keloid scarring and total knee replacment (Full Version)

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robinbauer -> keloid scarring and total knee replacment (April 28, 2005 2:30:00 PM)

I am treating 41 yo AA lady SP R TKA with hx of keloid scarring. So far (3 weeks PO) incsion looks fine, but pt is losing ROM!

Is this 2* interanl scar tissue?

Any suggestions?




JLS_PT_OCS -> Re: keloid scarring and total knee replacment (April 28, 2005 2:49:00 PM)

Is she infected?
If not, then we should be redoubling our ROM efforts.

Give us some medical hx here to help, 41's kinda early for a TKA. RA? Trauma?

And start mobilizing that knee....
J




KAK -> Re: keloid scarring and total knee replacment (April 28, 2005 4:49:00 PM)

Maybe a home CPM ? I realize it is kind of late and cost is a factor, but if she is scarring down the frequent movement might be a help. She could use it at night too.




tucker -> Re: keloid scarring and total knee replacment (April 28, 2005 5:31:00 PM)

I don't think a history of keloid scarring has anything to do with losing ROM of a new TKA. What is she losing? What are her current measurements 3 weeks post-op?




robinbauer -> Re: keloid scarring and total knee replacment (April 29, 2005 6:18:00 PM)

Traumatic arthritis with 2 previous surgeries: don't know exactly what. No signs of infection. She does have a CPM. Current ROM 15-72*. Had 90* flexion in hosp. On WED had only 60* !.

I don't understand the physiology behind keloids, and I guess that I am concerned that overdoing may result in inflamatory response and exacerbate the scarring. Any thoughts/experience with that?
How many hours a day should she be on CPM?

I'm going to suggest to Physician that we try. Ionto with Potassium Iodide.

Thanks for your input.




srcase -> Re: keloid scarring and total knee replacment (April 29, 2005 6:23:00 PM)

Robin,
Why ionto??
What types of joint mobs are you doing, are you mobilizing the patellofemoral joint?? Does she have significant edema (may need to be drained)
Sarah




robinbauer -> Re: keloid scarring and total knee replacment (April 30, 2005 1:44:00 PM)

Iontophoresis with iodide is supposed to inhibit scar tissue formation.

Robin




robinbauer -> Re: keloid scarring and total knee replacment (April 30, 2005 1:45:00 PM)

I'm doing patellar mob and AP tibial glides.

Robin




tucker -> Re: keloid scarring and total knee replacment (May 1, 2005 1:16:00 AM)

"I guess that I am concerned that overdoing may result in inflamatory response and exacerbate the scarring."

It's the exact opposite Robin, underdoing will cause a bigger problem...a contracture. Stop thinking about keloids. It's not relevant since you already said the incision looks fine. A keloid is just a raised scar...not adhesions in a joint or internal scarring.

Current ROM 15-72 3 weeks post op? The 72 flexion sucks, but I would be more concerned with a lack of 15 degrees extension. That trumps flexion since you need full extension in gait. I'd focus more on extension stretching at home instead of a CPM or this patient will have a flexion contracture. Flexion stretching should be as aggressive as tolerated. Looks to me like the patient is setting up for a manipulation under anesthesia if those numbers don't come up.

Ionto for scar formation? Again, scar formation is not a concern if the incision looks fine...it's not forming in the joint.

I've worked the past 7 years in a burn unit. With hypertrophic scarring near a joint, be as aggressive as possible with ROM. Maybe you're thinking of HO, in that aggressive Tx acutely may worsen the condition.




robinbauer -> Re: keloid scarring and total knee replacment (May 1, 2005 10:44:00 AM)

Thanks, tucker, that's what I needed to hear.

Robin




jma -> Re: keloid scarring and total knee replacment (May 1, 2005 11:04:00 AM)

The CPM should be discontinued, since it is not doing much, especially after 3 weeks. Mob the joint aggressively to tolerance. Yes, get to that extension immediately.




tucker -> Re: keloid scarring and total knee replacment (May 1, 2005 1:06:00 PM)

No problem. We stopped using CPMs in our TKA protocol (6 hours/day) about 5 years ago for this same reason...patients were coming out with limited extension. No matter how well the CPM is designed, patients can always get out of that terminal extension stretch.

So patients are positioned in extension with a pillow under the ankle (gravity-assist) when not in therapy. Flexion will typically come with aggressive stretching, but it's difficult to overcome limited extension. If a patient is poorly compliant with the extension stretching on their own, I may even go with a knee immobilizer between flexion stretching.

Of course, I would still use a CPM for those who are having difficulty with flexion, but extension is on schedule. That is pretty rare though. We do 4-8 TKAs a week and a CPM may be used once a month. Very low manipulation rate.




Jon Newman -> Re: keloid scarring and total knee replacment (May 2, 2005 8:23:00 AM)

Here are some references that may (unfortunately) be of use to you

[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12610433]link 1[/URL]

[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15252096]link 2[/URL]

Good luck to your patient.

jon




PTupdate.com -> Re: keloid scarring and total knee replacment (May 2, 2005 10:23:00 PM)

I'd be curious about infection, and/or complaince with HEP. Also, if it was not you doing the hospital measurements, you might consider someone just has crappy gonio skills. If on Wed had 60 and now up to 72, something is progressing. Get her doing prone hangs and other extension activities, including self stretching into extension.

I think that there is the chance that the keloid scar is telling us that the person may lay down more scar tissue than the average person, and this may create an anterior entrapment. I'd be curious to see if anybody ever did a study to see if external scar tissue correlates to either ROM deficits, or even internal scarring in those who undergo lysis.

John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]




Shill -> Re: keloid scarring and total knee replacment (May 3, 2005 8:54:00 AM)

Duff is right on with digging deep into home compliance. Perhaps the reason for non-compliance is fear, or perhaps its something else, but either way, it will wreck the outcome. It has to change. CPM or no CPM this patient has to get it moving.
Im sure you are well versed in this, but I'll throw it out there anyway, and that is the explanation that having pain during treatment, or HEP, does NOT mean that damage is occurring, but simply that the tissue is being moved beyond its current (premature end) range. This is necessary, and repeating this over and over to the patient is often rather reassuring. Honestly, I have nearly sat on knees before to stretch into extension, with NO worsening afterward. Tell the patient that they can expect pain during, but also tell them that they are in control of how much pain, and have them give you an "absolute stop sign", by holding up a hand when they get to their absolute limit. They simply wont let you hurt them, provided you add the force slowly of course.
Incidentally, I found a way (finally, after 12 years) to use a traction table with a moveable end to prevent the knee from coming out of the flexion stretch by the force of tissue tension. I have a picture of the position, if you would like, email me at sf.hill@hosp.wisc.edu

Good luck,
Steve




hmgross -> Re: keloid scarring and total knee replacment (May 3, 2005 9:49:00 AM)

I too had considered what John said about the goni measurements. I knew of a PT in an acute hospital setting who took the ROM measurement of the knee based on what the CPM was set at. That's not even close! I don't have a problem with CPMs the first couple of days post-op, but then get rid of them, get the patient in a more active role of increasing the ROM, and I seem to spend alot more time stressing the extension in my visits because patients are more focused on the flexion, no matter how much I drill in the importance of full extension. I also expect some loss of ROM when the patient is intially discharged to home, but if on the first visit I find that particularly tight knee, I push as hard as I can, and let the patient know how critical follow up at home is.




JLS_PT_OCS -> Re: keloid scarring and total knee replacment (May 3, 2005 12:16:00 PM)

I would second what the others have said, and also note that the formation of keloids (a type of hypertrophic scarring in which the scar tissue extends beyond the borders of the wound) is not associated with any specific complication rate that I am aware of.
I think it may just be a dermatologic condition, and nothing to do with any central process that might influence healing or collagen formation other places.

So forget the Ionto, and extend that knee!
:)
J




smithjinks -> Re: keloid scarring and total knee replacment (May 20, 2005 2:57:00 PM)

Robin, have you checked for patella mobility for superior/inferior glides; active mobilization with contract-relax at different ranges. I have even used cuff weights for prone hangs as part of a HEP and towel stretches.

Ken




smithjinks -> Re: keloid scarring and total knee replacment (May 20, 2005 3:08:00 PM)

Robin, I forgot to ask whether the knee has edema, if so then they need to be elevating their leg in supine for 30 min 1-2x's daily with ice pack preferrably after their ROM exercices due to edema limiting their range.




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