A protocol born in the 1990s, now an established standard of care

ERAS (Enhanced Recovery After Surgery) is no management trend. It emerged in Denmark in the 1990s, driven by Professor Henrik Kehlet, with a clear goal: to reduce surgical stress through a coordinated, multidisciplinary approach covering the pre-, intra-, and post-operative periods. Initially known as "fast-track" surgery in the abdominal field, it was formalised under the ERAS name in 2016 and its principles have since been extended to many specialties, including orthopaedics.

Spine surgery, long kept at arm's length from these protocols, is now progressively adopting them. A systematic review published in 2025, covering 81 studies, concluded that ERAS in spine surgery effectively reduces complications and length of stay, with a median complication rate nearly twice as low in the ERAS group compared to the control group.¹

One of the central pillars of these protocols is opioid reduction. The official ERAS® Society guidelines for orthopaedics emphasise the systematic adoption of opioid-sparing multimodal analgesia, both peri- and post-operatively. This is not a comfort recommendation: the adverse effects of morphine (nausea, constipation, confusion, respiratory depression, risk of dependence) all represent barriers to fast and safe recovery.²

Cryotherapy: a recognised component of ERAS protocols

In this context, non-pharmacological treatments are playing an increasingly important role. A narrative review published in Knee Surgery & Related Research in 2022, analysing 174 studies on ERAS in orthopaedics, identifies cryotherapy as a recognised non-pharmacological post-operative component. It acts on pain and oedema immediately after surgery, two factors directly linked to the quality of early mobilisation, which is itself a key discharge criterion in any ERAS protocol.

Published data on cryotherapy following total knee arthroplasty (TKA) illustrate this contribution clearly. A prospective study conducted on 384 consecutive patients, published in 2023,³ shows that the use of a cryotherapy device after TKA is associated with a significant reduction in pain at day 1, 2, and 3, a 63 % reduction in morphine consumption, and a shorter length of hospital stay.

Game Ready® within an ERAS protocol

The most directly relevant study for evaluating the contribution of a dynamic cryocompression device within an ERAS protocol was published in 2021 in Orthopaedics & Traumatology: Surgery & Research, from the Reims University Hospital, France. It has the rare distinction of evaluating Game Ready® specifically in the context of lumbar fusion surgery conducted under an ERAS protocol.⁴

Sixty patients operated in 2019 (lumbar fusions L4L5, L5S1, or L4S1, with or without laminectomy) were divided into two consecutive groups of 30 by the same surgeon, with an identical anaesthetic protocol including intrathecal morphine injection and subfascial ropivacaine infiltration. The experimental group received application of the Game Ready® belt from the moment of awakening, continuously at 4°C for 48 hours.

Morphine consumption: H24 and H48

At H6, no difference was observed between the groups, intrathecal morphine masks the effect in the short term. It is from H24 onwards that the differences become significant and persistent.

The 50 % reduction in morphine consumption over 48 hours is the most striking finding. It goes beyond analgesic comfort: it mechanically produces a reduction in opioid-related adverse effects. From a haematological standpoint, the reduction in blood loss is consistent with the literature on cold-induced vasoconstriction.

Home as the critical link in the ERAS chain

The ERAS® Society defines precise discharge criteria: no intravenous drip, controlled pain, ability to tolerate solid food, independent ambulation, normal bowel function, no signs of infection, and patient consent. These are not administrative formalities, they reflect a genuine physiological state that determines the safety of early discharge.

This is precisely what the study documents: in the Game Ready® group, these criteria are met earlier and under better conditions. Pain is controlled at H48, and the opioid-related adverse effects that typically delay mobilisation are significantly reduced.

But ERAS does not stop at the clinic door. The official ERAS® Society recommendations explicitly mention the need for clear instructions and structured support so that patients can progress independently after discharge. The growing trend toward shorter hospital stays makes this question even more pressing.

How Kolde fits into this continuum of care

For a patient discharged home as early as day 1 after orthopaedic surgery, the question becomes operational: how can access to dynamic cryocompression be maintained during the home recovery phase? Kolde is a Game Ready® device home rental service designed to cover precisely this window, from hospital to home to recovery.