Surgery: Current Research

A Safe and Effective Method to Enhance Rehabilitation Following Total Knee Arthroplasty is Cryoneurolysis

David James^{* *}Correspondence: David James, Editorial Office, Surgery: Current Research, Belgium, Email:

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Introduction

Total Knee Arthroplasty (TKA) is a very effective and affordable treatment for chronic knee osteoarthritis, with a 10-year survival rate of 94% and a 20- year survival rate of 71%. Patient satisfaction has been less predictable, with reports of up to a 20% dissatisfaction rate, despite the fact that TKA is a well-established option for improving patient’s quality of life through pain relief, restoration of function and range of motion, and correction of deformity. Furthermore, despite substantial advancements in surgical technique, biomaterials, implant designs, and technology, this rate of unhappiness has not changed. It is crucial for arthroplasty surgeons to continue to comprehend the causes of patient discontent and make an effort to resolve them before, during, and after surgery because it is predicted that the number of TKAs performed in the upcoming decades would increase exponentially. Orthopaedic surgeons must take into account a multimodal pain strategy for patients to reduce opioid use and lower the risk of opioid use dependence after surgery given the ongoing opioid consumption crisis in the United States and reports of over 30,000 opioid-related U.S. deaths in 2015. The American Association of Orthopaedic Surgeons does not endorse the use of opioids, and prolonged opioid use has been linked to worse postoperative functional results as well as higher morbidity and mortality rates. One such technique to treat knee discomfort and lessen chronic postoperative pain in individuals following TKA is cryoanalgesia (cryoneurolysis). Similar to a long-active nerve block, this method involves exposing nerve endings to temperatures below 20°C in order to cause neuronal degeneration. In TKA, the Anterior Femoral Cutaneous Nerve (AFCN) and Infrapatellar Branches of the Saphenous Nerve (ISN) are targeted to lessen pain across the front of the knee.

By evaluating the effectiveness and safety of cryoneurolysis treatment before TKA, with a focus on the assessment of postoperative knee range of motion and opioid use, we aimed to validate these findings in this study. Our prediction was that preoperative cryoneurolysis would improve postoperative knee range of motion, reduce stiffness, and reduce the need for postoperative opioids.

 

Discussion

To decrease opiate consumption and enhance knee functional outcomes, cryoneurolysis is a safe, efficient preoperative method that can be implemented into an integrated multimodal pain management route. Finding ways to lessen postoperative opioid dependence enhances physicianpatient communication about expected outcomes and discharge planning. Pain management is a critical component of patient care and satisfaction. According to earlier research, extended opioid postoperative usage following TKA is linked to higher rates of stiffness, subpar functional results, and lowered quality of life. To reduce opioid intake without weakening rehabilitation, the use of multimodal regimens that incorporate NSAIDs, gabapentinoids, acetaminophen, periarticular injections, and neuroaxial analgesia has been investigated in the past. However, whereas cryoneurolysis therapy may offer long-lasting analgesia many weeks after surgery, oral medicines and periarticular injection techniques only offer transient relief. In order to understand the dynamics of cryoneurolysis on shortand long-term recovery, we analyze inpatient and outpatient opioid intake, subjective functional outcome ratings, and rehabilitative mobility as measured by a physical therapist in this retrospective review. Overall, patients who had cryoneurolysis required less pain medication postoperatively had a better active range of motion and had better patient-reported outcomes without an increased risk of infections, deep vein thrombosis, or neurologic sequelae.

Cryoneurolysis patients needed on average less MMEs than the control group both throughout the acute inpatient stay and after release from the hospital, despite the difference not reaching statistical significance. The lower MME requirement is clinically significant because using fewer opioids overall lowers the risk of side effects that can significantly lengthen hospital stays, prolong the rehabilitation process, and raise hospital costs. These side effects include respiratory issues, falls, nausea, vomiting, constipation, urinary retention, and cognitive impairment. In fact, patients who had cryoneurolysis were often discharged one day earlier than the control group, which is clinically significant because the extended stay must be taken into account when calculating hospital quality metrics, billing, and bed space. It is crucial for surgeons to find ways to reduce the length of stay to lower risks for nosocomial infections and hospital problems emphasizing value-based bundled healthcare.

Our cryoneurolysis patients had almost half the quantity of opioids given compared to the control group at the 4 weeks-6 weeks clinic visit. Prolonged opioid use following TKA has been linked to higher rates of stiffness, infection, and low patient satisfaction. Even though it is not statistically significant, the overall lower opioid prescriptions 1 month after surgery compared to the control group point to a clinically improved perception of pain, which lowers the need for unnecessary visits to emergency rooms and office phone calls for pain that isn't relieved. Our anecdotal findings from hospital and physical therapy staff that describe higher happiness and improved functional rehabilitation in our cryoneurolysis patients reinforce the decrease in overall narcotics prescribed in both inpatient and outpatient.

Patients in the cryoneurolysis group ambulated on average 100 feet further than the control group on postoperative day 1 despite not attaining statistical significance in terms of active recovery and return to independence. The improvement in ambulation on the first postoperative day may be due to increased capacity and stamina for physical treatment, which is sometimes hampered by the confounding effects of nausea, vomiting, and sleepiness following excessive opioid intake. The combination of decreased overall opioid consumption and better pain management may increase participation in therapy sessions, resulting in an earlier and safer discharge to home. Although the treatment group's Boston AM-PAC scores, which measure the level of dependence required to carry out daily activities, did not significantly improve, day 1 ambulatory improvements may more accurately reflect the effectiveness of cryoneurolysis on the quadriceps coordination required for rapid rehabilitation. The tasks evaluated by the Boston AM-PAC scores, such as bed mobility and upper body grooming, may not always represent functional recovery following TKA.

Regaining knee ROM is a significant postoperative result that has been linked in the literature to improving the capacity to resume daily activities including climbing stairs and getting out of a chair. Cryoneurolysis patients showed statistically significant improvements in knee motion at the 6-week postoperative clinic visit compared to preoperative assessments, indicating improved knee motion that is less constrained by postoperative pain and muscle spasms. The Restoration of knee range of motion (ROM) is not linear, and examples of inadequate early restoration of motion have led to permanent dysfunction, revision surgery, and subpar satisfaction. In this study, the cryoneurolysis patients had an average ROM improvement of 12° by the 6- week visit compared to before surgery, which may indicate improved short-term rehabilitation, motion that is less restricted by pain, and a quicker return to activities.

Cryoneurolysis patients attained Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS Jr) mean clinically significant differences at both the three-month and one-year visits, which may indicate the effectiveness of cryoneurolysis in reducing chronic knee pain and trouble with everyday activities. The quality of life assessment as measured by the SF-12 mental had a stronger influence in the cryoneurolysis patients compared to the control at 1 year, in addition to functional mobility being reported to have improved. Improved overall scores in the cryoneurolysis gr-oup may be attributable to decreased opioid use, which has been shown to contribute to long-term catastrophic thinking as well as symptoms of depression and post-traumatic stress disorder. The SF-12 mental has been used as a diagnostic tool for depression. The SF-12 mental has been used as a diagnostic tool for depression.

The generalizability of our findings may be constrained by the retrospective design, non-randomized nature, and absence of patient blinding in our investigation, among other limitations. There were fewer patients included in the analysis and several patient-reported outcome measures were not fully completed due to the technique's recent introduction in a cohort of only one surgeon. Due to the small sample size, it is probable that many results that were deemed to be statistically insignificant were not able to reveal associations. It was unable to evaluate the interval change in the patient's symptoms from time between undergoing cryoneurolysis and surgery because there was no phone contact or documented measurement of pain scores the day before surgery. Additionally, prescription quantities of MME at clinic visits were employed in this study as a reflection of opioid requirements, despite the possibility that the outpatient opioids administered may have been used for other types of pain and may not accurately reflect the actual usage of the narcotic.

In general, cryoneurolysis is a safe procedure, and this study found no evidence of dyesthesias or numbness problems interfering with patient recovery. Other research suggest that cryoneurolysis may be limited by neuropathic pain, deep vein thrombosis, and wound infections related to the surgical incision, however this study identified no higher risk compared to the control group. Despite the fact that cryoneurolysis patients had statistically significantly higher surgical EBL, this finding is most likely an artefact of the sample size and is not related to the therapy, as previous studies have not linked cryoneurolysis to an increased risk of vascular damage or dermal bleeding. No cases of persistent sensory or motor proprioception block that raised the risk of falling or impeded therapy participation were seen.

Conclusion

For patients receiving TKA, cryoneurolysis is a safe, efficient therapy option that can decrease opioid usage, increase knee ROM, and boost patient satisfaction. There was a trend toward prescribing less MME at follow-up visits, even though there was no statistically significant reduction in MME ingested between groups. The cryoneurolysis group's better knee ROM at 6-week follow-up examinations might signify a more active recovery process and quicker return to daily activities.