Clinical Review

The Cold, Hard Facts of Cryotherapy in Orthopedics

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Cold therapy has been a mainstay of medical treatment since the days of Hippocrates. Initially used by ancient Egyptians to mitigate inflammation and by Hippocrates himself to treat hemorrhage, the therapeutic applications of ice evolved throughout history to become part of the treatment algorithm for a variety of health conditions.1 Ice made an ideal numbing agent for limb amputations and an anesthetic for certain cancers, but truly became ubiquitous when the first cold pack meant for medicinal use was patented in the early 1970s.1,2 Despite their armamentarium of advanced treatment modalities, physicians in the modern era continue to prescribe cryotherapy for their patients, particularly in the field of orthopedics. Most athletes know the “RICE” (Rest, Ice, Compression, Elevation) protocol and utilize it to minimize inflammation associated with soft tissue injuries.

Inflammation is a physiologic response to noxious stimuli. Cell damage results in the production of inflammatory mediators including prostaglandins, which play a crucial role in the vasodilation and pain associated with inflammation. Vasodilation and increased blood flow manifest as swelling, which can cause pain by putting pressure on nerve endings. The inflammatory prostaglandin E2 (PGE2) causes local increases in temperature and mediates pain.3,4 The application of cold therapy attenuates inflammatory microvascular and hemodynamic changes, reducing some of the deleterious effects of inflammation and minimizing pain. Animal models demonstrate that cryotherapy restores functional capillary density, reverses tumor necrosis factor-α (TNF-α)-induced microvasculature damage, and reduces the production of thrombogenic thromboxanes in injured soft tissue.5 Additionally, cold therapy after knee arthroscopy is associated with lower concentrations of PGE2 in the knee.3 Local cooling acts at the cellular level to decrease edema, reduce pain, and slow blood flow to the affected area, with the overall effect of alleviating inflammation.4,5

Cryotherapy is standard practice in postoperative orthopedic care, but there is limited literature demonstrating its efficacy in this setting. In addition, the advent of more advanced wearable cooling systems necessitates a thorough comparison of the various cryotherapy mechanisms both from healthcare and economic perspectives. The goal of this article is to examine the benefits of cryotherapy in the postoperative management of orthopedic surgical interventions and to review the effectiveness of differing types of cryotherapy. A secondary goal of this article is to review the literature on the adverse effects of cryotherapy in order to increase physician awareness of this issue and highlight the importance of patient education when utilizing cryotherapy postoperatively.

BENEFITS OF CRYOTHERAPY

Three standard types of cryotherapy are prescribed as postoperative therapy in orthopedics: compressive cryotherapy, continuous flow cryotherapy, and the application of ice. All aim to decrease the amount of inflammation of the surgical site, reduce patient pain, and aid in the recovery process. The application of ice or other cooling pack devices without compression is the most commonly used method, likely because it is the most economical and user-friendly cryotherapy option. Compressive cryotherapy is the application of ice or an ice pack secured to the site with a bandage or other device in a manner that also applies pressure to the site of injury. Finally, continuous flow cryotherapy systems are typically connected to a refrigeration control unit and apply compressive cooling through the uninterrupted flow of cold water or gas through a wrap around the injured site. Examples include the Game Ready® (CoolSystems, Inc.), Cryo/Cuff® IC Cooler (DJO Global), and Hilotherm Homecare (Hilotherm GmbH) systems, which are marketed as an improvement over traditional forms of cold therapy, as they are capable of cooling for hours at a time, allow for nighttime use, and provide the operator with temperature control.6-8

Postoperative cryotherapy is prescribed for a wide variety of orthopedic procedures, including anterior cruciate ligament (ACL) reconstruction surgery, rotator cuff surgery, and total knee arthroplasty (TKA). Current literature includes many studies monitoring postoperative outcomes in patients using cryotherapy as part of their treatment regimen, with the primary endpoints being visual analog scale (VAS) scores, analgesic consumption, and range of motion (ROM).9-16 As demonstrated by in Table 1, these studies do not provide conclusive evidence that cryotherapy significantly alters postoperative outcomes, despite its ubiquitous use by the orthopedics community. In fact, the literature reflects a seeming lack of consensus regarding the effect of cryotherapy on analgesic requirements, pain, and joint mobility following procedures. Interestingly, of the studies represented in Table 1, only half analyzed all 3 postoperative measures (analgesic consumption, pain, and ROM). Furthermore, solely Morsi13 concluded that cryotherapy resulted in significant improvements in all 3 outcome measures in a trial involving only 30 patients. Kullenberg and colleagues12 performed the largest study, but still included only 86 patients. In addition, all the studies focused on 1 joint or procedure. Thus, despite evidence that cryotherapy reduces inflammation at a molecular level, current literature does not unequivocally support the common belief that cryotherapy benefits patients in practice. More robust studies that include an analysis of analgesic consumption, VAS scores, and ROM (at minimum) and compare the relative efficacy of cryotherapy across joint types and procedures are necessary to determine whether postoperative cryotherapy in orthopedics is appropriate.

Table 1. Results from Studies that Compared Cryotherapy to Standard Care Within the First 2 Weeks Following Surgery

Author

Joint/Procedure Type

Number of Trial Participants

Cryotherapy Type

Analgesic Consumption

VAS Score

ROM

Yu et al9

Elbow arthrolysis

59

Continuous flow cryotherapy (Cryo/Cuff®; DJO Global)

No significant difference

Cryotherapy significantly decreased scores up to POD 7 (P < 0.05)

No significant difference

Dambros et al10

ACL reconstruction

25

Ice pack

Xa

No significant difference

No significant difference

Leegwater et al11

Hip arthroplasty

30

Continuous flow cryotherapy (Game Ready®; CoolSystems, Inc.)

Trend towards lower use (No significant difference)

No significant difference

Xa

Kullenberg et al12

Knee arthroplasty

86

Continuous flow cryotherapy (Cryo/Cuff®)

No significant difference

No significant difference

Significantly improved at POD 7 and POD 21

Morsi13

Knee arthroplasty

30

Continuous flow cryotherapy

Significantly lower consumption (P < 0.01)

Cryotherapy significantly decreased scores (P < 0.001)

Significantly improved at POD 7; No significant difference 6 weeks postoperative

Singh et al14

Open vs arthroscopic shoulder procedures

70

Continuous flow cryotherapy (Breg Polar Care Glacier® Cold Therapy unit; Breg Inc.)

Xa

Cryotherapy significantly decreased scores at arthroscopic POD 14 (P = 0.043); No significant difference for open procedures

Xa

Saito et al15

Hip arthroplasty

46

Continuous flow cryotherapy (Icing System 2000; Nippon Sigmax Co., Ltd.)

Significantly lower epidural analgesic use (P < 0.001); no significant difference in adjunct analgesic consumption

Cryotherapy significantly decreased scores POD 1-4 (P < 0.05)

Xa

Gibbons et al16

Knee arthroplasty

60

Continuous flow cryotherapy (Cryo/Cuff®)

No significant difference

No significant difference

No significant difference

aX indicates that the study did not include that measurement.
Abbreviations: ACL, anterior cruciate ligament; POD, postoperative day; ROM, range of motion; VAS, visual analog scale.

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