We need more evidence to guide postoperative care for children after anterior cruciate ligament reconstruction

Use of cryotherapy in the postoperative treatment of anterior cruciate ligament reconstruction in children: a prospective randomized controlled trial

Wong JYS, Ashik MBZ, Mishra N, Lee NKL, Mahadev A, Lam KY. J Pediatr Orthop B. August 25, 2023. doi: 10.1097/BPB.0000000000001120. E-publishing prior to printing. PMID: 37669155.
https://pubmed.ncbi.nlm.nih.gov/37669155/

Take home message

Young patients experienced minimal benefits in pain and range of motion with the use of an ice pack for the first six weeks after anterior cruciate ligament (ACL) reconstruction.

Background

ACL injuries and subsequent ACL complaints are becoming increasingly common among the young active population. However, we lack a consensus on the best treatment protocols after ACLRs within this population. For example, some physicians disagree on whether cryotherapy should be used acutely after ACLR.

Study aim

The authors sought to investigate the efficacy of cryotherapy in relieving postoperative pain and restoring knee range of motion after ACLR in pediatric patients for six weeks.

Methods

The authors randomized 42 pediatric patients (~15 years old; 55% female) who underwent ACLR from January 2019 to December 2020 to a postoperative ice group (n=21) or no ice group (n=21) and assessed pain at rest and movement via a visual analogue scale and range of motion of the knee at baseline (day 1 postoperatively) and then at 1, 4, and 6 weeks postoperatively. Patients in the ice group received an ice pack and applied the pack for 20 minutes three times a day with a minimum of 4 hours between ice treatments for six weeks. Patients were excluded from the data analysis if they missed more than two of six physical therapy visits.

Results

The ice treatments had minimal impact on knee extension range of motion and pain at rest or with movement. Immediately after surgery, the no-ice group had better knee flexion range of motion than those given ice (53 versus 31 degrees). The ice group subsequently showed greater improvements in range of motion during the first 6 weeks postoperatively compared to the no-ice group (99 vs. 65 degree improvement; final range of motion: 130 vs. 119 degrees). No one reported a cold injury or skin change.

Viewpoints

The authors suggest that adding cryotherapy during the acute phase after ACLR is a low-risk intervention that could improve range of motion. However, we must be careful as each group only had 21 participants and the groups started with different amounts of knee flexion range of motion. It would be useful to conduct larger studies examining these outcomes, medication use, adherence, and patient preferences/expectations. It would be interesting to know whether other strategies, such as cold water immersion or active recovery, would improve outcomes more than an ice pack. Additionally, it would be interesting to use newer assessment strategies to determine whether an ice pack provided pain relief immediately after treatment compared to before. The ice packs may provide minimal benefit for biweekly visits, but provide significant relief at that time. We need more evidence to determine the best way to treat young patients after an ACLR, but an ice pack is an inexpensive, low-risk treatment that can be used if a patient wishes.

Clinical implications

Medical professionals can continue to provide athletes with cryotherapy education and treatment options. However, they should note that the improvements in pain and range of motion are small. This information is important to communicate with patients so that they can make informed treatment decisions about whether to continue with ice.

Questions for discussion

Do you encourage your patients to use ice after surgery? What results have you seen from using ice? Within six weeks of surgery, will you use other alternative methods to reduce pain and increase range of motion?

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Written by Jane McDevitt
Reviewed by Jeffrey Driban