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ERAS protocols have transformed perioperative management in orthopaedics. One link in the chain remains fragile: the home recovery phase. Published data on dynamic cryocompression offer a concrete path forward.

Professional resources · KOLDE     |     Reading time: 8 min

A protocol born in the 1990s, now a global standard

The ERAS concept (Enhanced Recovery After Surgery) is not a management trend. It was developed in Denmark in the 1990s by Professor Henrik Kehlet, with a clear objective: reduce surgical stress through a coordinated multidisciplinary approach covering the pre-, intra- and postoperative periods. Originally known as "fast-track" in abdominal surgery, it was formalised under the ERAS name in 2016 and has since been extended to numerous specialties, including orthopaedics.

Spine surgery, long kept at the margins of these protocols, is progressively entering the fold. A systematic review published in 2025 covering 81 studies concludes that ERAS in spinal surgery is effective at reducing complications and length of stay, with a median complication rate almost twice as low in the ERAS group compared to the control group.

A cornerstone of these protocols is opioid reduction. The ERAS® Society's official guidelines for orthopaedics stress the systematic adoption of multimodal opioid-sparing analgesia, both peri- and postoperatively. This is not a comfort recommendation: the side effects of morphine (nausea, constipation, confusion, respiratory depression, addiction risk) are all barriers to fast and safe recovery.

Cryotherapy as a recognised ERAS component

In this context, non-pharmacological treatments play 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 postoperative 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 after total knee arthroplasty (TKA) illustrate this contribution clearly. A prospective study on 384 consecutive patients, published in 2023 in a PubMed-indexed journal, shows that the use of a cryotherapy device after TKA is associated with significantly reduced pain on days 1, 2 and 3 (p < 0.01 at each measurement), a 63% reduction in morphine consumption, and a shorter hospital stay.

Game Ready© within an ERAS protocol

The most directly relevant study evaluating the contribution of dynamic cryocompression within an ERAS protocol was published in 2021 in Orthopaedics & Traumatology: Surgery & Research by De Bie et al., from the CHU de Reims, France. It has the rare quality of evaluating the Game Ready© device specifically in the context of lumbar fusion surgery conducted under an ERAS protocol.

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 the Game Ready© belt from recovery, continuously at 4°C for 48 hours.

"The use of a cryotherapy device in the context of spine surgery is effective at controlling postoperative pain. It also decreases the consumption of analgesics, limits blood loss, reduces the need for transfusions, and contributes to enhanced recovery after surgery."

De Bie et al., OTSR 2021 · Study conclusion

Results in detail

At H6, there is no difference between groups (VAS 5.2 in both). Intrathecal morphine masks the short-term effect. From H24 onwards, the gaps become significant and persistent.

De Bie et al., Orthopaedics & Traumatology: Surgery & Research, 2021

The 50% reduction in morphine consumption over 48 hours (p < 0.0001) is the most striking result. It goes beyond analgesic comfort: it mechanically reduces opioid-related side effects. The Game Ready© group showed significantly fewer episodes of nausea and vomiting (5 vs 12, p = 0.01), pruritis (5 vs 9, p = 0.02) and confusion or disorientation (1 vs 4, p = 0.02).

On the haematological side, the reduction in blood loss is unexpected but consistent with the literature on cold-induced vasoconstriction. The transfusion rate dropped from 26.7% to 6.7%, a considerable clinical and economic impact in spinal surgery.

Beyond the clinic: home recovery as the critical link

The ERAS® Society defines precise criteria before any return home: no intravenous infusion, pain under control, ability to eat solid food, independent ambulation, GI transit re-established, no signs of infection, patient consent. These are not administrative formalities. They reflect a genuine physiological state that determines the safety of early discharge.

This is precisely what De Bie et al. document: in the Game Ready© group, these criteria are met earlier and under better conditions. Pain is controlled at H48, GI transit resumes at 0.8 days, and opioid-related side effects that typically delay mobilisation are significantly reduced.

But ERAS does not stop at the clinic door. The ERAS® Society's official guidelines explicitly state the need for clear instructions and structured support so that patients progress independently after discharge. The growing trend towards shorter stays makes this question even more pressing: patients go home earlier, often with residual pain.

Published data show that 54% of TKA patients report severe pain at least occasionally in the two weeks following discharge, and that 70% consume opioids. At the same time, only 47% had received information about non-pharmacological pain management methods.

54% of TKA patients report severe pain at least occasionally in the first two weeks at home. Only 47% had been informed about non-pharmacological pain relief options.

Chan et al., cited in ERAS protocols in orthopaedic surgery · Dove Medical Press, 2025

Study limitations and level of evidence

Intellectual honesty requires naming the limitations of De Bie et al.: retrospective design, absence of randomisation, limited sample size (30 patients per group), restriction to short fusions which generate less blood loss than long constructs. Level of evidence: IV. The authors themselves call for a prospective randomised study to confirm these results.

These limitations do not diminish the value of the published data, but define its scope of interpretation. The study does not establish absolute causality. It opens a solid line of inquiry, consistent with the existing literature on cryotherapy in orthopaedics, and statistically robust enough to warrant serious clinical attention.

Summary

ERAS protocols have demonstrated their capacity to transform postoperative recovery in orthopaedics and spinal surgery: fewer complications, shorter stays, reduced opioid consumption. Cryotherapy, and in particular dynamic cryocompression, is recognised as a relevant non-pharmacological tool for pain control, oedema reduction and early mobilisation support.

The Reims University Hospital study (De Bie et al., 2021) provides concrete data on the use of Game Ready© in this context: 50% less morphine, 47% less blood loss, transfusion rate divided by four, hospital stay shortened by 1.2 days. These results align directly with the logic of ERAS protocols, and raise a question not yet resolved in the literature: how to extend these benefits beyond discharge, into the home recovery phase where pain remains significant and non-pharmacological resources are largely under-utilised.

REFERENCES

1. De Bie A, Siboni R, Smati MF, Ohl X, Bredin S. Enhanced recovery after lumbar fusion surgery: Benefits of using Game Ready©. Orthop Traumatol Surg Res. 2021;107(7):102953. https://pubmed.ncbi.nlm.nih.gov/33957322/
2. ERAS® Society. Orthopaedics. https://erassociety.org/specialty/orthopaedics/
3. The Effects of Cryotherapy on Early Rehabilitation Following Total Knee Arthroplasty. PMC. 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10715749/
4. ERAS in Spine Surgery: A Systematic Review and Meta-Analysis. PMC. 2025. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12592135/
5. ERAS protocols in orthopaedic surgery. Dove Medical Press · Journal of Pain Research. 2025. https://www.dovepress.com/enhanced-recovery-after-surgery-eras-protocols-in-orthopaedic-surgery--peer-reviewed-fulltext-article-JPR