Correspondence  |   February 2018
Perioperative Pain Management for Total Knee Arthroplasty: Need More Focus on the Forest and Less on the Trees
Author Notes
  • Stanford University School of Medicine, Stanford, California (J.-L.H.). hornj@stanford.edu
  • (Accepted for publication October 27, 2017.)
    (Accepted for publication October 27, 2017.)×
Article Information
Correspondence
Correspondence   |   February 2018
Perioperative Pain Management for Total Knee Arthroplasty: Need More Focus on the Forest and Less on the Trees
Anesthesiology 2 2018, Vol.128, 420-421. doi:10.1097/ALN.0000000000001992
Anesthesiology 2 2018, Vol.128, 420-421. doi:10.1097/ALN.0000000000001992
We read with interest the recent network meta-analysis by Terkawi et al.,1  which focuses on pain management modalities for patients undergoing total knee arthroplasty. The authors conclude that the combination of femoral and sciatic nerve blocks provides the best analgesia.1  Although some may suggest that this study1  warrants a change in clinical practice,2  we believe that these results should be interpreted with caution. It is not surprising that anesthetizing multiple nerves is superior to blocking a single nerve. However, the authors’ preferred intervention is associated with the highest incidence of peroneal nerve palsy (7.6%) and patient falls (2.28%).1  Readers should be aware that the authors excluded studies that combined multiple analgesic modalities.1  However, combining peripheral nerve block with periarticular injections offers advantages.3  Additionally, the authors’ rehabilitative outcomes were limited to range of motion and degree of flexion1  at 72 h. These may have been measured and documented differently at various institutions (e.g., passively, actively with/without assistance, while on a continuous passive motion machine). In addition, range of motion and degree of flexion at 72 h may not correlate with long-term outcomes. Ambulation distance and active measurements were not reliably analyzed by network meta-analysis yet play critical roles for meeting discharge criteria.
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