Total and unicompartmental knee arthroplasty (TKA/UKA) is a widely accepted and effective
treatment option for end-stage osteoarthritis (OA) of the knee. Significant long-term
improvement in pain, function and quality of life after TKA are reported in literature,
yet rehabilitation in the first three months remains challenging. Pain and swelling due
to inflammatory reaction after tissue damage may obstruct effective rehabilitation in the
early postoperative period. This could result in stiffness of the knee and patient
dissatisfaction, also in the long-term. Despite encouraging results after implementing
rapid recovery protocols with perioperative local infiltration analgesia and early
mobilisation, treatment could still be optimised. Negative side effects (e.g., nausea,
vomiting, dizziness) and the increasing abuse of opioid analgesics in modern society
drives the search for alternative analgesic techniques. Cryotherapy could play a role in
optimising rehabilitation after surgery. Cryotherapy involves the application of cold to
the skin surrounding injured soft tissue. Application of cold reduces local blood flow
due to vasoconstriction and ensuing the local inflammatory reaction, swelling and heat
experience.
The effectiveness of cryotherapy on the recovery after surgery was studied in numerous
studies and in the majority - but not in all - of these studies a beneficial effect of
the cold therapy was found. Adie et al (2010) show in a systematic review and
meta-analysis based on 11 RCT's that using cryotherapy the blood loss is significant
lower and the range of motion is higher at discharge. In addition, a small effect on pain
is found, cryotherapy leads to lower levels of pain at day 2. This effect was not found
at day 1 and 3. No differences were found in complications, analgesics use, length of
stay and swelling. Functioning was only measured in one study, so no conclusions could be
drawn about that variable. These authors concluded that using cryotherapy postoperatively
after a TKA might have benefits, but that the clinical relevance was uncertain. A more
recent review performed by Ni et al (2015) confirmed, based on 12 studies, the beneficial
results concerning blood loss and pain reduction on day 2. Also, no complications were
documented related to the cryotherapy.
Sadoghi et al. (2018) focused on the effects of cryotherapy starting in the first
postoperative week and found significant beneficial effects on pain on day 2 and knee
flexion on day 6. They did not evidence significant effects in use of analgesics. By
contrast, Thijs et al. (2019) found that patients in the cryotherapy group used 2.6 times
less opioids as an escape medication during the first four postoperative days compared to
the control group. Despite a significant reduction in NRS pain scores before and after
cooling in the cryotherapy group, no clear differences on pain between the two groups in
the first postoperative week were found. In the long-term too - 2, 6 and 12 weeks
postoperatively - no differences could be evidenced. Our recently published RCT has shown
that computer-assisted cryotherapy during the first postoperative week following TKA has
beneficial in terms of pain reduction and diminished opioid consumption during this first
week. At 6 weeks no differences in pain were found. Also the physical examination tests -
aROM, knee circumference and Timed Up and Go - showed no difference between groups after
6 weeks. A period of only one week cooling postoperatively can be a reason for short term
beneficial effect of the cryotherapy. To our knowledge, no study has been conducted on
the effects of 6 weeks cryo and compression therapy after a TKA and UKA.
There are several ways to apply cryotherapy, using ice or cold packs, or mechanical
devices which create a standardized cooling treatment of the injured tissue, with and
without compression. A review of the currently available literature in TKA and UKA
patients stated that standardized continuous cold flow with compression was associated
with better outcomes. However, since the financial aspect is also a major element in
patient care, cost-effectiveness must be considered as well. Cost benefit analyses
demonstrated that simpler devices as ice bag compression bandages or cold packs are far
less costly, with no disadvantage in outcomes in several studies. This makes that in the
current study an easy-to-use brace with an inserted cold pack, that can be applied with a
close fit to the knee, with optional application of manual compression will be used. The
combination of cold and compression was suggested to result in longer and improved
anaesthetic effect after application.
Primary objective:
Investigating the effect of the use of cryo- and compression therapy during the first 6
postoperative weeks after surgery (TKA en UKA) on pain in rest.
Secondary objective:
Investigating the effect of the use of cryo- and compression therapy during the first 6
postoperative weeks after TKA/UKA surgery on pain while loading, opioid use, functioning,
self-perceived change in pain, patient satisfaction and general health. Also the
compliance with the cold- and compression therapy will be investigated.