Newly Published
Pain Medicine  |   March 2017
Pain Management Modalities after Total Knee Arthroplasty: A Network Meta-analysis of 170 Randomized Controlled Trials
Author Notes
  • From the Department of Anesthesiology (A.S.T., E.C.N.) and Claude Moore Health Sciences Library (M.S.N.), University of Virginia, Charlottesville, Virginia; Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia (A.S.T., K.S.D.); Outcomes Research Consortium, Cleveland, Ohio (A.S.T.); Department of Primary School Education and Department of Hygiene and Epidemiology (D.M., M.P.), University of Ioannina, Ioannina, Greece; Department of Outcomes Research, Anesthesiology Institute, Cleveland, Ohio (D.I.S.); Department of Surgery, Sanad Hospital, Riyadh, Saudi Arabia (R.S.T.); and Faculty of Medicine, Umm Durman University, Khartoum, Sudan (Y.S.T.).
  • Corresponding article on page XXX.
    Corresponding article on page XXX.×
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Presented, in part, at the American Society of Anesthesiologists Annual Meeting 2016 in Chicago, Illinois, October 22, 2016.
    Presented, in part, at the American Society of Anesthesiologists Annual Meeting 2016 in Chicago, Illinois, October 22, 2016.×
  • Submitted for publication October 11, 2016. Accepted for publication January 19, 2017.
    Submitted for publication October 11, 2016. Accepted for publication January 19, 2017.×
  • Acknowledgments: The authors are grateful to Gretchen Hallerberg, M.S.L.S., Director, Cleveland Clinic Alumni Library, Cleveland Clinic, Cleveland, Ohio, for helping in database search and Lucas G. Fernandez, M.D., and Wei Xing, M.D., from the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, and Rovnat Babazade, M.D., from the Department of Anesthesiology, University of Texas Medical Branch at Galveston, Galveston, Texas, for their help in translation.
    Acknowledgments: The authors are grateful to Gretchen Hallerberg, M.S.L.S., Director, Cleveland Clinic Alumni Library, Cleveland Clinic, Cleveland, Ohio, for helping in database search and Lucas G. Fernandez, M.D., and Wei Xing, M.D., from the Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, and Rovnat Babazade, M.D., from the Department of Anesthesiology, University of Texas Medical Branch at Galveston, Galveston, Texas, for their help in translation.×
  • Research Support: Support was provided solely from institutional and/or departmental sources.
    Research Support: Support was provided solely from institutional and/or departmental sources.×
  • Competing Interests: The authors declare no competing interests.
    Competing Interests: The authors declare no competing interests.×
  • Correspondence: Address correspondence to Dr. A. S. Terkawi: Department of Anesthesiology, University of Virginia, Charlottesville, Virginia. asterkawi@gmail.com. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Pain Medicine / Pain Medicine
Pain Medicine   |   March 2017
Pain Management Modalities after Total Knee Arthroplasty: A Network Meta-analysis of 170 Randomized Controlled Trials
Anesthesiology Newly Published on March 16, 2017. doi:10.1097/ALN.0000000000001607
Anesthesiology Newly Published on March 16, 2017. doi:10.1097/ALN.0000000000001607
Abstract

Background: Optimal analgesia for total knee arthroplasty remains challenging. Many modalities have been used, including peripheral nerve block, periarticular infiltration, and epidural analgesia. However, the relative efficacy of various modalities remains unknown. The authors aimed to quantify and rank order the efficacy of available analgesic modalities for various clinically important outcomes.

Methods: The authors searched multiple databases, each from inception until July 15, 2016. The authors used random-effects network meta-analysis. For measurements repeated over time, such as pain, the authors considered all time points to enhance reliability of the overall effect estimate. Outcomes considered included pain scores, opioid consumption, rehabilitation profile, quality of recovery, and complications. The authors defined the optimal modality as the one that best balanced pain scores, opioid consumption, and range of motion in the initial 72 postoperative hours.

Results: The authors identified 170 trials (12,530 patients) assessing 17 treatment modalities. Overall inconsistency and heterogeneity were acceptable. Based on the surface under the cumulative ranking curve, the best five for pain at rest were femoral/obturator, femoral/sciatic/obturator, lumbar plexus/sciatic, femoral/sciatic, and fascia iliaca compartment blocks. For reducing opioid consumption, the best five were femoral/sciatic/obturator, femoral/obturator, lumbar plexus/sciatic, lumbar plexus, and femoral/sciatic blocks. The best modality for range of motion was femoral/sciatic blocks. Femoral/sciatic and femoral/obturator blocks best met our criteria for optimal performance. Considering only high-quality studies, femoral/sciatic seemed best.

Conclusions: Blocking multiple nerves was preferable to blocking any single nerve, periarticular infiltration, or epidural analgesia. The combination of femoral and sciatic nerve block appears to be the overall best approach. Rehabilitation parameters remain markedly understudied.