Knotless Suture Review and Catalog

Prindeze N, Profant C, Snow T, Mobbs, K, Mukherjee I, Renton, D

Product history

The first patent for barbed suture was issued in 1964 and featured unidirectional “roughened” suture material in differing patterns.¹ It was originally intended to be part of an automatic suturing device previously patented in 1961, however this was ultimately never comercialized.²

Barbed suture as we know it today first received FDA approval in 2004 under the brand Quill Medical. These sutures were originally developed and marketed towards facial rejuvenation procedures however, with the realization of a broader application to general wound care, focus was shifted.^3,4 Covidien (Medtronic) introduced the loop-end and brought the V-loc competitor to the market in 2009, and the Quill (Surgical Specialties, Angiotech) IP was purchased by Ethicon (J&J) in 2012.^4,5

The intended purpose of the barb was to distribute tension more evenly along a suture line instead of only at the knotted ends, evening tension gradients in a lift procedure and potentially reducing suture breakage due to weak points at knots.^4,6 Other advantages of these sutures were identified, including speed and ease of use and they have since found applications in many other specialties including OB/GYN, orthopedics and minimally-invasive surgery.^3,4,6

Outcome data

Backed now by over 20 years of data, barbed suture has been shown to be safe in general surgery, gynecologic, orthopedic and urologic applications. Through multiple large-scale reviews, no significant differences have been identified in overall post-operative complications, wound infection rates, or length of hospital stay.^7–10 The primary benefits of these sutures are demonstrated in decreased suture time^7–10 and overall decreased operative time^7,10.

Anchor geometry

Anchors are the initial securement component of the knotless suture and give these products their ability to start a closure without a traditional knot. With minor variability, anchors come in two forms, loop configuration (A) and tab configuration (B) as shown below.

Loop closure

Similar to a traditional knot, A loop anchor is secured by passing the needle through tissue and then through the loop, cinching the securement.

Tab securement

A tab anchor is a truly knotless securement mechanism, however it is still recommended to fix the tab in place with a loop of suture as shown below. The tab is set at the end of the wound (A) by taking a suture pass aimed towards the apex (B), a second pass is then taken around the initial suture to lock the tab in place (C).

^*Images reprinted from product catalogues with permission of Ethicon and Covidien

Barb geometry

Barbs allow the suture to hold tension along the entire length of the strand and provide terminal end securement. Barbs exist in two forms, external to the core (1A), or cut into the core (1B).

Manufacturing

At present, the Ethicon Stratafix^™ Symmetric suture is the only barbed suture with the barb external to the core (1A). These sutures are press-cut out of larger material, leaving the suture core un-modified.

All other barbed sutures are manufactured through the incision of barbs into the material core. In the production of cut barbs, suture strands are typically rated a size smaller than their starting material, providing the final product with comparable tensile strength to similar size suture. Uniquely, the Covidien V-loc^™ sutures are manufactured through a two-angle cut (2A) resulting in a shallower incision into the suture.

^*Images reprinted from product catalogues with permission of Ethicon and Covidien

Ancillary features

Antimicrobial coating

At present the only barbed suture with an antimicrobial coating are the Stratafix^™ Symmetric and Spiral Plus products

Knotless Suture Catalog

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References

1. Alcamo, J. Surgical Suture. U. S. Pat. Off. 1964, No. 3,123,077.
2. Alcamo, J. Surgeon’s Suturing Device. U. S. Pat. Off. 1961, No. 2,988,028.
3. Greenberg, J. A.; Goldman, R. H. Barbed Suture: A Review of the Technology and Clinical Uses in Obstetrics and Gynecology. Rev. Obstet. Gynecol. 2013, 6 (3–4), 107–115.
4. Ruff, G. L. The History of Barbed Sutures. Aesthet. Surg. J. 2013, 33 (3 Suppl), 12S-6S.
5. Levin, J. Angiotech Pharmaceuticals, Inc. Announces Transaction with Johnson & Johnson Relating to Angiotech’s Quill Technology; Fierce Biotech. https://www.fiercebiotech.com/biotech/angiotech-pharmaceuticals-inc-announces-transaction-johnson-johnson-relating-to-angiotech-s.
6. Nambi Gowri, K.; King, M. W. A Review of Barbed Sutures—Evolution, Applications and Clinical Significance. Bioengineering 2023, 10 (4), 419.
7. Raischer, H. B.; Massalha, M.; Iskander, R.; Izhaki, I.; Salim, R. Knotless Barbed versus Conventional Suture for Closure of the Uterine Incision at Cesarean Delivery: A Systematic Review and Meta-Analysis. J. Minim. Invasive Gynecol. 2022, 29 (7), 832–839.
8. Lin, Y.-F.; Lai, S.-K.; Liu, Q.-Y.; Liao, B.-H.; Huang, J.; Du, L.; Wang, K.-J.; Li, H. Efficacy and Safety of Barbed Suture in Minimally Invasive Radical Prostatectomy: A Systematic Review and Meta-Analysis. Kaohsiung J. Med. Sci. 2017, 33 (3), 107–115.
9. Sun, C.; Chen, L.; Du, R.; Wu, S.; Ma, Q.; Cai, X. Barbed Sutures in Total Knee Arthroplasty: A Meta-Analysis of Randomized-Controlled Trials. J. Knee Surg. 2021, 34 (14), 1516–1526.
10. Hafermann, J.; Silas, U.; Saunders, R. Efficacy and Safety of V-Loc^TM Barbed Sutures versus Conventional Suture Techniques in Gynecological Surgery: A Systematic Review and Meta-Analysis. Arch. Gynecol. Obstet. 2024, 309 (4), 1249–1265.