Scar Tissue/Spacer

[2goldens]

I'm 8-1/2 months from a Zimmer TKR (December 18, 2007); had manual manipulation on January 31, 2008. The surgeon reported that he achieved 125 degrees of flexion in the manipulation and that he was able to break adhesions (but perhaps not all). Had two arthoscopies prior to the TKR. I "enjoy" psoriatic arthritis; being treated with Remicade and MTX. My extension is 0-1 (I'm thrilled), but flexion (cold) is 103, and depending on how the PT measures, flexion after PT session can be 117 or with intense assistance, as much as 129 (owing to different PT's, and the nature of the assistance at the time of measurement). Cold flexion has been as high as +/- 115, but in the last 4-6 weeks has dropped to 103-104 (ugh; wrong direction). Faithfully doing exercises 5 days a week (PT once a week, which counts as a day of exercise); have been having PT sessions once a week since the procedure. Swelling now under control, after 4 weeks of thrice a day ice -- circumference of knees is almost identical. Knee itself really is without pain, but I have a feeling like there's something in the prosthesis that won't let the femur end of the prosthesis roll on the tray like it's illustrated on the various vendors' websites; so, I'm not getting the range of motion that I believe I should expect.

So, now I'm four months out. Early on, surgeon said that I should expect cold flexion of at least 120 (Zimmer and others would have you believe that the number to be expected is higher, but I dunno). Surgeon has now indicated that there's an issue with scar tissue that may need to be excised (my sense is that excising scar tissue has the potential to create additional scar tissue) and perhaps the spacer should be decreased in size. Would welcome thoughts from Josephine or anyone having similar experiences.

PS: This website is terrific. What a wonderful fraternity (sorority) to be a part of.

 

[Josephine]

Welcome to the forum, 2goldens. Nice to have you aboard!

Okaaay - well the flexion you have achieved would seem to indicate that the spacer is the correct size.

Thing about scar tissue, in theory you are right, it does have that potential but the good news is, it rarely does! The original surgery you had was somewhat extensive by comparison to the surgery to excise scar tissue. That could be done arthroscopically but even if not, it's still not as extensive as the original TKR. Therefore the scar tissue response won't be as pronounced.

 

[1jt@atime]

So Jo, what you are saying is that by going into the kr arthroscopically to remove scar tissue, your body will not regenerate as much scar tissue as is curently there because there will be less trauma to the soft tissue this go round. Is that correct? I am still having pain under my knee cap of my almost 11 month old knee when I go up/down steps and get up/sit down in chairs and I'm thinking it's scar tissue. I would really LOVE to get rid of this pain. I already had a lot of scar tissue going into the kr so I know there is even more there now. I'll be seeing my OS in about 3 weeks and I'm lining up my Qs now.

Welcome Twogoldens!!!! Karen

 

[AlaskanTKR]

Josephine!
Thank you for this answer. I just got back from PT and the PT says that the OS may talk about manipulation due to the problems I am having. I see him Friday PM next. She feels that I have quite a bit of scar tissue built up which is literally blocking the knee from passing 82-85 degrees ROM after almost 6 weeks of fairly agressive PT (with th eexception of 1 day that I was extremely swollen). I was wondering about what happens to the scar tissue after the Manipulation and wondered if they scope to remove it would it just reform. What you said makes such good sense. I don't know why I didn't realize that the scope is much less invasive (way lessss!!!!).

You are a wonder!!!!

Marianne

 

[2goldens]

Josephine, thanks so much for your insight.

As you can tell from the thread, there are concerns with how to remove scar tissue without creating more scar tissue. My PT regularly massages scar tissue around the top of the prosthesis (to the extent that the tissue is near the skin and can be massaged), but has indicated that she believes that there is also "deep" scar tissue that she can massage. The OS has talked about an open procedure to address the spacer size, and at the same time, remove scar tissue. While that might on its face seem efficient, if the spacer isn't really a problem, then a scope to remove the scar tissue seems like a more conservative approach, and less challenging to a prompt/less painful recovery.

As to the issues that have been identified, my rheumatologist has recommended a sonnogram of my knee. I understand from him that a sonnogram will show how well the prosthesis moves and also show scar tissue. I assume from this that the sonnogram will show images of the motion of the prosthesis and whether the spacer is properly sized. Is this correct thinking, and what kind of imaging should I expect the OS to order to identify what's restricting my range of motion? Since the OS hasn't ordered any imaging, are there other dynamics that could be affecting my range of motion (my flexion in my left knee is 146 for comparison)? With the OS achieving 125 degrees in the manual manipulation, can that be considered a benchmark of sorts (for instance, the amount of cold flexion that can be expected; or does it mean anything)? Finally, what is the difference between a sonnogram and an MRI?

Thanks so much.

 

[Josephine]

Arthroscopic excision will be more of a trim and dividing tight bands.

Open excision, illogical as it seems, doesn't very often make the scar tissue reoccur although it is a theoretical possibility, of course.

As for the situation requiring manipulation, that is more often a case of adhesions which may or may not be due to actual scar tissue. Often adhesions occur because the natural lubricant between the various ligaments and other layers of tissues isn't present in sufficient quantity or quality (in other words, it's dried up!) and the structures start adhering to one another. This is one form of scarring.

The other type is where tissue is cut or split, what gets laid down between the divided layers is a fibrous, dense tissue, quite unlike anything that normally occurs in the body. You can see this on the surface where the incision has been made in the skin. In some people the body can over-produce this abnormal tissue which is where problems with blocking ROM can occur. In skin this over-production can become discoloured when it is known as a keloid scar.

It also needs to be mentioned that there are people who have a proclivity toward one or other of these tendencies. It's not anything you have or haven't done - just rotten back luck!


The difference between an MRI (Magnetic Resonance Imagery) and a sonogram is that the first is when you have to sit in a big donut filled with magnets which make a slice by slice image of your body. A sonogram is another term for ultrasound which pregant ladies have to check on their sprogs!

 

[AlaskanTKR]

Josephine

What color is the keloid scar. Since the beginning at the base of the scar under the kneecap area along the medial side of the scar there has been a discoloration - like the skin in browner or tanner - sometimes it seems redder. We looked at it yesterday at PT and they said just to check with the OS. It is also in the area where the PT says she can really "feel" scar tissue. It is in what I would think is a thinner area of skin unlike up by the quad. How do we get rid of this stuff - we have been massaging the heck out of the whole scar area.

Marianne

 

[AlaskanTKR]

whew - Josephine. I thought maybe that was my issue - I just googled keloid - my area is not raised or bubbly there. It is flat and just slightly discolored - more shaded than my other areas. From whatthe keloids look like - its not my issue. Mine may be a pressure issue or something like that - stretching of the skin. Opposite side of the scar (lateral) has no feeling - no isssue - just weird feeling when shaving! What did we ever do before google!

Enjoy the day!
MArianne

 

[Josephine]

This is a fairly typical keloid scar. Seems to be more common in darker skinned types of people of African origin. Another name is 'hypertrophic' scar which just means overgrown.



If one gets a real keloid, there's not an awful lot can be done as - so far as I am aware - no amount of massage or topical treatment will make it go away.

However, it's not uncommon for caucasion people to get slightly discoloured scars but that doesn't necessarily mean they are keloid.

 

[Linda2]

My very pale son developed this type of scar when he had wrist surgery. The surgeon revised the scar (i.e. cut it out) and the healing was much smoother the second time around.

 

[2goldens]

Josephine, you don't know how comforting your advice is.

And does the sonogram show images of the motion of the prosthesis and whether the spacer is properly sized? With an MRI (and being in a doughnut), are the technicians able to mobilize the knee to snap pictures of how it is functioning? I guess my question is what kind of imaging is needed to identify what's restricting my range of motion?

 

[AlaskanTKR]

2 goldens = love your question for Josephine - and your timing is great - I too am struggling and will see the OS Friday - Now I will be ready for him - my questions and his suggestions and recs.

Marianne

 

[Josephine]

My very pale son developed this type of scar when he had wrist surgery. The surgeon revised the scar (i.e. cut it out) and the healing was much smoother the second time around.

Yes - forgot that bit!

Josephine, you don't know how comforting your advice is.

And does the sonogram show images of the motion of the prosthesis and whether the spacer is properly sized? With an MRI (and being in a doughnut), are the technicians able to mobilize the knee to snap pictures of how it is functioning? I guess my question is what kind of imaging is needed to identify what's restricting my range of motion?

Pleased to be able to help.

As far as the movement of the leg during the scans, for the MRI it will be a definite no-no. The subject must be perfectly still throughout else the image will be blurred. As for the sonogram, to be honest, I'm not sure. I've not had personal experience of it. I know that in a straightforward ultrasound it's more usual to have the subject still. It all rather depends upon exactly what the surgeon wants.