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193 The Use of Cold Therapy in the Postoperative Management of Patients Undergoing Arthroscopic Anterior Cruciate Ligament Reconstruction Dennis J. Edwards,* FRCS, Martin Rimmer, FRCS, and Greg C. R. Keene, FRACS From SPORTSMED SA, Adelaide, Australia ABSTRACT In this prospective, randomized study we assessed the use of cold therapy after arthroscopic anterior cruciate ligament reconstruction. Seventy-one patients were randomly allocated, without the knowledge of the sin- gle surgeon, to one of three groups: Group I had an ice water-filled CryoCuff fitted in the operating theater after surgery, Group II had room temperature water in the CryoCuff, and Group III patients had no CryoCuff. Pa- tients were well matched for age, sex, and associated surgery. An independent observer measured blood loss, analgesic use, range of motion, and visual analog pain scores postoperatively. There were no differences between any of the three groups regarding the vari- ables measured. The use of cold therapy devices as an adjunct to the postoperative management of these pa- tients must be questioned. The application of a cold compressive dressing after acute injury to the musculoskeletal system is well estab- lished, 1,3,4,8,10-12,15 and cold therapy has recently been advocated after surgery with similarly impressive re- sults. 6,13,14 Researchers have documented the ability of cold therapy to reduce pain and swelling,2 but the physi- ologic basis for this effect is still incompletely understood. It is thought that the locally induced vasoconstriction contributes to the reduction in bleeding, edema, and local inflammatory responses.1,3,4,11 Local cooling has also been shown to reduce or eliminate neuronal pain signal transmission,’ inhibit the stretch reflex, and reduce mus- cle spindle activity. The role of compression after injury is similarly ill un- derstood.5 Splinting the limb with a bulky dressing can be desirable at times, but it can hinder the postoperative rehabilitation program. The pressure produced under these dressings is not constant, and researchers have claimed that it reduces dramatically after application. Brodell et al.5 reported significant compression using a 2 inch thick bandage for at least 24 hours after total knee replacement. However, this thickness of bandage, when used in conjunction with cold therapy, may inhibit cold transmission to the skin and underlying joint. We have conducted a prospective, double-blind, random- ized trial to assess the use of cold therapy and compres- sion after arthroscopic ACL reconstruction. We used the CryoCuff device (Aircast, Summit, New Jersey) because it is thought to allow compression and cooling at the same time while allowing knee flexion-extension exercises. PATIENTS AND METHODS Between September 1993 and March 1994, 71 patients undergoing arthroscopic ACL reconstruction by a single surgeon were randomly selected. All patients underwent the same procedure using an autograft from the middle third of the patella tendon to reconstruct the ACL. Pa- tients with bilateral injuries or those who had previous surgery on the knee were excluded. Patients were ran- domly allocated into one of three groups at the end of the surgical procedure. Data collection was done by an impar- tial observer who had no knowledge of the group to which the patient belonged. Patients in Group I (N = 26) had a CryoCuff fitted in the operating theater. The cuff was filled with ice water and was drained and refilled hourly from the container for the first 36 hours. The reservoir container of ice was changed every 6 hours, or sooner if needed, to ensure that the cuff *Address correspondence and reprnt requests to Dennis J Edwards, FRCS, 31 Angle End, Great Wilbraham, Cambndge, CB1 5JG, United King- dom No author or related institution has received any financial benefit from research m this study

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Page 1: The Use of Cold Therapy in the Postoperative Management of Patients Undergoing Arthroscopic Anterior Cruciate Ligament Reconstruction

193

The Use of Cold Therapy in thePostoperative Management of PatientsUndergoing Arthroscopic Anterior CruciateLigament Reconstruction

Dennis J. Edwards,* FRCS, Martin Rimmer, FRCS, and Greg C. R. Keene, FRACS

From SPORTSMED SA, Adelaide, Australia

ABSTRACT

In this prospective, randomized study we assessed theuse of cold therapy after arthroscopic anterior cruciateligament reconstruction. Seventy-one patients wererandomly allocated, without the knowledge of the sin-gle surgeon, to one of three groups: Group I had an icewater-filled CryoCuff fitted in the operating theater aftersurgery, Group II had room temperature water in theCryoCuff, and Group III patients had no CryoCuff. Pa-tients were well matched for age, sex, and associatedsurgery. An independent observer measured bloodloss, analgesic use, range of motion, and visual analogpain scores postoperatively. There were no differencesbetween any of the three groups regarding the vari-ables measured. The use of cold therapy devices as anadjunct to the postoperative management of these pa-tients must be questioned.

The application of a cold compressive dressing after acuteinjury to the musculoskeletal system is well estab-

lished, 1,3,4,8,10-12,15 and cold therapy has recently beenadvocated after surgery with similarly impressive re-

sults. 6,13,14 Researchers have documented the ability ofcold therapy to reduce pain and swelling,2 but the physi-ologic basis for this effect is still incompletely understood.It is thought that the locally induced vasoconstrictioncontributes to the reduction in bleeding, edema, and localinflammatory responses.1,3,4,11 Local cooling has alsobeen shown to reduce or eliminate neuronal pain signal

transmission,’ inhibit the stretch reflex, and reduce mus-cle spindle activity.The role of compression after injury is similarly ill un-

derstood.5 Splinting the limb with a bulky dressing can bedesirable at times, but it can hinder the postoperativerehabilitation program. The pressure produced underthese dressings is not constant, and researchers haveclaimed that it reduces dramatically after application.Brodell et al.5 reported significant compression using a 2inch thick bandage for at least 24 hours after total kneereplacement. However, this thickness of bandage, whenused in conjunction with cold therapy, may inhibit coldtransmission to the skin and underlying joint.We have conducted a prospective, double-blind, random-

ized trial to assess the use of cold therapy and compres-sion after arthroscopic ACL reconstruction. We used theCryoCuff device (Aircast, Summit, New Jersey) because itis thought to allow compression and cooling at the sametime while allowing knee flexion-extension exercises.

PATIENTS AND METHODS

Between September 1993 and March 1994, 71 patientsundergoing arthroscopic ACL reconstruction by a singlesurgeon were randomly selected. All patients underwentthe same procedure using an autograft from the middlethird of the patella tendon to reconstruct the ACL. Pa-tients with bilateral injuries or those who had previoussurgery on the knee were excluded. Patients were ran-

domly allocated into one of three groups at the end of thesurgical procedure. Data collection was done by an impar-tial observer who had no knowledge of the group to whichthe patient belonged.

Patients in Group I (N = 26) had a CryoCuff fitted in theoperating theater. The cuff was filled with ice water andwas drained and refilled hourly from the container for thefirst 36 hours. The reservoir container of ice was changedevery 6 hours, or sooner if needed, to ensure that the cuff

*Address correspondence and reprnt requests to Dennis J Edwards,FRCS, 31 Angle End, Great Wilbraham, Cambndge, CB1 5JG, United King-dom

No author or related institution has received any financial benefit fromresearch m this study

Page 2: The Use of Cold Therapy in the Postoperative Management of Patients Undergoing Arthroscopic Anterior Cruciate Ligament Reconstruction

194

TABLE 1

Demographic Data on Patients Undergoing ACL Reconstruction

was filled with ice water at all times. Patients in Group II(N = 21) also had a CryoCuff fitted in the operatingtheater, but the cuff was filled with room temperaturewater. The water in the cuff was not changed and the cuffwas removed at 36 hours. Patients in Group III (N = 24)had no CryoCuff fitted. The average age, weight, and sexof the patients in the groups were similar (Table 1).The first nine patients had a thin layer of orthopaedic

wool over the wound closure, but this procedure waschanged in the remaining 62 patients because of concernsabout the effectiveness of cold transmission and the de-

gree of compression achieved by this method. The final 62patients had a sterile compression stocking of the appro-priate size fitted from midcalf to midthigh over the wound.The CryoCuff was then applied directly over this dressing.

All patients underwent an accelerated rehabilitationprogram. Active and passive knee motion (with the aid ofa continuous passive motion machine) was encouragedimmediately. Full extension was checked at the time ofthe operation and patients reached flexion to 90° beforedischarge.The patients received similar intraoperative analgesics

and used injectable morphine via a patient-controlled sys-tem postoperatively. Oral preparations of acetaminophenand codeine were dispensed as required. The dose perkilogram weight equivalent of injectable and oral prepa-ration was then calculated for the patient’s hospital stay.

Patients were asked to rate their pain on a visual analogscale (0 = no pain to 10 = worst pain imaginable) on theevening of the operation and 24 and 48 hours after theprocedure. Blood loss (as measured from the intraarticu-lar drain before removal) and the range of motion at 48hours were recorded. No effort was made to assess the

change in thigh circumference because this measurementwas not accurate enough to produce any valid information.

Statistical analysis using an analysis of variance testwas used to detect differences in the means of the three

groups.

Figure 1. Visual analog pain scores.

RESULTS

Each group was well matched for the patients’ age, sex,and weight (Table 1). On average, patients stayed in thehospital for 3 days after their reconstructions. Additionalsurgical procedures other than ACL reconstruction wererequired in a number of patients. In Group I (ice), fivepatients required meniscectomies, four required meniscalsutures, and seven required notchplasties. In Group II(room temperature), eight patients required meniscecto-mies, three required meniscal sutures, and eight requirednotchplasties. In Group III (no cuff), 7 patients requiredmeniscectomies, 2 required meniscal sutures, and 10 re-quired notchplasties.The total blood loss in all three groups was similar and

no significant differences were found. In Group I the meanloss was 277.3 ml (range, 80 to 560), in Group II, 282.38 ml(range, 90 to 560), and in Group III, 276.7 ml (range, 100to 600).

Patients who received room temperature water throughthe cuff required a nonsignificantly smaller amount ofinjectable analgesics than the others (0.60 mg/kg bodymass compared with 0.65 mg/kg for those patients receiv-ing ice and those with no cuff). The oral intake of acet-aminophen, codeine, or both was again similar and nosignificant difference was noted in any of the groups (Ta-ble 2).There were no significant differences between the visual

analog pain scores as measured on Day 1, 2, or 3 betweenany of the groups (Fig. 1).There were similarly no significant differences in range

of motion as measured at 48 hours. Patients in Group Iachieved a mean of 78°, those in Group II, 76°, and thosein Group III, 72°.

TABLE 2Amount of Analgesic Required by Patients During Their Hospital Stay’

&dquo; Values expressed as mean (range).b Milligrams per kilogram of body weight.

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For all of these measured parameters, the inclusion ofthe first nine patients with a different underbandage didnot change the significance of the above results. No

change was found in the amount of analgesics used, painscores, blood loss, or the range of motion.

DISCUSSION

This prospective, randomized, double-blind trial has notdemonstrated the beneficial effects of cold therapy in thepostoperative management of patients undergoing arthro-scopic ACL reconstruction. We have confirmed the find-ings of Daniel et al.’ in not being able to demonstrate theclaimed benefits of this type of postoperative manage-ment. This study has the advantage of excluding a poten-tial placebo effect of the cuff, and no significant differenceswere found in the blood loss, analgesic intake, visual an-alog pain scores, or the range of motion achieved.The large differences in the analgesic intake reported by

Cohn et al.~ in a similar review of patients treated with aHot/Ice Thermal Blanket (Thermo Temp Inc., Tampa,Florida) after ACL surgery has not been seen in this

study. Interestingly, in the present study those patientstreated with room temperature water in the cuff requiredless total injectable analgesics per kilogram body weightthan those treated with the ice-filled cuff.The cuff has to fit tightly against the thigh, and the

manufacturer recommends filling with the reservoir at aheight of 15 inches above the cuff to generate a cuff pres-sure of 30 mm Hg around the knee. We have not measuredthis pressure directly, but we fitted and filled the cuff ashas been our standard practice in the past. There was nochange in the measurable values once we changed thedressing, even though we changed to a dressing that intheory would produce more compression and allow forgreater transmission of cold to the joint.The CryoCuff can be a little bulky and at times does

interfere with the knee movements postoperatively. Wehave not found this to be of major concern, and patientshave been able to continue with continuous passive mobi-lization with the cuff in place. We have not seen anyadverse reactions to this cuff and have not seen any per-oneal nerve palsies, as has been reported after the use ofcold compressive dressings around the knee.’

Accelerated rehabilitation, as advocated by Shelbourneand Wilckens 14 after ACL surgery, was used for all ofthese patients. On average, patients were discharged fromthe hospital 3 days after surgery. Unfortunately, we werenot able to allow patients to go home with the cuff (as hasbeen advocated in the United States). It is doubtful, how-ever, that the analgesic intake would differ after 3 days. Ifthere was to be a beneficial effect from cold therapy, webelieve it would occur within the first 36 hours, when theeffects of edema, hemorrhage, and pain from the surgicalinsult are greatest.

This prospective study has failed to show the claimedbeneficial effects from cold therapy after ACL reconstruc-tion. However, we are repeating this study with the Au-tochill cuff (Aircast), because this may exclude some of theindependent variables. We hope to report on the results ofthis in the near future.

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