Cryotherapy Treatment After Unicompartmental and Total Knee Arthroplasty: A Review

A reassessment of existing systematic reviews evaluating the effectiveness of cryotherapy in patients following total knee arthroplasty

OBJECTIVE

This study reassessed systematic reviews on cryotherapy efficacy following total knee arthroplasty (TKA).

METHODS

Ten databases were searched from January 1, 2018 to September 15, 2023 for relevant systematic reviews. Two researchers independently screened articles and extracted data.

RESULTS

Five systematic reviews were included. Two of the studies were found to exhibit high methodological quality, while the remaining three demonstrated exceedingly low methodological quality. The deficiencies in quality were attributed to several factors, including the lack of a predefined research protocol, absence of exclusion criteria, unclarified funding sources for the included studies, and potential for publication bias. Of the 18 outcome indicators, Swelling was intermediate-quality evidence , Hemoglobin, Pain score within 24 hours after surgery, Pain score within 48 hours after surgery, Pain score within 72 hours after surgery, Blood loss volume, Pain score on the next day of surgery and Range of Motion (ROM) were low-quality evidence, and other outcome indicators were exceedingly low-quality evidence.

CONCLUSION

Cryotherapy appears to offer benefits such as pain relief, reduction in joint swelling, and improved joint mobility during the initial post-operative phase following TKA. However, further high-quality studies are required to validate the efficacy and safety of cryotherapy for patients undergoing TKA, given the identified limitations in the quality of the available outcome indicators.

Efficacy of Different Doses of Intra-Articular Tranexamic Acid for Reducing Blood Loss and Lower Limb Swelling After Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial

OBJECTIVE

Both blood loss and lower extremity swelling after total knee arthroplasty (TKA) can affect a patient's postoperative recovery. The aim of this trial was to investigate whether different doses of intra-articular tranexamic acid (TXA) can reduce blood loss and postoperative lower limb swelling.

METHODS

In a prospective, randomized-controlled trial, a total of 225 patients were randomly assigned to three groups from September 2020 through January 2021: intra-articular injections of 3 g, 1 g of TXA, or placebo (saline solution). The primary outcome indicators were perioperative blood loss and decreased hemoglobin levels. The secondary outcome indicators were lower extremity swelling, functional recovery indicators (hospital for special surgery [HSS] scores, range of motion), visual analog scale [VAS] scores, and transfusion rates and safety outcomes, including thromboembolic events, incidence of wound-related complications, and length of hospital stay. One-way analysis of variance (ANOVA), post hoc Bonferroni correction, Pearson chi-square test and Fisher exact test were used for statistical analysis.

RESULTS

Postoperative blood loss was lower in the 1 and 3 g TXA groups (754.00 ± 409.67 mL and 568.70 ± 408.27 mL, respectively) than in the placebo group (977.32 ± 418.69 mL) (p < 0.001). The maximum postoperative decrease in hemoglobin was lower in the 1 and 3 g TXA groups (2.4 ± 0.9 and 1.8 ± 0.9 g/dL, respectively) than in the placebo group (3.1 ± 1.2 g/dL) (p < 0.001). On postoperative Days 1, 2, and 3, the TXA group presented significantly reduced thigh, suprapatellar, and calf swelling and significantly reduced pain scores during exercise. Compared with that in the low-dose group, perioperative blood loss was further reduced in the high-dose TXA group (p = 0.006). However, while patients in the TXA group had improved pain scores, Hospital for Special Surgery scores, and joint range of motion at postoperative rest, these differences were not statistically significant. There were no significant differences in thromboembolic events or complication rates among the three groups.

CONCLUSION

Topical TXA in total knee arthroplasty was effective in reducing postoperative blood loss by 24%-43% and in reducing postoperative lower extremity swelling and pain during exercise. Higher doses (3 g) of TXA further controlled perioperative blood loss without affecting postoperative lower extremity swelling, and there was no increase in the incidence of related complications during follow-up.

TRIAL REGISTRATION

This study was a single-center, prospective, randomized controlled trial (RCT). The trial was approved by the Clinical Trials and Biomedical Ethics Committee at our institution (number: 2018.676), all participants provided written informed consent, and the trial was prospectively registered in the Chinese Clinical Trial Registry (ChiCTR2000035271).

Comparison of three cryotherapy techniques for early post-TKA pain control in terms of efficacy and patient satisfaction: a randomized controlled trial

BACKGROUND

Cryotherapy is a non-pharmacological option that complements drug therapy to achieve the most comprehensive multimodal analgesia. Various techniques are currently available, including the conventional gel cold pack, the cryo-cuff, and a novel mobile cold compression device (MCCD). This study aimed to evaluate and compare three cryotherapy techniques in terms of efficacy and patient satisfaction in patients undergoing total knee arthroplasty (TKA).

METHODS

This prospective randomized study included 108 patients who were scheduled for primary unilateral TKA. The patients were allocated to 3 groups for postoperative cryotherapy techniques: gel cold pack, cryo-cuff, and MCCD. Scores on the visual analog scale (VAS) for pain intensity, morphine consumption, knee range of motion (ROM), knee swelling, length of hospital stay, and patient satisfaction were collected.

RESULTS

Postoperative VAS scores showed a significant difference among the groups at 8 and 72 h after surgery (P = 0.002 and 0.026, respectively). At the earliest postoperative time point, post hoc analysis demonstrated that patients in the MCCD group had lower pain scores than those in the gel cold pack (P < 0.001) and the cryo-cuff group (P = 0.030). However, cryo-cuff reduced knee swelling significantly compared to gel cold pack (P = 0.028) and MCCD (P = 0.011) at postoperative 72 h. The total satisfaction score was 86.8, 82.8, and 89.1 with gel cold pack, cryo-cuff, and MCCD, respectively.

CONCLUSIONS

Cryotherapy is an adjunct to post-TKA pain control at the surgical site. MCCD has shown superior efficacy in pain reduction during the earliest postoperative period, and achieved high patient satisfaction.

TRIAL REGISTRATION

This study was registered in the Thai Clinical Trials Registry database (no. TCTR20200517002).

Is outpatient joint arthroplasty safe in a high volume academic centre? A retrospective monocentric study using an institutional pathway

PURPOSE

Hip and knee arthroplasties are daily procedures in orthopaedic departments. Recently, same-day discharge (SDD) became increasingly popular, but doubts remain about its safety and generalization. Our hypothesis is that outpatient arthroplasty, in a high volume centre and with an institutional protocol, is an effective and reliable practice.

METHODS

We realized a monocentric retrospective study of patients undergoing outpatient partial (UKA) or total (TKA) knee or hip arthroplasty (THA) in a high volume academic centre using a well-defined institutional pathway. Epidemiological data and complications occurring in the month following surgery were studied.

RESULTS

498 patients undergoing 501 arthroplasties (219 hips and 282 knees) were examined. The percentage of men and women was 60.28% and 39.72% respectively, mean age was 64.56 ± 9.59 years, mean BMI was 26.87 ± 4.2 and the most represented ASA score was 2. The success rate for same-day discharge was 97.21%. The most frequent causes of failure were urinary retention (28.6%), orthostatic hypotension (28.6%) and insufficiently controlled pain (14.3%). The readmission rate in the month following the operation was 0.8% and the rate of emergency department visits was 1.6%. Finally, the rate of early consultation visits was 7.98%. The comparison between success and failure subgroups in the outpatient setting of our cohort did not highlight statistically significant differences for studied parameters.

CONCLUSION

Outpatient arthroplasty, performed in a center used to managing such operations and with a well-established institutional pre- and post-operative protocol, is a safe practice.

Cryotherapy for Rehabilitation After Total Knee Arthroplasty: A Comprehensive Systematic Review and Meta-Analysis

OBJECTIVE

Despite being well-studied and widely utilized, the efficacy of cryotherapy after total knee arthroplasty (TKA) in enhancing early rehabilitation lacks consensus. The aim of this systematic review and meta-analysis was to investigate (1) whether cryotherapy is able to promote the rehabilitation of patients undergoing TKA and (2) whether continuous cold flow device has superior results than cold pack in cryotherapy.

METHODS

A comprehensive trial searching was performed in the PubMed, Embase, Cochrane Library, and Google Scholar electronic databases in May, 2024. Randomized controlled trials (RCTs) comparing cryotherapy with no cryotherapy or comparing continuous cold flow device with cold pack after TKA were included. The primary outcome was visual analogue scale (VAS) of pain, and secondary outcomes included opioid consumption, blood loss (hemoglobin decrease and drainage), range of motion (ROM), swelling, length of stay (LOS), and adverse event.

RESULTS

A total of 31 RCTs were included in this meta-analysis with 18 trials comparing cryotherapy with no cryotherapy and 13 trials comparing continuous cold flow device with cold pack. Pooled results showed cryotherapy group had significantly lower VAS scores than no cryotherapy group on postoperative day (POD) 1 (MD, -0.59 [95% CI, -1.14 to -0.04]; p = 0.04), POD 2 (MD, -0.84 [95% CI, -1.65 to -0.03]; p = 0.04), and POD 3 (MD, -0.86 [95% CI, -1.65 to -0.07]; p = 0.03). Cryotherapy group also showed reduced opioid consumption, reduced hemoglobin loss, decreased drainage, and improved ROM after TKA. Continuous cold flow device group had comparable VAS, opioid consumption, blood loss, ROM, knee swelling, and LOS with cold pack group.

CONCLUSION

Cryotherapy can effectively alleviate postoperative pain, reduce blood loss, improve ROM, and thus promote the postoperative rehabilitation for TKA patients, but the continuous cold flow device did not show better efficacy than cold packs. These findings support the routine use of cryotherapy for the rapid rehabilitation of TKA patients, and the traditional cold pack is still recommended.

Effect of intraoperative cold solution irrigation to reduce postoperative pain in knee osteoarthritis patients who underwent unilateral primary total knee arthroplasty: a double-blinded randomized controlled trial

PURPOSE

To compare the postoperative pain score, opioid consumption, and blood loss in knee osteoarthritis patients who underwent unilateral primary total knee arthroplasty with and without intraoperative cold solution irrigation.

METHOD

In total, 70 knee osteoarthritis patients were randomly included in the study and allocated into 2 groups. The first group was irrigated intraoperatively with a cold solution and the second group was irrigated intraoperatively with a room-temperature solution.

RESULTS

The cold solution group showed significantly lower pain scores (numerical rating scale, NRS) at 28 h postoperatively (p = 0.047). There were no significant differences in opioid consumption or blood loss between the groups.

CONCLUSIONS

Intraoperative cold solution irrigation in unilateral primary total knee arthroplasty patients may provide the benefit of early postoperative pain reduction for up to 28 h but has no effect in terms of reducing opioid consumption or blood loss.

TRIAL REGISTRATION

The trial was registered in the Thai Clinical Trials Registry (TCTR) Trial registration number ID: TCTR20200706001 on 06/07/2020.

Total Joint Arthroplasty and Sleep: The State of the Evidence

Background

As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively.

Methods

A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively.

Results

Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids.

Conclusions

Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.

Cyclic cryotherapy with vitamin D facilitates early rehabilitation after total knee arthroplasty

Objective

This study aimed to evaluate the efficacy of cyclic cryotherapy and vitamin D administration on early rehabilitation after total knee arthroplasty (TKA), as its efficacy remains unclear.

Methods

We divided 150 patients (three groups) who underwent TKA into those treated with or without cyclic cryotherapy and vitamin D.

Results

Compared with patients who did not receive cyclic cryotherapy, those who received postoperative cyclic cryotherapy and vitamin D supplementation had significantly higher American Knee Society Scores (AKSS) on postoperative day (POD) 7 and at 1 month postoperatively; higher visual analogue scale (VAS) values on POD1-3 and POD7; reduced thigh swelling on POD3 and POD7; increased range of motion (ROM) on POD3, POD7, and at 1 month postoperatively; and reduced postoperative length of stay (PLOS). However, no significant difference in patient satisfaction was observed between the patient groups. At 1 and 3 months postoperatively, patients administered cyclic cryotherapy and vitamin D had significantly higher AKSS, ROM, and vitamin D levels than those who did not receive vitamin D. No perioperative complications such as surgical site infection, skin frostbite, or vitamin D intoxication were observed.

Conclusion

Cyclic cryotherapy post-TKA had short-term advantages in terms of AKSS, VAS, thigh swelling, ROM, PLOS, and accelerated rehabilitation, but did not improve patient satisfaction. Cyclic cryotherapy combined with vitamin D improved AKSS and ROM at 1 and 3 months postoperatively.

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).

Effects of 6 weeks of cryotherapy plus compression therapy after total or unicompartmental knee arthroplasty: protocol for a single-centre, single-blind randomised controlled trial

INTRODUCTION

Effective rehabilitation after total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) is often impeded by pain and swelling. Beneficial short-term effects in terms of pain and opioid use after a short period of cryotherapy (±compression therapy) have been demonstrated. The effectiveness of a longer intervention period on longer-term postoperative outcomes is unclear. This study aims to assess the effects of 6 weeks of cryotherapy plus compression therapy on pain, functioning and patient satisfaction after TKA or UKA.

METHODS AND ANALYSIS

A single-centre, single-blind randomised controlled trial will be conducted at a teaching hospital in the Netherlands. Patients over age 18 with end-stage osteoarthritis planned for a TKA or UKA are eligible; 104 UKA and 104 TKA patients will be included. Both groups will be randomly allocated (1:1) into an intervention group receiving 6 weeks of cryotherapy plus compression therapy (commencing after discharge from hospital) or a control group (usual care). The primary endpoint is perceived pain at rest at 6 weeks postoperatively. Secondary outcomes include compliance with cold protocol, pain at rest during the first six postoperative weeks and at 6 and 12 months postoperatively, pain on weight bearing, opioid use, functioning, patient satisfaction and complications.

ETHICS AND DISSEMINATION

The local medical ethics committee MEC-U approved the study protocol (R22.095/NL-number NL81956.100.22). The study will be conducted in accordance with the Declaration of Helsinki and Good Clinical Practice regulations, and personal data will be handled in agreement with the Dutch Personal Data Protection Act (AGV). Written informed consent will be obtained prior to performing any of the study procedures. We will disseminate study results through multiple peer-reviewed publications and through conference presentations.

TRIAL REGISTRATION NUMBER

NCT05572359.

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.

Robot-assisted rehabilitation training improves knee function and daily activity ability in older adults following total knee arthroplasty

To evaluate the effects of robot-assisted rehabilitation training on knee function and the daily activity ability of older adults following total knee arthroplasty (TKA). Eighty-eight patients who underwent TKA were randomly assigned to a robot-assisted rehabilitation or traditional therapy group. The patients in the control group were treated with traditional manual rehabilitation therapy, while the patients in the experimental group were subjected to the robot-assisted rehabilitation program. Range of motion of the knee joint, Hospital for Special Surgery Knee Rating Score, and the modified Barthel Index were assessed on the first or second day after TKA (preintervention) and the discharge day (postintervention). Additionally, the length of hospital stay and related hospitalization expenses of the two groups were collected on the discharge day. Improvements in the active range of motion (p < 0.001), passive range of motion (p = 0.001), Hospital for Special Surgery Knee Rating Score (p < 0.001), and modified Barthel Index score (p = 0.004) were significantly better in the robot-assisted rehabilitation group than in the traditional therapy group. Interestingly, the length of hospital stay in the experimental group (9 days) was shorter than that in the control group (13 days), and the total cost of hospitalization was lower (p = 0.002). The robot-assisted rehabilitation training program is an effective intervention that significantly improves the daily activity ability and knee function of older adults following TKA.

Impact of the COVID-19 Pandemic on the Usage of Blood for Transfusions: A 2-Year Experience from a Tertiary Center in Korea

The coronavirus disease (COVID-19) outbreak affected the utilization and management of blood products in hospitals. Blood shortages occurred owing to social distancing policies and reduction in blood donors. However, only a few studies examined whether these changes affected blood usage and transfusion patterns. We retrospectively reviewed blood component usage according to hospital departments and phases of surgery in transfused patients admitted between 1 March 2019 and 28 February 2021, in a single center in Anyang, Korea. We also analyzed the length of hospital stay and mortality to determine prognosis. In 2020, 32,050 blood components were transfused to 2877 patients, corresponding to 15.8% and 11.8% less than the rates in 2019, respectively. Postoperative usage of blood products significantly decreased in 2020 (3.87 ± 6.50) compared to 2019 (7.12 ± 21.71) (p = 0.047). The length of hospital stay of the patients who underwent postoperative transfusion in 2019 (n = 197) was 13.97 ± 11.95 days, which was not significantly different from that in 2020 (n = 167), i.e., 16.44 ± 17.90 days (p = 0.118). Further, 9 of 197 postoperative transfusion patients died in 2019, while 8 of 167 patients died in 2020 (p = 0.920). The COVID-19 pandemic resulted in limited blood supply and reduced postoperative transfusions; however, patient prognosis was not affected.

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.

[Prevention, physiotherapeutic preoperative and postoperative treatment and rehabilitation of arthrofibrosis]

The physiotherapeutic and rehabilitative treatment of patients suffering from primary arthrofibrosis following total joint replacement or joint reconstruction is challenging for both patients and therapists. It can be successful if basic principles are applied. The necessary treatment techniques are presented in detail immediately postoperatively and in the subsequent rehabilitation process.

Does Application of Lymphatic Drainage with Kinesiology Taping Have Any Effect on the Extent of Edema and Range of Motion in Early Postoperative Recovery following Primary Endoprosthetics of the Knee Joint?

Background: The surgery of knee replacement due to degenerative changes is the last step of the treatment. After surgery, a major problem in patients is pain, swelling, intraarticular hematoma, and the restriction of the mobility of the joint. The aim of this work was to determine the effect of Kinesio Taping (KT) on reducing edema of the subcutaneous tissue and improving the range of motion in the joint. Methods: 82 patients were qualified for the study. After surgery, 42 patients received postoperative edema treatment with KT bands, and 40 patients did not receive the treatment. The swelling thickness and range of mobility were measured on the third and eighth days after the operation. Results: A statistical difference between the longitudinal measurements of the KT group and the group without KT application was shown at the level of the fibula head, 25 mm below the fibula neck, and 50 mm below the fibular neck. There were no statistically significant differences in the change in knee angle between the applied and non-applied patients. Conclusion: The lymphatic application technique KT influences the absorption of subcutaneous edema after primary knee joint replacement surgery but has no influence on mobility.

The effect of local injection of tranexamic acid into peri-articular tissue versus drain clamping in total knee arthroplasty: a randomized controlled trial

Background

Tranexamic acid (TXA) is used as a synthetic anti-fibrinolytic agent for total knee arthroplasty (TKA) to reduce postoperative bleeding. Though the effects on bleeding reduction of several methods of administering TXA have been demonstrated, the optimal method remains controversial. Recently, the hemostatic effect of periarticular local injection of TXA during TKA was reported. Although this method can be expected to suppress postoperative bleeding without placing a drain, its hemostatic effect has not yet been assessed in comparison with local injection and other methods of administering TXA. The aim of this randomized, prospective study was to assess the efficacy of local injection of TXA during TKA.

Methods

To confirm the effect of the local injection of TXA, drain clamping was set as the control. The subjects included a prospective series of 109 patients randomly divided into 2 groups: the local injection (group L) and the drain clamping (group D). The main outcome measure was postoperative bleeding. Secondary outcomes included pain, physical measurements, and laboratory findings.

Results

The calculated total blood loss (CTBL) in groups L and D was nearly equal and did not show the non-inferiority of group L to group D (883 ± 248 vs. 841 ± 257 ml, P = .564). Drained blood loss was significantly higher in group L than in group D (395 ± 130 vs 276 ± 78.8 ml, P < .0001). There was no significant difference in hidden blood loss between the groups (488 ± 269 vs 565 ± 261 ml, P = .131). The other laboratory findings and physical measurements were identical between the groups.

Conclusions

Although CTBL in group L did not show non-inferiority to group D, the local injection of TXA was considered to be superior for suppressing bleeding considering the risk of the adverse effects of using a drain.

Trial registration

This was a randomized, prospective study registered with UMIN Clinical Trials Registry (Registration number: UMIN000036146, date of disclosure: 10/3/2019).

Enhanced recovery after lumbar fusion surgery: Benefits of using Game Ready©

INTRODUCTION

The primary aim of this study was to evaluate how the Game Ready© cryotherapy system impacts postoperative analgesia following lumbar fusion. The secondary aim was to study the effect of cryotherapy on blood loss, transfusion rate and recovery after surgery.

MATERIALS AND METHODS

This was a retrospective study of 60 patients divided into two consecutive sets. The first set of 30 patients underwent the current anesthesia protocol at our facility (control group) while the second set of 30 underwent the same protocol but the patient wore the Game Ready© cryotherapy belt immediately postoperative (GR group).

RESULTS

VAS for pain at H6 did not differ between groups [5.2±1.7 vs. 5.2±1.8 (p=0.94)]; however, there was a significant decrease in pain at H24 and H48 in the GR group relative to the control group (p=0.04; p=0.01; p=0.01). Consumption of morphine over the first 24 and 48hours was 50% less in the GR group than in the control group (p=0.01 and p<0.0001). Discharge occurred significantly earlier in the GR group (3.9±1.0 days) than the control group (5.1±0.9 days) (p<0.001). The estimated blood loss was greater in the control group than the GR group (574.7ml±339.2 vs. 305.9ml±229.6; p=0.0003).

CONCLUSION

Use of a cryotherapy device in the context of spine surgery is effective at controlling postoperative pain. It also decreases the consumption of analgesics, limits blood loss, reduces the need for transfusions, and contributes to enhanced recovery after surgery.

LEVEL OF EVIDENCE

IV.

Should corticosteroids be administered for local infiltration analgesia in knee arthroplasty? A meta-analysis and systematic review

WHAT IS KNOWN AND OBJECTIVE

The benefits of local infiltration analgesia (LIA) in knee arthroplasty (KA) have been well-documented. However, it is unknown whether adding a corticosteroid to the composition of the LIA is beneficial. This study aimed to investigate the efficacy and safety of administering periarticular steroids intraoperatively in patients who underwent KA through a systematic review and meta-analysis.

METHODS

A systematic search was conducted to identify relevant randomized controlled trials in the PubMed, Embase, Web of Science and Cochrane databases up to January 19th, 2021 to perform a meta-analysis. Outcome variables included pain scores, total opioid consumption, knee range of motion (ROM) and postoperative complications.

RESULTS

Corticosteroid injections did not reduce pain scores at 6, 12, 24 or 72 h postoperatively, although a minimal degree of transient pain relief was achieved at 48 h postoperatively compared with those in the placebo group, nor was there a significant difference in total opioid consumption. However, patients receiving corticosteroids did exhibit a transient ROM increase on postoperative days 1, 2 and 3. Since the minimal clinically important difference (MCID) for ROM is unclear, it is unknown if the improvement in ROM is clinically significant.

WHAT IS NEW AND CONCLUSION

Our specific end-point analysis demonstrated that corticosteroid administration did not provide pain relief or reduce opioid consumption compared with placebo. However, corticosteroids might provide a statistically significant, though transient and minimal improvement in knee ROM after KA, although no firm conclusions about the benefits of administering corticosteroids in KA can be made based on the available evidence.

Study protocol: randomized controlled trial of opioid-free vs. traditional perioperative analgesia in elective orthopedic surgery

BACKGROUND

The medical community is beginning to recognize the contribution of prescription opioids in the growing national opioid crisis. Many studies have compared the safety and efficacy of alternative analgesics to opioids, but none utilizing a completely opioid-free perioperative protocol in orthopedics.

METHODS

We developed and tested an opioid-free perioperative analgesic pathway (from preoperative to postoperative period) among patients undergoing common elective orthopedic procedures. Patients will be randomized to receive either traditional opioid-including or completely opioid-free perioperative medications. This study is being conducted across multiple orthopedic subspecialties in patients undergoing the following common elective orthopedic procedures: single-level or two-level ACDF/ACDA, 1st CMC arthroplasty, Hallux Valgus/Rigidus corrections, diagnostic knee arthroscopies, total hip arthroplasty (THA), and total shoulder arthroplasty/reverse total shoulder arthroplasty (TSA/RTSA). The primary outcome measure is pain score at 24 h postoperatively. Secondary outcome measures include pain scores at additional time points, medication side effects, and several patient-reported variables such as patient satisfaction, quality of life, and functional status.

DISCUSSION

We describe the methods for a feasibility randomized controlled trial comparing opioid-free perioperative analgesics to traditional opioid-including protocols. We present this study so that it may be replicated and incorporated into future studies at other institutions, as well as disseminated to additional orthopedic and/or non-orthopedic surgical procedures. The ultimate goal of presenting this protocol is to aid recent efforts in reducing the impact of prescription opioids on the national opioid crisis.

TRIAL REGISTRATION

The protocol was approved by the local institutional review board and registered with clinicaltrials.gov (Identifier: NCT04176783 ) on November 25, 2019, retrospectively registered.

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.

Comparison of 8-year knee osteoarthritis progression in 2 siblings: a case-based review

Because the pathophysiology of knee osteoarthritis is poorly understood, optimal evidence-based clinical management is uncertain. Sibling comparison studies can help inform a clinical model to guide preventive care. We compared the 8-year clinical outcomes in 2 sisters with a family history of osteoarthritis, normal BMI, and absence of knee pain at baseline. Both patients had Kellgren–Lawrence grade 1 in the affected knee at the time of twisting knee injuries leading to osteoarthritis diagnoses at age 50 (patient 1) and 51 (patient 2). Patient 1 developed a chronic right knee effusion, and progressed to Kellgren–Lawrence grade 3 bilaterally by the time she had a right total knee replacement at age 58. Patient 2 had subchondral fractures of the right knee with transient effusion, which healed after 1 year of partial weight-bearing with crutches and subsequent daily use of knee sleeves. Patient 2 had Kellgren–Lawrence grade 0 bilaterally upon surveillance imaging at age 58. The terms “osteoarthritis and knee and diagnostic imaging and subchondral bone and pathophysiology” were searched in the PubMed database to identify original research articles to inform a clinical model consistent with the patients’ outcomes. A fluid model of osteoarthritis was the best explanatory model for the discordant clinical trajectories of the age-matched siblings. Patient recommendations are presented based on these findings.

Reduction of postoperative swelling with a negative pressure treatment-A prospective study

PURPOSE

Perioperative swelling and edema are the main factors that influence the time to definitive operative care, healing rate, as well as postoperative infection rate. Device-based negative pressure treatment is a new method to reduce post-traumatic and postoperative swelling of the upper extremities. The objective of this study was to evaluate a new negative pressure treatment with LymphaTouch® (Helsinki, Finland) to reduce perioperative swelling in upper extremity injuries.

METHODS

We analyzed 45 patients (26 female and 19 male) after operative treatment of upper extremity injuries. A predefined treatment algorithm of 30 min using LymphaTouch® was performed on the patients every day for five consecutive days. Swelling was measured according to the neutral-zero method with six points of measurement.

RESULTS

A total of 16 patients underwent an operation on their upper arm. An average of 3.5 measurements was performed per patient, with the start of therapy at a mean of 5.13 days after the operation. All of the measured circumferences except the elbow and 10 cm below the elbow were reduced from day 0 to 3. The percent reduction of swelling (relative to day 0) was 10.36%, 11.35%, 17.34%, and 3.25% for days 1-4, respectively. The greatest reduction of circumference was obtained in the metacarpus (-51.6%) and wrist (-33.1%).

CONCLUSION

The LymphaTouch® system and a 30-min treatment program can reduce postoperative swelling of the upper arm, wrist, and hand on the first 5 days after surgery. The ease of learning and self-applicability of LymphaTouch® makes it interesting for further controlled randomized trials.

Should we routinely perform a post-operative hemoglobin check following unicompartmental knee arthroplasty?

OBJECTIVES

To study the significance of checking post-operative hemoglobin and hematocrit following unicompartmental knee arthroplasty (UKA).

SETTING

Single center. Multiple surgeons.

DESIGN

Retrospective case series. Level of evidence IV.

MATERIALS AND METHODS

Following institutional approval, a retrospective analysis of all patients undergoing UKA at our level one academic university hospital was conducted. Operative records of all patients undergoing primary UKA were reviewed between March 2016 and March 2019. Patients' pre-operative hemoglobin and hematocrit, BMI, co-morbidities, application of tourniquet, tourniquet time, administration of tranexamic acid, need for post-operative blood transfusion, hospital length of stay, complications, and re-admission were all recorded. Blood loss was estimated using the post-operative hematocrit.

RESULTS

A total number of 155 patients were included. There were 70 females (45%) and 85 males (55%). The mean age was 66 ± 10 years. Median pre-op blood volume was 4700 mLs (interquartile range (IQR); 4200-5100). Median blood loss was 600 mLs (IQR; 400-830). Mean pre-op hemoglobin was 135 ± 14 g/L and mean post-op hemoglobin was 122 ± 13 g/L. No patient had a post-op hemoglobin under 80 g/L (range 93-154). No patients in our study needed transfusion.

CONCLUSION

The results of our study indicated that post-operative hemoglobin and hematocrit check proved unnecessary in all of our patients and could have been omitted from post-operative routines. We conclude that routine post UKA check of hemoglobin and hematocrit can be avoided and be saved for special circumstances depending on patient's physiology.

Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use

BACKGROUND

We sought to identify independent modifiable risk factors for delayed discharge after total knee arthroplasty (TKA) that have been previously underrepresented in the literature, particularly postoperative opioid use, postoperative laboratory abnormalities, and the frequency of hypotensive events.

METHODS

Data from 1033 patients undergoing TKA for primary osteoarthritis of the knee between June 2012 and August 2014 at an academic orthopedic specialty hospital were reviewed. Patient demographics, comorbidities, inpatient opioid medication, postoperative hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1, were collected. Multivariate logistic regression analysis was performed to identify independent risk factors for a prolonged length of stay (LOS) >3 days.

RESULTS

The average age of patients undergoing primary TKA in our cohort was 65.9 (standard deviation, 9.1) years, and 61.7% were women. The mean LOS for all patients was 2.64 days (standard deviation, 1.14; range, 1-9). And 15.3% of patients had a LOS >3 days. On multivariate logistic regression analysis, nonmodifiable risk factors associated with a prolonged LOS included nonwhite race (odds ratio [OR], 2.01), single marital status (OR, 1.53), and increasing age (OR, 1.47). Modifiable risk factors included every 5 postoperative hypotensive events (OR, 1.31), 10-mg increases in oral morphine equivalent consumption (OR, 1.04), and postoperative laboratory abnormalities (hypocalcemia: OR, 2.15; low hemoglobin: OR, 2.63).

CONCLUSION

This study identifies potentially modifiable factors that are associated with increased LOS after TKA. Doubling down on efforts to control the narcotic use and to use opioid alternatives when possible will likely have efficacy in reducing LOS. Attempts should be made to correct laboratory abnormalities and to be cognizant of patient opioid use, age, and race when considering potential avenues to reduce LOS.

Evaluation of the Clinical Efficacy of Using Thermal Camera for Cryotherapy in Patients with Total Knee Arthroplasty: A Prospective Study

Background and objectives: Cryotherapy is a method of treatment using cold application. This study aimed to evaluate postoperative clinical and hematological parameters and pain associated with total knee arthroplasty in patients and compared cryotherapy to the conventional method of cold ice pack compressions. Materials and Methods: Between January 2015 and January 2016, 90 patients who underwent total knee arthroplasty for grade 4 gonarthrosis were prospectively evaluated. The patients were divided into three groups (n = 30, each): Group 1, cryotherapy was applied in the pre- and postoperative periods; Group 2, cryotherapy was applied only in the postoperative period; and Group 3 (control group), only a cold pack (gel ice) was applied postoperatively. In all groups, pre- and postoperative evaluations at 6, 24, and 48 h, hemorrhage follow-up, knee circumference measurement, visual analog scale pain score, knee circumference, and temperature measured by thermal camera were recorded. Results: Of the 90 patients, 10% were men and 90% were women. The mean age was 64.3 ± 8.1 (range: 46–83) years. The patella upper end diameter values were significantly lower in the postoperative period in Groups 1 and 2 than in Group 3 (p = 0.003). Hemoglobin levels at 24 and 48 h postoperatively were significantly lower in Group 3 than in Group 1 (p < 0.001, each) and Group 2 (p = 0.038, p < 0.001). At 6, 24, and 48 h follow-ups, pain values were significantly lower in Group 2 than in Group 3 (p < 0.001). Preoperative 6, 24, and 48 h temperature values were significantly lower in Group 1 than in Group 3 (p < 0.001 for each). It was found that the difference between preoperative and postoperative knee flexion measurements was significantly different in both groups or the difference between the groups was changed in each period (p < 0.001). Conclusions: Postoperative cryotherapy is a potentially simple, noninvasive option and beneficial for the reduction of reducing pain, bleeding, length of stay, analgesic requirement and swelling after total knee arthroplasty. Moreover, there was no early or late prosthesis infection in cryotherapy groups, which may be considered as an additional measure to prevent prosthesis infection.

Effects of low-intensity pulsed ultrasound on recovery of physical impairments, functional performance and quality of life after total knee arthroplasty: Protocol for a quasi-experimental study

INTRODUCTION

The presence of significant pain and swelling during the acute stage following total knee arthroplasty (TKA) may limit the patients' ability to cooperate in intensive physiotherapy interventions. Low-intensity pulsed ultrasound is one of the modalities that can be used for acute pain and swelling management. However, only one study investigated the effect of this modality in patients with TKA. There is limited documentation of the effects of combining low-intensity pulsed ultrasound in TKA rehabilitation in the recovery of physical impairments and how these influence the recovery of function after TKA. Therefore, this study is proposed with the aim to evaluate the effects of low-intensity pulsed ultrasound as an adjunct to conventional physiotherapy on the recovery of physical impairments, functional performance and quality of life after TKA surgery.

METHODS

This is an assessor-blinded quasi-experimental study comparing two approaches of physiotherapy, namely pulsed ultrasound-added physiotherapy and conventional physiotherapy. Total number of participants with TKA required for this study will be calculated based on the result of a pilot study. Participants will be alternately allocated into either pulsed ultrasound-added physiotherapy group (low-intensity pulsed ultrasound and conventional physiotherapy) or control group (conventional physiotherapy). Pulsed ultrasound-added physiotherapy group will receive low-intensity pulsed ultrasound starting at post-operative day 2 (4-5 times for the first-week after surgery and 2-3 times a week for a further 2 weeks). Both groups will receive conventional physiotherapy 4 to 5 times for the first-week after surgery and 2 to 3 times a week for a further 11 weeks. This procedure and process will be tested and established in a pilot study. Primary outcomes of interest are pain level, swelling, active range of knee motion, and quadriceps strength. The secondary outcomes are functional performance and quality of life.

DISCUSSION

This study will fill the gaps in knowledge relating the benefits of including low-intensity pulsed ultrasound into conventional physiotherapy for patients with TKA.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12618001226291.

The efficiency and safety of steroid addition to multimodal cocktail periarticular injection in knee joint arthroplasty: a meta-analysis of randomized controlled trials

Steroids are frequently used for postoperative pain relief without definite evidence. This study was conducted to assess the pain management effect of the addition of steroids to a multimodal cocktail periarticular injection (MCPI) in patients undergoing knee arthroplasty and evaluate their safety. Pubmed, Embase, and Cochrane Library were searched through April, 2018. A total of 918 patients from ten randomized controlled trials (RCTs) were ultimately included. Compared with placebo groups, steroids application could effectively relieve pain on postoperative day (POD)1; decrease C-Reactive protein (CRP) level on POD3; improve range of motion (ROM) in postoperative 5 days; reduce morphine consumption, achieve earlier straight leg raising (SLR), and shorten the length of stay (LOS) in hospital. With regards to adverse effects, it did not increase the risk of postoperative infection, postoperative nausea and vomiting (PONV), or other complications. However, no significant difference in pain relief, ROM, or increased Knee Society Knee Function Scores were found during long-term follow up. Overall, this meta-analysis ensured the efficiency and safety of steroids with MCPI in knee arthroplasty patients during the early postoperative period.

Blood management in total knee arthroplasty: state-of-the-art review

Total blood loss from primary total knee arthroplasty may exceed 2 L with greater blood loss during revision procedures. Blood loss and allogeneic transfusion are strongly associated with adverse outcomes from surgery including postoperative mortality, thromboembolic events and infection. Strategies to reduce blood loss and transfusion rates improve patient outcomes and reduce healthcare costs. Interventions are employed preoperatively, intraoperatively and postoperatively. The strongest predictor for allogeneic blood transfusion is preoperative anaemia. Over 35% of patients are anaemic when scheduled for primary and revision knee arthroplasty, defined as haemoglobin <130 g/L for men and women, and the majority of cases are secondary to iron deficiency. Early identification and treatment of anaemia can reduce postoperative transfusions and complications. Anticoagulation must be carefully managed perioperatively to balance the risk of thromboembolic event versus the risk of haemorrhage. Intraoperatively, tranexamic acid reduces blood loss and is recommended for all knee arthroplasty surgery; however, the optimal route, dose or timing of administration remains uncertain. Cell salvage is a valuable adjunct to surgery with significant expected blood loss, such as revision knee arthroplasty. Autologous blood donation is not recommended in routine care, sealants may be beneficial in select cases but further evidence of benefit is required, and the use of a tourniquet remains at the discretion of the surgeon. Postoperatively, restrictive transfusion protocols should be followed with a transfusion threshold haemoglobin of 70 g/L, except in the presence of acute coronary syndrome. Recent studies report no allogeneic transfusions after primary knee arthroplasty surgery after employing blood conservation strategies. The current challenge is to select and integrate different blood conserving interventions to deliver an optimal patient pathway with a multidisciplinary approach.