An Updated Review on Layered Closure Techniques for Total Hip Arthroplasty

One of the main concerns with total hip arthroplasty is the development of periprosthetic joint infections (PJIs). Appropriate wound closure can contribute to the prevention of PJIs with a watertight closure effectively sealing the implant from the outside. It is important to continuously investigate which materials as well as techniques are potentially the most efficacious and cost effective for wound closure. Therefore, the purpose of this review article was to critically appraise the current total hip arthroplasty wound closure materials and techniques as reported in the literature. Specifically, we evaluated: 1) fascial approximations; 2) subdermal closures; 3) subcuticular and skin closures; 4) wound dressings; as well as 5) capsular and short external rotator repairs.

A literature search was performed using the PubMed database from inception to February 2022. The query consisted of terms including "hip, arthroplasty, wound, closure, capsular closure, fascial closure, subcutaneous closure, and skin closure." References from selected texts were also reviewed for inclusion. Only manuscripts written in the English language were included for final analysis. A systematic review was performed for the five topics: 1) fascial approximations; 2) subdermal closures; 3) subcuticular and skin closures; 4) wound dressings; as well as 5) capsular and short external rotator repairs. Additionally, a meta-analysis was performed on the closing time of fascial approximations.

The current literature supports performing a layered closure of the wound by approximating the fascial layers, which can help close any empty spaces. The techniques for closure at this layer seem to be equal regarding wound complications between running knotless barbed sutures versus interrupted throws; however, knotless sutures have the potential of a quicker closure time. A total of three out of four reports and the meta-analyses demonstrated that wound closure time can be reduced with barbed sutures, along with decreased number of sutures required as also shown by three out of four reports. The most superficial layers, subcuticular and skin, can be closed with either sutures, staples, or skin adhesives, all of which appear to have adequate outcomes. A report found that patients who had skin closure with barbed suture had faster time to a dry postoperative wound and lower rates of delayed discharge. For the overlying dressing, an occlusive and absorbent dressing can both protect the wound as well as collect any residual wound drainage. Two reports found increased dryness, decreased wound drainage, and decreased rates of delayed wound healing with use of 2-octyl cyanoacrylate topical adhesive with flexible self-adhesive polyester mesh dressings. If the capsule and short external rotators are taken down during the approach, repairing these can potentially help increase postoperative hip stability as well as decrease dislocation rates.

The variety of materials and techniques available to close a THA wound allows surgeons to tailor closure to be patient specific. In general, the authors recommend performing layered closures from the capsule and short external rotators (if taken down during the approach), fascial layer closure with either a running knotless suture, subcutaneous closure either with the same knotless suture as the fascial layer brought more superficially, or with simple interrupted sutures to tack down any empty space, as well as finally subcuticular and skin sutures with a skin adhesive glue overtop. The skin adhesive can help provide an extra layer, particularly in active patients.