Impact of a new cryotherapy device on early rehabilitation after primary total knee arthroplasty (TKA): a prospective randomised controlled trial

Skin temperature of the knee was effectively reduced when using a new continuous cold-flow cryocompression device: a randomised controlled crossover trial

OBJECTIVE

To determine which temperature settings on a new continuous cold-flow cryocompression device effectively reduce knee skin temperature to 10-15 °C, where pain and swelling are expected to be attenuated.

DESIGN

Randomised controlled crossover trial.

SETTING

University laboratory.

PARTICIPANTS

32 healthy adult participants recruited (1 dropout) with no contraindications to cryocompressive therapy.

INTERVENTION

A k-type thermocouple was used to record skin temperature at baseline and every five minutes during a 30-minute cryocompression treatment in a control condition and when using four different device temperature settings (6 °C, 8 °C, 10 °C, and 12 °C) on a continuous cold-flow cryocompression device. Conditions were labelled Control, Con-6, Con-8, Con-10, and Con-12, respectively.

MAIN OUTCOME MEASURES

Skin temperature change (°C) throughout cryocompression; time taken (mins) to achieve skin temperature < 15 °C; and the difference between final skin temperature and device temperature setting (°C).

RESULTS

Median (IQR) skin temperature after cryocompression was 32.1 °C (29.3-33.4), 12.8 °C (12.1-14.6), 14.3 °C (13.8-15.7), 16.1 °C (15.2-17.3), and 17.7 °C (16.9-18.9) for the Control condition and Con-6, Con-8, Con-10 and Con-12, respectively. It took 20 min (Con-6) and 25 min (Con-8) for skin temperature to reach < 15 °C. A median (IQR) difference of 6.8 °C (6.1-8.6), 6.3 °C (5.8-7.7), 6.1 °C (5.2-7.3), and 5.7 °C (4.9-6.9) for Con-6, Con-8, Con-10, and Con-12, respectively was observed between device temperature setting and final skin temperature.

CONCLUSIONS

The device is recommended as it reduced skin temperature to the therapeutic range of 10-15 °C during a 30-minute treatment when using the 6 °C or 8 °C device temperature settings. Future research should determine optimal treatment lengths for cryocompression. CONTRIBUTION OF THE PAPER.

Randomized controlled trial of compressive cryotherapy versus standard cryotherapy after total knee arthroplasty: pain, swelling, range of motion and functional recovery

BACKGROUND

After total knee arthroplasty (TKA), patients have limited knee range of motion (ROM), trophic changes and pain. Cryotherapy and compression are recommended in the literature, but no study has shown that cryotherapy and compression combined leads to better results than cryotherapy alone. The primary objective was to compare knee ROM after 21 days of rehabilitation post-TKA between patients who underwent rehabilitation with compressive cryotherapy with those who had cryotherapy alone. The secondary objectives were to compare other trophic, pain and functional outcomes.

METHODS

Forty patients were randomized into two groups: Standard Cryotherapy (SC = 20, median age 77 years), which applied cold packs along with their rehabilitation; and Compressive Cryotherapy (CC = 20, median age 76 years), which received cold compression. Knee joint's passive and active ROM (primary outcome) were measured with a goniometer. Knee's circumference, fluctuation test, pain at rest and during activity, 6-minute walking test (6MWT) and KOOS questionnaire were secondary outcomes. The groups were compared on D1 (baseline) and D21 of rehabilitation. A survival analysis has compared the groups on D1, D8, D15, D21.

RESULTS

All subjects had a significant improvement in all the parameters on D21 relative to D1 (p < .05), except for pain at rest (p = .065 for CC and p = .052 for SC). On D21, the CC group had a significantly larger improvement in the joint effusion (p = .002), pain during activity (p = .005), 6MWT (p = .018) and KOOS (p = .004) than the SC group. Based on the survival analysis, the CC group had significantly faster improvement in the joint ROM (p = .011 for flexion and p = .038 for extension) and knee circumference (p = .013) than the SC group.

CONCLUSIONS

Both cryotherapy methods improved joint ROM, trophic changes, pain and function. Adding dynamic compression to a cryotherapy protocol provided further benefits: a significantly faster improvement in passive knee flexion ROM, a greater reduction of swelling, and pain during activity. Similarly, walking distance and KOOS questionnaire were significantly better for CC.

TRIALS REGISTRATION

The study was registered in the ClinicalTrials.gov database on 14/09/2023 (identifier: NCT06037824).

A randomised crossover trial of five cryocompression devices' ability to reduce skin temperature of the knee

BACKGROUND

The application of cold and pressure to the knee is a common part of post-operative rehabilitation. Skin temperature should be reduced to within 10-15 °C to optimise the therapeutic benefits of cryocompression. The purpose of this study was to investigate the ability of five different cryocompression devices to reduce skin temperature to within this therapeutic range.

MATERIALS AND METHODS

32 healthy adult participants (mean (SD): age 26.3 (7.9) years; BMI 24.8 (2.7) kg/m2; 20 males) were recruited for this randomised crossover study. Skin temperature was measured 20 mm distal to the patella using a k-type thermocouple every five minutes during a 30-minute treatment with one of five different cryocompression devices (Physiolab S1, GameReady, Cryo/Cuff, VPulse, and a Gel Wrap). Changes in skin temperature over time were compared to baseline within and between conditions. A subjective rating of comfort was also recorded for each device.

RESULTS

The Physiolab S1 and GameReady devices caused significantly lower skin temperatures compared to the VPulse, Gel Wrap, and Cryo/Cuff after 30 minutes (p<0.05). 87-96% reported a positive comfort rating for the Physiolab S1, VPulse, Cryo/Cuff and Gel Wrap, whereas 53% of participants reported a positive comfort rating for the GameReady.

CONCLUSIONS

Only the Physiolab S1 and GameReady devices reduced skin temperature of the knee to within the target range of 10-15 °C. The Physiolab S1 was reportedly more comfortable than the GameReady. Clinicians should be aware of the performance differences of different cryocompression devices to understand which is most likely to provide an effective dose of cold therapy to a joint.

A Physiotherapeutic Approach to a Rare Case of Windswept Deformity in a Male Adolescent

Primary hyperparathyroidism (PHPT) can lead to a rare condition in children and adolescents known as windswept deformity. This deformity involves one knee exhibiting an abnormal outward angulation (valgus deformity), while the other knee shows an abnormal inward angulation (varus deformity). This asymmetrical syndrome, resembling the effect of strong winds, gives the impression that the knees are being swept in opposite directions. Various factors, such as structural bone or joint defects, accidents, or underlying disorders, can contribute to the development of windswept deformity. PHPT, a common endocrine condition characterized by elevated levels of parathyroid hormone and blood calcium, is unusual in the pediatric and adolescent populations. It can result in complications like osteoporosis and bone abnormalities, with genu valgus (outward knee angulation) being an exceptionally rare symptom. This case discusses a 19-year-old male who underwent corrective surgery for genu valgus and presented with windswept deformity due to teenage hyperparathyroidism. The case study outlines the physiotherapeutic rehabilitation strategy, emphasizing treatments such as cryotherapy, patellar mobilization, and gait training. Tailored physical therapy rehabilitation plays a crucial role in the postoperative care of patients undergoing corrective osteotomies. The results indicated a significant improvement in muscle strength, an expansion of the range of motion (ROM), and a noticeable enhancement in the individual's functional autonomy following adherence to the postoperative physiotherapy (PT) plan.

Cryotherapy following total knee replacement

BACKGROUND

Total knee replacement (TKR) is a common intervention for people with end-stage symptomatic knee osteoarthritis, resulting in significant improvements in pain, function and quality of life within three to six months. It is, however, acutely associated with pain, local oedema and blood loss. Post-operative management may include cryotherapy. This is the application of low temperatures to the skin surrounding the surgical site, through ice or cooled water, often delivered using specialised devices. This is an update of a review published in 2012.

OBJECTIVES

To evaluate the effect of cryotherapy in the acute phase after TKR (within 48 hours after surgery) on blood loss, pain, transfusion rate, range of motion, knee function, adverse events and withdrawals due to adverse events.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers, as well as reference lists, related links and conference proceedings on 27 May 2022.

SELECTION CRITERIA

We included randomised controlled trials or controlled clinical trials comparing cryotherapy with or without other treatments (such as compression, regional nerve block or continuous passive motion) to no treatment, or the other treatment alone, following TKR for osteoarthritis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We discussed any disagreements and consulted another review author to resolve them, if required. Major outcomes were blood loss, pain, transfusion rate, knee range of motion, knee function, total adverse events and withdrawals from adverse events. Minor outcomes were analgesia use, knee swelling, length of stay, quality of life, activity level and participant-reported global assessment of success.

MAIN RESULTS

We included 22 trials (20 randomised trials and two controlled clinical trials), with 1839 total participants. The mean ages reflected the TKR population, ranging from 64 to 74 years. Cryotherapy with compression was compared to no treatment in four studies, and to compression alone in nine studies. Cryotherapy without compression was compared to no treatment in eight studies. One study compared cryotherapy without compression to control with compression alone. We combined all control interventions in the primary analysis. Certainty of evidence was low for blood loss (downgraded for bias and inconsistency), pain (downgraded twice for bias) and range of motion (downgraded for bias and indirectness). It was very low for transfusion rate (downgraded for bias, inconsistency and imprecision), function (downgraded twice for bias and once for inconsistency), total adverse events (downgraded for bias, indirectness and imprecision) and withdrawals from adverse events (downgraded for bias, indirectness and imprecision). The nature of cryotherapy made blinding difficult and most studies had a high risk of performance and detection bias. Low-certainty evidence from 12 trials (956 participants) shows that cryotherapy may reduce blood loss at one to 13 days after surgery. Blood loss was 825 mL with no cryotherapy and 561 mL with cryotherapy: mean difference (MD) 264 mL less (95% confidence interval (CI) 7 mL less to 516 mL less). Low-certainty evidence from six trials (530 participants) shows that cryotherapy may slightly improve pain at 48 hours on a 0- to 10-point visual analogue scale (lower scores indicate less pain). Pain was 4.8 points with no cryotherapy and 3.16 points with cryotherapy: MD 1.6 points lower (95% CI 2.3 lower to 1.0 lower). We are uncertain whether cryotherapy improves transfusion rate at zero to 13 days after surgery. The transfusion rate was 37% with no cryotherapy and 79% with cryotherapy (risk ratio (RR) 2.13, 95% CI 0.04 to 109.63; 2 trials, 91 participants; very low-certainty evidence). Low-certainty evidence from three trials (174 participants) indicates cryotherapy may improve range of motion at discharge: it was 62.9 degrees with no cryotherapy and 71.2 degrees with cryotherapy: MD 8.3 degrees greater (95% CI 3.6 degrees more to 13.1 degrees more). We are uncertain whether cryotherapy improves function two weeks after surgery. Function was 75.4 points on the 0- to 100-point Dutch Western Ontario and McMaster Universities Arthritis Index (WOMAC) scale (lower score indicates worse function) in the control group and 88.6 points with cryotherapy (MD 13.2 points better, 95% CI 0.5 worse to 27.1 improved; 4 trials, 296 participants; very low-certainty evidence). We are uncertain whether cryotherapy reduces total adverse events: the risk ratio was 1.30 (95% CI 0.53 to 3.20; 16 trials, 1199 participants; very low-certainty evidence). Adverse events included discomfort, local skin reactions, superficial infections, cold-induced injuries and thrombolytic events. We are uncertain whether cryotherapy reduces withdrawals from adverse events (RR 2.71, 95% CI 0.42 to 17.38; 19 trials, 1347 participants; very low-certainty evidence). No significant benefit was found for secondary outcomes of analgesia use, length of stay, activity level or quality of life. Evidence from seven studies (403 participants) showed improved mid-patella swelling between two and six days after surgery (MD 7.32 mm less, 95% CI 11.79 to 2.84 lower), though not at six weeks and three months after surgery. The included studies did not assess participant-reported global assessment of success.

AUTHORS' CONCLUSIONS

The certainty of evidence was low for blood loss, pain and range of motion, and very low for transfusion rate, function, total adverse events and withdrawals from adverse events. We are uncertain whether cryotherapy improves transfusion rate, function, total adverse events or withdrawals from adverse events. We downgraded evidence for bias, indirectness, imprecision and inconsistency. Hence, the potential benefits of cryotherapy on blood loss, pain and range of motion may be too small to justify its use. More well-designed randomised controlled trials focusing especially on clinically meaningful outcomes, such as blood transfusion, and patient-reported outcomes, such as knee function, quality of life, activity level and participant-reported global assessment of success, are required.

Efficacy of perioperative cryotherapy combined with intra-articular injection of tranexamic acid in total knee arthroplasty

OBJECTIVE

To evaluate the efficacy and safety of perioperative cryotherapy combined with intra-articular injection of tranexamic acid (TXA) in total knee arthroplasty (TKA) and explore a new strategy of enhanced recovery after TKA.

METHODS

We randomly divided 200 patients into 4 groups: normal saline (10 mL) by drainage (Group A, placebo); intra-articular injection of TXA (1 g, 10 mL, Group B); normal saline (10 mL) and continuous cryotherapy postoperatively (Group C) and intra-articular injection of TXA (1 g, 10 mL) and continuous cryotherapy postoperatively (Group D). Primary outcomes were blood loss volume, postoperative pain and circumference variation. We also recorded consumption of analgesics, postoperative length of stay (p-LOS), range of motion (ROM), function score (Hospital for Special Surgery) and severe complications.

RESULTS

There were statistically significant differences in postoperative drainage volume, total blood loss, hidden blood loss, and visual analogue scale at rest and walking on postoperative day 1 (POD1), POD2, POD3, ROM (POD3, 7, discharge, postoperative month), circumference variation (POD3, 7), p-LOS, Hospital for Special Surgery score (discharge) and drop of hemoglobin on POD3 (P < .05) among 4 groups, but there were no significant differences in intraoperative blood loss, postoperative prothrombin, activated partial thromboplastin time, overall number of patients or total consumption of oxycodone and perioperative complications (e.g., incidence of surgical site infection, deep venous thrombosis, and cold injury) among them (P > .05).

CONCLUSION

Continuous cryotherapy combined with intra-articular injection of TXA provides short-term advantages in reducing blood loss, pain, postoperative swelling, p-LOS and increasing ROM and joint function in the early postoperative period after TKA without increasing any severe complications.

Continuous cryotherapy vs. traditional cryotherapy after total knee arthroplasty: A systematic review and meta-analysis of randomized controlled trials

Background

Cryotherapy is widely applied to relieve pain and improve functional outcomes after total knee arthroplasty (TKA). New cryotherapy devices have recently been developed to guarantee a fixed temperature for a prolonged time. Therefore, we conducted a systematic review and meta-analysis to compare continuous cryotherapy and traditional cryotherapy (ice bag or gel pack) for patients after TKA.

Methods

This study was conducted according to a predefined protocol registered on PROSPERO. Two independent reviewers performed an electronic database search of PubMed, Embase, Cochrane, Web of Science, Google Scholar, and ClinicalTrials.gov. Dichotomous outcomes were reported as risk difference (RD) with 95% confidence intervals (CIs), and continuous outcomes were reported as mean difference (MD), or standardized mean difference (SMD) with 95% CIs.

Results

Seven trials enrolling a total of 519 patients were included. There were no differences in pain intensity (MD: -0.54, 95% CI: -1.55 to 0.47; P = 0.30), analgesics consumption (MD: -0.37, 95% CI: -1.28 to 0.55; P = 0.43), postoperative range of motion (MD: 0.47, 95% CI: -4.09 to 5.03; P = 0.84), swelling of the knee joint, blood loss, change in hemoglobin, or transfusion rate. Meanwhile, there were no differences in length of hospital stay (MD: -0.77, 95% CI: -1.62 to 0.08; P = 0.07) and adverse events (RD: 0, 95% CI: -0.02 to 0.03; P = 0.74). In addition, continuous cryotherapy leads to extra costs and resources than traditional cryotherapy.

Conclusions

Continuous cryotherapy does not appear to offer significant benefits for TKA when compared with traditional cryotherapy. Based on currently available evidence, traditional cryotherapy is still recommended as continuous cryotherapy is not cost-effective. Further well-designed studies with larger sample sizes are warranted to further confirm these preliminary results. PROSPERO Registration: Identifier [CRD42022308217].

The Role of Cryotherapy After Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Previous research shows conflicting evidence regarding the postoperative role of cryotherapy after total knee arthroplasty (TKA). This systematic review aims to further investigate the effect of various methods of cryotherapy on the following: (1) pain; (2) swelling; (3) postoperative opioid use; and (4) range of motion (ROM).

METHODS

A strategic keyword search of Medline, Cochrane, Embase, and CINAHL retrieved randomized controlled trials examining cryotherapy following TKA published between February 1, 2017, and February 24, 2022. The studied outcomes included pain ratings, knee/limb swelling, opioid use, and ROM. Six studies were selected for inclusion in this review.

RESULTS

Opioid use was significantly decreased in cryotherapy groups compared to noncryotherapy groups within the first postoperative week only (P < .05). This effect may be augmented by the use of computer-assisted (temperature regulated) cryotherapy devices, compared to other modalities including ice packs. Pain ratings also decrease, but this decrease may not be clinically relevant. Cryotherapy appears to confer no consistent benefit to ROM and swelling at any time point. Computer-assisted cryotherapy may be associated with decreased opioid consumption after TKA compared to traditional ice packs.

CONCLUSION

Cryotherapy's role after TKA appears to be in decreasing opioid consumption primarily in the first postoperative week. Pain ratings also decrease consistently with cryotherapy use, but this decrease may not be clinically relevant. Study heterogeneity requires further research focusing on optimizing cryotherapy modalities within the first postoperative week, and analyzing cost associated with modern outpatient postoperative TKA protocols.

The role of computer-assisted cryotherapy in the postoperative treatment after total knee arthroplasty: positive effects on pain and opioid consumption

PURPOSE

The aim of this study was to investigate whether computer-assisted cryotherapy is effective in reducing postoperative pain and analgesics consumption, next to improving functional outcome and patient satisfaction after total knee arthroplasty (TKA). The hypothesis is that computer-assisted cryotherapy has positive effects on postoperative pain after TKA.

METHODS

A single-centre non-blinded randomised controlled trial was designed to study the early (first postoperative week) and late (2 and 6 weeks postoperatively) additive effect of computer-assisted cooling after TKA. Participants scheduled for a TKA were randomly allocated to a cold (cryotherapy) C-group or a regular (control) R-group. Next to usual postoperative care for both groups, the C-group received computer-assisted cryotherapy during the first seven postoperative days. Primary outcome was pain, monitored with the numerical rating scale for pain and use of opioid escape medication. Secondary outcomes were function and swelling, monitored by active range of motion, timed up and go test and circumference measurements; patient-reported outcome measurements (KOOS and WORQ questionnaires); and patient satisfaction, monitored by the numerical rating scale for satisfaction.

RESULTS

102 patients participated in this study, both groups contained 51 patients. On most days during the first week, patients in the C-group scored significantly lower NRS pain scores and registered significantly less use of opioid escape medication. In a sub-analysis of 57 patients using the same standard pain protocol, patients in the C-group (n = 28) used less oxycodone during the first postoperative week. There were no significant differences between both groups in active range of motion, timed up and go, or circumference measurements. For the WORQ questionnaire, there was a significant difference between the two groups 6 weeks postoperatively in favour of the C-group. This could be however due to a reduced validity of this questionnaire shortly after TKA. The satisfaction score was not significantly different between both groups.

CONCLUSION

Computer-assisted cryotherapy following TKA can be beneficial during the first postoperative week in terms of pain reduction and diminished opioid consumption. No clear differences in knee function or swelling were seen.

LEVEL OF EVIDENCE

Therapeutic study with level of evidence I.

Effects of 7 Consecutive Systematic Applications of Cryotherapy With Compression

CONTEXT

Postsurgical and acute orthopedic patients are frequently treated with consecutive systematic cryotherapy despite the void of data to support treatment safety or effectiveness. The purpose of this study was to examine the occurrence of frostbite and measure skin temperatures during the systematic application of 2 cryocompression protocols.

DESIGN

A repeated-measures design guided this study.

METHODS

Nine healthy, college-aged participants (4 men and 5 women; age = 20.7 [1.2] y; height = 174 [11.01] cm; mass = 74 [14] kg) received both cryocompression protocols separated by ≥ 1 week. The static cryocompression protocol consisted of seven 40-minute "on" cycles of cryotherapy (4.4°C) with 45 mm Hg of compression, each followed by a 30-minute "off" cycle (no cryotherapy, compression set at 5 mm Hg). The intermittent cryocompression protocol consisted of seven 40-minute "on" cycles of cryotherapy (4.4°C) with compression alternating between 5 and 45 mm Hg, each followed by a 30-minute "off" cycle (no cryotherapy, compression set at 5 mmHg). At the end of each "on" and "off" cycle, we used a checklist to assess for frostbite, a PT-6 thermocouple to measure skin temperature (in degrees Celsius), and a 10-cm Likert scale to assess comfort.

RESULTS

None of the participants experienced any signs or symptoms of frostbite. There were no differences in skin temperature between the compression conditions over time (F14,112 = 1.43; P = .149) nor were there any differences between the 2 compression conditions (F1,8 = 3.75; P = .087; 1-β = 0.40). The skin temperatures were statistically different over the course of all 7 "on" and "off" cycles (F14,112 = 95.12; P < .001). There was no difference between the skin temperatures produced at the end of each "on" cycle.

CONCLUSIONS

The application of 7 consecutive cryotherapy treatments with compression did not result in any signs or symptoms of frostbite and produced similar skin temperatures with each "on" cycle.

Evaluation and Management of a Painful Knee After Total Knee Arthroplasty

Pain after total knee arthroplasty (TKA) is not infrequent and may be indicative of a broad spectrum of prosthesis-related, intra-articular, or extra-articular pathologies. To diagnose and treat the underlying cause of a painful TKA, systematic evaluation of the patient is critical to ensure that they are managed appropriately and expeditiously. This evidence-based review presents current concepts regarding the pathophysiology, etiology, and diagnosis of painful TKA and our recommended approach for management. [Orthopedics. 2021;44(6):341-352.].

Shall we use cryotherapy in the treatment in surgical procedures, in acute pain or injury, or in long term pain or dysfunction? - A systematic review

PURPOSE

This review aimed to evaluate the certainty of evidence for the use of cryotherapy in patients with musculoskeletal disorders.

METHODS

PubMed, Embase, Cochrane Library and AMED were searched from January 2000 to January 2018 (update June 2019) for systematic reviews (SRs) and randomized controlled trials (RCTs) reporting outcomes on pain, swelling, range of motion (ROM), function, blood loss, analgesic use, patient satisfaction and adverse advents. The papers were categorised into: surgical procedures, acute pain or injury and long-term pain or dysfunction. Methodological quality and risk of bias were assessed using the AMSTAR and the Swedish Health Technology Assessment instruments. Level of certainty of evidence was synthesized using GRADE.

STUDY SELECTION

Eight SRs and 50 RCTs from a total of 6027 (+839) were included. In total 34 studies evaluated cryotherapy in surgical procedures, twelve evaluated cryotherapy use in acute pain or injury and twelve studies evaluated cryotherapy in long-term pain and dysfunction.

RESULTS

The certainty of evidence is moderate (GRADE III) after surgical procedures to reduce pain, improve ROM, for patient satisfaction and few adverse events are reported. Cryotherapy in acute pain and injury or long-term pain and dysfunction show positive effects but have a higher number of outcomes with low certainty of evidence (GRADE II).

CONCLUSION

Cryotherapy may safely be used in musculoskeletal injuries and dysfunctions. It is well tolerated by patients. More advanced forms of cryotherapy may accentuate the effect. Future research is needed where timing, temperature for cooling, dose (time) and frequency are evaluated.

Orthopaedic Application of Cryotherapy: A Comprehensive Review of the History, Basic Science, Methods, and Clinical Effectiveness

»

Cold therapy, also known as cryotherapy, includes the use of bagged ice, ice packs, compressive cryotherapy devices, or whole-body cryotherapy chambers. Cryotherapy is commonly used in postoperative care for both arthroscopic and open orthopaedic procedures.

»

Cryotherapy is associated with an analgesic effect caused by microvasculature alterations that decrease the production of inflammatory mediators, decrease local edema, disrupt the overall inflammatory response, and reduce nerve conduction velocity.

»

Postoperative cryotherapy using bagged ice, ice packs, or continuous cryotherapy devices reduced visual analog scale pain scores and analgesic consumption in approximately half of research studies in which these outcomes were compared with no cryotherapy (11 [44%] of 25 studies on pain and 11 [48%] of 23 studies on opioids). However, an effect was less frequently reported for increasing range of motion (3 [19%] of 16) or decreasing swelling (2 [22%] of 9).

»

Continuous cryotherapy devices demonstrated the best outcome in orthopaedic patients after knee arthroscopy procedures, compared with all other procedures and body locations, in terms of showing a significant reduction in pain, swelling, and analgesic consumption and increase in range of motion, compared with bagged ice or ice packs.

»

There is no consensus as to whether the use of continuous cryotherapy devices leads to superior outcomes when compared with treatment with bagged ice or ice packs. However, complications from cryotherapy, including skin irritation, frostbite, perniosis, and peripheral nerve injuries, can be avoided through patient education and reducing the duration of application.

»

Future Level-I or II studies are needed to compare both the clinical and cost benefits of continuous cryotherapy devices to bagged ice or ice pack treatment before continuous cryotherapy devices can be recommended as a standard of care in orthopaedic surgery following injury or surgery.

Mirabilite with Ice Pack after Total Knee Arthroplasty: A Randomized Controlled Trial Study

Background

Total knee arthroplasty (TKA) is a well-established procedure for end-stage arthritis of the knee with complications such as swelling and pain. The aim of this study is to estimate the effect of mirabilite with ice pack versus ice pack in relieving pain, swelling, range of motion (ROM), and serum CRP level on patients after TKA.

Methods

Eighty patients undergoing primary unilateral TKA were randomly assigned to two groups (MIP group and WIP group). We used VAS to measure knee pain at 24 h, 48 h, and 72 h after the surgery, respectively. Knee swelling degree was evaluated by measuring the girth of the leg at the center of the patella and 10 cm above and below it at the same frequency. The active ROM of the knee was measured by using a universal goniometer of plastic material at 72 h postoperatively. The serum CRP level was also measured at 72 h postoperatively.

Results

The MIP group showed statistically significant lower knee girth at 48 h (p < 0.05) and 72 h (p < 0.05) postoperatively and VAS score at 72 h (p=0.018) postoperatively after TKA than the WIP group. The ROM of the MIP group was significantly wider than the WIP group (p=0.024). The CRP level (p=0.036) and length of stay (LOS) (p=0.037) of the MIP group were significantly lower than the WIP group.

Conclusion

Mirabilite with ice pack after TKA showed superiority in relieving pain, reducing swelling, and improving ROM than ice pack only.

1H-NMR-Based Analysis for Exploring Knee Synovial Fluid Metabolite Changes after Local Cryotherapy in Knee Arthritis Patients

Rehabilitation using cryotherapy has widely been used in inflammatory diseases to relieve pain and decrease the disease activity. The aim of this study was to explore the metabolite changes in inflammatory knee-joint synovial fluids following local cryotherapy treatment (ice or cold CO2). We used proton nuclear magnetic resonance (1H NMR) spectroscopy to assess the metabolite patterns in synovial fluid (SF) in patients with knee arthritis (n = 46) before (D0) and after (D1, 24 h later) two applications of local cryotherapy. Spectra from aqueous samples and organic extracts were obtained with an 11.75 Tesla spectrometer. The metabolite concentrations within the SF were compared between D1 and D0 using multiple comparisons with the application of a false discovery rate (FDR) adjusted at 10% for each metabolite. A total of 32 metabolites/chemical structures were identified including amino acids, organic acids, fatty acids or sugars. Pyruvate, alanine, citrate, threonine was significantly higher at D1 vs D0 (p < 0.05). Tyrosine concentration significantly decreases after cryotherapy application (p < 0.001). We did not observe any effect of gender and cooling technique on metabolite concentrations between D0 and D1 (p > 0.05). The present study provides new insight into a short-term effect of cold stimulus in synovial fluid from patients with knee arthritis. Our observations suggest that the increased level of metabolites involved in energy metabolism may explain the underlying molecular pathways that mediate the antioxidant and anti-inflammatory capacities of cryotherapy.

How to predict early clinical outcomes and evaluate the quality of primary total knee arthroplasty: a new scoring system based on lower-extremity angles of alignment

Background

A method that can accurately predict the outcome of surgery can give patients timely feedback. In addition, to some extent, an objective evaluation method can help the surgeon quickly summarize the patient’s surgical experience and lessen dependence on the long wait for follow-up results. However, there was still no precise tool to predict clinical outcomes of total knee arthroplasty (TKA). This study aimed to develop a scoring system to predict clinical results of TKA and then grade the quality of TKA.

Methods

We retrospectively reviewed 98 primary TKAs performed between April 2013 and March 2017 to determine predictors of clinical outcomes among lower-extremity angles of alignment. Applying multivariable linear-regression analysis, we built Models (i) and (ii) to predict detailed clinical outcomes which were evaluated using the Knee Society Score (KSS). Multivariable logistic-regression analysis was used to establish Model (iii) to predict probability of getting a good clinical outcome (PGGCO) which was evaluated by Knee Injury and Osteoarthritis Outcome Score (KOOS) score. Finally, we designed a new scoring system consisting of 3 prediction models and presented a method of grading TKA quality. Thirty primary TKAs between April and December 2017 were enrolled for external validation.

Results

We set up a scoring system consisting of 3 models. The interpretations of Model (i) and (ii) were good (R² = 0.756 and 0.764, respectively). Model (iii) displayed good discrimination, with an area under the curve (AUC) of 0.936, and good calibration according to the calibration curve. Quality of surgery was stratified as follows: “A” = PGGCO ≥0.8, “B” = PGGCO ≤0.6 but < 0.8, and “C” = PGGCO < 0.6. The scoring system performed well in external validation.

Conclusions

This study first developed a validated, evidence-based scoring system based on lower-extremity angles of alignment to predict early clinical outcomes and to objectively evaluate the quality of TKA.

A Bibliometric Analysis Using CiteSpace of Publications from 1999 to 2018 on Patient Rehabilitation After Total Knee Arthroplasty

BACKGROUND Following total knee arthroplasty (TKA), postoperative patient rehabilitation is important to achieve the optimal level of knee function and mobility. Clinical research in this field is growing, and bibliometric analysis of publication may provide direction for research clinicians and raise awareness of research trends, journal selection, and key topics. Therefore, this bibliometric study aimed to analyze the current status and trends during the past two decades, between 1999 and 2018, of publications on rehabilitation after total knee arthroplasty (TKA) and used CiteSpace. MATERIAL AND METHODS The global literature was searched between 2018 to 2019 for publications related to rehabilitation after TKA. Publication data were identified using relevant search terms and the Web of Science Core Collection database. CiteSpace (5.3.R11) software was used to analyze the journals, authors, institutions, countries, cited references, and keywords using standard bibliometric indicators. RESULTS A total of 1,292 publications were retrieved between 1999 to 2018, and the most active journals, countries, authors, and institutions in the field of TKA rehabilitation were identified. Key areas of research included postoperative analgesia, muscle inhibition, range of motion, inhibitors, knee flexion, pain control, self-reporting, spectral analysis, in vivo forces, and rotator cuff repair. The emerging research topics included epidural analgesia, physiotherapy, postoperative analgesia, recovery, and the use of ropivacaine local analgesia. CONCLUSIONS The findings from this bibliometric study provided insight into trends in clinical research publications in the field of rehabilitation following TKA for the past 20 years, including global trends in emerging areas of research.

Reduced opiate use after total knee arthroplasty using computer-assisted cryotherapy

PURPOSE

Despite multimodal pain management and advances in anesthetic techniques, total knee arthroplasty (TKA) remains painful during the early postoperative phase. This trial investigated whether computer-assisted cryotherapy (CAC) is effective in reduction of pain and consumption of opioids in patients operated for TKA following an outpatient surgery pathway.

METHODS

Sixty patients scheduled for primary TKA were included in this prospective, double-blind, randomized controlled trial receiving CAC at 10-12 °C (Cold-group, n = 30) or at 21 °C (Warm-group, n = 30) during the first 7 days after TKA according to a fixed schedule. All patients received the same pre-, peri- and postoperative care with a multimodal pain protocol. Pain was assessed before and after every session of cryotherapy using the numerical rating scale for pain (NRS-pain). The consumption of opioids was strictly noted during the first 4 postoperative days. Secondary outcomes were knee swelling, visual hematoma and patient reported outcome measures (PROMs). These parameters were measured pre-, 1, 2 and 6 weeks postoperatively.

RESULTS

In both study groups, a reduction in NRS-pain after every CAC session were seen during the postoperative period of 7 days. A mean reduction of 0.9 and 0.7 on the NRS-pain was seen for respectively the Cold- (P = 0.008) and Warm-group (n.s.). A significant (P = 0.001) lower number of opioids were used by the Cold-group during the acute postoperative phase of 4 days, 47 and 83 tablets for respectively the Cold and Warm-group. No difference could be observed for secondary outcomes and adverse effects between both study groups.

CONCLUSIONS

Postoperative CAC can be in added value in patients following an outpatient surgery pathway for TKA, resulting in reduced experienced pain and consumption of opioids during the first postoperative days.

Cryotherapy Relieves Pain and Edema After Inguinal Hernioplasty in Males With End-Stage Renal Disease: A Prospective Randomized Study

CONTEXT

Tension-free hernioplasty under local anesthetic infiltration is a reasonable choice for end-stage renal disease patients with hernia.

OBJECTIVES

The purpose of the study was to investigate the feasibility of cryotherapy after hernioplasty surgery to relieve pain and scrotal edema.

METHODS

This was a prospective, randomized, and controlled trial held in a large integrated health care facility in South China. One hundred sixty-nine male patients on hemodialysis and scheduled for hernioplasty were enrolled between March 2013 and February 2017. The participants were divided into an intervention group and a control group. In the intervention group, ice packs were applied after surgery. Demographic information, vital signs, pain score, opioid consumption, wound inflammation, scrotal edema, and patient satisfaction were compared between the two groups. The primary outcome was pain score.

RESULTS

Cryotherapy-treated patients required less opioid consumption (5.95 vs. 15.29 mg; P < 0.05), reported lower pain scores from 30 minutes to 48 hours after operation (P < 0.05), less wound inflammation (11.90 vs. 32.94%; P < 0.05), lower incidence of scrotal edema in the first and second days (P < 0.05), and higher patient satisfaction (8.95 vs. 6.50 cm; P < 0.05), with stable vital signs throughout the monitoring period (P > 0.05).

CONCLUSION

Owing to its favorable cost, convenience, and low frequency of adverse effects, cryotherapy is useful for end-stage renal disease populations after hernioplasty to relieve pain and scrotal edema.