ORIGINAL ARTICLE Bali Medical Journal (Bali MedJ) 2021, Volume 10, Number 1: 225-228 P-ISSN.2089-1180, E-ISSN: 2302-2914 Keloid after orthopedic surgery: prevention, current therapy modalities, and Published by Bali Medical Journal emerging therapies modalities Andrew Sutheno1* ABSTRACT Keloid is a benign fibroproliferative tissue growth that exceeds the initial wound margins. It is caused by the disruption in the wound healing phase with increased fibroblast activity and excess collagen deposition. Keloid usually develops after 1Santo Antonius Hospital, West Kalimantan, Indonesia tissue trauma. Orthopedic surgery inevitably causes tissue trauma that will lead to the formation of keloids in a few patients. Keloids can cause cosmetic and functional problems, thus interfere with a person’s quality of life. Keloid therapy modalities are mainly divided into three, which are prophylactic therapy modalities, current therapy modalities, and emerging therapy *Corresponding author: Andrew Sutheno; modalities that are being developed. This literature review aims to evaluate further prevention, current therapy modalities, Santo Antonius Hospital, and emerging therapies modalities in Keloid following orthopedic surgery. West Kalimantan, Indonesia; [email protected] Keywords: Keloid, Orthopaedic Surgery, Prevention, Management. Received: 2021-02-11 Cite This Article: Sutheno, A. 2021. Keloid after orthopedic surgery: prevention, current therapy modalities, and emerging Accepted: 2021-04-05 therapies modalities. Bali Medical Journal 10(1): 225-228. DOI: 10.15562/bmj.v10i1.2264 Published: 2021-04-28 INTRODUCTION PATHOGENESIS OF KELOID phase which can last for several months. Excess extracellular matrix formation will Keloid is a benign fibroproliferative Keloids are considered the end product be degraded by matrix metalloproteinase tissue growth that exceeds the initial of the abnormal wound healing process. (MMP).6 wound margin in individuals with genetic In general, there are 3 phases of wound Abnormal fibroblast proliferation is the susceptibility without spontaneous healing that consist of the inflammatory 1,2 main basis for keloid formation. Keloid regression. The term ‘cheloid’ comes phase, the proliferation phase, and the fibroblasts proliferated more rapidly from Greek which means crab claws due remodeling phase. After the injury, platelet than fibroblasts from hypertrophic scars to the nature of the growth of keloid tissue degranulation, complement activation, 2,3 with higher collagen formation. Besides, that exceeds the initial wound margin. and a clotting cascade form fibrin clots increased inflammatory response and Keloid usually develops after tissue for hemostasis. Platelet degranulation imbalance between deposition and trauma. Orthopedic surgery inevitably will cause the release of various cytokines, degradation of the extracellular matrix causes tissue trauma that will lead to keloid including transforming growth factor-b 4 also play a role in the pathogenesis of formation in a few patients. Keloids can (TGF-b), platelet-derived growth factor keloids. There is a balance between cause cosmetic and functional problems. (PDGF), epidermal growth factor (EGF), the inflammatory, proliferation and Keloids often cause a cosmetic problem and insulin-like growth factor-1 (IGF-1), remodeling phases in the normal wound that leads to the embarrassment of the which play a role as a chemotactic agent healing process.2 In Keloid, there is a patient and decreased self-esteem. Most to recruit neutrophils, macrophages, prolonged inflammatory phase, increase importantly, keloids in joints can cause epithelial cells, mast cells, endothelial fibroblast activity, and excess deposition of joint contractures, thus limiting joint cells, and fibroblasts. Within 48-72 hours the extracellular matrix. This causes keloid movement. Problems that arise due to of injury, the wound healing process will tissue to grow beyond the margins of the keloids can interfere with a person’s quality enter a proliferation phase which can last initial wound.6 of life.5 3-6 weeks. Fibroblasts will synthesize Based on the brief explanation above, an extracellular matrix consisting of CLINICAL MANIFESTATION OF this literature study aims to review the procollagen, elastin, proteoglycans, and KELOID prevention and management of Keloid hyaluronic acid, which functions to after orthopedic surgery. repair wound structures and form wound Keloid has the clinical appearance of a pink bridges. After the wound is closed, the to purplish solid mass with a shiny surface, wound healing phase enters a remodeling well-defined borders, and irregular edges. PublishedOpen access: by Baliwww.balimedicaljournal.org Medical Journal | Bali Medical Journal 2021; 10(1): 225-228 | doi: 10.15562/bmj.v10i1.2264 225 ORIGINAL ARTICLE Keloids can be accompanied by itch and Patients diagnosed with keloids are at Silicon pain. The predilection for keloids is the an increased risk of arthrofibrosis after Silicone sheets can prevent wound chest, shoulders, earlobe, and upper primary total knee arthroplasty (TKA). stretching, provide occlusion, and hydrate arm. Keloids usually form after a tissue Arthrofibrosis is reported to be the the surface of the wound tissue. The trauma, although they can even form leading cause of TKA failure. Both keloids silicone sheet should be used as early as 2 spontaneously in the chest area without and arthrofibrosis are associated with an weeks from the start of the wound for more prior trauma. Keloid tissue grows beyond overexpression of TGF-b1. Patients who than 12 hours a day. This silicone sheet can the initial wound margin and there is no reported stiffness from arthrofibrosis be used for a minimum of 2 months.10 spontaneous regression.6 Keloids should be usually require surgical intervention such differentiated from hypertrophic scars. In as manipulation under anesthesia, which Flavonoid hypertrophic scars, the scar tissue formed consists of manipulating the knee through Flavonoids or bioflavonoids are natural does not exceed the initial wound margin a full range of motion while sedated. They substances from various plants that have and spontaneous regression may occur. are also at a higher risk of lysis of adhesion, been used to prevent the formation of heavy Hypertrophic scars are more common an open or arthroscopic approach to access scar tissue. Several studies have shown than keloids, with an incidence of 40-70% and debride adhesion.9 good results from using flavonoid gel on after surgery. Hypertrophic scars can be scars, but the efficacy of this product is observed 4-8 weeks after injury, develop TREATMENT OF KELOID controversial. The mechanism underlying rapidly for up to 6 months, then regress the use of flavonoids in scars is through the According to some recent literature, keloid gradually over several years.1,6 induction of matrix metalloproteinase-1 therapy modalities are mainly divided (MMP-1) and inhibition of small mothers into prophylaxis therapy, current therapy, PROBLEMS ARISING FROM against decapentaplegic 2 (SMAD 2), and emerging therapy modalities that are KELOID SMAD 3, SMAD 4 protein expression. being developed.5,10–12 The recommendation use of flavonoid is 2 Keloids can cause cosmetic and functional times a day for 4 to 6 months.10 problems.5 A study by Gürbüz et al. A. PROPHYLAXIS THERAPY showed that children with elbow fractures Skin Incision along the Main Folding B. CURRENT THERAPY accompanied by keloid lesions should Lines MODALITIES be followed up for possible neurologic The formation of hypertrophic scar and deficits with late-onset.7 The causative Triamcinolone acetonide (TA) keloids could be prevented by making factor of late-onset neurologic deficits is Intralesional TA injection is the most the skin incisions along the main folding the penetration of the callus to the nerve frequently used therapeutic modality for lines.13,14 The skin tension lines depend and neural fibrosis. Neural fibrosis could keloid management, but it is estimated on the interrelation of elastic fibers and be precipitated by excessive fibroblastic that 50% of keloids are resistant to steroid collagen fibers and the anchorage of activity.7 Most importantly, keloids in therapy.15 Triamcinolone acetonide works collagen bundles on each other. Incisions joints can cause joint contractures, thus by suppressing the inflammatory process, parallel to folds separate the collagen limiting joint movement.5 decreasing fibroblast proliferation, and bundles longitudinally and heal without Keloids often cause a cosmetic problem decreasing collagen synthesis. Side retraction. A linear incision develops a that leads to the embarrassment of the effects of TA that often occur include wider gape if it occurs transversely to the patient and decreased self-esteem. A telangiectasis, hypopigmentation, and skin main folding lines.13 study by Motoki et al. shows that 40% of atrophy. These side effects were reported keloid patients have a negative picture of Compression Therapy to be reduced when combined with their bodies.8 In addition, keloid patients 5-fluorouracil for keloid management.16 Wound compression with a pressure of may have body dysmorphic disorders 15-40 mmHg for more than 23 hours because pathological scar tissue causes 5-Fluorouracil (5-FU) a day for at least 6 months has been dissatisfaction with self-image. This 5-fluorouracil is a pyrimidine analog that said to prevent keloids. Although this can interfere with the patient’s social inhibits DNA synthesis by irreversibly