u003c/p\u003e \u003cp\u003eIn terms of functional outcomes, although no statistically significant differences were noted between the groups in preoperative or postoperative assessments (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), both the Knee Society Score (KSS) and knee ROM demonstrated significant improvements in both groups at 24 months postoperatively compared to baseline (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These findings align with previous literature [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Regarding cosmetic assessment, barbed sutures exhibited comparable cosmetic outcomes to Vicryl sutures (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Consistent with our findings, Gililland et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] reported no significant difference in cosmetic outcomes between barbed and traditional sutures. Similarly, Ting et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] found that the cosmetic effect of barbed sutures was equivalent to that of conventional sutures. This result may be explained by the practice of performing skin closure with the knee flexed at 90\u0026deg;. By minimizing suture tension during postoperative rehabilitation, this technique likely helped to mitigate the risk of infection secondary to ischemia. Furthermore, continuous subcuticular closure facilitates optimal physiological blood flow, promoting wound healing [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] and achieving an aesthetically pleasing result.\u003c/p\u003e \u003cp\u003eThere are several limitations to this study that should be noted. First, the retrospective nature of the design inherently implies a potential for selection bias. Second, although our dataset was larger than those in many previous studies, the statistical power to detect rare adverse events remained constrained. Specifically, the overall low incidence of infections, coupled with the low prevalence of certain comorbidities, resulted in wide confidence intervals, which suggests that caution is warranted regarding the precision of these estimates. Third, our use of unidirectional barbed sutures differs from the bidirectional sutures employed in other studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]; this divergence may limit the direct comparability of our results. Finally, the currently available data did not permit the differentiation of infectious mechanisms based on the specific level of wound closure.\u003c/p\u003e \u003cp\u003eIn conclusion, the results of this study indicated that barbed sutures were associated with comparable rates of major wound complications and a significantly lower incidence of minor wound complications compared to Vicryl sutures in TKA incision closure. When used for full-thickness wound closure, barbed sutures appeared to correlate with fewer superficial wound complications, reduced closure time, and cosmetic outcomes equivalent to those achieved with conventional methods. These findings suggest that barbed sutures may represent a viable alternative for incision closure in TKA. However, caution is advised when considering their use in subcutaneous and adipose tissue, and further research is necessary to clarify their safety profile within these anatomical layers. For superficial skin closure, the adjunctive use of staples or skin adhesives alongside conventional sutures may be considered. Additionally, it is advisable to conduct​ a comprehensive preoperative assessment of inflammatory markers and comorbidities to help mitigate potential surgical risks.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e This study was approved by the Ethics Committee of the Fourth Affiliated Hospital of Guangxi Medical University (ethics approval number: KY2025651). Written informed consent was obtained from all patients. This retrospective cohort study involving human participants was conducted in strict accordance with the ethical principles outlined in the World Medical Association (WMA) Declaration of Helsinki (adopted at the 18th WMA General Assembly, Helsinki, Finland, June 1964, and amended at the 75th WMA General Assembly, Helsinki, Finland, October 2024).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors thank the study funded by the First Affiliated Hospital of Guangxi Medical University Innovation Team Cultivation Program (Grant Number: YYZS2023004), the Guangxi Natural Science Foundation (Grant Number: 2025GXNSFAA069791), the Key Project of the Guangxi Science and Technology Department (Grant Number: AB22080096), the Liuzhou Science and Technology Project (Grant Number: 2024RA0102A001, 2024SB0104E001).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZH, YP, JM and QL gathered the data. ZH, JM, HL and GL performed data analyses. ZH and JY drafted the manuscript. HL, GL, and JY critically revised the manuscript for intellectual content. All the authors have reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTing NT, Moric MM, Della Valle CJ, Levine BR. Use of knotless suture for closure of total hip and knee arthroplasties. 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Diagnostics. 2025;15:2230. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/diagnostics15172230\u003c/span\u003e\u003cspan address=\"10.3390/diagnostics15172230\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89:33\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2106/JBJS.F.00163\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.F.00163\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJ\u0026auml;rvenp\u0026auml;\u0026auml; J, Kettunen J, Kr\u0026ouml;ger H, Miettinen H. 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Clin Orthop. 2016;474:47\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11999-015-4209-x\u003c/span\u003e\u003cspan address=\"10.1007/s11999-015-4209-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\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":"Total knee arthroplasty, barbed sutures, incision closure, wound complications","lastPublishedDoi":"10.21203/rs.3.rs-8561219/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8561219/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNumerous studies have investigated the utilization of absorbable knotless barbed sutures in total knee arthroplasty (TKA) and compared various techniques and materials; however, the efficacy of full-thickness closure remains inconsistent. This retrospective study aimed to evaluate whether full-thickness wound closure in TKA using absorbable knotless barbed sutures, compared with running-coated Vicryl Plus antibacterial sutures, was associated with a reduction in complication rates.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients who underwent primary unilateral TKA with incision closure using either absorbable knotless barbed sutures or coated Vicryl Plus antibacterial sutures between January 2020 and September 2023 were retrospectively enrolled. Demographics, comorbidities, perioperative data, postoperative complications, Knee Society Scores (KSS), knee range of motion (ROM), and scar appearance were systematically collected and analyzed over a 24-month follow-up. Perioperative risk factors associated with superficial wound infection were also evaluated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAt the 24-month postoperative follow-up, no statistically significant differences were observed in major complication rates among the four groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), including periprosthetic joint infection (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) and revision surgery (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, a statistically significant difference was observed in the overall incidence of minor superficial wound complications among the groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Although no significant differences were found in superficial wound infection, effusion, or wound dehiscence between the groups (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), Groups A, B, and C exhibited lower incidence rates than Group D. The use of barbed sutures was associated with significantly shorter suture time and operative duration (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while maintaining equivalent cosmetic outcomes (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe results of this study indicate that the use of barbed sutures for incision closure in TKA was not associated with an increased risk of major or minor wound complications. These findings suggest that barbed sutures may be considered a viable alternative for incision closure in TKA; however, careful application is advised when involving subcutaneous or adipose tissue.\u003c/p\u003e\u003ch2\u003eClinical trial number:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"The Effect of Absorbable Knotless Barbed Suture on Total Knee Arthroplasty Incision Closure: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 19:54:52","doi":"10.21203/rs.3.rs-8561219/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-10T15:43:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319257791120859931442974388825953340569","date":"2026-04-13T14:03:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79765924252610090299517597050916290224","date":"2026-04-10T15:14:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221503923714708662557507044832937442273","date":"2026-04-08T17:40:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-05T14:00:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13918474680079506805915941380573373599","date":"2026-04-05T12:07:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-03T22:00:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"135537288858925803278145421602935267365","date":"2026-02-21T12:37:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317339583430883469534405227359638294939","date":"2026-01-21T09:17:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-21T08:28:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T08:25:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-16T06:01:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-15T13:00:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-01-15T12:52:51+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":"5ba1e688-0938-4ee5-8f3f-fa2a7ab585c8","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-10T15:43:14+00:00","index":324,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-23T19:54:52+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 19:54:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8561219","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8561219","identity":"rs-8561219","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}