“In the Canadian health system where I completed my residency training, the average inpatient stay for fractured tibia surgery is 5 to 11 days, and an inpatient day costs about 4 to 6 times as much as a cryotherapy cuff,” he added. “So saving even one day could significantly reduce costs and improve a patient’s experience.”

AAOS Now

Published 5/1/2012
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Sally T. Halderman

Pre- and Postoperatively, Ice Could Be Nice

OREF grant recipient investigates the effects of cryotherapy on fracture patients

Jesse A. Shantz, MD, MBA, is looking for a win-win-win. Currently a research fellow with the Orthopaedic Trauma Institute at the University of California at San Francisco (UCSF), Dr. Shantz is examining cryotherapy as a means of improving clinical outcomes, patient satisfaction, and costs associated with surgical repair of upper tibia fractures.

Dr. Shantz, with support from a 2010 Orthopaedic Research and Education Foundation (OREF)/Zimmer Career Development Award in Total Joint and Trauma Surgery, is investigating the effects of pre- and postoperative use of a cryotherapy cuff, a device that provides calibrated tissue compression and cooling around the wound.

“With upper tibia fractures, patients may need to stay in the hospital and wait until their soft-tissue injuries and swelling subside enough for surgery. Or they may need to go home to wait with a cumbersome and costly external fixator stabilizing their legs,” said Dr. Shantz. “Cryotherapy could offer a cost-effective, satisfying adjunct to care both before and after surgery.


Jesse A. Shantz, MD, MBA,

Dr. Shantz’s personal experience as a patient—he had a corneal transplant to correct a vision-distorting defect 2 years into his surgical residency at the University of Manitoba, Winnipeg, Manitoba—drives his concern. “I gained a deep appreciation for the most common question my patients ask me: When can I get back to work? My transplant may have sharpened my perspective as much as my vision,” he said.

A demanding schedule
Dr. Shantz said his demanding schedule would have made it impossible to conduct the study without the OREF/Zimmer support. “There just weren’t enough hours in the day for a resident orthopaedist to do everything this study required. My OREF/Zimmer grant enabled me to hire and train a research coordinator to handle day-to-day logistics.”

The study involves 110 consecutive patients seen in the emergency department with proximal tibia fractures requiring surgery. Patients receive immediate splinting or bracing, patient-controlled narcotic analgesia, and a cryotherapy cuff. The study randomizes participants to receive cuffs that circulate either chilled or room-temperature water. Following surgery, patients resume their patient-controlled analgesia and use of the chilled or room-temperature cuffs until a physiotherapist clears them for discharge.

Outcome measures compare use of narcotic pain medication; pain levels as assessed by patients and hospital staff; time from injury to surgery; postoperative complications such as compartment syndrome, infection, and skin and thermal reactions; inpatient length of stay; postacute care needs; range of motion; patient satisfaction; and treatment cost.

Beyond science
Managing the study’s nonscientific challenges brought Dr. Shantz great satisfaction.

“It was completely beyond our control at what hour patients might be seen with a fracture that met our inclusion criteria. Making sure we gave all eligible patients the opportunity to enroll in the study required leadership to keep my fellow residents motivated. They weren’t necessarily thinking about my study when they were called in the middle of the night. I had to keep the project on their radar screens in a collegial, engaging way. That human dimension of research—bringing people together to work as a team—is what attracts me most strongly to the life of a clinician scientist,” he said.

Addressing a perceptual challenge involved a creative twist. “Our outcomes data could have been complicated if patients realized whether or not they’d gotten the chilled version of the cuff. We tried to keep the study as rigorous as possible by maintaining the room-temperature cuffs with fake ice from a novelty store,” he explained.

Down the road, Dr. Shantz said, the results of the study could help set the standard of care for upper tibia fractures. Previous research has shown that cryotherapy can reduce pain, decrease use of narcotics, and speed discharge after reconstruction of the anterior cruciate ligament or a total knee replacement. Those data have led many treatment centers to adopt cryotherapy after total knee replacement as the standard of care.

Additional dividends
Not only did the OREF grant make his study possible, Dr. Shantz said it has paid additional dividends.

“Getting the grant inspired confidence,” he said. “It’s heartening to know that colleagues at the pinnacle of their orthopaedic careers reviewed my proposal and deemed it worthy of funding.”

The OREF grant also enabled Dr. Shantz to serve as a volunteer peer reviewer. “Almost as exciting as getting funding for our study was being asked to sit on the review committee for another project,” he recalled. “Serving as a reviewer enabled me to tune into each reviewer’s thought process in evaluating the merits of a proposal and the opportunity to frame my own thoughts and contribute as an equal voice.”

Dr. Shantz’s experiences as a peer reviewer and as a grant recipient touched on professional and personal satisfaction. “Getting an OREF grant has not only helped me launch my career as a clinician scientist—it’s introduced me to the process of peer review, which is really just another dimension of the teamwork that most attracts me to research.”

Sally T. Halderman is a contributing writer for OREF. She can be reached at communications@oref.org