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Krioterapija nakon operacije potpune zamjene koljena

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Abstract

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Background

Total knee replacement (TKR) is a common intervention for patients with end‐stage osteoarthritis of the knee. Post‐surgical management may include cryotherapy. However, the effectiveness of cryotherapy is unclear.

Objectives

To evaluate the acute (within 48 hours) application of cryotherapy following TKR on pain, blood loss and function.

Search methods

We searched the Cochrane Database of Systematic Reviews, CENTRAL, DARE, HTA Database, MEDLINE, EMBASE, CINAHL, PEDro and Web of Science on 15th March 2012.

Selection criteria

Randomised controlled trials or controlled clinical trials in which the experimental group received any form of cryotherapy, and was compared to any control group following TKR indicated for osteoarthritis.

Data collection and analysis

Two reviewers independently selected trials for inclusion. Disagreements were discussed and resolved involving a third reviewer if required. Data were then extracted and the risk of bias of trials assessed. Main outcomes were blood loss, visual analogue score (VAS) pain, adverse events, knee range of motion, transfusion rate and knee function. Secondary outcomes were analgesia use, knee swelling, length of hospital stay, quality of life and activity level. Effects of interventions were estimated as mean differences (MD), standardised mean differences (SMD) or given as risk ratios (RR), with 95% confidence intervals (CI). Meta‐analyses were performed using the inverse variance method and pooled using random effects.

Main results

Eleven randomised trials and one controlled clinical trial involving 809 participants met the inclusion criteria. There is very low quality evidence from 10 trials (666 participants) that cryotherapy has a small benefit on blood loss (SMD ‐0.46, 95% CI, ‐0.84 to ‐0.08), equivalent to 225mL less blood loss in cryotherapy group (95% CI, 39 to 410mL). This benefit may not be clinically significant. There was very low quality evidence from four trials (322 participants) that cryotherapy improved visual analogue score pain at 48 hours (MD = ‐1.32 points on a 10 point scale, 95% CI, ‐2.37 to ‐0.27), but not at 24 or 72 hours. This benefit may not be clinically significant. There was no difference between groups in adverse events (RR = 0.98, 95% CI, 0.28 to 3.47). There is low quality evidence from two trials (107 participants) for improved range of motion at discharge (MD 11.39 degrees of additional flexion, 95% CI 4.13 to 18.66), but this benefit may not be clinically significant. There was no difference between groups in transfusion rate (RR 2.13, 95% CI 0.04 to 109.63), and knee function was not measured in any trial. No significant benefit were found for analgesia use, swelling or length of stay. Outcomes measuring quality of life or activity level were not reported.

Authors' conclusions

Potential benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use, and the quality of the evidence was very low or low for all main outcomes. This needs to be balanced against potential inconveniences and expenses of using cryotherapy. Well designed randomised trials are required to improve the quality of the evidence.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Laički sažetak

Terapija ledom/hladnoćom nakon operacije potpune zamjene koljena.

Ovaj Cochrane sustavni pregled analizira do sada poznata istraživanja o učincima terapijske intervencije hladnoćom/ledom (krioterapija) nakon operacije potpune zamjene koljena u pacijenata s osteoartritisom.

Sustavni pregled pokazuje da u ljudi kojima je operativno zamijenjeno koljeno:

‐ Krioterapija može blago smanjiti gubitak krvi i bol

‐ Krioterapija je općenito sigurna intervencija i nije povezana s ozbiljnim nuspojavama

‐ Krioterapija može povećati opseg pokreta u koljenu u prvih tjedan do dva poslije operacije

‐ Studije koje bi proučavale učinak krioterapije na aktivnosti povezane s funkcijom koljena (ili kvalitetom života ili općenitom količinom aktivnosti) nisu pronađene.

Što su potpuna zamjena koljena i krioterapija?

Osteoartritis je bolest zglobova, primjerica koljena. Zahvaćeno koljeno je bolno i smanjene funkcije. Zamjena zgloba koljena je terapija koja može dugoročno pomoći kod takvog stanja, ali učinci operacije za vrijeme perioda oporavka (prvih šest mjesec, npr.) su iscrpljujući. Terapija hladnoćom (krioterapija) uključuje primjenu vrlo niskih temperatura na koži u blizini ozljede ili mjesta kirurške intervencije. Za to se mogu koristiti vrećice s ledom ili posebna oprema koja zahvaćeno područje hladi vodom.

Ovaj pregled pokazuje kako postoje dokazi da krioterapija može smanjiti bol i povećati opseg pokreta u prvih nekoliko dana nakon potpune zamjene koljena, ali uporaba terapije hladnoćom ne smanjuje potrebu za transfuzijama krvi. Uporaba krioterapije je sigurna i ne dovodi do većeg broja ozbiljnih komplikacija.

Najbolja procjena o ishodima pacijenata koji su podvrgnuti potpunoj zamjeni koljena i krioterapiji:

Gubitak krvi:

‐ Pacijenti koji su primijenili krioterapiju u prosjeku su gubili 225 ml manje krvi nego pacijenti koji nisu.

Bol

‐ Pacijenti koji su primijenili krioterapiju su prijavili kako ih manje boli drugi dan poslije operacije, u prosjeku 1,3 bodova manje u upitniku o boli (na ljestvici od 0 do 10), ali razine boli prvog i trećeg dana nisu pokazali nikakvu razliku.

Neželjeni učinci (uključujući neugodu, lokalne reakcije na koži, infekcije kože, ozljede povezane s hladnoćom i krvne ugruške)

‐ 34 od 1000 ljudi koji su podvrgnuti krioterapiji su iskusili jedan ili više neželjenih učinaka

‐ 34 od 1000 ljudi koji nisu bili podvrgnuti krioterapiji također su iskusili jedan ili više neželjenih učinaka

Opseg pokreta

‐ Pacijenti koji su podvrgnuti krioterapiji su u prosjeku mogli savinuti koljeno 11 stupnjeva više u vrijeme otpusta iz bolnice

Učestalost transfuzije (odnosno potreba za transfuzijom poslije operacije)

‐ Učestalost nije bila smanjena u pacijenata koji su podvrgnuti krioterapiji

Funkcija

‐ Nema dokaza o utjecaju krioterapije na funkciju koljena.