Total knee arthroplasty (TKA) is an important option in the management of severe osteoarthritis. Despite excellent long-term results following TKA, the immediate postoperative period is often associated with pain, bleeding, edema, and reduced range of movement. So, what can we do to assist in making rehab better than traditional post-surgery methods?
The aim of this article is to look at how cryotherapy may assist in rehabilitation of TKA.
Despite the encouraging results of TKA, the immediate postoperative period is often associated with significant issues such as pain, surgical blood loss, and localized edema resulting from tissue damage and the inflammatory response (1). These are considered crucial factors due to their influence on postoperative opiate use, requirement for blood transfusion and its associated risks as well as a negative impact on postoperative rehabilitation (2). This can result in increased length of stay in hospital, in turn creating increased cost and inconvenience to the patient (3).
Despite progress in anaesthesia and multimodal pain management, TKA remains a challenging procedure for many patients. This has led to the use of nonpharmaceutical management adjuncts such as cryotherapy to address the immediate postoperative concerns described earlier.
Physiology of action
Cryotherapy involves the application of a cold substance, such as ice, to the skin surrounding inflamed soft tissues and joints. The theoretical physiological benefits of clinical cryotherapy have been widely documented since its use in the 1960s and the effects of ice have been demonstrated in several animal and human studies (4,5).
The proposed mechanism of action is that a reduction in temperature reduces intra-articular temperature and limits pain through reducing nerve conduction velocity in addition to promoting immediate vasoconstriction, reducing vascular spasm and slowing down of blood flow, ultimately decreasing tissue edema (6).
Pain has been the most investigated outcome measure in studies involving cryotherapy post-TKA. Kullenberg et al, observed significantly better pain control and patient satisfaction in patients treated with cryotherapy compared to epidural anaesthesia in 86 patients following TKA (7). Ohkoshi et al, found that that continuous cold application resulted in greater than 50% reduction in analgesic demands (8).
Blood loss can be a significant problem post-operatively, requiring blood transfusions at times. Levy and Marmar (9), reported a significant reduction in post-operative blood loss in patients treated with cold therapy compared to controls in a cohort of patients who underwent 10 bilateral and 80 unilateral TKAs with similar findings also shared by Ni et al, (10) Desteli et al, (11) assessed the effect of cryoceutical treatment both pre- and post-TKA versus no intervention. Despite concluding that this approach was effective at reducing peri-operative and postoperative haemorrhage, they did not report a statistically significant difference in need for transfusion between groups.
Cryotherapy was found to reduce the inflammatory processes thought to decrease macrophage infiltration and the accumulation of TNF-α, NF-κB, TGF-β and MMP-9 mRNA levels (12).
Range of motion
Restrictions in range of motion (ROM) can hinder early rehabilitation. Kullenberg et al, reported an increased range of flexion when cryotherapy was used post-TKA in their study of 86 patients (7).
Management of postoperative pain following TKA still poses a challenge. However, nonpharmaceutical adjuncts such as cryotherapy are becoming increasingly popular and have evolved from simple ice packs to more refined devices employing whole body cryotherapy and local cryotherapy treatments. The current research shows this adjunct treatment is benefiting many patients with little to no contraindications.
1. Adie, S, Kwan, A, Naylor, JM. Cryotherapy following total knee replacement. Cochrane Database Syst Rev 2012; 12(9): CD007911.
2. Sehat, KR, Evans, RL, Newman, JH. Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br 2004; 86(4): 561–565.
3. Duellman, TJ, Gaffigan, C, Milbrandt, JC. Multi-modal, pre-emptive analgesia decreases the length of hospital stay following total joint arthroplasty. Orthopedics 2009; 32(3): 167.
4. Gage, AA . Cryosurgical societies: ahistorical note. Cryobiology 1989; 26: 302.
5. Hubbard, TJ, Denegar, CR. Does cryotherapy improve outcomes with soft tissue injury? J Athl Train 2004; 39(3): 278–279.
6. Abramson, DI, Chu, LS, Tuck, JR. Effect of tissue temperatures and blood flow on motor nerve conduction velocity. JAMA 1966; 198: 1082.
7. Kullenberg, B, Ylipää, S, Söderlund, K. Postoperative cryotherapy after total knee arthroplasty: a prospective study of 86 patients. J Arthroplasty 2006; 21(8): 1175–1179.
8. Ohkoshi, Y, Ohkoshi, M, Nagasaki, S. The effect of cryotherapy on intraarticular temperature and postoperative care after anterior cruciate ligament reconstruction. Am J Sports Med 1999; 27(3): 357–362.
9. AS Levy, E Marmar - Clinical orthopaedics and related research, 1993
10. Ni, SH, Jiang, WT, Guo, L. Cryotherapy on postoperative rehabilitation of joint arthroplasty. Knee Surg Sports Traumatol Arthrosc 2015; 23(11): 3354–3361.
11. Desteli, EE, Imren, Y, Aydın, N. Effect of both preoperative and postoperative cryoceutical treatment on hemostasis and postoperative pain following total knee arthroplasty. Int J Clin Exp Med 2015; 8(10): 19150–19155.
12. Forsyth, AL, Zourikian, N, Valentino, LA. The effect of cooling on coagulation and haemostasis: should ‘Ice’ be part of treatment of acute haemarthrosis in haemophilia? Haemophilia 2012; 18(6): 843–850.