Arch Orthop Trauma Surg DOI 10.1007/s00402-014-1942-7

Knee Arthroplasty

The effect of topical scar treatment on postoperative scar pain and pruritus after total knee arthroplasty Chae‑Gwan Kong · Geon‑Hyeong Kim · Dong‑Wook Kim · Yong In 

Received: 13 May 2013 © Springer-Verlag Berlin Heidelberg 2014

Abstract  Introduction  The surgical wound of total knee arthroplasty (TKA) needs continuous flexion and extension movement. Silicone gel treatment is widely used to treat hypertrophic scars and keloids since it is easily applied and prevents scar pain and itching. The aim of this study was to evaluate the clinical efficacy and safety of silicone gel applied to surgical scars of TKA on postoperative scar pain and pruritus. Materials and methods  One hundred TKAs were randomized into a silicone gel group (silicone gel was applied to the wound after stitch-out for 1 month) or a placebo group. The postoperative scar pain and pruritus were evaluated with the use of a visual analog scale (VAS) at postoperative 3 months, 6 months and 1 year. Scar assessment was done using the Vancouver scar scale by evaluating scar pigmentation, vascularity, pliability, and height. Results  Although silicone gel group showed better pigmentation and height scales than placebo group (P  0.05). Conclusions  Application of silicone gel had no beneficial effects on scar pain and itching relief during the early postoperative period of TKA. Level of evidence  I-Randomized Controlled Trial C.-G. Kong  Department of Orthopaedic Surgery, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea G.-H. Kim · D.-W. Kim · Y. In (*)  Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222 Banpodaero, Seocho‑Gu, Seoul 137‑701, Korea e-mail: [email protected]

Keywords  Total knee arthroplasty · Postoperative scar · Silicone gel · Pain · Pruritus

Introduction The main goal of total knee arthroplasty (TKA) for treatment of osteoarthritis is the relief of pain and the restoration of functional activities including range of motion (ROM) [1, 2]. However, most patients experience marked pain after the TKA procedure, and the pain may affect optimal postoperative outcomes [3, 4]. Painful hypertrophic scars or keloids are another postoperative concern for TKA patients. A surgical wound of TKA has distinct characteristics that need continuous flexion–extension motion following the surgery. Although painful and itching scars are not uncommon after TKA, to the best of our knowledge, there is a paucity of data on clinical results of scar management after TKA. Hypertrophic scars and keloids represent an exaggerated proliferative response to wound healing and manifest raised, red, nodular lesions [5]. They frequently develop within 8 weeks of burn, wound closure with excess tension, wound infection, hypoxia or other traumatic skin injury [6– 8]. Since the early 1980s, the use of silicone gel in various forms has represented an option in prevention and treatment of hypertrophic scars and keloids [8]. Silicone gel helps to soften, flatten and smooth the scar while maintaining the moisture balance and elasticity of the adjacent skin [9, 10]. Eishi et al. reported that silicone gel application to scars clearly reduced the pain and itching after 4 weeks [11]. It has also been shown to reduce the discoloration and itching associated with scars [8, 9]. The purpose of this study was to evaluate the clinical efficacy and safety of silicone gel applied to surgical

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Arch Orthop Trauma Surg

scars of TKA on postoperative scar pain and pruritus. We hypothesized that use of topical silicone gel would have a beneficial effect on decreasing postoperative scar pain and pruritus after TKA by preventing hypertrophic scars or keloids.

Materials and methods Between April and August 2011, a prospective, randomized, controlled trial was carried out to determine if topical silicone gel treatment provided the benefits of decreasing scar pain and pruritus after TKA. The Consolidated Standards of Reporting Trials (CONSORT) statement [12] was followed to conduct the present study. The protocol was registered and approved by the hospital Institutional Review Board (number: UC11MISI0053). Patients undergoing a primary, unilateral, tricompartmental cemented TKA due to primary osteoarthritis were included in this study. Exclusion criteria were a diagnosis other than

Fig. 1  CONSORT diagram for the present trial

primary osteoarthritis, previous knee surgery and sensory and motor disorders in the operated limb. If patients met these inclusion and exclusion criteria, they were randomized in equal number into one of the two groups. One hundred patients were enrolled in the study. Patients were blinded to the treatment assignment. Fifty patients of one group managed operation scars with application of Kelocote® (Advanced Bio-Technologies, Inc., Silverdale, WA, USA) for 1 month after stitch-out (silicone gel group). Two Kelo-cote® gels (15 g/ea) were offered to each patient of the study group. Fifty patients of the other group managed operation scars with application of placebo. Petrolatum which has no medicinal effect was used as the placebo. All patients gave written informed consent. The CONSORT diagram is shown in Fig. 1. The same surgical procedure and rehabilitation protocol were applied to both groups. Under general anesthesia, all the operations were performed by one surgeon using the subvastus approach [13]. Single posterior-stabilized TKA prostheses (Vanguard; Biomet, Warsaw, IN, USA)

Assessed for eligibility (n = 106) Excluded (n = 6) Rheumatoid arthritis (n = 1) Previous knee surgery (n = 4) Parkinson’s disease (n = 1) Randomized (n = 100)

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Assigned to silicone gel group

Assigned to placebo group

(n = 50)

(n = 50)

Lost to follow-up

Lost to follow-up

(n = 2)

(n = 2)

Analyzed

Analyzed

(n = 48)

(n = 48)

Arch Orthop Trauma Surg

were used for all patients. The patella was resurfaced in all patients, and cement fixation was done for all components. After operation, the operation wound was closed using layer by layer technique, and skin suture was done by staples. After applying a sterile compression dressing, a Jones bandage was applied with the knee in extension, and this was retained for the day after the operation. The first day after the operation, all patients began full weight-bearing walking with a walker, and they began working on activeassisted ROM exercise. For all patients in the study, we did not use a continuous passive motion machine or physical therapy, but supervised and encouraged active ROM exercise for gaining the full ROM. We used oral medication, celecoxib 200 mg q day, for pain control in all patients for 6 weeks. Skin staples were routinely removed on day 10 after surgery, and Steri-Strip™ (3 M, St. Paul, MN, USA) was applied to the wound to lessen scarring for 5 days. The patients who classified silicone gel group managed the operation wound with Kelo-cote®, which was applied twice daily for 1 month after the removal of Steri-Strip™. In contrast, the placebo group managed the operation wound with placebo. Patients were asked whether they followed the application protocol. Follow-up examinations were carried out at 3, 6 months and 1 year after surgery. At each follow-up, visual analog scale (VAS) score for scar pain and itching, Vancouver scar scale [14], and Knee Society score [15] were measured. Pre- and postoperative data collection was performed by one of the authors of the study, who was kept blinded to the treatment. Patients were asked about the severity of scar pain and pruritus. The patients’ scar pain and pruritus were evaluated with the use of an ordinal VAS of 0–10, with 0 indicating no pain or pruritus and 10 indicating maximum pain or pruritus. Scar assessment was done using the Vancouver scar scale by assessing scar pigmentation (0: normal color, 1: hypopigmentation, 2: mixed pigmentation, 3: hyperpigmentation), vascularity (0: normal color, 1: pink, 2: red, 3: purple), pliability (0:

normal, 1: supple, 2: yielding, 3: firm, 4: banding-rope tissue, 5: contracture) and height (0: normal/flat, 1:

The effect of topical scar treatment on postoperative scar pain and pruritus after total knee arthroplasty.

The surgical wound of total knee arthroplasty (TKA) needs continuous flexion and extension movement. Silicone gel treatment is widely used to treat hy...
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