Post operative Surgical Site Complications

Post operative Surgical Site Complications, including Prolonged Wound Drainage, Surgical Site Infection and Periprosthetic Joint Infections, can occur following surgery.3 These costly, and potentially preventable4 complications can lead to increased length of stay, higher re-admission rates, increased re-intervention rates5, and increased morbidity6 and mortality7.

Optimal Wound Closure methods can reduce postoperative complications6

For over a century, Ethicon has transformed healing and we don’t plan to stop – innovation is in our DNA. STRATAFIX™ Knotless Tissue Control Devices provided stronger*, faster, more secure closure than traditional suturing.8 Incisions closed with DERMABOND® PRINEO® Closure System (22 cm) was significantly stronger when compared with the average strength of staples.9,D

STRATAFIX™ Knotless Tissue Control Devices

STRATAFIX Knotless Tissue Control Devices

DERMABOND® PRINEO® Skin Closure System

DERMABOND® PRINEO® Skin Closure System

Traditional wound closure techniques involving conventional suture, staples and wound dressings may not be the optimal choice to achieve the primary objective of multi-layer, watertight closure.1

Reducing risk factors and improving healing can be achieved with appropriate surgical technique and postoperative care. You can optimise tissue management through the principles of wound healing: gentle handling of tissues, careful haemostasis, obliteration of dead space, and avoidance of tension.2,10 Appropriate choice of wound dressing should manage wound bioburden, limit cross contamination and promote a wound healing environment.11

Strength & Security

Strength & Security

  • Closure must be strong enough to maintain appropriate tension and approximation throughout healing.12 
  • Continuous suturing closure can be compromised with a break in the suture. 13
Watertight Closure & Obliteration of Dead Space

Watertight Closure & Obliteration of Dead Space

  • An optimal tension watertight closure may also reduce the risk of dead space hematomas and infection.14 
  • Suture knots can create inconsistent suture tension, risking tissue gapping between knots.15 
  • Saturated and/or leaking wound dressings allow migration of bacteria to the wound in a rapid manner.16
Antibacterial & Microbial Barrier Protection

Antibacterial & Microbial Barrier Protection

  • Use of metal clips is associated with a significantly greater risk of wound infection than traditional sutures.17 
  • Any implant, including a suture, increases the risk of bacterial colonization and biofilm formation and may contribute to an infection.18
  • Wound dressings are typically changed 3 to 5 times in TJA.18  This can increase potential risk of introducing SSI causing pathogens to the wound. 19-21

Let’s work together to reduce infection risk, shorten length of stay and minimise readmissions.

In Total Joint Arthroplasty orthopaedics, STRATAFIX™ Knotless Tissue Control Devices and DERMABOND® PRINEO® Skin Closure System vs. traditional sutures and staples, respectively, were associated with:

Shorter Operating Time 25-27

Shorter Operating Time 22,23

Lower SSI Rates

Lower SSI Rates 22,23

Reduced LOS

Reduced Re-Admission 23,24  

Reduced Re-Admission 26,27

Reduced LOS 23,24

Lower Healthcare Resource Utilisation1,21

Lower Healthcare Resource Utilisation1,19

Easier Patient Care21

Easier Patient Care 19

Find out more about Ethicon’s innovation in wound closure & healing


A.  Refers to STRATAFIX™ Symmetric PDS™ Plus Knotless Tissue Control Device only.  Benchtop assessment using porcine fascia, greater maximum tissue holding strength compared to Looped PDS or VICRYL interrupted closures (p<0.05). [127444-211126]

B. Comparing STRATAFIX™ symmetric polydioxanone Plus to interrupted closure (p< 0.001); and STRATAFIX™ Spiral to VICRYL™ (first layer continuous closure, second layer interrupted closure, p<0.001).

C. Benchtop testing in porcine tissue. Security refers to the ability to maintain optimal tissue approximation when damage to the closure device occurs.

D. Study performed ex vivo. P value = 0.00. Average maximum load at or prior to 3 ± 1 mm gap between the approximated tissues.

1. Mark A. Snyder, Brian P. Chen, Andrew Hogan, George W.J. Wright, Multilayer Watertight Closure to Address Adverse Events From Primary Total Knee and Hip Arthroplasty: A Systematic Review of Wound Closure Methods by Tissue Layer, Arthroplasty Today, Volume 10, 2021, Pages 180-189.e7, ISSN 2352-3441,

2.  World Union of Wound Healing Societies (WUWHS) Consensus Document. Closed surgical incision management: understanding the role of NPWT. Wounds International, 2016 5. Available at:

3.  Marie Carbonnel, Domitille Brot, Charlotte Benedetti, Titouan Kennel, Rouba Murtada, Aurelie Revaux, Jean Marc Ayoubi, Risks factors FOR wound complications after cesarean section, Journal of Gynecology Obstetrics and Human Reproduction, Volume 50, Issue 7, 2021,101987,

4.  Andersen BM. Prevention of Postoperative Wound Infections. Prevention and Control of Infections in Hospitals. 2018;377-437. Published 2018 Sep 25. doi:10.1007/978-3-319-99921-0_33

5. Wagenaar, F-C. B. M., Lowik, C. A. M., Zahar, A., Jutte, P. C., Gehrke, T., & Parvizi, J. (2019). Persistent Wound Drainage After Total Joint Arthroplasty: A Narrative Review. Journal of Arthroplasty, 34(1), 175-182.

6.  Bullocks J, Basu CB, Hsu P, Singer R. Prevention of Hematomas and Seromas. Semin Plast Surg. 2006;20(4):233-240. doi:10.1055/s-2006-951581

7. Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J. Periprosthetic joint infection increases the risk of one-year mortality. J Bone Joint Surg Am. 2013;95(24):2177-2184. doi:10.2106/JBJS.L.00789.

8. Evidence for Faster: Sundaram K, Warren J, Klika A, Piuzzi N, Mont M, Krebs V. Barbed sutures reduce arthrotomy closure duration compared to interrupted conventional sutures for total knee arthroplasty: a randomized control trial. Musculoskelet Surg. 2020;1‐7. (127444‐220111)

Zayed M, Fouda U, Elsetohy K, Zayed S, Hashem A, Youssef M. Barbed sutures versus conventional sutures for uterine closure at cesarean section; a randomized controlled trial. The journal of maternal‐fetal & neonatal medicine. 2017:1‐8. (127444‐220111)

Evidence for more secure: Ethicon, AST‐2012‐0331. Tissue gapping under tension ofporcine cadaveric skin incisions closed with Stratafix Spiral in comparison to Monocryl in both interrupted and continuous stitching patterns. Aug 2012. Data on File. (127444‐220111)

Ethicon, AST‐2013‐0056. Performance Testing of STRATAFIX Symmetric PDSSize2‐0 suture device for Tissue Holding Strength with Multiple Incision Defects to Measure Gapping. April 2013. Data on
File. (127444‐220111)

Evidence for stronger: Ethicon, 100326296: Time zero tissue holding ‐ Competitive claims comparisons for STRATAFIX Knotless Tissue Control Devices vs various products. 2015. Data on File. (127444‐220111)

9.  Ethicon, AST-2014-0246, Study to compare the tissue holding strength of DERMABOND™ PRINEO™ 22 cm Skin Closure System (DP22) to conventional wound closure techniques, September 2014, Data on File.

Ethicon, AST-2012-0290, Study to Compare the tissue holding strength of PRINEO™ skin closure system with conventional wound closure techniques, October 2012, Data on File [142233-200603]

10.  Charles M. Lawrie, Ryan M. Nunley, Advances in closure technology and technique for total joint arthroplasty: Stitches in time, Seminars in Arthroplasty, Volume 29, Issue 1, 2018, Pages 14-19, ISSN 1045-4527, (

11.  Steven L. Percival, Chapter Eight - Wounds and Infection, Editor(s): Steven L. Percival, David W. Williams, Jacqueline Randle, Tracey Cooper,Biofilms in Infection Prevention and Control, Academic Press, 2014,Pages 127-139,

12.  Dubay DA, Franz MG. Acute wound healing: the biology of acute wound failure. Surg Clin North Am. 2003;83(3):463-481.[ 060122-200722]

13.  Sissener T. Suture patterns. Comp Anim. 2006;11:14–19 

14. Kharat K. Closure in Knee Replacement Surgery. Journal of Orthopaedic Case Reports 2012;2:31-32

15. Greenberg JA and Goldman RH. Barbed suture: a review of the technology and clinical uses in obstetrics and gynecology. Rev Obstet Gynecol. 2013;6(3-4):107–15.

16. Harris CL, Kuhnke J, Haley J, Cross K, Somayaji R, Dubois J, et al. Best practice recommendations for the prevention and management of surgical wound complications. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2021 Jan 25]. 668 p. Available from: bpr-prevention-and-management-of-surgical-wound-complications-v2/file

17. Smith TO, Sexton D, Mann C, Donell S (2010) Sutures versus staples for skin closure in orthopedica surgery meta-analysis. BMJ 340 c1199.

18. Edmiston C, Seabrook G, Goheen M et al, Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination?  J Am Coll Surg. 2006 203(4):481-9. Epub 2006 Aug 22

19. Sadik K, Flener J, Gargiulo J, Post Z, Wurzelbacher S, Hogan A, Hollmann S, Ferko N. A US hospital budget impact analysis of a skin closure system compared with standard of care in hip and knee arthroplasty. Clinicoecon Outcomes Res. 2019;11:1-11

20. Chowdhry M, Chen AF (2015) Wound dressings for primary and revision total joint arthroplasty. Ann Transl Med 3 (18): 268.

21. Springer BD, Beaver WB, Griffin WL, Mason JB, Odum SM. Role of Surgical Dressings in Total Joint Arthroplasty: A Randomized Controlled Trial. Am J Orthop (Belle Mead NJ). 2015;44(9):415-420.

22. Johnston S, Fortin S, Pracyk J, Tommaselli G, Elangovanraaj N, Chen B.  Economic and clinical outcomes of spinal fusion surgeries with skin closure through skin staples plus waterproof wound dressings versus 2-octyl cyanoacrylate plus polymer mesh tape. The Spine Journal. 2020 [175713-210504]

23. Sutton N, Schmitz ND, Johnston SS. Comparing outcomes between barbed and conventional sutures in patients undergoing knee or hip arthroplasty. J Comp Eff Res. 2018;7(10):975-987

24. Sutton, N., Schmitz, N. D., & Johnston, S. S. Economic and clinical comparison of 2-octyl cyanoacrylate/polymer mesh tape with skin staples in total knee replacement. Journal of wound care. 2018 27(Sup4), S12-S22.


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