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Review Article
2026
:5;
100661
doi:
10.1016/j.jorep.2025.100661

Use of novel postoperative recovery brace improves pain and function while decreasing narcotic dependence in the early recovery period: A narrative review

,
a St. George University School of Medicine, Grenada
b Valley Orthopedic Bone and Joint, United States

⁎Corresponding author: Jesua I. Law. mcbayash@gmail.com

Received: , Accepted: ,
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Total knee arthroplasty (TKA) is a frequently performed procedure that is expected to increase substantially in the coming decades. Patient satisfaction following TKA is largely contingent upon pain control, swelling management, range of motion, and functionality. Addressing each individual area can be a challenge, especially as therapies directed toward mitigation of swelling and pain fail to prioritize extension. Knee extension in the early postoperative period has generally been overlooked, this lack of priority increases the patient's risk of developing a flexion contracture and suffering from lifelong gait abnormalities. The present study will discuss the common pitfalls in the early TKA recovery period and demonstrate the benefits of cryotherapy, compression, and extension bracing. Administration of each of these individual therapies have been shown to promote pain control, reduce narcotic use, improve outcomes, and increase patient satisfaction following TKA. To the author's knowledge, the TR CC brace ® is the only apparatus that combines proven multimodal pain management strategies while maintaining proper joint positioning. It would stand to reason that the presence of all therapies in one device would have a synergistic effect on recovery and maximally optimize postoperative outcomes.

1

1 Introduction

For millions of patients suffering from end-stage osteoarthritis, joint reconstruction with a total knee arthroplasty (TKA) is the treatment of choice for pain relief and improved functional status. However, the postoperative period following TKA can be a challenge for many patients, with approximately 60 % endorsing severe postoperative pain.1 Despite advances in the field, pain control is often inadequate and can hinder rehabilitation,2 increase the patient's risk for narcotic dependence,3 induce feelings of anxiety and depression,4 and effectuate lifelong detriments to the physical and emotional wellbeing of the patient.5 Successful long-term recovery is contingent upon adequate pain control, management of swelling, and proper positioning. Strong pain control fosters an improved and rapid rehabilitation with restoration of strength and joint mobility. Swelling management starts immediately after surgery and can involve a variety of different modalities, most of which include some form of mild compression and cryotherapy, but knee extension in the early postoperative period has generally been overlooked. By holding the knee in full extension, the joint capsule is held in a tightened and compressed fashion, thereby minimizing the space allowed for swelling. The purpose of this article is to discuss the efficacy of each of the components listed above: cryotherapy, pneumatic compression, and proper patient positioning in accelerating and improving patient recovery. It should stand to reason that if these variables are optimized, the patient would have an improved and more rapid recovery.

2

2 Methods

Studies reporting outcomes of patients who received cryotherapy, compression cryotherapy, and extension bracing in the acute postoperative period following TKA were retrieved and assessed to be included in this review. Analysis of available evidence highlights the efficacy of each individual therapeutic modality in improving the rehabilitation period as well as long term function.

3

3 Discussion

3.1

3.1 Use of cryotherapy

The primary goal of the postoperative period is to minimize pain and facilitate early mobilization while ensuring patient satisfaction and wellbeing. Opioids have been a commonly prescribed and highly effective pain management tool in the postoperative period following TKA; however, the associated risk of chronic use and physical dependence has been a well-established concern. In a 3 year cohort study following 1507 Medicaid enrollees undergoing TKA, chronic opioid use occurred in 69 % of patients.6 Additionally, a longitudinal study of 574 patients undergoing arthroplasty found that 8.2 % of TKA patients who were opioid naive the day of surgery were still using opioids 6 months postoperatively.7 These results emphasize the importance of caution while prescribing narcotics and necessitate the exploration of alternative strategies to effectively manage postoperative pain. The concept of multimodal analgesia emerged as a strategy to control pain while minimizing reliance on opioids. Cryotherapy is an effective, yet frequently overlooked component of multimodal pain control that has been shown to reduce opioid use within the first postoperative week.8 Application of cold to the skin overlying an injured soft tissue or joint decreases intraarticular temperature,9 slows tissue metabolism, minimizes oxygenation requirements,10 induces vasoconstriction, slows blood flow, and diminishes swelling.11 The local anesthetic effect, known as cold-induced neuropraxia, is achieved by blunting the response of tissue nociceptors and decreasing the conduction velocity of pain nerve signals.12 Cryotherapy has shown particular benefit in the management of bone and joint trauma or injury. A study13 using bone scanning demonstrated that the application of an ice wrap to one knee for 20 min decreased arterial blood flow by 38 %; soft tissue blood flow by 26 %; and bone uptake, which reflects changes in bone blood flow and metabolism, by 19 %. In a review of 22 clinical trials comparing the effects of cryotherapy on the postoperative course of 1839 patients undergoing a TKA, the cryotherapy groups not only reported lower pain scores 2 days postoperatively, but also demonstrated improved flexion at discharge and greater knee function at 2 weeks than the control group.14 Use of cryotherapy post-TKA has been shown to reduce time to discharge,15 inspire patients' autonomy, decrease the time to “out-of-bed” activity, and improve patients’ postoperative self-care ability and quality of life.16

3.2

3.2 Use of compression cryotherapy

Cryotherapy alone improves the postoperative course, but benefits are propagated even further when cryotherapy is administered in adjunct with compression therapy. Compression therapy is an effective strategy for mitigating swelling, a byproduct of the inflammatory response that occurs secondary to increased vascular permeability and vasodilation. The presence of peripheral inflammation and swelling sensitizes peripheral nerve terminals and increases the excitability of spinal cord neurons,17 profoundly increasing the patient's perception of pain. Hyperalgesia and allodynia lead to less physical activity, promote negative psychological states such as anxiety, depression, and poor quality of life, resulting in heavy social and economic burdens.18 By increasing tissue pressure and venous blood flow,19 compression therapy reduces swelling, edema, muscle vibration, and enhances proprioception to protect healing tissues from microtrauma.20 In a randomized study21 evaluating the effects of intermittent compression and continuous ice water cryotherapy, groups receiving combined treatments demonstrated a 47 % decrease in swelling, compared to a 33 % decrease in groups treated with continuous ice water alone, and 17 % decrease in conventional intermittent ice pack treatment. Cryotherapy with dynamic intermittent compression has been found to result in less postoperative bleeding, significantly less pain on day 3, and a significantly higher functional score than the control group.22 In a 2024 clinical trial,23 Quesnot and colleagues discovered patients who had received cryotherapy alone and patients who had received compression cryotherapy both showed improvement in joint range of motion, trophic changes, pain, and function; however, the compression cryotherapy group showed a significantly faster improvement in joint range of motion, a greater reduction in swelling, and less pain during activity at 21 days post-TKA. Walking distance and KOOS questionnaires were significantly better in the compressive cryotherapy group as well.

3.3

3.3 Avoidance of a flexion contracture and swelling management

Postoperative flexion contracture is an unfortunate complication that occurs in up to 17 % of total knee arthroplasties24,25 and negatively impacts patient satisfaction24 due to lifelong range of motion (ROM) deficits, low knee function scores, and anterior knee pain26; most likely due to the abnormal distribution of forces across the prostheses and an increased load in the posterior aspect of the tibial plateau and patellofemoral joint.27 Joint effusion is a transient sequela of TKA that is associated with the development of flexion contractures detected in the immediate postoperative period.28 Joint effusion, or swelling within the joint space, sensitizes and increases the patient's perception of painful stimuli. Since the majority of effusion occurs in the knee capsule,29 patients often prefer to position the knee in 30° of flexion, as the knee capsule is maximally relaxed. Increasing the space available for joint effusion is less agitating to the capsule and more comfortable for the patient; however, this relaxed posture allows swelling to persist uncontested and decreases extension strength.30 This combination of uncontested swelling and decreased extension strength ultimately promotes the development of a flexion contracture. Effective management of swelling and prioritization of extension are key in the early postoperative period as gait biomechanics become altered at 5° of flexion31 due to shifting of the foot pressure center. The result is acutely impaired balance, walking ability, velocity, and increased energy requirements in the affected leg. Over time, adjacent joints are forced to compensate by assuming abnormal postures, which compounds the effects of abnormal gait kinematics and results in a dissatisfied patient.32 Once established, a flexion contracture is difficult to treat. Multiple studies27,32–34 have shown that patients with a flexion contracture greater than 15° at 3 months post-TKA are unlikely to achieve resolution, despite appropriate intraoperative correction. Maintaining gains in extension achieved intraoperatively is critical in preventing a flexion contracture from developing in the recovery period. Postoperative physical therapy is a tool used frequently by physicians to help patients achieve early extension and prevent contracture and morbidities associated with altered gait, but relies on a compliant patient. Up to 65 % of patients are non- or partially adherent to therapy35–37 and many elderly patients experience difficulties getting to outpatient therapy sessions and oftentimes have confusion when trying to continue these exercises at home. Emphasizing early extension is imperative, as studies have shown that the majority of long-term improvement occurs within the first three months following surgery38 and that ROM at one39 and three40 months post-TKA are indicative of future functional status. One study41 found that patients not only gained the majority of knee extension in the first two weeks post-TKA, but that those with limited knee ROM at one month suffered even greater mobility deficits by weeks seven and eight. In another study, patients who started knee extension exercise within 4 h of TKA had better range of motion, improved gait patterns, and better functional outcomes one year after surgery.42 Extension bracing is another useful tool for achieving extension and preventing a postoperative flexion contracture. In a recent clinical trial,43 patients placed in an extension-locking splint immediately after TKA reported lower pain levels, consumed less opioids, and had improved function compared to the control group. In a case study44 conducted by Finger and colleagues, a patient who developed a flexion contracture of −20° after TKA was only able to improve to −12° after 28 physical therapy sessions; however, after 2 months of nighttime extension bracing, which provided approximately 400 h of passive extension therapy, the patient's contracture was eliminated and full extension was achieved. In a 2024 prospective study,45 Goodwin and colleagues evaluated the effect of sleeping position post-TKA on terminal knee extension, ROM, and developing a flexion contracture. They found that after one month, lateral sleeping patients demonstrated an average of 6°of flexion, fulfilling criteria for a grade I flexion contracture and surpassing the 5° flexion cutoff where gait biomechanics become altered. Supine sleeping patients reached full extension or were within 5° as they received passive extension support each night. The results of these studies highlight the importance of time spent in extension postoperatively and supports the use of nighttime extension bracing following TKA as a valuable strategy for preventing flexion contractures.

4

4 Conclusion

Total knee arthroplasty (TKA) is one of the most common,46–48 clinically successful,49 and cost-effective50 surgical procedures of the modern era. In 2019, 480,958 primary total knee arthroplasties were performed amongst Medicare patients alone. For each 5-year period after 2020, TKAs are projected to increase by 24.28 %, estimating 1,222,988 per year by 2040 and 2,917,959 per year by 2060. This data47 predicts a 469 % increase in TKA from 2019 to 2060 in Medicare patients over 65 years of age alone. As the patient population undergoing TKA continues to increase, the surgeon should be mindful of postoperative complications impeding patient satisfaction and use the tools available to optimize recovery and function. While some compressive cryotherapy braces provide pain relief, failing to maintain the knee in critical full extension puts the patient at risk for a flexion contracture and lifelong dissatisfaction. The TR CC brace ® addresses this disparity with design features that encourage the knee into full extension, thereby protecting the patient from this deleterious complication. To the author's knowledge, the Top Shelf TR CC brace ® is the only postoperative brace that facilitates a complete range of motion while concurrently administering cold therapy and compression. By combining proven multimodal pain management strategies with proper joint positioning, the TR CC brace ® offers a comprehensive solution to the most common obstacles faced in the postoperative recovery period. After elaborating on the benefits of each of these components individually, it would stand to reason that the presence of all therapies in one device would have a synergistic effect on recovery and maximally optimize postoperative outcomes.

CRediT authorship contribution statement

Ashley Conner: Investigation, Writing – original draft. Jesua I. Law: Conceptualization, Writing – review & editing, Supervision, Project administration.

Funding

This research was funded in part by Top Shelf Orthopedics.

Ethical statement

This research was conducted in accordance with the ethical standards of the world medical association.

Guardian/patient's consent

Research did not require guardian/Patient's consent.

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