Korean J Pain.  2021 Jun;34(3):271-287. 10.3344/kjp.2021.34.3.271.

A meta-analysis on advantages of peripheral nerve block post-total knee arthroplasty

Affiliations
  • 1China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
  • 2Center for Applied Statistical Research and College of Mathematics, Jilin University, Changchun, Jinlin, China
  • 3Jilin University, Changchun, China

Abstract

Background
Postoperative pain management is crucial for patients undergoing total knee arthroplasty (TKA). There have been many recent clinical trials on post-TKA peripheral nerve block; however, they have reported inconsistent findings. In this meta-analysis, we aimed to comprehensively analyze studies on post-TKA analgesia to provide evidence-based clinical suggestions.
Methods
We performed a computer-based query of PubMed, Embase, the Cochrane Library, and the Web of Science to retrieve related articles using neurothe following search terms: nerve block, nerve blockade, chemodenervation, chemical neurolysis, peridural block, epidural anesthesia, extradural anesthesia, total knee arthroplasty, total knee replacement, partial knee replacement, and others. After quality evaluation and data extraction, we analyzed the complications, visual analogue scale (VAS) score, patient satisfaction, perioperative opioid dosage, and rehabilitation indices. Evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation approach.
Results
We included 16 randomized controlled trials involving 981 patients (511 receiving peripheral nerve block and 470 receiving epidural block) in the final analysis. Compared with an epidural block, a peripheral nerve block significantly reduced complications. There were no significant between-group differences in the postoperative VAS score, patient satisfaction, perioperative opioid dosage, and rehabilitation indices.
Conclusions
Our findings demonstrate that the peripheral nerve block is superior to the epidural block in reducing complications without compromising the analgesic effect and patient satisfaction. Therefore, a peripheral nerve block is a safe and effective postoperative analgesic method with encouraging clinical prospects.

Keyword

Analgesia; Epidural; Analgesics; Opioid; Arthroplasty; Replacement; Knee; Evidence-Based Medicine; Femoral Nerve; Meta-Analysis; Nerve Block; Pain Management; Pain; Postoperative

Figure

  • Fig. 1 Flowchart of the study selection process.

  • Fig. 2 Risk of bias graph and summary.

  • Fig. 3 Forest plot for the incidence of nausea and vomiting after nerve block vs. epidural block. M-H: Mantel-Haenszel, CI: confidence interval, df: degree of freedom.

  • Fig. 4 Forest plot for the incidence of hypotension after nerve block vs. epidural block. M-H: Mantel-Haenszel, CI: confidence interval, df: degree of freedom.

  • Fig. 5 Forest plot for the incidence of urinary retention after nerve block vs. epidural block. M-H: Mantel-Haenszel, CI: confidence interval, df: degree of freedom.

  • Fig. 6 Forest plot for the incidence of pruritus after nerve block vs. epidural block. M-H: Mantel-Haenszel, CI: confidence interval, df: degree of freedom.

  • Fig. 7 Forest plot for the incidence of sedation after nerve block vs. epidural block. M-H: Mantel-Haenszel, CI: confidence interval, df: degree of freedom.

  • Fig. 8 Forest plot for the visual analogue scale score during 0-12 hours after surgery after nerve block vs. epidural block. SD: standard deviation, IV: inverse variance, CI: confidence interval, df: degree of freedom.

  • Fig. 9 Forest plot for the visual analogue scale score within 12-24 horrs after nerve block vs. epidural analgesia. SD: standard deviation, IV: inverse variance, CI: confidence interval, df: degree of freedom.

  • Fig. 10 Forest plot for the sensitivity analyses (24-48 hr). SD: standard deviation, IV: inverse variance, CI: confidence interval, df: degree of freedom.

  • Fig. 11 Forest plot for patient satisfaction after nerve block vs. epidural block. M-H: Mantel-Haenszel, CI: confidence interval, df: degree of freedom.

  • Fig. 12 Forest plot for intraoperative opioid use. SD: standard deviation, IV: inverse variance, CI: confidence interval, df: degree of freedom.

  • Fig. 13 Forest plot for sensitivity analyses of the length of hospital stay. SD: standard deviation, IV: inverse variance, CI: confidence interval, df: degree of freedom.

  • Fig. 14 Forest plot for active knee flexion after nerve block vs. epidural analgesia. SD: standard deviation, IV: inverse variance, CI: confidence interval, df: degree of freedom.


Reference

1. Kester BS, Minhas SV, Vigdorchik JM, Schwarzkopf R. 2016; Total knee arthroplasty for posttraumatic osteoarthritis: is it time for a new classification? J Arthroplasty. 31:1649–53.e1. DOI: 10.1016/j.arth.2016.02.001. PMID: 26961087.
Article
2. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. 1998; Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg. 87:88–92. DOI: 10.1213/00000539-199807000-00019. PMID: 9661552.
Article
3. Ibrahim MS, Khan MA, Nizam I, Haddad FS. 2013; Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review. BMC Med. 11:37. DOI: 10.1186/1741-7015-11-37. PMID: 23406499. PMCID: PMC3606483.
Article
4. Webb CA, Mariano ER. 2015; Best multimodal analgesic protocol for total knee arthroplasty. Pain Manag. 5:185–96. DOI: 10.2217/pmt.15.8. PMID: 25971642.
Article
5. Wheatley RG, Shepherd D, Jackson IJ, Madej TH, Hunter D. 1992; Hypoxaemia and pain relief after upper abdominal surgery: comparison of i.m. and patient-controlled analgesia. Br J Anaesth. 69:558–61. DOI: 10.1093/bja/69.6.558. PMID: 1467096.
Article
6. Moen V, Dahlgren N, Irestedt L. 2004; Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology. 101:950–9. DOI: 10.1097/00000542-200410000-00021. PMID: 15448529.
Article
7. Zinkus J, Mockutė L, Gelmanas A, Tamošiūnas R, Vertelis A, Macas A. 2017; Comparison of 2 analgesia modalities in total knee replacement surgery: is there an effect on knee function rehabilitation? Med Sci Monit. 23:3019–25. DOI: 10.12659/MSM.899320. PMID: 28634320. PMCID: PMC5486887.
Article
8. Runge C, Børglum J, Jensen JM, Kobborg T, Pedersen A, Sandberg J, et al. 2016; The analgesic effect of obturator nerve block added to a femoral triangle block after total knee arthroplasty: a randomized controlled trial. Reg Anesth Pain Med. 41:445–51. DOI: 10.1097/AAP.0000000000000406. PMID: 27171822.
9. Macrinici GI, Murphy C, Christman L, Drescher M, Hughes B, Macrinici V, et al. 2017; Prospective, double-blind, randomized study to evaluate single-injection adductor canal nerve block versus femoral nerve block: postoperative functional outcomes after total knee arthroplasty. Reg Anesth Pain Med. 42:10–6. DOI: 10.1097/AAP.0000000000000507. PMID: 27811526.
Article
10. Elkassabany NM, Antosh S, Ahmed M, Nelson C, Israelite C, Badiola I, et al. 2016; The risk of falls after total knee arthroplasty with the use of a femoral nerve block versus an adductor canal block: a double-blinded randomized controlled study. Anesth Analg. 122:1696–703. DOI: 10.1213/ANE.0000000000001237. PMID: 27007076.
11. Sundarathiti P, Ruananukul N, Channum T, Kitkunasathean C, Mantay A, Thammasakulsiri J, et al. 2009; A comparison of continuous femoral nerve block (CFNB) and continuous epidural infusion (CEI) in postoperative analgesia and knee rehabilitation after total knee arthroplasty (TKA). J Med Assoc Thai. 92:328–34. PMID: 19301724.
12. Osawa M, Takahama Y, Kondo Y. 2012; [Comparison of postoperative pain relief by continuous femoral nerve block and that by epidural block during physiotherapy after minimally invasive surgery of total knee arthroplasty and uni-condylar knee arthroplasty]. Masui. 61:1316–23. Japanese. PMID: 23362767.
13. Sakai N, Inoue T, Kunugiza Y, Tomita T, Mashimo T. 2013; Continuous femoral versus epidural block for attainment of 120° knee flexion after total knee arthroplasty: a randomized controlled trial. J Arthroplasty. 28:807–14. DOI: 10.1016/j.arth.2012.09.013. PMID: 23434107.
Article
14. Moher D, Liberati A, Tetzlaff J, Altman DG. 2010; Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 8:336–41. DOI: 10.1016/j.ijsu.2010.02.007. PMID: 20171303.
Article
15. Shoji H, Solomonow M, Yoshino S, D'Ambrosia R, Dabezies E. 1990; Factors affecting postoperative flexion in total knee arthroplasty. Orthopedics. 13:643–9. DOI: 10.3928/0147-7447-19900601-08. PMID: 2367246.
Article
16. Ryu J, Saito S, Yamamoto K, Sano S. 1993; Factors influencing the postoperative range of motion in total knee arthroplasty. Bull Hosp Jt Dis. 53:35–40. PMID: 8012266.
17. Naylor JM, Walker R. 2018; Low value care and inpatient rehabilitation after total knee replacement. Med J Aust. 209:207–8. DOI: 10.5694/mja18.00663. PMID: 30157411.
Article
18. Kuo AC, Raghunathan K, Lartigue AM, Bryan WE 3rd, Pepin MJ, Takemoto S, et al. 2019; Freedom from opioids after total knee arthroplasty. J Arthroplasty. 34:893–7. DOI: 10.1016/j.arth.2019.01.054. PMID: 30777627.
Article
19. Roberts KC, Moser SE, Collins AC, McCardel BR, Schultz KA, Schaffer NE, et al. 2020; Prescribing and consumption of opioids after primary, unilateral total hip and knee arthroplasty in opioid-naive patients. J Arthroplasty. 35:960–5.e1. DOI: 10.1016/j.arth.2019.08.036. PMID: 31924487.
Article
20. Higgins JPT, Altman DG. Higgins JPT, Green S, editors. 2008. Assessing risk of bias in included studies. Cochrane handbook for systematic reviews of interventions: Cochrane book series. John Wiley & Sons;Chichester: p. 187–241. DOI: 10.1002/9780470712184.ch8.
Article
21. Hou X, Shi J, Chen X. 2015; How to estimate the mean and standard deviation based on the median, range and sample size when conducting meta-analysis. Chin J Evid Based Med. 15:484–7.
22. Jüni P, Altman DG, Egger M. Egger M, Smith GD, Altman DG, editors. 2008. Assessing the quality of randomised controlled trials. Systematic reviews in health care: meta-analysis in context. 2nd ed. BMJ;London: p. 87–108.
Article
23. Higgins JP, Thompson SG, Deeks JJ, Altman DG. 2003; Measuring inconsistency in meta-analyses. BMJ. 327:557–60. DOI: 10.1136/bmj.327.7414.557. PMID: 12958120. PMCID: PMC192859.
Article
24. Adams HA, Saatweber P, Schmitz CS, Hecker H. 2002; Postoperative pain management in orthopaedic patients: no differences in pain score, but improved stress control by epidural anaesthesia. Eur J Anaesthesiol. 19:658–65. DOI: 10.1017/S0265021502001084. PMID: 12243289.
Article
25. Campbell A, McCormick M, McKinlay K, Scott NB. 2008; Epidural vs. lumbar plexus infusions following total knee arthroplasty: randomized controlled trial. Eur J Anaesthesiol. 25:502–7. DOI: 10.1017/S0265021508003724. PMID: 18298872.
26. Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d'Athis F. 1999; Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 91:8–15. DOI: 10.1097/00000542-199907000-00006. PMID: 10422923.
Article
27. Fedriani de Matos JJ, Atienza Carrasco FJ, Díaz Crespo J, Moreno Martín A, Tatsidis Tatsidis P, Torres Morera LM. 2017; Effectiveness and safety of continuous ultrasound-guided femoral nerve block versus epidural analgesia after total knee arthroplasty. Rev Esp Anestesiol Reanim. 64:79–85. DOI: 10.1016/j.redar.2016.05.008. PMID: 27400891.
Article
28. Horasanli E, Gamli M, Pala Y, Erol M, Sahin F, Dikmen B. 2010; A comparison of epidural anesthesia and lumbar plexus-sciatic nerve blocks for knee surgery. Clinics (Sao Paulo). 65:29–34. DOI: 10.1590/S1807-59322010000100006. PMID: 20126343. PMCID: PMC2815279.
Article
29. Kim JH, Cho MR, Kim SO, Kim JE, Lee DK, Roh WS. 2012; A comparison of femoral/sciatic nerve block with lateral femoral cutaneous nerve block and combined spinal epidural anesthesia for total knee replacement arthroplasty. Korean J Anesthesiol. 62:448–53. DOI: 10.4097/kjae.2012.62.5.448. PMID: 22679542. PMCID: PMC3366312.
Article
30. Shanthanna H, Huilgol M, Manivackam VK, Maniar A. 2012; Comparative study of ultrasound-guided continuous femoral nerve blockade with continuous epidural analgesia for pain relief following total knee replacement. Indian J Anaesth. 56:270–5. DOI: 10.4103/0019-5049.98776. PMID: 22923827. PMCID: PMC3425288.
Article
31. Zaric D, Boysen K, Christiansen C, Christiansen J, Stephensen S, Christensen B. 2006; A comparison of epidural analgesia with combined continuous femoral-sciatic nerve blocks after total knee replacement. Anesth Analg. 102:1240–6. DOI: 10.1213/01.ane.0000198561.03742.50. PMID: 16551931.
Article
32. Barrington MJ, Olive D, Low K, Scott DA, Brittain J, Choong P. 2005; Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial. Anesth Analg. 101:1824–9. DOI: 10.1213/01.ANE.0000184113.57416.DD. PMID: 16301267.
Article
33. Davies AF, Segar EP, Murdoch J, Wright DE, Wilson IH. 2004; Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty. Br J Anaesth. 93:368–74. DOI: 10.1093/bja/aeh224. PMID: 15247111.
Article
34. Raimer C, Priem K, Wiese AA, Birnbaum J, Dirkmorfeld LM, Mossner A, et al. 2007; Continuous psoas and sciatic block after knee arthroplasty: good effects compared to epidural analgesia or i.v. opioid analgesia: a prospective study of 63 patients. Acta Orthop. 78:193–200. DOI: 10.1080/17453670710013672. PMID: 17464606.
Article
35. Chelly JE, Greger J, Gebhard R, Coupe K, Clyburn TA, Buckle R, et al. 2001; Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty. 16:436–45. DOI: 10.1054/arth.2001.23622. PMID: 11402405.
Article
36. Al-Zahrani T, Doais KS, Aljassir F, Alshaygy I, Albishi W, Terkawi AS. 2015; Randomized clinical trial of continuous femoral nerve block combined with sciatic nerve block versus epidural analgesia for unilateral total knee arthroplasty. J Arthroplasty. 30:149–54. DOI: 10.1016/j.arth.2014.07.032. PMID: 25149364.
Article
37. Kayupov E, Okroj K, Young AC, Moric M, Luchetti TJ, Zisman G, et al. 2018; Continuous adductor canal blocks provide superior ambulation and pain control compared to epidural analgesia for primary knee arthroplasty: a randomized, controlled trial. J Arthroplasty. 33:1040–4.e1. DOI: 10.1016/j.arth.2017.11.013. PMID: 29233569.
Article
38. Gandhi HJ, Trivedi LH, Tripathi DC, Dash DM, Khare AM, Gupta MU. 2019; A randomized, controlled trial of comparison of a continuous femoral nerve block (CFNB) and continuous epidural infusion (CEI) using 0.2% ropivacaine for postoperative analgesia and knee rehabilitation after total knee arthroplasty (TKA). J Anaesthesiol Clin Pharmacol. 35:386–9. DOI: 10.4103/joacp.JOACP_134_16. PMID: 31543590. PMCID: PMC6748000.
Article
39. Fowler SJ, Symons J, Sabato S, Myles PS. 2008; Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J Anaesth. 100:154–64. DOI: 10.1093/bja/aem373. PMID: 18211990.
Article
40. Gerrard AD, Brooks B, Asaad P, Hajibandeh S, Hajibandeh S. 2017; Meta-analysis of epidural analgesia versus peripheral nerve blockade after total knee joint replacement. Eur J Orthop Surg Traumatol. 27:61–72. DOI: 10.1007/s00590-016-1846-z. PMID: 27592218.
Article
41. Yuan Z, Wei J, Wen J, Yang S, Quan D. 2015; A meta-analysis of countious femoral nerve block versus continuous epidural analgesia after total knee arthroplasty. Chin J Tissue Eng Res. 19:5728–34.
42. Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. 2011; Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am. 93:1988–93. DOI: 10.2106/JBJS.J.01473. PMID: 22048093.
Article
43. Patel N, Solovyova O, Matthews G, Arumugam S, Sinha SK, Lewis CG. 2015; Safety and efficacy of continuous femoral nerve catheter with single shot sciatic nerve block vs epidural catheter anesthesia for same-day bilateral total knee arthroplasty. J Arthroplasty. 30:330–4. DOI: 10.1016/j.arth.2014.09.015. PMID: 25445854.
Article
44. Patterson ME, Bland KS, Thomas LC, Elliott CE, Soberon JR Jr, Nossaman BD, et al. 2015; The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty--a retrospective study. J Clin Anesth. 27:39–44. DOI: 10.1016/j.jclinane.2014.08.005. PMID: 25468584.
Article
45. Ritter MA, Wing JT, Berend ME, Davis KE, Meding JB. 2008; The clinical effect of gender on outcome of total knee arthroplasty. J Arthroplasty. 23:331–6. DOI: 10.1016/j.arth.2007.10.031. PMID: 18358368.
Article
46. Long WT, Ward SR, Dorr LD, Raya J, Boutary M, Sirianni LE. 2006; Postoperative pain management following total knee arthroplasty: a randomized comparison of continuous epidural versus femoral nerve infusion. J Knee Surg. 19:137–43. DOI: 10.1055/s-0030-1248096. PMID: 16642893.
Article
Full Text Links
  • KJP
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr