Barbed versus traditional sutures in primary total knee arthroplasty: systematic review and meta-analysis of clinical outcomes and wound-related complications

BACKGROUND: Despite the widespread use of total knee arthroplasty (TKA), the optimal wound closure technique remains clinically unresolved. Barbed sutures have been proposed as a knotless alternative to traditional sutures, with potential advantages in operative efficiency and wound closure; however, concerns remain regarding postoperative complications. This systematic review and meta-analysis aimed to compare the clinical outcomes and postoperative complications associated with barbed versus traditional sutures in patients undergoing primary TKA. METHODS: A comprehensive literature search was conducted using MEDLINE/PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), ScienceDirect, Scopus, and Embase from database inception through November 2025. Eligible studies were restricted to randomized controlled trials (RCTs) involving adults undergoing primary TKA that directly compared barbed with traditional (knotted) sutures and reported at least one predefined clinical or wound-related outcome. Primary outcomes included wound closure time, superficial wound infection, postoperative Knee Society Score (KSS), knee range of motion (ROM), and wound-related adverse events. Meta-analysis was performed using RevMan version 5.3. The study was registered in PROSPERO (CRD420251128395) and received Institutional Review Board (IRB) approval from King Abdullah International Medical Research Center (Protocol No. NRJ25/044/8). RESULTS: Five randomized controlled trials involving 1035 patients mettheeligibilitycriteria. Barbed sutures appeared to be associated with shorter wound closure times (MD = - 5.39 min, 95% CI: - 9.89 to - 0.88; P = 0.02). However, substantial heterogeneity was observed across studies. Superficial wound infection was significantly more frequent with barbed sutures (OR = 2.33, 95% CI: 1.07-5.05; P = 0.03). No significant differences were observed in postoperative KSS at 6 weeks and 3 months (MD = 0.42, 95% CI: - 0.88 to 1.72; P = 0.53). CONCLUSION: Barbed sutures may reduce wound closure time during TKA but are associated with a higher risk of superficial wound infection. No significant differences were observed in early functional outcomes, and further high-quality studies are needed to clarify long-term safety and efficacy.