Running subcuticular closure technique provides most perfusion to support wound closure after TKA

Total knee arthroplasty (TKA) is one of most commonly performed orthopedic surgeries in the U.S. A 2013 report in The Journal of Bone & Joint Surgery estimated 4 million adults were living with TKAs. Successful outcomes of TKA are linked to wound closure technique that supports optimal perfusion.

Mayo's pioneering study

Despite consensus that this linkage exists, and multiple investigations to evaluate technique, no study has yet produced convincing data of a superior wound closure technique for optimizing perfusion — until now.

In a randomized clinical trial conducted by Mayo Clinic Department of Orthopedic Surgery, investigators conducted a pioneering study to compare three closure techniques and evaluate their effects on perfusion. Their work is the first to provide quantitative evidence showing that running subcuticular closure enables the most robust blood flow to the incision site among commonly used closure techniques in reconstructive knee surgery.

Explains Robert T. Trousdale, M.D., an orthopedic surgeon at Mayo Clinic in Rochester, Minnesota: "Skin and soft tissue complications can lead to a devastating outcome for patients after reconstructive knee surgery. Perfusion status is perhaps the most important factor in appropriate wound healing; however, to date no study has adequately determined which surgical closure technique optimizes this parameter. This investigation determined unequivocally that running subcuticular closure was superior to vertical mattress and staple closure with regard to perfusion status."

Because closure technique is an important modifiable factor in determining blood flow to the wound, Dr. Trousdale believes surgeons can now use this information to provide patients with the best possible opportunity for excellent postoperative wound healing.

Comparing 3 techniques

In the study, the Mayo Clinic team compared three wound closure techniques in 45 patients undergoing TKA using the same surgical approach. Patients all lacked comorbidities or other risk factors for wound healing complications and were prospectively randomized to one of three wound closure techniques. The three techniques compared were:

  • Running subcuticular
  • Vertical mattress
  • Skin staple closure

The team's research objective was to determine which closure technique enables the most robust wound perfusion postoperatively.

Novel measurement method

To assess perfusion, investigators used a novel method that assesses dynamic tissue properties through the use of laser-assisted indocyanine green angiography (LA-ICGA). The device and software system quantifies fluorescence to indicate perfusion, with higher rankings indicating greater blood flow.

"As a technology, LA-ICGA is several decades old, but it has recently been revived by plastic surgeons for its ability to provide point-of-care, real-time definition of blood flow to skin and soft tissue that is both dynamic and precise," explains plastic and reconstructive surgeon Steven R. Jacobson, M.D., at Mayo Clinic's campus in Minnesota, and one of Dr. Trousdale's Mayo Clinic collaborators in the study.

He adds that a recently published work he co-authored shows that LA-ICGA has reduced complications in patients undergoing breast reconstruction at Mayo Clinic, providing more-encouraging evidence for the surgical utility of this technology.


Researchers concluded that the method of closure can influence skin and soft tissue perfusion after TKA and that running subcuticular closure enables the most physiologic robust blood flow, which may improve wound healing.

While further studies of this approach are needed to include patients at higher risk of wound complications, the team believes the results are valid and generalizable across patient populations. "We excluded comorbidities for a good reason: to create experimental isolation of closure technique as the primary factor driving differences in perfusion," Dr. Trousdale says. "Despite lack of data on patients with comorbidities at this time, we feel the results are extremely helpful in guiding surgical decision-making about wound closure."

For more information

Weinstein AM, et al. Estimating the burden of total knee replacement in the United States. The Journal of Bone & Joint Surgery. 2013;95:385.

Wyles CC, et al. The Chitranjan Ranawat Award: Running subcuticular closure enables the most robust perfusion after TKA: A randomized clinical trial. Clinical Orthopaedics and Related Research. In press.