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Lee B, Yoon D, Yim J. Effects of an Early Exercise Program with Cryotherapy on Range of Motion, Pain, Swelling, and Gait in Patients with Total Knee Arthroplasty: A Randomized Controlled Trial. J Clin Med 2024; 13:1420. [PMID: 38592218 PMCID: PMC10933851 DOI: 10.3390/jcm13051420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/21/2024] [Accepted: 02/28/2024] [Indexed: 04/10/2024] Open
Abstract
Background: This study aimed to investigate the effects of cryotherapy on range of motion, pain, swelling, and gait in patients who underwent total knee arthroplasty. Methods: Forty-three patients who underwent TKA (total knee arthroplasty) and met the inclusion criteria were randomly divided into two groups. The experimental (n = 21) and control (n = 22) groups underwent cryotherapy and non-cryotherapy treatments, respectively, six times a week for two weeks, and once each before and after exercise for 3 min. Both groups followed a similar initial rehabilitation exercise program using a continuous passive motion device. Results: The results showed a significant difference in knee flexion range of motion, pain, edema, and 10 MWT comparisons from pre- to post-test (p < 0.001). The above values were also significantly different in the comparison between the two groups (p < 0.05). Conclusions: Therefore, this study confirmed that an initial rehabilitation exercise program accompanied by cryotherapy could be an effective intervention method for range of motion, pain, edema, and walking in patients undergoing total knee arthroplasty.
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Affiliation(s)
| | | | - Jongeun Yim
- Department of Physical Therapy, The Graduate School of Sahmyook University, Seoul 01795, Republic of Korea; (B.L.); (D.Y.)
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Xu AL, Humbyrd CJ. Strategies for Reducing Perioperative Opioid Use in Foot and Ankle Surgery: Education, Risk Identification, and Multimodal Analgesia. Orthop Clin North Am 2023; 54:485-494. [PMID: 37718087 DOI: 10.1016/j.ocl.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
There remains a high prevalence and substantial risks of opioid utilization amongst orthopedic patients. The goal of this review is to discuss strategies for responsible opioid use in the perioperative setting following foot and ankle orthopedic surgeries. We will highlight 1) education interventions, 2) risk identification, and 3) non-opioid alternatives for postoperative pain management.
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Affiliation(s)
- Amy L Xu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Casey Jo Humbyrd
- Orthopedic Surgery, University of Pennsylvania, 230 West Washington Square, 5th Floor, Philadelphia, PA 19107, USA.
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Abstract
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.
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Affiliation(s)
- Ashwin Aggarwal
- School of Clinical Medicine, UNSW Medicine & Health, South West Sydney Clinical School, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Sam Adie
- School of Clinical Medicine, UNSW Medicine & Health, St George & Sutherland Clinical Campuses, Sydney, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine & Health, South West Sydney Clinical School, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Justine Naylor
- School of Clinical Medicine, UNSW Medicine & Health, South West Sydney Clinical School, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
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Lee Y, Shin YS, Kim HJ, An J. Effectiveness and methods of cryotherapy in reducing swelling after total knee arthroplasty: A systematic review on randomized controlled trials. Nurs Open 2023; 10:5989-5998. [PMID: 37334865 PMCID: PMC10415999 DOI: 10.1002/nop2.1906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 05/25/2023] [Accepted: 06/05/2023] [Indexed: 06/21/2023] Open
Abstract
AIM This study aims to investigate the effect and methods of cryotherapy in reducing swelling after total knee arthroplasty. DESIGN Systematic review. METHODS We searched PubMed, Embase, CINAHL, Cochrane Library, KoreaMed, KERIS and National Science Digital Library for randomized controlled trials on 19 August 2021. This systematic review was conducted according to the PRISMA 2009 checklist. RESULTS A total of eight randomized controlled trials were systematically reviewed to determine the effect and methods of cryotherapy on reducing postoperative swelling. The effects were not significantly different in six studies. Application time per cryotherapy session was 10-20 min when using an ice pack and up to 48 h when using an automated device. The duration ranged from 2 days to 1 week or until discharge, and the frequency varied from 2 to 72 times per day.
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Affiliation(s)
- Yoonyoung Lee
- Department of Nursing, Sunchon National UniversityJeonnamKorea
| | | | | | - Jiwon An
- Far East UniversityEumseong‐gunKorea
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Li Y, Shuai M. Modified Robert Jones Bandage in reducing blood loss in total knee arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e27156. [PMID: 34664841 PMCID: PMC8448027 DOI: 10.1097/md.0000000000027156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 08/10/2021] [Accepted: 08/15/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The purpose of this meta-analysis was to assess the effects of Modified Robert Jones Bandage (MRJB) in primary total knee arthroplasty (TKA). METHODS PubMed, EMBASE, the Cochrane Library, Web of Science, and Google Scholar were systematically searched for randomized controlled trials (RCTs). All RCTs were compared to receive either MRJB (study group) or conventional wound dressing (control group) in TKA. Statistical analysis was assessed using RevMan 5.3 software. RESULTS A total of 5 RCTs involving 362 patients were included in the meta-analysis. No significant difference between the 2 groups was found in terms of total blood loss (Mean difference [MD], -25.41; 95% confidence interval [CI], -90.52 to 39.70; P = .44), intra-operative blood loss (MD, -13.77; 95% CI, -31.84 to 4.29; P = .14), drain blood loss (MD, 0.83; 95% CI, -30.07 to 31.72; P = .96), and transfusion rate (risk ratio, 0.95; 95% CI, 0.55-1.64; P = .86); There was also no significant difference in terms of range of motion (MD, -0.93; 95% CI, -3.64 to 1.79; P = .50), visual analog scale pain sores (MD, -0.02; 95% CI, -0.34 to 0.30; P = .90), and operative time (MD, -3.12; 95% CI, -13.42 to 7.18; P = .55), without increasing the risk of wound-related complications (risk ratio, 0.75; 95% CI, 0.27-2.08; P = .58) in both groups. No deep venous thrombosis occurred in all studies. CONCLUSIONS The current meta-analysis of the available evidence indicates patients with MRJB had not required the additional advantage compared to the conventional wound dressing for TKA. However, more high-quality studies are needed to confirm the above conclusions. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Yueping Li
- Department of Obstetric Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Mingying Shuai
- Department of Obstetric Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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Kunkle BF, Kothandaraman V, Goodloe JB, Curry EJ, Friedman RJ, Li X, Eichinger JK. Orthopaedic Application of Cryotherapy: A Comprehensive Review of the History, Basic Science, Methods, and Clinical Effectiveness. JBJS Rev 2021; 9:e20.00016. [PMID: 33512971 DOI: 10.2106/jbjs.rvw.20.00016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» 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.
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Affiliation(s)
- Bryce F Kunkle
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | | | - Jonathan B Goodloe
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | - Emily J Curry
- Department of Orthopaedics, Boston University School of Medicine, Boston, Massachusetts
| | - Richard J Friedman
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
| | - Xinning Li
- Department of Orthopaedics, Boston University School of Medicine, Boston, Massachusetts
| | - Josef K Eichinger
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina
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A Better Way to Decrease Knee Swelling in Patients with Knee Osteoarthritis: A Single-Blind Randomised Controlled Trial. Pain Res Manag 2019; 2019:8514808. [PMID: 31191790 PMCID: PMC6525802 DOI: 10.1155/2019/8514808] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/22/2019] [Accepted: 03/31/2019] [Indexed: 11/18/2022]
Abstract
Objective In this study, we compared the effects of intermittent pneumatic compression along with conventional treatment with cold-pack treatment along with conventional treatment on clinical outcomes in patients with knee osteoarthritis. Methods Eighty-nine patients with knee osteoarthritis participated in this study. One group received ultrasound, transcutaneous electrical nerve stimulation, electrical stimulation, exercise, and cold packs. The second group received ultrasound, transcutaneous electrical nerve stimulation, electrical stimulation, exercise, and intermittent pneumatic compression. Range of motion, muscle strength, knee swelling, pain intensity, and functional status were measured at baseline and 4th week. Results We found significant improvements in range of motion, muscle strength, pain intensity, and functional status after the treatment in both groups (p < 0.05). When comparing the effects of these two treatment programs, it was observed that the intermittent pneumatic compression treatment group had a better outcome in terms of knee swelling (p=0.028). Conclusions According to the results, we could report that intermittent pneumatic compression therapy in addition to conventional treatment has significant positive effects on clinical outcomes in patients with knee osteoarthritis. We could also report that intermittent pneumatic compression therapy along with conventional treatment is superior to cold-pack therapy along with conventional treatment in terms of knee swelling in patients with knee osteoarthritis. This trial is registered with NCT03806322.
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Abstract
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.
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Pornrattanamaneewong C, Ruangsomboon P, Chareancholvanich K, Wilairatana V, Narkbunnam R. Modified Robert Jones bandage can not reduce invisible blood loss after total knee arthroplasty: a randomized-controlled trial. Arch Orthop Trauma Surg 2018; 138:1151-1157. [PMID: 29931392 DOI: 10.1007/s00402-018-2978-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION To compare the efficacy and safety of modified Robert Jones bandage (MRJB) and non-compressive dressing (NCD) on reducing invisible blood loss (IBL) after total knee arthroplasty (TKA). MATERIALS AND METHODS Eighty patients who underwent unilateral TKA were randomly assigned into two groups: MRJB and NCD groups. Pre- and post-operative hematocrit levels, amount of drained blood and transfused blood were measured and calculated into IBL. Pain score, amount of morphine usage, range of motion (ROM) at discharge, blood transfusion rate, and complications were also recorded and compared between both groups. RESULTS There was no significant difference in the mean IBL between MRJB (221.2 ± 233.3 ml) and NCD groups (158.5 ± 186.7 ml) (p = 0.219). Post-operative pain score at rest and during ambulation, amount of morphine usage, ROM at discharge, blood transfusion rate, and complications were also similar between two groups. CONCLUSIONS This study cannot determine the benefit of MRJB over NCD. The use of MRJB may not be necessary after primary TKA.
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Affiliation(s)
| | - Pakpoom Ruangsomboon
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Keerati Chareancholvanich
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Vajara Wilairatana
- Department of Orthopedic Surgery, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Rapeepat Narkbunnam
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Ueyama M, Takamura D, Nakajima R, Harada J, Iwata K, Maekawa T, Iwaki K, Yasuda T. Alterations in deep tissue temperature around the knee after total knee arthroplasty: its association with knee motion recovery in the early phase. Phys Ther Res 2018; 21:1-8. [PMID: 30050747 DOI: 10.1298/ptr.e9931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 12/26/2017] [Indexed: 11/23/2022]
Abstract
PURPOSE Cryotherapy has been employed to reduce postoperative inflammation for enhancement of the recovery of total knee arthroplasty (TKA). However, the clinical advantages in functional recovery after TKA remain controversial. This study was conducted to clarify the postoperative alterations in deep temperature around the knee and to evaluate the association between the temperature changes and functional recovery in the early phase after TKA. METHODS Postoperative changes in deep temperature around the knee were evaluated with the probe that can measure subcutaneous tissue temperature at the depth of 1 cm in 28 patients with medial knee osteoarthritis undergoing unilateral TKA through medial parapatellar approach. The same rehabilitation protocol was provided without cryotherapy. Outcome assessment included knee range of motion (ROM) and 10-meter fast speed walking test. RESULTS The operated knee showed a greater increase in deep temperature at postoperative days 1 and 2, followed by a gradual decrease by day 14 when the temperature was still higher than the baseline. When deep temperature change around the operated knee was calculated by subtracting the preoperative temperature from the highest postoperative one, significant association was found between deep temperature change and knee ROM recovery at day 14. The operated knees with more than 2°C increase in postoperative deep temperature resulted in poor ROM recovery. There was no association of deep temperature change with 10-meter fast speed walking test improvement at day 14 or ROM recovery at 1-year follow-up. CONCLUSIONS This study has provided the first data on deep temperature alterations around the knee after TKA. More than 2°C increase in postoperative deep temperature could result in poor ROM recovery after TKA. The results may support establishment of adequate procedures of cryotherapy for early gain in knee motion after TKA.
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Multifaceted Comparison of Two Cryotherapy Devices Used After Total Knee Arthroplasty: Cryotherapy Device Comparison. Orthop Nurs 2018; 35:309-16. [PMID: 27648792 DOI: 10.1097/nor.0000000000000276] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Some form of cryotherapy used after total knee arthroplasty is commonplace. However, various factors determine the specific device deployed. PURPOSE This study aimed to answer the following questions: METHODS : A group of 100 patients undergoing primary total knee arthroplasty by a single surgeon were enrolled in an institutional review board-approved, prospective study and randomized to receive either a circulating cold water or ice/gel pack cryotherapy device postoperatively. Demographic, pain, swelling, blood loss, range of motion, compliance, satisfaction, and adverse event outcomes were recorded until 6 weeks after surgery. Hospital staff satisfaction and economic variables were examined. RESULTS The ice/gel pack cryotherapy wrap was noninferior to the cold water cryotherapy device for any patient outcome measured. Average pain level at 6 weeks postoperative was significantly less in the ice/gel pack cryotherapy wrap group. Hospital staff satisfaction was higher with the ice/gel pack cryotherapy wrap.Substantial economic savings can be realized at our institution by switching to the lower cost cryotherapy device. CONCLUSION In this study, the lower cost ice/gel pack cryotherapy wrap was noninferior to the circulating ice water cryotherapy device with respect to objective patient outcomes and subjective patient satisfaction after total knee arthroplasty. Hospital staff satisfaction and economic considerations also favor the ice/gel pack compression cryotherapy wraps.
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13
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Wound complications after ankle surgery. Does compression treatment work? A randomized, controlled trial. Eur J Trauma Emerg Surg 2018; 44:947-956. [DOI: 10.1007/s00068-017-0892-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
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Zhang P, Liang Y, He J, Fang Y, Chen P, Wang J. Timing of tourniquet release in total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2017; 96:e6786. [PMID: 28445317 PMCID: PMC5413282 DOI: 10.1097/md.0000000000006786] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/21/2017] [Accepted: 04/07/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND For total knee arthroplasty (TKA), the tourniquet is routinely employed for better visualization, less blood loss, and easier cementation. However, the time to release tourniquet remains controversial. Therefore, we performed current meta-analysis to assess whether releasing tourniquet before wound closure is more effective in reducing blood loss than releasing tourniquet after wound closure in TKA without an increased risk of complications. METHODS To conduct this meta-analysis, we searched Medline, Embase, Web of science, and the Cochrane library up to November 2016, for randomized controlled trials comparing tourniquet releasing before and after wound closure in TKA. A meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement. Methodological quality of the trials was assessed using the Cochrane risk assessment scale. The data of the included studies were analyzed using Stata 12.0. RESULTS Sixteen trials involving 1010 patients were identified in current meta-analysis. Our meta-analysis demonstrated that there were no significant differences in the 2 groups in terms of calculated blood loss (weighted mean difference [WMD] = 160.65, 95% confidence interval [CI]: -0.2 to 321.49, P = .05), postoperative blood loss (WMD = -45.41, 95% CI: -120.11 to 29.29, P = .233),postoperative hemoglobin decline (WMD = 0.16, 95% CI: -2.5 to 2.82, P = .905), transfusion volume (WMD = 79.19, 95% CI: -5.05 to 163.44, P = .065),transfusion rates (relative risk [RR] = 1.19, 95% CI: 0.95-1.50, P = .134), major complications (RR = 0.51, 95% CI: 0.15-1.73, P = .278), and deep vein thrombosis (RR = 0.44, 95% CI: 0.14-1.37, P = .157).Compared with the group of releasing tourniquet after wound closure, the group of releasing tourniquet before wound closure had a higher volume of total blood loss (WMD = 130.96, 95% CI: 58.83-203.09, P = .000) and a longer operation time (WMD = 6.56, 95% CI: 3.12-10.01, P = .000). However, releasing tourniquet before wound closure could reduce minor complications (RR = 0.53, 95% CI: 0.34-0.82, P = .004). CONCLUSIONS On the basis of current meta-analysis, the method of releasing tourniquet before wound closure could increase total blood loss and operation time; nevertheless, the risk of complications decreased. Thus, if patients are in severe anemia condition, the tourniquet perhaps should be released after wound closure to decrease blood loss. In contrary, releasing tourniquet before wound closure to decrease the risk of complications would be a better choice.
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Affiliation(s)
- Pei Zhang
- Dalian Medical University, Dalian, Liaoning, China
| | - Yuan Liang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou
| | - Jinshan He
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou
| | - Yongchao Fang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou
| | - Pengtao Chen
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou
| | - Jingcheng Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou
- Dalian Medical University, Dalian, Liaoning, China
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Abstract
: There is some controversy over the use of cryotherapy. Low temperatures (Temp) could interfere with coagulation and increase the risk of bleeding. We sought to examine the effect of cryotherapy on joint swelling, temperature, friction, and inflammatory condition after experimental hemarthrosis. The left knee of 23 albino rabbits, 10 in heparin Ice, five in citrate Ice, four in heparin control, and four in citrate control were injected intraarticularly with 1 ml of blood. In total, four animals were considered to be in normal control group. Joint diameter, Temp, and ultrasonography were assessed before the blood injection. One day after the intraarticular blood injection, cryotherapy was applied 4 times per day for 4 consecutive days. Joint diameter and Temp were measured twice a day. After cessation of the protocol, joint diameter and Temp were assessed and sonography performed, animals euthanized, the friction test was performed and the synovial membrane collected, respectively. Joint diameter and Temp were increased after the intraarticular blood injection. Cryotherapy was capable of reducing the swelling and Temp. Ultrasonography findings approved the positive effect of cryotherapy on joint swelling. The proinflammatory tumor necrosis factor (TNF-α) reduced by cryotherapy in both cryotherapy groups but Interleukin 1β was only reduced in heparin group. Interleukin-4 increased in heparin Ice group that was in comparison with TNF-α reduction. Cryotherapy reduced joint swelling and has a positive effect on controlling joint inflammation and Temp.
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Effects of ethyl chloride spray on early recovery after total knee arthroplasty: A prospective study. J Orthop Sci 2017; 22:89-93. [PMID: 27986370 DOI: 10.1016/j.jos.2016.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 10/10/2016] [Accepted: 10/17/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ethyl chloride spray as a common cooling modality has been widely used in acute sports injuries and joint injection procedures. Several clinical studies reported that use of ethyl chloride has positive effects on swelling, pain reduction and recovery from sports injuries. The main aim of present study was to analyze whether postoperative use of ethyl chloride spray benefits results after primary total knee arthroplasty (TKA). METHODS Between April 1, 2014 and October 21, 2015, 306 subjects undergoing primary TKA used ethyl chloride spray for improving recovery from the damage from surgery. After exclusion of 31 subjects due to adverse events including periprosthetic joint infection (PJI), deep venous thrombosis (DVT), acute myocardial infarction, finally 275 subjects' data regarding pain score, knee range of motion (ROM), knee girth, time of being able to reach 90° knee flexion and analgesic consumption were analyzed. RESULTS Significant differences in pain score, knee ROM at each time point and knee girth at on 21st and 28th postoperatively were detected without increased incidence of adverse events. Besides, time of being able to reach 90° knee flexion and analgesic consumption in the treatment group were significantly decreased in comparison to the control group. CONCLUSION Use of ethyl chloride spray can help patients recovery from the damage from TKA safely.
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Alfuth M, Strietzel M, Vogler T, Rosenbaum D, Liem D. Cold versus cold compression therapy after shoulder arthroscopy: a prospective randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2016; 24:2209-15. [PMID: 25677503 DOI: 10.1007/s00167-015-3534-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 02/04/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE Purpose of the present study was to investigate the acute effects of a cold compression bandage on pain, swelling and skin-surface temperature after the first 24 h after arthroscopic surgery of the shoulder in a stationary setting and to compare it with cold therapy using only a cold pack. It was hypothesized that using the bandage is more effective in reducing pain and swelling after 24 h compared with using only a cold pack. METHODS Fifty-two patients (53 ± 12.2 years) were randomly assigned to two groups after arthroscopic surgery. The first group wore a cold compression bandage, and the second group a conventional frozen cold pack. Pain, swelling and skin-surface temperature were measured 2, 8 and 24 h after surgery. Differences within and between groups were analysed. RESULTS Both groups showed a significant reduction of the circumference of the arm 15 and 20 cm proximal of the lateral epicondyle 24 h after surgery (cold compression: p = 0.003; p < 0.001; cold: p < 0.001). Pain at rest was significantly reduced with cold compression bandage 24 h after surgery (p = 0.001). Skin temperature increased in both groups 24 h after surgery (bandage: p < 0.001; cold pack: p = 0.002). After 24 h, pain during activity was significantly decreased in the group wearing the bandage compared with the group using the cold pack (p = 0.026). CONCLUSIONS Based on the results of this study, no recommendation can be made with respect to the question whether cold compression therapy or cold therapy should be preferred immediately after arthroscopic surgery of the shoulder. Clinicians should question the need of expensive cold compression bandages in the short-term post-operative treatment after arthroscopic surgery of the shoulder. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Martin Alfuth
- Funktionsbereich Bewegungsanalytik, Institut für Experimentelle Muskuloskelettale Medizin, Universitätsklinikum Münster, Münster, Germany. .,Fachbereich Gesundheitswesen (Therapiewissenschaften), Hochschule Niederrhein, Krefeld, Germany.
| | - Marion Strietzel
- Klinik und Poliklinik für Allgemeine Orthopädie und Tumororthopädie, Universitätsklinikum Münster, Münster, Germany
| | - Tim Vogler
- Klinik und Poliklinik für Allgemeine Orthopädie und Tumororthopädie, Universitätsklinikum Münster, Münster, Germany
| | - Dieter Rosenbaum
- Funktionsbereich Bewegungsanalytik, Institut für Experimentelle Muskuloskelettale Medizin, Universitätsklinikum Münster, Münster, Germany
| | - Dennis Liem
- Klinik und Poliklinik für Allgemeine Orthopädie und Tumororthopädie, Universitätsklinikum Münster, Münster, Germany
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Min BW, Kim Y, Cho HM, Park KS, Yoon PW, Nho JH, Kim SM, Lee KJ, Moon KH. Perioperative Pain Management in Total Hip Arthroplasty: Korean Hip Society Guidelines. Hip Pelvis 2016; 28:15-23. [PMID: 27536639 PMCID: PMC4972874 DOI: 10.5371/hp.2016.28.1.15] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/23/2016] [Accepted: 03/07/2016] [Indexed: 11/27/2022] Open
Abstract
Effective perioperative pain management techniques and accelerated rehabilitation programs can improve health-related quality of life and functional status of patients after total hip arthroplasty. Traditionally, postoperative analgesia following arthroplasty was provided by intravenous patient-controlled analgesia or epidural analgesia. Recently, peripheral nerve blockade has emerged alternative analgesic approach. Multimodal analgesia strategy combines analgesics with different mechanisms of action to improve pain management. Intraoperative periarticular injection of multimodal drugs is one of the most important procedures in perioperative pain control for total hip arthroplasty. The goal of this review article is to provide a concise overview of the principles of multimodal pain management regimens as a practical guide for the perioperative pain management for total hip arthroplasty.
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Affiliation(s)
- Byung-Woo Min
- Department of Orthopaedic Surgery, Keimyung University Hospital, Daegu, Korea
| | - Yeesuk Kim
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, Korea
| | - Hong-Man Cho
- Department of Orthopaedic Surgery, Gwangju Veterans Hospital, Gwangju, Korea
| | - Kyung-Soon Park
- Department of Orthopaedic Surgery, Center for Joint Disease, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Pil Whan Yoon
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Hwi Nho
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital, Seoul, Korea
| | - Sang-Min Kim
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, Korea
| | - Kyung-Jae Lee
- Department of Orthopaedic Surgery, Keimyung University Hospital, Daegu, Korea
| | - Kyong-Ho Moon
- Department of Orthopaedic Surgery, Inha University Hospital, Incheon, Korea
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Kuyucu E, Bülbül M, Kara A, Koçyiğit F, Erdil M. Is cold therapy really efficient after knee arthroplasty? Ann Med Surg (Lond) 2015; 4:475-8. [PMID: 26779338 PMCID: PMC4685204 DOI: 10.1016/j.amsu.2015.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/15/2015] [Accepted: 10/31/2015] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Knee arthroplasty is a frequently used surgery. The purpose of this study is to evaluate the effects of cold therapy after knee arthroplasty. METHODS 60 patients who were operated in our clinic between the years 2013 and 2014 were evaluated prospectively, and the patients were randomized into two groups. The cold therapy by Cryo/Cuff application was started 2 h before the surgery in Group-2 patients; it was repeated in a postoperative 6th hour and continued for postoperative four days. We analyzed the visual analog scales (VAS) for pain, Knee Society Scores (KSS), hemoglobin, and bleeding parameters. RESULTS The data of the group that did not receive the Cryo/Cuff application (Group-1) are as follows; the number of the patients was 33; the mean age value was 68,4 (53-78). Group-2 data was as follows; the number of the patients was 27; the mean age value was 67.2 years (range 57-78). The mean KSS scores of the patients increased from 79.6 (75-83) and to 90.5 (88-92) postoperatively (p < 0.05). DISCUSSION In our study, the pain and functional knee scores of the patients who received Cryo/Cuff application were significantly different and as expected, the use of analgesics was much lower. Cryotherapy did not affect the amount of bleeding during the surgery (p > 0.05), which was not reported previously in the literature. CONCLUSION After knee arthroplasty, the preoperative and postoperative use of cryotherapy is effective in terms of the pain control and functional knee scores without a significant change in surgical blood loss.
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Affiliation(s)
- Ersin Kuyucu
- Istanbul Medipol University, Department of Orthopaedics & Traumatology, Turkey
| | - Murat Bülbül
- Istanbul Medipol University, Department of Orthopaedics & Traumatology, Turkey
| | - Adnan Kara
- Istanbul Medipol University, Department of Orthopaedics & Traumatology, Turkey
| | - Figen Koçyiğit
- Pamukkale University, School of Physical Therapy and Rehabilitation, Denizli, Turkey
| | - Mehmet Erdil
- Istanbul Medipol University, Department of Orthopaedics & Traumatology, Turkey
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Mumith A, Pavlou P, Barrett M, Thurston B, Garrett S. Enhancing Postoperative Rehabilitation Following Knee Arthroplasty Using a New Cryotherapy Product: A Prospective Study. Geriatr Orthop Surg Rehabil 2015; 6:316-21. [PMID: 26623168 PMCID: PMC4647202 DOI: 10.1177/2151458515609722] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
To compare a novel cooling product, Physicool (P, Physicool Ltd, London, England, UK) with a well-established cryotherapy system, Cryocuff (C, Aircast, DJO Global, Vista, California, USA) using pain scores, range of movement (ROM), and cost as outcome measures in the early phase following total knee arthroplasty. We prospectively studied 90 consecutive patients undergoing unilateral total knee arthroplasty by a single surgeon. Following exclusions, 40 patients were recruited to each group. Visual analogue scale (VAS) for pain and ROM before and after application of cooling device was recorded at 24 and 48 hours after surgery. The cost of treatment per patient was also calculated. The VAS were significantly reduced in P on day 1 postsurgery (p = 0.013) and day 2 (p = 0.001) compared to C. A significant increase in ROM was recorded in P at 24 hours (p = 0.004) and at 48 hours (p = 0.009) postsurgery compared to C. The cost benefit of using P over C was approximately £25 per patient. The Physicool system is a safe and effective cooling method for improving pain and ROM in the early postoperative phase following total knee arthroplasty. Furthermore, it offers substantial cost savings.
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Affiliation(s)
- Aadil Mumith
- Institute of Orthopaedics and Musculoskeletal Science, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London, England
| | - Paul Pavlou
- Department of Trauma and Orthopaedics, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, United Kingdom
| | - Matthew Barrett
- Department of Trauma and Orthopaedics, Poole Hospital, Longfleet Road, Poole, United Kingdom
| | - Benjamin Thurston
- Department of Trauma and Orthopaedics, Dorset County Hospital, Williams Avenue, Dorchester, England
| | - Simon Garrett
- Department of Trauma and Orthopaedics, Dorset County Hospital, Williams Avenue, Dorchester, England
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Cryotherapy on postoperative rehabilitation of joint arthroplasty. Knee Surg Sports Traumatol Arthrosc 2015; 23:3354-61. [PMID: 24928371 DOI: 10.1007/s00167-014-3135-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 06/04/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The effectiveness of cryotherapy on joint arthroplasty recovery remains controversial. This systematic review was conducted to assess the effectiveness of cryotherapy in patients after joint arthroplasty. METHODS Comprehensive literature searches of several databases including Cochrane Library (2013), MEDLINE (1950-2013), and Embase (1980-2013) were performed. We sought randomised controlled trials that compared the experimental group received any form of cryotherapy with any control group after joint arthroplasty. The main outcomes were postoperative blood loss, adverse events, and pain. Analyses were performed with Revman 5.0. Results were shown as mean differences (MD) and standard deviations or as risk difference and 95 % confidence intervals (CIs). RESULTS Ten trials comprised 660 total knee arthroplastys and three trials comprised 122 total hip arthroplastys (THAs) met the inclusion criteria. Blood loss was significantly decreased by cryotherapy (MD = -109.68; 95 % CI -210.92 to -8.44; P = 0.03). Cryotherapy did not increase the risk of adverse effect (n.s.). Cryotherapy decreased pain at the second day of postoperative (MD = -1.32; 95 % CI -2.37 to -0.27; P = 0.0003), but did not decreased pain at the first and third day of postoperative (n.s.). CONCLUSIONS Cryotherapy appears effective in these selected patients after joint arthroplasty. The benefits of cryotherapy on blood loss after joint arthroplasty were obvious. However, the subgroup analysis indicated that cryotherapy did not decreased blood loss after THA. Cryotherapy did not increase the risk of adverse effect. Cryotherapy decreased pain at the second day of postoperative, but did not decreased pain at the first and third day of postoperative. LEVEL OF EVIDENCE II.
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Halawi MJ, Grant SA, Bolognesi MP. Multimodal Analgesia for Total Joint Arthroplasty. Orthopedics 2015; 38:e616-25. [PMID: 26186325 DOI: 10.3928/01477447-20150701-61] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/17/2014] [Indexed: 02/03/2023]
Abstract
Optimal perioperative pain control for total joint arthroplasty remains a challenge. Whereas traditional regimens have relied heavily on opioids, newer multimodal pathways are increasingly gaining popularity as safer and more effective alternatives. The main premise of multimodal analgesia is decreased consumption of opioids, and hence lesser opioid-related adverse events. Other reported advantages include lower pain scores, faster functional recovery, higher patient satisfaction, and shorter length of hospital stay. Unfortunately, despite the advent of numerous analgesic techniques, the multimodal approach has remained widely variable, making direct comparison between studies difficult to interpret. This article provides an extensive review of traditional and modern perioperative interventions in pain management for total joint arthroplasty, including intravenous patient-controlled analgesia, epidural infusion, oral opioids, nonsteroidal anti-inflammatory drugs, acetaminophen, peripheral nerve blocks, periarticular infiltration, steroids, anticonvulsants, and long-acting local anesthetics. Emphasis is placed on pathophysiology, clinical evidence, and timing. A standardized multimodal analgesia protocol is also proposed based on best available evidence. In addition to pharmacologic interventions, patient education and interdisciplinary collaboration among the care teams play an important role in the success of any treatment pathway. With a growing demand for total joint arthroplasty in an era of bundled payments and accountable care, there has never been a greater need for a standardized multimodal analgesia pathway.
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Bech M, Moorhen J, Cho M, Lavergne MR, Stothers K, Hoens AM. Device or ice: the effect of consistent cooling using a device compared with intermittent cooling using an ice bag after total knee arthroplasty. Physiother Can 2015; 67:48-55. [PMID: 25931653 DOI: 10.3138/ptc.2013-78] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Purpose : To determine the comparative effectiveness of consistent cooling using an icing device (DonJoy Iceman, DJO Canada, Mississauga, ON) versus intermittent cooling using an ice bag (usual care) for the first 48 hours after total knee arthroplasty (TKA). Method : A sample of 78 patients (intervention group, n=37; control group, n=34) undergoing primary TKA were randomized to intervention (device) or control (ice) groups. The primary outcome was pain intensity, measured by numerical pain rating scale (NPRS). Secondary outcomes were passive range of motion (PROM), nausea or vomiting, opioid use, blood loss, lower limb function, hospital length of stay, and patient-reported compliance and satisfaction. Results : No significant differences in the primary outcome (pain intensity measured via NPRS) were observed between control and intervention groups. Patients in the intervention group were significantly more satisfied (8.4 vs. 6.0, p=0.002); used the device more consistently, day and night (85.7% vs. 29.6% and 87.6% vs. 30.8%, respectively, p<0.001); and were more likely to recommend this method of cooling (96.8% vs. 68.0%, p=0.004). Conclusion : The study found no additional benefit of consistent cryotherapy using the icing device over intermittent ice bags on postoperative pain, PROM, nausea or vomiting, opioid use, blood loss, lower limb function, or length of stay, despite significant differences in patient-reported compliance and satisfaction.
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Affiliation(s)
| | - Joanne Moorhen
- St Paul's Hospital, Providence Health Care ; UBC Department of Physical Therapy, Faculty of Medicine
| | - Mary Cho
- St Paul's Hospital, Providence Health Care
| | - M Ruth Lavergne
- UBC Centre for Health Services and Policy Research, University of British Columbia, Vancouver
| | | | - Alison M Hoens
- St Paul's Hospital, Providence Health Care ; UBC Department of Physical Therapy, Faculty of Medicine
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Thienpont E. Does advanced cryotherapy reduce pain and narcotic consumption after knee arthroplasty? Clin Orthop Relat Res 2014; 472:3417-23. [PMID: 25059851 PMCID: PMC4182365 DOI: 10.1007/s11999-014-3810-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 07/08/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cryotherapy has been used to enhance recovery after orthopaedic surgery. Several cooling devices are available but few can guarantee a fixed temperature during a prolonged time and therefore have been criticized. The arrival of new advanced cryotherapy devices made it possible to test the effect of prolonged cooling on rehabilitation after joint replacement. QUESTIONS/PURPOSES The hypotheses of this randomized controlled trial (RCT) were that advanced cryotherapy devices compared with cold packs result in (1) better postoperative pain control resulting in a lower consumption of narcotics; (2) better early ROM; and (3) less postoperative bleeding and swelling. METHODS A priori sample size calculation had determined that to detect a difference of 2 points on the VAS, a sample size of 50 subjects per group at followup would be required, given a study power of 80%. One hundred sixteen patients were included and randomly allocated to receive advanced cryotherapy (n=58) or use of cold packs (n=58). The primary outcomes for the study were to evaluate pain with the VAS and analgesics consumption. Secondary outcomes were postoperative ROM, swelling, and blood loss. One hundred (50 in each group) patients had complete data available for analysis. RESULTS No statistically significant differences in VAS, need for analgesics, nor in secondary outcomes were observed, except for substantially reduced flexion at 6 weeks in the advanced cryotherapy group (114° versus 120°). CONCLUSIONS Advanced cryotherapy with a continuous temperature for a prolonged period does not deliver expected results of superior early recovery after knee arthroplasty. Greater sample sizes are required to fully determine significant differences between the two techniques for these study parameters. Immobilization of the knee in extension during the prolonged cryotherapy session resulted in lower active flexion at 6 weeks after surgery for the advanced cryotherapy group. Advanced cryotherapy should not be used in fast track knee arthroplasty if the economic cost is higher than the price of cold packs or offers no other concomitant advantages. LEVEL OF EVIDENCE Level II, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Emmanuel Thienpont
- Cliniques Universitaires Saint Luc-UCL, Avenue Hippocrate 10, 1200 Brussels, Belgium
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Kvederas G, Porvaneckas N, Andrijauskas A, Svensen CH, Ivaskevicius J, Mazunaitis J, Marmaite U, Andrijauskas P. A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2013; 21:2790-9. [PMID: 23052115 DOI: 10.1007/s00167-012-2221-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Accepted: 09/17/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE The optimal timing of pneumatic lower limb tourniquet application during primary elective total knee arthroplasty surgery (TKA) is a matter of debate. Most previous reports have failed to show significant differences between different tourniquet timings. The aim of the work was to determine how three strategies of lower limb pneumatic tourniquet application affect the outcome for TKA patients. METHODS Forty-three patients who undergo TKA were randomized into one of the three groups, and 36 of these patients completed the study. The tourniquet was inflated just before incision and deflated after the hardening of the cement for twelve patients (Group 1), it was inflated just before cement application and deflated after its hardening for another twelve patients (Group 2), and it was inflated before incision and deflated after the last suture of the skin for a further twelve patients (Group 3). Fit-to-discharge criteria and six methods for calculating estimated blood loss were used. RESULTS The estimated blood loss in Group 1 was lower than in Group 2, as determined by six methods of calculation (p < 0.05). Estimated blood loss in Group 3 was lower than in Group 2, as determined by one method (p = 0.050). The mobilization performance in Group 1 was better than in Group 2 (p = 0.023) and in Group 3 (p = 0.033). Group 1 was better fit to discharge than Group 3 (p = 0.030). CONCLUSIONS Inflation of an automatic pneumatic lower limb tourniquet before skin incision and its deflation after hardening of cement tends to give better outcomes in TKA patients during six postoperative days. The estimated blood loss was highest when the tourniquet was inflated just before cement application and deflated after its hardening.
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Affiliation(s)
- Giedrius Kvederas
- Faculty of Medicine, Vilnius University, Siltnamiu 29, 04130, Vilnius, Lithuania,
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Pinsornsak P, Chumchuen S. Can a modified Robert Jones bandage after knee arthroplasty reduce blood loss? A prospective randomized controlled trial. Clin Orthop Relat Res 2013; 471:1677-81. [PMID: 23307631 PMCID: PMC3613516 DOI: 10.1007/s11999-013-2786-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 01/02/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND A bulky compression dressing (Robert Jones bandage) is commonly used after TKA to reduce blood loss, pain, and swelling. However, it is unclear whether these dressings in fact reduce blood loss. QUESTIONS/PURPOSES We compared postoperative blood loss, pain, knee swelling, and postoperative complications in two types of postoperative dressings after TKA: a modified Robert Jones dressing (MRJB) and a conventional wound dressing. METHODS We conducted a prospective, randomized, controlled trial of 60 patients who underwent a unilateral primary TKA at our institution between November 2010 and July 2011. After wound closure, the patients were allocated into two groups. Thirty patients had the MRJB applied for 24 hours (Group 1) and 30 patients had a conventional wound dressing applied (Group 2). Postoperative hemorrhages in the vacuum drain, units of transfused blood, postoperative pain, knee swelling, and complications were assessed at 24 and 48 hours postoperatively. RESULTS We found no differences in the mean postoperative blood loss between the groups (Group 1, 418 mL versus Group 2, 467 mL). Blood transfusion amounts, postoperative pain, and knee swelling also were similar. Three patients in Group 1 experienced bruising and two patients in Group 2 also had bruising. One patient in Group 1 had a blister. CONCLUSIONS Although previous studies have shown reduced blood loss, pain, and knee swelling after application of a MRJB, we found no benefit of this bandage. Our data suggest a postoperative compression dressing is not necessary after primary TKAs.
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Affiliation(s)
- Piya Pinsornsak
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, 12120 Thailand
| | - Sukanis Chumchuen
- Department of Orthopaedic Surgery, Thammasat University, 99 Moo 18, Khlong Nueng, Khlong Luang, Pathumthani, 12120 Thailand
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Su EP, Perna M, Boettner F, Mayman DJ, Gerlinger T, Barsoum W, Randolph J, Lee G. A prospective, multi-center, randomised trial to evaluate the efficacy of a cryopneumatic device on total knee arthroplasty recovery. ACTA ACUST UNITED AC 2013; 94:153-6. [PMID: 23118406 DOI: 10.1302/0301-620x.94b11.30832] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pain, swelling and inflammation are expected during the recovery from total knee arthroplasty (TKA) surgery. The severity of these factors and how a patient copes with them may determine the ultimate outcome of a TKA. Cryotherapy and compression are frequently used modalities to mitigate these commonly experienced sequelae. However, their effect on range of motion, functional testing, and narcotic consumption has not been well-studied. A prospective, multi-center, randomised trial was conducted to evaluate the effect of a cryopneumatic device on post-operative TKA recovery. Patients were randomised to treatment with a cryopneumatic device or ice with static compression. A total of 280 patients were enrolled at 11 international sites. Both treatments were initiated within three hours post-operation and used at least four times per day for two weeks. The cryopneumatic device was titrated for cooling and pressure by the patient to their comfort level. Patients were evaluated by physical therapists blinded to the treatment arm. Range of motion (ROM), knee girth, six minute walk test (6MWT) and timed up and go test (TUG) were measured pre-operatively, two- and six-weeks post-operatively. A visual analog pain score and narcotic consumption was also measured post-operatively. At two weeks post-operatively, both the treatment and control groups had diminished ROM and function compared to pre-operatively. Both groups had increased knee girth compared to pre- operatively. There was no significant difference in ROM, 6MWT, TUG, or knee girth between the 2 groups. We did find a significantly lower amount of narcotic consumption (509 mg morphine equivalents) in the treatment group compared with the control group (680 mg morphine equivalents) at up to two weeks postop, when the cryopneumatic device was being used (p < 0.05). Between two and six weeks, there was no difference in the total amount of narcotics consumed between the two groups. At six weeks, there was a trend toward a greater distance walked in the 6MWT in the treatment group (29.4 meters versus 7.9 meters, p = 0.13). There was a significant difference in the satisfaction scores of patients with their cooling regimen, with greater satisfaction in the treatment group (p < 0.0001). There was no difference in ROM, TUG, VAS, or knee girth at six weeks. There was no difference in adverse events or compliance between the two groups. A cryopneumatic device used after TKA appeared to decrease the need for narcotic medication from hospital discharge to 2 weeks post-operatively. There was also a trend toward a greater distance walked in the 6MWT. Patient satisfaction with the cryopneumatic cooling regimen was significantly higher than with the control treatment.
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Affiliation(s)
- E P Su
- Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021, USA.
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Abstract
BACKGROUND Total knee replacement (TKR) is a common intervention for patients with end-stage osteoarthritis of the knee. Post-surgical management may include cryotherapy. However, the effectiveness of cryotherapy is unclear. OBJECTIVES To evaluate the acute (within 48 hours) application of cryotherapy following TKR on pain, blood loss and function. SEARCH METHODS We searched the Cochrane Database of Systematic Reviews, CENTRAL, DARE, HTA Database, MEDLINE, EMBASE, CINAHL, PEDro and Web of Science on 15th March 2012. SELECTION CRITERIA Randomised controlled trials or controlled clinical trials in which the experimental group received any form of cryotherapy, and was compared to any control group following TKR indicated for osteoarthritis. DATA COLLECTION AND ANALYSIS Two reviewers independently selected trials for inclusion. Disagreements were discussed and resolved involving a third reviewer if required. Data were then extracted and the risk of bias of trials assessed. Main outcomes were blood loss, visual analogue score (VAS) pain, adverse events, knee range of motion, transfusion rate and knee function. Secondary outcomes were analgesia use, knee swelling, length of hospital stay, quality of life and activity level. Effects of interventions were estimated as mean differences (MD), standardised mean differences (SMD) or given as risk ratios (RR), with 95% confidence intervals (CI). Meta-analyses were performed using the inverse variance method and pooled using random effects. MAIN RESULTS Eleven randomised trials and one controlled clinical trial involving 809 participants met the inclusion criteria. There is very low quality evidence from 10 trials (666 participants) that cryotherapy has a small benefit on blood loss (SMD -0.46, 95% CI, -0.84 to -0.08), equivalent to 225mL less blood loss in cryotherapy group (95% CI, 39 to 410mL). This benefit may not be clinically significant. There was very low quality evidence from four trials (322 participants) that cryotherapy improved visual analogue score pain at 48 hours (MD = -1.32 points on a 10 point scale, 95% CI, -2.37 to -0.27), but not at 24 or 72 hours. This benefit may not be clinically significant. There was no difference between groups in adverse events (RR = 0.98, 95% CI, 0.28 to 3.47). There is low quality evidence from two trials (107 participants) for improved range of motion at discharge (MD 11.39 degrees of additional flexion, 95% CI 4.13 to 18.66), but this benefit may not be clinically significant. There was no difference between groups in transfusion rate (RR 2.13, 95% CI 0.04 to 109.63), and knee function was not measured in any trial. No significant benefit were found for analgesia use, swelling or length of stay. Outcomes measuring quality of life or activity level were not reported. AUTHORS' CONCLUSIONS Potential benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use, and the quality of the evidence was very low or low for all main outcomes. This needs to be balanced against potential inconveniences and expenses of using cryotherapy. Well designed randomised trials are required to improve the quality of the evidence.
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Affiliation(s)
- Sam Adie
- Whitlam Orthopaedic Research Centre, Liverpool Hospital, Liverpool, Australia.
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Demoulin C, Brouwers M, Darot S, Gillet P, Crielaard JM, Vanderthommen M. Comparison of gaseous cryotherapy with more traditional forms of cryotherapy following total knee arthroplasty. Ann Phys Rehabil Med 2012; 55:229-40. [PMID: 22516265 DOI: 10.1016/j.rehab.2012.03.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 03/07/2012] [Accepted: 03/13/2012] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to assess the efficacy of gaseous cryotherapy following total knee arthroplasty (TKA) and to compare it to routinely used strategies for applying cold therapy. PATIENTS AND METHODS Sixty-six patients undergoing primary unilateral TKA were randomized into three groups and received "gaseous cryotherapy (GC)", "cold pack" and "cryocuff" applications, respectively throughout the hospital stay. Primary outcomes (knee pain intensity, mobility and girth measurements) were recorded on preoperative day 1 as well as on postoperative day (POD) 7. Cutaneous temperature of the knee sides were also measured on POD7 just before and immediately after cold application. RESULTS Although skin temperature dropped to 14°C following GC versus 22 to 24°C for the other two applications (P<0,05), the three groups did not differ at POD7 regarding the three primary outcomes. No adverse effects were observed with any of the ways of application. CONCLUSIONS Gaseous cryotherapy was not more beneficial than routinely used strategies for applying cold therapy. Further studies with larger sample size and with a more frequent and closer gaseous cryotherapy applications are needed to confirm our results.
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Affiliation(s)
- C Demoulin
- Department of Motricity Sciences and Rehabilitation, Liège University, Belgium.
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Adie S, Naylor JM, Harris IA. Cryotherapy after total knee arthroplasty a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty 2010; 25:709-15. [PMID: 19729279 DOI: 10.1016/j.arth.2009.07.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 07/06/2009] [Indexed: 02/01/2023] Open
Abstract
Cryotherapy has theoretical and practical applications in the reduction of pain, swelling, and blood loss after trauma. We performed a systematic review and meta-analysis of randomized controlled trials on the efficacy of cryotherapy after total knee arthroplasty (TKA). Eleven studies involving 793 TKAs were included. There was considerable clinical and methodological heterogeneity. Cryotherapy resulted in small benefits in blood loss and discharge knee range of motion. There were no benefits in transfusion and analgesia requirements, pain, swelling, length of stay, and gains in knee range of motion after discharge. Despite some early gains, cryotherapy after TKA yields no apparent lasting benefits. Patient-centered outcomes remain underinvestigated. The current evidence does not support the routine use of cryotherapy after TKA.
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Affiliation(s)
- Sam Adie
- South West Sydney Clinical School University of New South Wales Sydney, New South Wales, Australia
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Shin YS, Lim NY, Yun SC, Park KO. A randomised controlled trial of the effects of cryotherapy on pain, eyelid oedema and facial ecchymosis after craniotomy. J Clin Nurs 2009; 18:3029-36. [DOI: 10.1111/j.1365-2702.2008.02652.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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LOBET S, PENDEVILLE E, DALZELL R, DEFALQUE A, LAMBERT C, POTHEN D, HERMANS C. The role of physiotherapy after total knee arthroplasty in patients with haemophilia. Haemophilia 2008; 14:989-98. [DOI: 10.1111/j.1365-2516.2008.01748.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Fischer HBJ, Simanski CJP, Sharp C, Bonnet F, Camu F, Neugebauer EAM, Rawal N, Joshi GP, Schug SA, Kehlet H. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty. Anaesthesia 2008; 63:1105-23. [PMID: 18627367 DOI: 10.1111/j.1365-2044.2008.05565.x] [Citation(s) in RCA: 230] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://www.postoppain.org). Evidence-based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors, plus intravenous strong opioids (high-intensity pain) or weak opioids (moderate- to low-intensity pain).
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Affiliation(s)
- H B J Fischer
- Department of Anaesthesia, Alexandra Hospital, Redditch, UK.
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Becher C, Springer J, Feil S, Cerulli G, Paessler HH. Intra-articular temperatures of the knee in sports - an in-vivo study of jogging and alpine skiing. BMC Musculoskelet Disord 2008; 9:46. [PMID: 18405365 PMCID: PMC2330048 DOI: 10.1186/1471-2474-9-46] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 04/11/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Up to date, no information exists about the intra-articular temperature changes of the knee related to activity and ambient temperature. METHODS In 6 healthy males, a probe for intra-articular measurement was inserted into the notch of the right knee. Each subject was jogging on a treadmill in a closed room at 19 degrees C room temperature and skiing in a ski resort at -3 degrees C outside temperature for 60 minutes. In both conditions, temperatures were measured every fifteen minutes intra-articulary and at the skin surface of the knee. A possible influence on joint function and laxity was evaluated before and after activity. Statistical analysis of intra-articular and skin temperatures was done using nonparametric Wilcoxon's sign rank sum test and Mann-Whitney's-U-Test. RESULTS Median intra-articular temperatures increased from 31.4 degrees C before activity by 2.1 degrees C, 4 degrees C, 5.8 degrees C and 6.1 degrees C after 15, 30, 45 and 60 min of jogging (all p < or = 0.05). Median intra-articular temperatures dropped from 32.2 degrees C before activity by 0.5 degrees C, 1.9 degrees C, 3.6 degrees C and 1.1 degrees C after 15, 30, 45 and 60 min of skiing (all n.s.). After 60 minutes of skiing (jogging), the median intra-articular temperature was 19.6% (8.7%) higher than the skin surface temperature at the knee. Joint function and laxity appeared not to be different before and after activity within both groups. CONCLUSION This study demonstrates different changes of intra-articular and skin temperatures during sports in jogging and alpine skiing and suggests that changes are related to activity and ambient temperature.
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Affiliation(s)
- Christoph Becher
- Department of Orthopaedic Surgery, Phillips University, Marburg, Germany.
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Abstract
Diligent posttreatment wound care management undoubtedly will improve wound outcome and patient satisfaction. There are limited recommendations in the literature to guide management plans. Nevertheless patients must receive specific instructions to complete wound care. These instructions should include whether a dressing is indicated, which dressing should be used, the duration of use, and the method of application. The plan must explain clearly the reasons for returning for further medical attention, for follow-up, for routine removal of sutures/staples, and an earlier return for possible concerns of infection or dehiscence. Preprinted discharge instruction sheets are useful, and illustrations can be helpful.
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Affiliation(s)
- Paresh R Patel
- Department of Emergency Medicine, Darnall Army Medical Center, 36000 Darnall Loop, Fort Hood, Temple, TX 76544, USA
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Kullenberg B, Ylipää S, Söderlund K, Resch S. Postoperative cryotherapy after total knee arthroplasty: a prospective study of 86 patients. J Arthroplasty 2006; 21:1175-9. [PMID: 17162178 DOI: 10.1016/j.arth.2006.02.159] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2004] [Revised: 09/19/2005] [Accepted: 02/06/2006] [Indexed: 02/01/2023] Open
Abstract
A study of 86 patients undergoing total knee arthroplasty (TKA) was performed to evaluate the role of cold compression. The patients were treated with cold compression or epidural analgesia for 3 days after TKA. Pain was measured on a visual analog scale, and total consumption of analgesics was recorded. Range of movement (ROM) was recorded before TKA until 3 weeks postoperatively. Weight bearing, blood loss, and time in hospital were recorded. Visual analog scale scores and analgesic consumption were equal in both groups. Range of movement at discharge was 75 degrees in the cold compression group vs 63 degrees in the control group. By 3 weeks' follow-up, ROM was 99 degrees vs 88 degrees. Mean Hb values averaged 120 mmol/L in the cold compression group vs 109 mmol/L in the control group after surgery. Mean time in hospital of patients with cold compression averaged 4.8 days vs 6.2 days in the control group. The study shows that cold compression therapy improves the control of pain and might thus lead to improvement in ROM and shorter hospital stay.
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Selfe J, Hardaker N, Thewlis D, Karki A. An Accurate and Reliable Method of Thermal Data Analysis in Thermal Imaging of the Anterior Knee for Use in Cryotherapy Research. Arch Phys Med Rehabil 2006; 87:1630-5. [PMID: 17141644 DOI: 10.1016/j.apmr.2006.08.346] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Revised: 08/06/2006] [Accepted: 08/14/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop an anatomic marker system (AMS) as an accurate, reliable method of thermal imaging data analysis, for use in cryotherapy research. DESIGN Investigation of the accuracy of new thermal imaging technique. SETTING Hospital orthopedic outpatient department in England. PARTICIPANTS Consecutive sample of 9 patients referred to anterior knee pain clinic. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Thermally inert markers were placed at specific anatomic locations, defining an area over the anterior knee of patients with anterior knee pain. A baseline thermal image was taken. Patients underwent a 3-minute thermal washout of the affected knee. Thermal images were collected at a rate of 1 image per minute for a 20-minute re-warming period. A Matlab (version 7.0) program was written to digitize the marker positions and subsequently calculate the mean of the area over the anterior knee. Virtual markers were then defined as 15% distal from the proximal marker, 30% proximal from the distal markers, 15% lateral from the medial marker, and 15% medial from the lateral marker. The virtual markers formed an ellipse, which defined an area representative of the patella shape. Within the ellipse, the mean value of the full pixels determined the mean temperature of this region. Ten raters were recruited to use the program and interrater reliability was investigated. RESULTS The intraclass correlation coefficient produced coefficients within acceptable bounds, ranging from .82 to .97, indicating adequate interrater reliability. CONCLUSIONS The AMS provides an accurate, reliable method for thermal imaging data analysis and is a reliable tool with which to advance cryotherapy research.
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Affiliation(s)
- James Selfe
- Department of Allied Health Professions, University of Central Lancashire, Preston, England
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Naylor J, Harmer A, Fransen M, Crosbie J, Innes L. Status of physiotherapy rehabilitation after total knee replacement in Australia. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2006; 11:35-47. [PMID: 16594314 DOI: 10.1002/pri.40] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND PURPOSE Owing to a scarcity of clinical research, evidence-based clinical guidelines are not available to guide physiotherapy rehabilitation after total knee replacement surgery. This is despite the fact that, annually, over 20000 patients in Australia, over 300 000 patients in North America and 36 000 patients in the UK potentially require rehabilitation at this time to regain functional independence and to resume recreational and work-related physical activities. This survey of clinicians aimed to describe standard (usual) care after total knee replacement in Australia and to provide possible explanations for practice variance, if such variation exists. METHOD A nationwide postal survey involving public and privately funded hospital physiotherapy departments was conducted. Purposive sampling was used to randomly select hospitals from the National Joint Replacement Registry. A series of closed and open-ended protocol-based questions were asked. RESULTS A response rate of 65% (65/100) was obtained. Elements of consistency and diversity across the acute and post-acute phases were evident. Consistent findings included the provision of gait retraining and exercise prescription in the acute period, the requirement for independent ambulation as a criterion for discharge from acute care and the routine referral to ongoing outpatient or community-based physiotherapy. Less consistency was reported for the use of continuous passive motion and cryotherapy in the acute phase, the modes of ongoing rehabilitation, discharge from rehabilitation criteria and the tools for measuring outcomes. Both institutional and non-institutional factors appeared to explain the demonstrated practice variation. CONCLUSIONS In order to propagate evidence-based practice guidelines and uniformity in care, well-designed clinical trials are required to identify cost-effective rehabilitation programmes after total knee replacement.
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Affiliation(s)
- Justine Naylor
- Whitlam Joint Replacement Centre, Fairfield Hospital, Sydney, NSW, Australia.
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Barry S, Wallace L, Lamb S. Cryotherapy after total knee replacement: a survey of current practice. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2006; 8:111-20. [PMID: 14533367 DOI: 10.1002/pri.279] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Cryotherapy is commonly used during physiotherapeutic rehabilitation after total knee replacement (TKR). Evidence for treatment effectiveness is contradictory and there are no clinical guidelines to inform treatment protocols within this patient group. The present survey investigated current cryotherapy practice after TKR throughout the United Kingdom (UK). METHOD A postal survey, containing open and closed questions, was distributed to senior inpatient orthopaedic physiotherapists (n = 453). RESULTS The response rate was 67% (304/453) and 58% (263/453) of the responses were completed by physiotherapists who treated TKR patients in the acute phase. Of these, 33% (85/263) routinely applied some form of cryotherapy after TKR. Physiotherapists working in the private sector were more likely to use cryotherapy and had greater access to Cryocuff equipment. The two main methods of cryotherapy application were the Cryocuff device, 59% (155/263) and crushed ice, 30% (79/263). Treatments were applied most frequently between 24 and 48 hours post-surgery, for 20 minutes, twice a day. Lack of proven efficacy was the most frequently stated reason for not applying cryotherapy treatment, and swelling was the most common indicator for treatment. There was particular uncertainty about the physical management of the Cryocuff device. CONCLUSIONS There was little consensus with regard to treatment indicators, method of application and the management of cryotherapy after TKR. The results highlight a lack of consistency in the application of cryotherapy after TKR, indicating a need for further research.
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Affiliation(s)
- Simon Barry
- School of Health and Social Sciences, Coventry University, UK.
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Ishii Y, Matsuda Y. Perioperative blood loss in cementless or hybrid total knee arthroplasty without patellar resurfacing: a prospective, randomized study. J Arthroplasty 2005; 20:972-6. [PMID: 16376250 DOI: 10.1016/j.arth.2004.12.059] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2004] [Accepted: 12/29/2004] [Indexed: 02/01/2023] Open
Abstract
The use of cement is considered as an important way to control perioperative blood loss in knee arthroplasty. We prospectively randomized 57 patients (60 knees) who underwent total knee arthroplasty with (30 knees) or without (30 knees) tibial cement to evaluate perioperative blood loss. The measured total blood loss did not differ significantly between the 2 groups (with tibial cement, 731 +/- 288 mL; without cement, 731 +/- 331 mL; P = .9117). The red blood cell count, hemoglobin level, and hematocrit returned to the preoperative levels within 3 months in both groups. Therefore, tibial cement does not appear to affect perioperative blood loss. This finding has implications when planning blood replacement in cementless and hybrid-type arthroplasties.
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Ishii Y, Matsuda Y. Effect of the timing of tourniquet release on perioperative blood loss associated with cementless total knee arthroplasty: a prospective randomized study. J Arthroplasty 2005; 20:977-83. [PMID: 16376251 DOI: 10.1016/j.arth.2005.01.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The control of perioperative blood loss is a major concern in cementless knee arthroplasty surgery. We randomized retrospectively 55 patients (60 knees in total) who had undergone cementless total knee arthroplasty and determined the efficacy of tourniquet release either "before" (30 knees) or "after" (30 knees) wound closure. Measurements of total blood loss showed significant differences between the groups ("Before" group, 906 +/- 238 mL; "After" group, 731 +/- 332 mL; P = .0225). The levels of red blood cells, hemoglobin, and hematocrit recovered to the preoperative levels by 3 months after surgery in both groups. In summary, we recommend that the tourniquet be released after wound closure and that a compressive dressing be applied with the aim of limiting or reducing perioperative blood loss without significant effects of the transfer requirement in the 2 groups, provided that tourniquet time is kept below 60 minutes to avoid ill effects of the tourniquet.
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Affiliation(s)
- Yoshinori Ishii
- Ishii Orthopaedic and Rehabilitation Clinic, Saitama 361-0037, Japan
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Ishii Y, Matsuda Y. Effect of tourniquet pressure on perioperative blood loss associated with cementless total knee arthroplasty: a prospective, randomized study. J Arthroplasty 2005; 20:325-30. [PMID: 15809950 DOI: 10.1016/j.arth.2004.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Perioperative blood loss is an issue of concern in cementless total knee arthroplasty (TKA). We randomly assigned 57 patients (60 knees) who underwent cementless TKA treatment to 2 groups with tourniquet pressure (TP) of either 350 mm Hg (30 knees) or systolic blood pressure (SBP) plus 100 mm Hg (30 knees) to assess the effect of TP on blood loss. The mean TP in the SBP plus 100 mm Hg group was 238 +/- 13 mm Hg. There was no significant difference between groups. Red blood cell count, hemoglobin levels, and hematocrit recovered to preoperative levels by 3 months after surgery in both groups. In conclusion, we recommend using a TP of 100 mm Hg above SBP during TKA, rather than using the conventional TP of 350 mm Hg.
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Affiliation(s)
- Yoshinori Ishii
- Ishii Orthopaedic and Rehabilitation Clinic, Gyoda, Saitama 361-0037, Japan
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Ibrahim T, Ong SM, Saint Clair Taylor GJ. The effects of different dressings on the skin temperature of the knee during cryotherapy. Knee 2005; 12:21-3. [PMID: 15664873 DOI: 10.1016/j.knee.2004.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2003] [Accepted: 02/05/2004] [Indexed: 02/02/2023]
Abstract
AIM To assess the effect of different dressing types on the efficiency of cryotherapy. METHODS Eighteen normal volunteers were divided equally into group 1-no dressing, group 2-thin adhesive dressing (tegaderm), and group 3--bulky dressing ("wool and crepe"). Cryotherapy (cryocuff and autochill) was applied to one knee with the other knee serving as control. Skin temperature was measured bilaterally every 5 min for 2 h. Statistical analysis used temperature differences between control and test knees. RESULTS The mean baseline skin temperature differences were not statistically different among the three groups (p=0.96). The mean skin temperature decreases at 2 h measured, 17 degrees C (S.D.=0.8) in group 1, 17 degrees C (S.D.=1.9) in group 2, and 5 degrees C (S.D.=1.4) in group 3. "Wool and crepe" significantly impaired the cooling effect of cryotherapy (p<0.001). Tegaderm showed no significant effect (p=0.6). CONCLUSIONS Wool and crepe dressings following knee surgery would prevent effective cryotherapy, whereas, thin adhesive dressings would not.
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Affiliation(s)
- Talal Ibrahim
- Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK.
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Abstract
Hospitals are experiencing an increase in surgical procedures aimed at improving function and quality of life for elders. However, recent reports of pain management practices of elder patients show that pain is underassessed and undertreated. High postoperative pain intensities have been associated with delayed ambulation, postoperative pulmonary complications, increased hospital length of stay, long-term functional impairment, and chronic pain syndromes in this age group. Aggressive pain control is needed, but challenges in assessing and treating pain in older adults make this difficult. The purpose of this article is to review strategies for assessing and treating postoperative pain in older adults. Attention is given to the challenges associated with mental and physical impairments experienced by elders and a review of assessment and pharmacologic and nonpharmacologic strategies are included.
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Affiliation(s)
- Barbara Rakel
- University of Iowa Hospitals and Clinics, Iowa City, IA 52242 , USA.
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Glenn RE, Spindler KP, Warren TA, McCarty EC, Secic M. Cryotherapy decreases intraarticular temperature after ACL reconstruction. Clin Orthop Relat Res 2004:268-72. [PMID: 15123958 DOI: 10.1097/01.blo.0000126302.41711.eb] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cryotherapy has been shown to decrease intraarticular temperature in all regions of the knee after arthroscopy. The purpose of our study was to determine if similar declines in intraarticular temperature were seen with the use of cryotherapy after anterior cruciate ligament reconstruction, a procedure which, unlike simple arthroscopy, produces postoperative hemarthrosis. Sixteen patients had intraarticular temperatures measured for 2 hours after anterior cruciate ligament reconstruction with cryotherapy instituted for only 1 of the 2 hours (eight patients for the first hour and eight patients for the second hour). Significant declines were seen in the suprapatellar pouch after either hour (-2.7 degrees C in Group 1, -2.7 degrees C in Group 2) but not in the lateral gutter. The difference between cryotherapy versus no cryotherapy in the first hour in the suprapatellar pouch was 6.0 degrees C, a clinically meaningful temperature difference. We hypothesize the swelling and hemarthrosis was more pronounced in the lateral gutter because of its dependent position and therefore blunted the effect of cryotherapy seen in the lateral gutter. Cooling of the intraarticular temperature should be considered in the clinical benefits of cryotherapy.
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Affiliation(s)
- Ronald Edward Glenn
- Vanderbilt Sports Medicine Center, Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN 37212, USA
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Saito N, Horiuchi H, Kobayashi S, Nawata M, Takaoka K. Continuous local cooling for pain relief following total hip arthroplasty. J Arthroplasty 2004; 19:334-7. [PMID: 15067647 DOI: 10.1016/j.arth.2003.10.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
This study is the first to evaluate whether continuous cryotherapy can relieve pain soon after total hip arthroplasty (THA). Patients who had undergone THA for osteoarthritis were divided into 2 prospective, randomized groups: the cryotherapy group was fitted with a computer-controlled cooling device for 4 days, and the control group was not. The pain scores measured on a visual analog scale between days 1 and 4 following surgery were significantly lower for the cryotherapy group than for the control group. Furthermore, postoperative analgesic use by the cryotherapy group was significantly lower than by the control group. The results of this study support the potential benefit of a cold compressive device for pain reduction during the postoperative recovery of patients undergoing THA.
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Affiliation(s)
- Naoto Saito
- Department of Orthopedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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Warren TA, McCarty EC, Richardson AL, Michener T, Spindler KP. Intra-articular knee temperature changes: ice versus cryotherapy device. Am J Sports Med 2004; 32:441-5. [PMID: 14977671 DOI: 10.1177/0363546503258864] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cryotherapy is commonly applied without research documenting the intra-articular (IA) temperature changes or subject discomfort between ice and a cryotherapy device. HYPOTHESIS The null hypothesis is that no difference would be observed in IA temperature decline or subject tolerance between ice and the cryotherapy device in normal knees. STUDY DESIGN Prospective, within-subject controlled clinical trial. METHODS Twelve subjects had IA temperature in suprapatellar pouch and skin recorded bilaterally after application of cryotherapy versus ice. Subject tolerance was recorded by 10-cm visual analog scale (VAS). Statistical evaluation was by Spearman's correlation analysis and paired, nonparametric Wilcoxon's signed rank test. RESULTS Both significantly lowered (P < 0.001) skin and IA temperature with median decreases (ice/cryotherapy) at 30 (3.3 degrees C/2.2 degrees C), 60 (12.8 degrees C/7.1 degrees C), and 90 (15.2 degrees C/9.7 degrees C) minutes. However, ice lowered the IA temperature significantly more than the cryotherapy device (P < 0.001) and was more painful by VAS at 30 and 60 minutes (P < 0.01). CONCLUSIONS Both methods produced large declines in skin and IA temperatures. However, ice was more effective yet resulted in higher pain scores. The authors hypothesize that IA temperatures below a threshold are associated with increased perceived pain.
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Affiliation(s)
- Todd A Warren
- Vanderbilt Sports Medicine Center, Department of Orthopaedics & Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Abstract
Analgesic electrotherapy is now based on more consistent scientific data; the biological action of the electric current, of the electromagnetic radiations and of the mechanical vibrations is better approached. But the randomized control trials still provide contradictory results concerning the analgesic efficiency of the cryotherapy, the TENS, the pulsed electro-magnetic fields, the ultrasound and laser therapy, the shock waves; iontophoresis, short waves, microwaves, infrasound vibrations are very few investigated. The analgesic electrotherapy cannot be recommended nor prohibited; physical agents represent only therapeutic options. On the basis of the scientific data and of their personal experience, the therapists can use them. More controlled clinical investigations of higher methodological levels are still required.
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Affiliation(s)
- C-F Roques
- Service de médecine physique et de réadaptation, CHU de Toulouse, hôpital Rangueil, 1, avenue du Professeur-Poulhès, 31403 Toulouse 4, France.
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50
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Abstract
Determination of the severity of injury to the soft tissues is an important component of patient assessment and affects management of closed fractures. The response of soft tissue to blunt injury involves microvascular and inflammatory processes that produce localized tissue hypoxia and acidosis. Incisions placed through such compromised tissue can lead to wound breakdown and deep infection. Therefore, recognizing the signs of soft-tissue injury is the foundation for successful management of closed fractures. Many treatment options, including splinting, cryotherapy, compression, and delayed surgery, help limit further soft-tissue injury and facilitate its rapid recovery before surgical intervention. Emerging surgical techniques based on improved management have resulted in decreased rates of soft-tissue complications.
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Affiliation(s)
- Frank Tull
- Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO 63110, USA
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