Does the use of a brief cryotherapy intervention with analgesic administration improve pain management after total knee arthroplasty?

The effect of cryotherapy on pain in patients with total knee replacement surgery: a meta-analysis

Cryotherapy is used to reduce edema and pain after total knee replacement surgery. This study was conducted as a meta-analysis study to determine the effect of cryotherapy on pain in patients undergoing total knee arthroplasty. The words 'total knee prosthesis,' 'pain,' 'cryotherapy,' 'cold application,' and 'orthopedic surgery' were searched in Turkish and English in scientific articles in the last 20 years from Scopus, Science Direct, Google Scholar, Pubmed databases. As a result of the research, a total of 8.406 studies were identified. Funnel Plot, Rosenthal's Secure N, and Orwin's Secure N methods were used to demonstrate that the meta-analysis study was reliable and valid and to determine publication bias. The sample size of the studies included in the analysis was 1462. The total effect size was 2.929, with a lower bound of 1.641 and an upper bound of 5.223 at a 95% confidence interval. The study determined that patients who underwent cryotherapy in total knee replacement surgery had 2.9 times less pain than patients who did not undergo cryotherapy.

The Effect of the Timing of Cold Application on Pain and Satisfaction in Patients With Fractures

This experimental study used a repeated-measures design to examine the effect of the timing of cold application on pain and satisfaction in a sample of 60 patients who had fracture surgery. Cold was applied for 20 minutes each hour for four hours to patients assigned to the experimental group. Whereas cold was applied once to those in the control group: for 20 minutes during the first hour after surgery. Results following data analysis from repeated measurements of pain before and after cold application in both groups showed a significant difference between the groups (p < .05). Patients' levels of satisfaction with nursing care practice were higher in the experimental group than in the control group, although not significantly (p > .05). The pain score in the experimental group decreased significantly with each cold application. In the control group, the pretreatment pain score decreased significantly after one cold application, increasing again in 3 hours without cold application. These findings are important for nurses caring for postoperative patients and giving discharge instructions. Our findings suggest repeated cold applications for 20 minutes at hourly intervals may result in better overall pain reduction than a single cold application.

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.

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.].

Total Knee Arthroplasty in the Ambulatory Surgery Center Setting: Best Practices for Cost Containment and Clinical Care Delivery

As the current population continues to increase in age, so does the degeneration of the musculoskeletal system and the development of knee osteoarthritis. Total knee arthroplasty (TKA) will be the treatment of choice when it comes to improving physical function and decreasing pain associated with osteoarthritis of the knee. The global push for more cost-effective healthcare services has led to new models of care and payment delivery methods such as performing TKA in the ambulatory surgery center (ASC) setting. With deeply invasive surgical procedures such as TKA being done in the ASC setting, orthopaedic nurses must be mindful of best practices that will promote quality and safety while considering the importance of using current evidence to guide nursing practice when promoting appropriate patient selection and effective patient education of self-management of postoperative care pertaining to TKA being performed in the ASC setting. This is critical to consider during a time when financial profits in the ASC setting may take a front seat to the delivery of high-quality and safe patient care.

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

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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.

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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.

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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).

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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.

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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.

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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.

Effects of Nurse-Led Pain Management Interventions for Patients with Total Knee/Hip Replacement

BACKGROUND

A literature review was conducted to assess nurse-led nonpharmacologic pain management interventions intended for total knee/hip replacement patients.

DESIGN

This was a systematic review and meta-analysis.

DATA SOURCES

The PubMed, Embase, CINAHL, and Cochrane Library databases were searched to identify relevant studies.

REVIEW METHODS

The systematic review was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and all Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines. Two reviewers independently selected the studies and appraised their quality. Thereafter, the effects of all described nurse-led nonpharmacologic pain management interventions were estimated regarding pain, anxiety, and satisfaction through a meta-analysis.

RESULTS

In total, 219 relevant studies were found through a search. Finally, 23 studies were selected for review, with 17 included in the meta-analysis. Nurse-led nonpharmacologic pain management was effective for pain relief (effect size, -0.22; 95% confidence interval [CI], -0.42 to -0.02), and educational interventions were especially effective (effect size, -0.36; 95% CI, -0.69 to -0.03). Although interventions reduced anxiety and improved satisfaction, these results were not statistically significant based on the analysis.

CONCLUSION

Our findings support that nurse-led nonpharmacologic pain management interventions could help reduce pain in patients with total knee/hip replacement by supplementing pharmacologic pain management.

IMPLICATIONS FOR NURSING

Nurse-led nonpharmacologic pain interventions should be considered to reduce patient pain with total knee/hip replacement.

Pain Management for Orthopedic Patients; Closing the Gap

Total joint replacement (TJR) is one of the most commonly performed and painful surgeries in the United States. Over the past few decades, regulatory changes increased the use of oral narcotics as a first-line treatment of this population. In the current opioid crisis, new pain management techniques and therapies have emerged. Research of current therapies, their effectiveness, and emerging best practices are discussed. Clear, thoughtful, and thorough education is an essential next step for closing the gap of the pain experience. Specifically, education of the frontline nurses, patients, and their caregivers on pain reduction techniques is essential.

Cryotherapy following total knee arthroplasty: What is the evidence?

BACKGROUND

Total knee arthroplasty (TKA) is an important option in the management of severe osteoarthritis. Despite excellent long-term results following TKA, the immediate postoperative period is often associated with pain, bleeding, edema, and reduced range of movement. Cryotherapy has been shown to provide some benefit in addressing these factors but results are largely controversial. This study aims at reviewing the current existing literature on the effects of cryotherapy following TKA.

METHODS

A comprehensive review of the current literature on the use of cryotherapy in knee arthroplasty was performed. The literature search was performed using PubMed, Cochrane Library, Google Scholar, and cross references using the search words "cryotherapy" AND "knee arthroplasty" for articles published between January 1990 and November 2016.

RESULTS

A total of 51 articles were analyzed and 24 of them were selected based on clinical relevance.

CONCLUSION

Immediate and early postoperative management following TKA remains challenging. Cryotherapy has been shown to have some benefits but the severe lack of level 1 studies supporting its use make it difficult to reach a suitable conclusion. Further multicenter randomized controlled trials with representative populations and fair comparison of devices are needed.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Postoperative continuous-flow cryocompression therapy in the acute recovery phase of hip fracture surgery-A randomized controlled clinical trial

BACKGROUND

The acute recovery phase after hip fracture surgery is often complicated by severe pain, postoperative blood loss with subsequent transfusion, and delirium. Prevalent comorbidity in hip fracture patients limit the use of opioid-based analgesic therapies, yielding a high risk for inferior pain treatment. Postoperative cryotherapy is suggested to provide an analgesic effect, and to reduce postoperative blood loss. In this prospective, open-label, parallel, multicentre, randomized controlled, clinical trial, we aimed to determine the efficacy of continuous-flow cryocompression therapy (CFCT) in the acute recovery phase after hip fracture surgery.

METHODS

Patients with an intra or extracapsular hip fracture scheduled for surgery were included. Subjects were allocated to receive postoperative CFCT or usual care. The primary endpoint was numeric rating scale (NRS) pain the first 72 postoperative hours. Secondly, analgesic use; postoperative haemoglobin change and transfusion incidence; functional outcome; length of stay; delirium incidence; location of rehabilitation; patient-reported health outcome; complications and feasibility were assessed.

RESULTS

Sixty-one subjects in the control group, and 64 subjects in the CFCT group were analysed. Within the CFCT group, post treatment NRS pain declined 0.31 (p=0.07) at 24h, 0.28 (p=0.07) at 48h, and 0.47 (p=0.002) at 72h relative to pre treatment NRS pain. Sensitivity analysis at 72h showed that NRS pain was 0.92 lower in the CFCT group when compared to the control group (1.50 vs. 2.42; p=0.03). Postoperative analgesic use was comparable between groups. Between postoperative day one and three haemoglobin declined 0.29mmol/l in the CFCT group and 0.51mmol/l in controls (p=0.06), and transfusion incidence was comparable. The timed up and go test and length of stay were also comparable between both groups. Complications, amongst delirium and cryotherapy-related adverse events were not statistically significantly different. Discharge locations did not differ between groups. At outpatient follow-up subjects did not differ in patient-reported health outcome scores. Subjects rated CFCT satisfaction with an average of 7.1 out of 10 points.

CONCLUSIONS

No evidence was recorded to suggest that CFCT has an added value in the acute recovery phase after hip fracture surgery. If patients complete the CFCT treatment schedule, a mild analgesic effect is observed at 72h.

Cryotherapy Treatment After Unicompartmental and Total Knee Arthroplasty: A Review

BACKGROUND

Cryotherapy is widely utilized to enhance recovery after knee surgeries. However, the outcome parameters often vary between studies. Therefore, the purpose of this review is to compare (1) no cryotherapy vs cryotherapy; (2) cold pack cryotherapy vs continuous flow device cryotherapy; (3) various protocols of application of these cryotherapy methods; and (4) cost-benefit analysis in patients who had unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA).

METHODS

A search for "knee" and "cryotherapy" using PubMed, EBSCO Host, and SCOPUS was performed, yielding 187 initial reports. After selecting for RCTs relevant to our study, 16 studies were included.

RESULTS

Of the 8 studies that compared the immediate postoperative outcomes between patients who did and did not receive cryotherapy, 5 studies favored cryotherapy (2 cold packs and 3 continuous cold flow devices). Of the 6 studies comparing the use of cold packs and continuous cold flow devices in patients who underwent UKA or TKA, 3 favor the use of continuous flow devices. There was no difference in pain, postoperative opioid consumption, or drain output between 2 different temperature settings of continuous cold flow device.

CONCLUSION

The optimal device to use may be one that offers continuous circulating cold flow, as there were more studies demonstrating better outcomes. In addition, the pain relieving effects of cryotherapy may help minimize pain medication use, such as with opioids, which are associated with numerous potential side effects as well as dependence and addiction. Meta-analysis on the most recent RCTs should be performed next.