Preoperative Cryoneurolysis in Total Knee Arthroplasty: Current Concepts in Pain Control and Opioid Stewardship

Total knee arthroplasty (TKA) is increasingly common, yet postoperative pain remains a major driver of delayed recovery and opioid exposure. Cryoneurolysis is a preoperative, non-opioid adjunct that temporarily ablates peripheral sensory nerves to reduce pain signaling. This narrative review summarizes the mechanism, clinical evidence, and practical implementation of cryoneurolysis for perioperative pain control and opioid reduction after TKA. Published clinical studies evaluating preoperative cryoneurolysis in patients undergoing TKA or with end-stage knee osteoarthritis in perioperative pathways were narratively synthesized, including retrospective analyses, cohort studies, randomized or sham-controlled trials, registry studies, and relevant systematic reviews and meta-analyses. Comparative perioperative analgesic literature relevant to multimodal TKA protocols was also considered. The review was organized around three domains: (1) biologic mechanisms and technical targets, (2) outcomes related to pain, opioid consumption, and length of stay, and (3) opioid stewardship endpoints, including refill requirements and prolonged opioid use, when available. Cryoneurolysis produces reversible axonotmesis via controlled cooling, inducing Wallerian degeneration while preserving nerve architecture and motor function. Across published studies, cryoneurolysis was associated with reduced acute postoperative pain and lower early opioid use, with some studies reporting approximately 45% to 51% reductions in opioid consumption and shorter hospital length of stay. Evidence on postdischarge opioid utilization is mixed, with one retrospective cohort finding no difference in 90-day opioid consumption or refill rates, while other registry and longitudinal data suggest possible reductions in longer-term opioid use and improved pain outcomes, although functional benefits appear modest and inconsistently demonstrated. Available studies have not identified a clear increase in complications, and the motor-sparing nature of cryoneurolysis may support early rehabilitation. Preoperative cryoneurolysis is a promising adjunct within multimodal TKA analgesia, offering prolonged sensory analgesia without motor blockade and short-term reductions in pain and inpatient opioid use. Heterogeneous protocols and limited long-term, high-level evidence constrain broad adoption. Standardized multicenter trials with pharmacy-based opioid endpoints are needed to define optimal targets, timing, and durable benefit.