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Meta-Analysis
. 2014 May 13;2014(5):CD009941.
doi: 10.1002/14651858.CD009941.pub2.

Femoral nerve blocks for acute postoperative pain after knee replacement surgery

Ee-Yuee Chan  1 , Marlene Fransen, David A Parker, Pryseley N Assam, Nelson Chua
Affiliations
Meta-Analysis

Femoral nerve blocks for acute postoperative pain after knee replacement surgery

Ee-Yuee Chan et al. Cochrane Database Syst Rev. .

Abstract

Background: Total knee replacement (TKR) is a common and often painful operation. Femoral nerve block (FNB) is frequently used for postoperative analgesia.

Objectives: To evaluate the benefits and risks of FNB used as a postoperative analgesic technique relative to other analgesic techniques among adults undergoing TKR.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 1, MEDLINE, EMBASE, CINAHL, Web of Science, dissertation abstracts and reference lists of included studies. The date of the last search was 31 January 2013.

Selection criteria: We included randomized controlled trials (RCTs) comparing FNB with no FNB (intravenous patient-controlled analgesia (PCA) opioid, epidural analgesia, local infiltration analgesia, and oral analgesia) in adults after TKR. We also included RCTs that compared continuous versus single-shot FNB.

Data collection and analysis: Two review authors independently performed study selection and data extraction. We undertook meta-analysis (random-effects model) and used relative risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) or standardized mean differences (SMDs) for continuous outcomes. We interpreted SMDs according to rule of thumb where 0.2 or smaller represents a small effect, 0.5 a moderate effect and 0.8 or larger, a large effect.

Main results: We included 45 eligible RCTs (2710 participants) from 47 publications; 20 RCTs had more than two allocation groups. A total of 29 RCTs compared FNB (with or without concurrent treatments including PCA opioid) versus PCA opioid, 10 RCTs compared FNB versus epidural, five RCTs compared FNB versus local infiltration analgesia, one RCT compared FNB versus oral analgesia and four RCTs compared continuous versus single-shot FNB. Most included RCTs were rated as low or unclear risk of bias for the aspects rated in the risk of bias assessment tool, except for the aspect of blinding. We rated 14 (31%) RCTs at high risk for both participant and assessor blinding and rated eight (18%) RCTs at high risk for one blinding aspect.Pain at rest and pain on movement were less for FNB (of any type) with or without a concurrent PCA opioid compared with PCA opioid alone during the first 72 hours post operation. Pooled results demonstrated a moderate effect of FNB for pain at rest at 24 hours (19 RCTs, 1066 participants, SMD -0.72, 95% CI -0.93 to -0.51, moderate-quality evidence) and a moderate to large effect for pain on movement at 24 hours (17 RCTs, 1017 participants, SMD -0.94, 95% CI -1.32 to -0.55, moderate-quality evidence). Pain was also less in each FNB subgroup: single-shot FNB, continuous FNB and continuous FNB + sciatic block, compared with PCA. FNB also was associated with lower opioid consumption (IV morphine equivalent) at 24 hours (20 RCTs, 1156 participants, MD -14.74 mg, 95% CI -18.68 to -10.81 mg, high-quality evidence) and at 48 hours (MD -14.53 mg, 95% CI -20.03 to -9.02 mg), lower risk of nausea and/or vomiting (RR 0.47, 95% CI 0.33 to 0.68, number needed to treat for an additional harmful outcome (NNTH) four, high-quality evidence), greater knee flexion (11 RCTs, 596 participants, MD 6.48 degrees, 95% CI 4.27 to 8.69 degrees, moderate-quality evidence) and greater patient satisfaction (four RCTs, 180 participants, SMD 1.06, 95% CI 0.74 to 1.38, low-quality evidence) compared with PCA.We could not demonstrate a difference in pain between FNB (any type) and epidural analgesia in the first 72 hours post operation, including pain at 24 hours at rest (six RCTs, 328 participants, SMD -0.05, 95% CI -0.43 to 0.32, moderate-quality evidence) and on movement (six RCTs, 317 participants, SMD 0.01, 95% CI -0.21 to 0.24, high-quality evidence). No difference was noted at 24 hours for opioid consumption (five RCTs, 341 participants, MD -4.35 mg, 95% CI -9.95 to 1.26 mg, high-quality evidence) or knee flexion (six RCTs, 328 participants, MD -1.65, 95% CI -5.14 to 1.84, high-quality evidence). However, FNB demonstrated lower risk of nausea/vomiting (four RCTs, 183 participants, RR 0.63, 95% CI 0.41 to 0.97, NNTH 8, moderate-quality evidence) and higher patient satisfaction (two RCTs, 120 participants, SMD 0.60, 95% CI 0.23 to 0.97, low-quality evidence), compared with epidural analgesia.Pooled results of four studies (216 participants) comparing FNB with local infiltration analgesia detected no difference in analgesic effects between the groups at 24 hours for pain at rest (SMD 0.06, 95% CI -0.61 to 0.72, moderate-quality evidence) or pain on movement (SMD 0.38, 95% CI -0.10 to 0.86, low-quality evidence). Only one included RCT compared FNB with oral analgesia. We considered this evidence insufficient to allow judgement of the effects of FNB compared with oral analgesia.Continuous FNB provided less pain compared with single-shot FNB (four RCTs, 272 participants) at 24 hours at rest (SMD -0.62, 95% CI -1.17 to -0.07, moderate-quality evidence) and on movement (SMD -0.42, 95% CI -0.67 to -0.17, high-quality evidence). Continuous FNB also demonstrated lower opioid consumption compared with single-shot FNB at 24 hours (three RCTs, 236 participants, MD -13.81 mg, 95% CI -23.27 to -4.35 mg, moderate-quality evidence).Generally, the meta-analyses demonstrated considerable statistical heterogeneity, with type of FNB, allocation concealment and blinding of participants, personnel and outcome assessors reducing heterogeneity in the analyses. Available evidence was insufficient to allow determination of the comparative safety of the various analgesic techniques. Few RCTs reported on serious adverse effects such as neurological injury, postoperative falls or thrombotic events.

Authors' conclusions: Following TKR, FNB (with or without concurrent treatments including PCA opioid) provided more effective analgesia than PCA opioid alone, similar analgesia to epidural analgesia and less nausea/vomiting compared with PCA alone or epidural analgesia. The review also found that continuous FNB provided better analgesia compared with single-shot FNB. RCTs were insufficient to allow definitive conclusions on the comparison between FNB and local infiltration analgesia or oral analgesia.

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Conflict of interest statement

Ee‐Yuee Chan, Marlene Fransen and Nelson Chua were the study authors of an RCT (Chan 2013) that was eligible for inclusion in this Cochrane review.

Pryseley N Assam is a co‐author of a possible publication arising from the RCT authored by Chan et al (Chan 2013).

David A Parker co‐authored an RCT (Widmer 2012) that was also included in this review.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 FNB versus PCA opioid. Outcome: 1.8 Pain on movement at 24 hours.
5
5
Forest plot of comparison: 2 FNB versus epidural. Outcome: 2.5 Pain on movement at 24 hours.
6
6
Forest plot of comparison: 4 Continuous FNB versus single‐shot FNB. Outcome: 4.5 Pain on movement at 24 hours.
1.1
1.1. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 1 Pain at rest first 2 hours.
1.2
1.2. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 2 Pain at rest 3 to 12 hours.
1.3
1.3. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 3 Pain at rest 24 hours.
1.4
1.4. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 4 Pain at rest 48 hours.
1.5
1.5. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 5 Pain at rest 72 hours.
1.6
1.6. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 6 Pain on movement first 2 hours.
1.7
1.7. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 7 Pain on movement 3 to 12 hours.
1.8
1.8. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 8 Pain on movement 24 hours.
1.9
1.9. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 9 Pain on movement 48 hours.
1.10
1.10. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 10 Pain on movement 72 hours.
1.11
1.11. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 11 Pain at rest 24 hours—subgrouped by FNB with and without concurrent PCA.
1.12
1.12. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 12 Pain on movement 24 hours—subgrouped by FNB with and without concurrent PCA.
1.13
1.13. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 13 Pain at rest 24 hours—subgrouped by FNB ropivacaine vs bupivacaine.
1.14
1.14. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 14 Pain on movement 24 hours—subgrouped by FNB ropivacaine vs bupivacaine.
1.15
1.15. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 15 Pain at rest 24 hours—sensitivity analysis by low bias for allocation concealment.
1.16
1.16. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 16 Pain on movement 24 hours—sensitivity analysis by low bias for allocation concealment.
1.17
1.17. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 17 Pain on rest 24 hours—sensitivity analysis by blinding of participants, personnel and outcome assessor.
1.18
1.18. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 18 Pain on movement 24 hours—sensitivity analysis by blinding of participants, personnel and outcome assessor.
1.19
1.19. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 19 Opioid consumption 24 hours (mg).
1.20
1.20. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 20 Opioid consumption 48 hours (mg).
1.21
1.21. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 21 Nausea and/or vomiting.
1.22
1.22. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 22 Sedation.
1.23
1.23. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 23 Urinary retention.
1.24
1.24. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 24 Knee flexion range of motion (postoperative day 2 to 4).
1.25
1.25. Analysis
Comparison 1 FNB versus PCA opioid, Outcome 25 Participant satisfaction with analgesia during hospital stay.
2.1
2.1. Analysis
Comparison 2 FNB versus epidural, Outcome 1 Pain at rest first 2 hours.
2.2
2.2. Analysis
Comparison 2 FNB versus epidural, Outcome 2 Pain at rest 3 to 12 hours.
2.3
2.3. Analysis
Comparison 2 FNB versus epidural, Outcome 3 Pain at rest 24 hours.
2.4
2.4. Analysis
Comparison 2 FNB versus epidural, Outcome 4 Pain at rest 48 hours.
2.5
2.5. Analysis
Comparison 2 FNB versus epidural, Outcome 5 Pain on movement 24 hours.
2.6
2.6. Analysis
Comparison 2 FNB versus epidural, Outcome 6 Pain on movement 48 hours.
2.7
2.7. Analysis
Comparison 2 FNB versus epidural, Outcome 7 Pain at rest 24 hours—subgrouped by FNB ropivacaine vs bupivacaine.
2.8
2.8. Analysis
Comparison 2 FNB versus epidural, Outcome 8 Pain on movement 24 hours—subgrouped by FNB ropivacaine vs bupivacaine.
2.9
2.9. Analysis
Comparison 2 FNB versus epidural, Outcome 9 Pain at rest 24 hours—sensitivity analysis by low bias for allocation concealment.
2.10
2.10. Analysis
Comparison 2 FNB versus epidural, Outcome 10 Pain on movement 24 hours—sensitivity analysis by low bias for allocation concealment.
2.11
2.11. Analysis
Comparison 2 FNB versus epidural, Outcome 11 Opioid consumption 24 hours (mg).
2.12
2.12. Analysis
Comparison 2 FNB versus epidural, Outcome 12 Opioid consumption 48 hours (mg).
2.13
2.13. Analysis
Comparison 2 FNB versus epidural, Outcome 13 Nausea and/or vomiting.
3.1
3.1. Analysis
Comparison 3 FNB versus local infiltration analgesia, Outcome 1 Pain at rest 24 hours.
3.2
3.2. Analysis
Comparison 3 FNB versus local infiltration analgesia, Outcome 2 Pain at rest 48 hours.
3.3
3.3. Analysis
Comparison 3 FNB versus local infiltration analgesia, Outcome 3 Pain on movement 24 hours.
3.4
3.4. Analysis
Comparison 3 FNB versus local infiltration analgesia, Outcome 4 Pain on movement 48 hours.
3.5
3.5. Analysis
Comparison 3 FNB versus local infiltration analgesia, Outcome 5 Nausea and/or vomiting.
4.1
4.1. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 1 Pain at rest first 2 hours.
4.2
4.2. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 2 Pain at rest 3 to 12 hours.
4.3
4.3. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 3 Pain at rest 24 hours.
4.4
4.4. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 4 Pain at rest 48 hours.
4.5
4.5. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 5 Pain on movement 24 hours.
4.6
4.6. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 6 Pain on movement 48 hours.
4.7
4.7. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 7 Pain on rest 24 hours—subgrouped by continuous FNB with or without concurrent PCA.
4.8
4.8. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 8 Pain on movement 24 hours—subgrouped by continuous FNB with or without concurrent PCA.
4.9
4.9. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 9 Pain at rest 24 hours—sensitivity analysis by low bias for allocation concealment.
4.10
4.10. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 10 Pain on movement 24 hours—sensitivity analysis by low bias for allocation concealment.
4.11
4.11. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 11 Opioid consumption 24 hours (mg).
4.12
4.12. Analysis
Comparison 4 Continuous FNB versus single‐shot FNB, Outcome 12 Opioid consumption 48 hours (mg).
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References

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Xie 2012 {published data only}
    1. Xie Z, Hussain W, Cutter TW, Apfelbaum JL, Drum ML, Manning DW. Three‐in‐one nerve block with different concentrations of bupivacaine in total knee arthroplasty. Randomized, placebo‐controlled, double‐blind trial. Journal of Arthroplasty 2012;27(5):673‐8.e1. [PUBMED: 21945081] - PubMed
Yu 2010 {published data only}
    1. Yu H‐P, Liu Z‐H, Guo W‐S, Jiang H‐Y, Zhao J. Effect of continuous femoral nerve block in analgesia and the early rehabilitation after total knee replacement. [Chinese]. Zhongguo Gushang [China Journal of Orthopaedics and Traumatology] 2010;23(11):825‐7. [PUBMED: 21254673] - PubMed
Zaric 2006 {published and unpublished data}
    1. Zaric D, Boysen K, Christiansen C, Christiansen J, Stephensen S, Christensen B. A comparison of epidural analgesia with combined continuous femoral‐sciatic nerve blocks after total knee replacement. Anesthesia and Analgesia 2006;102(4):1240‐6. [PUBMED: 16551931] - PubMed

References to studies excluded from this review

Affas 2012 {published data only}
    1. Affas F, Stiller CO, Nygards EB, Stephanson N, Wretenberg P, Olofsson C. A randomized study comparing plasma concentration of ropivacaine after local infiltration analgesia and femoral block in primary total knee arthroplasty. Scandinavian Journal of Pain 2012;3(1):46‐51. [DOI: 10.1016/j.sjpain.2011.09.001] - DOI - PubMed
Bagry 2008 {published data only}
    1. Bagry H, Cuadra Fontaine JC, Asenjo JF, Bracco D, Carli F. Effect of a continuous peripheral nerve block on the inflammatory response in knee arthroplasty. Regional Anesthesia and Pain Medicine 2008;33(1):17‐23. [PUBMED: 18155052] - PubMed
Blisard 2012 {published data only}
    1. Blisard R, Haddad FS. Pre‐emptive peripheral nerve block delays recovery after total knee arthroplasty. Orthopedics Today 2012; Vol. 32, issue 2:31‐2.
Cappelleri 2011 {published data only}
    1. Cappelleri G, Ghisi D, Fanelli A, Albertin A, Somalvico F, Aldegheri G. Does continuous sciatic nerve block improve postoperative analgesia and early rehabilitation after total knee arthroplasty? A prospective, randomized, double‐blinded study. Regional Anesthesia and Pain Medicine 2011;36(5):489‐92. [PUBMED: 21857276] - PubMed
Carvalho 2012 {published data only}
    1. Carvalho R, Braganca JP, Calixto L. Effect of a single shot sciatic nerve block combined with a continuous femoral block on pain scores after knee arthroplasty. A randomized controlled trial. British Journal of Anaesthesia 2012;108:23‐4. [DOI: 10.4236/ojanes.2012.24025] - DOI
Chelly 2001 {published data only}
    1. Chelly JE, Greger J, Gebhard R, Coupe K, Clyburn TA, Buckle R, et al. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. Journal of Arthroplasty 2001;16(4):436‐45. [PUBMED: 11402405]] - PubMed
Combes 2000 {published data only}
    1. Combes X, Cerf C, Bouleau D, Duvaldestin P, Dhonneur G. The effects of residual pain on oxygenation and breathing pattern during morphine analgesia. Anesthesia and Analgesia 2000;90(1):156‐60. [PUBMED: 10624997] - PubMed
Dang 2005 {published data only}
    1. Pham Dang C, Gautheron E, Guilley J, Fernandez M, Waast D, Volteau C, et al. The value of adding sciatic block to continuous femoral block for analgesia after total knee replacement. Regional Anesthesia and Pain Medicine 2005;30(2):128‐33. [PUBMED: 15765454] - PubMed
Edwards 1992 {published data only}
    1. Edwards ND, Wright EM. Continuous low‐dose 3‐in‐1 nerve blockade for postoperative pain relief after total knee replacement. Anesthesia and Analgesia 1992;75(2):265‐7. [PUBMED: 1632541] - PubMed
Frassanito 2009 {published data only}
    1. Frassanito L, Vergari A, Messina A, Pitoni S, Puglisi C, Chierichini A. Anaesthesia for total knee arthroplasty: efficacy of single‐injection or continuous lumbar plexus associated with sciatic nerve blocks—a randomized controlled study. European Review for Medical and Pharmacological Sciences 2009;13(5):375‐82. [MEDLINE: ] - PubMed
Frassanito 2010 {published data only}
    1. Frassanito L, Vergari A, Zanghi F, Messina A, Bitondo M, Antonelli M. Post‐operative analgesia following total knee arthroplasty: comparison of low‐dose intrathecal morphine and single‐shot ultrasound‐guided femoral nerve block: a randomized, single blinded, controlled study. European Review for Medical & Pharmacological Sciences 2010;14(7):589‐96. [PUBMED: 20707248] - PubMed
Hakkalamani 2008 {published data only}
    1. Hakkalamani S, Carroll FA, Ford C, Mereddy P, Jefferies G, Parkinson RW. Analgesia in total knee replacement: a comparison between femoral versus combined femoral and sciatic nerve block. Journal of Bone and Joint Surgery (Proceedings) 2008;90b (supp):328‐E0A.
Ilfeld 2008 {published data only}
    1. Ilfeld BM, Le LT, Meyer RS, Mariano ER, Vandenborne K, Duncan PW, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple‐masked, placebo‐controlled study. Anesthesiology 2008;108(4):703‐13. [PUBMED: 18362603] - PMC - PubMed
Ilfeld 2009 {published data only}
    1. Ilfeld BM, Meyer RS, Le LT, Mariano ER, Williams BA, Vandenborne K, et al. Health‐related quality of life after tricompartment knee arthroplasty with and without an extended‐duration continuous femoral nerve block: a prospective, 1‐year follow‐up of a randomized, triple‐masked, placebo‐controlled study. Anesthesia and Analgesia 2009;108(4):1320‐5. [PUBMED: 19299806] - PMC - PubMed
Ilfeld 2010 {published data only}
    1. Ilfeld BM, Mariano ER, Girard PJ, Loland VJ, Meyer RS, Donovan JF, et al. A multicenter, randomized, triple‐masked, placebo‐controlled trial of the effect of ambulatory continuous femoral nerve blocks on discharge‐readiness following total knee arthroplasty in patients on general orthopaedic wards. Pain 2010;150(3):477‐84. [PUBMED: 20573448] - PMC - PubMed
Johnson 2011 {published data only}
    1. Johnson CB, Steele‐Moses SK. The use of continuous femoral nerve blocks versus extended release epidural morphine: a study comparing outcomes in total knee arthroplasty procedures. Orthopedic Nursing 2011;30(1):44‐53. [MEDLINE: ] - PubMed
Koh 2011 {published data only}
    1. Koh IJ, Kang YG, Chang CB, Do SH, Seong SC, Kim TK. Does periarticular injection have additional pain relieving effects during contemporary multimodal pain control protocols for TKA? A randomised, controlled study. Knee 2012;19(4):253‐9. [PUBMED: 21507661] - PubMed
McMeniman 2010 {published data only}
    1. McMeniman TJ, McMeniman PJ, Myers PT, Hayes DA, Cavdarski A, Wong M, et al. Femoral nerve block vs fascia iliaca block for total knee arthroplasty postoperative pain control: a prospective, randomized controlled trial. Journal of Arthroplasty 2010;25(8):1246‐9. [PUBMED: 20178889] - PubMed
Meftah 2012 {published data only}
    1. Meftah M, Wong AC, Nawabi DH, Yun RJ, Ranawat AS, Ranawat CS. Pain management after total knee arthroplasty using a multimodal approach. Orthopedics 2012;35(5):e660‐4. [PUBMED: 22588407] - PubMed
Morin 2005 {published data only}
    1. Morin AM, Kratz CD, Eberhart LHJ, Dinges G, Heider E, Schwarz N, et al. Postoperative analgesia and functional recovery after total‐knee replacement: comparison of a continuous posterior lumbar plexus (psoas compartment) block, a continuous femoral nerve block, and the combination of a continuous femoral and sciatic nerve block. Regional Anesthesia and Pain Medicine 2005;30(5):434‐45. [PUBMED: 16135347] - PubMed
Ng 2012b {published data only}
    1. Ng F‐Y, Chiu K‐Y, Yan CH, Ng K‐FJ. Continuous femoral nerve block versus patient‐controlled analgesia following total knee arthroplasty. Journal of Orthopaedic Surgery 2012;20:23‐6. [PUBMED: 22535806] - PubMed
Niskanen 2005 {published data only}
    1. Niskanen RO, Strandberg N. Bedside femoral block performed on the first postoperative day after unilateral total knee arthroplasty: a randomized study of 49 patients. The Journal of Knee Surgery 2005;18(3):192‐6. [PUBMED: 16152867] - PubMed
Rais 2009 {published data only}
    1. Rais K, Ben Said A, Soussi M, Chahed S, Kaabachi O. Multimodal regional and systemic approach for postoperative analgesia in total knee arthroplasty. European Journal of Anaesthesiology 2009;26:123.
Rajeev 2007 {published data only}
    1. Rajeev S, Batra YK, Panda NB, Kumar M, Nagi ON. Combined continuous "3‐in‐1" and sciatic nerve blocks provide improved postoperative analgesia with no correlation to catheter tip location after unilateral total knee arthroplasty. Journal of Arthroplasty 2007;22(8):1181‐6. [PUBMED: 18078888] - PubMed
Rasiah 2012 {published data only}
    1. Rasiah R, Azhar AA, Thevanthiran MN. Single injection of femoral nerve block for bilateral total knee arthroplasty for post‐operative pain management. British Journal of Anaesthesia 2012;108:ii411.
Safa 2011 {published data only}
    1. Safa B, Haslam L, Gollish J, McCartney C. A prospective, randomized trial, comparing analgesic efficacy and postoperative functional recovery of either single shot sciatic nerve block or posterior capsule infiltration combined with femoral block for total knee arthroplasty. Regional Anesthesia and Pain Medicine 2011;36:508.
Serrano 2011 {published data only}
    1. Serrano A, Santiveri X, Bisbe E, Ortiz P, Puig L, Castillo J. Analgesic efficacy of associating a sciatic block to a femoral block in the postoperative period of total knee arthroplasty. European Journal of Anaesthesiology 2011;28:119‐20.
Sites 2004 {published data only}
    1. Sites BD, Beach M, Gallagher JD, Jarrett RA, Sparks MB, Lundberg CJF. A single injection ultrasound‐assisted femoral nerve block provides side effect‐sparing analgesia when compared with intrathecal morphine in patients undergoing total knee arthroplasty. Anesthesia and Analgesia 2004;99(5):1539‐43; table of contents. [PUBMED: 15502061] - PubMed
Taninishi 2011 {published data only}
    1. Taninishi H, Sato K, Morita K. Effects of anterior sciatic nerve block on intraoperative hemodynamics and pain relief in the postanesthesia care unit for patients undergoing total knee arthroplasty. Regional Anesthesia and Pain Medicine 2011;36(5):E263.
Tarkkila 1998 {published data only}
    1. Tarkkila P, Tuominen M, Huhtala J, Lindgren L. Comparison of intrathecal morphine and continuous femoral 3‐in‐1 block for pain after major knee surgery under spinal anaesthesia. European Journal of Anaesthesiology 1998;15(1):6‐9. [PUBMED: 9522133] - PubMed
Tricarico 2009 {published data only}
    1. Tricarico E, Tomasino S, D'Orlando L. Epidural analgesia compared with peripheral nerve blockade after major knee surgery. Critical Care 2009;13:S160.
Watson 2005 {published data only}
    1. Watson MW, Mitra D, McLintock TC, Grant SA. Continuous versus single‐injection lumbar plexus blocks: comparison of the effects on morphine use and early recovery after total knee arthroplasty. Regional Anesthesia & Pain Medicine 2005;30(6):541‐7. [PUBMED: 16326339] - PubMed
Wegener 2011 {published data only}
    1. Wegener JT, Ooij B, Dijk CN, Hollmann MW, Preckel B, Stevens MF. Value of single‐injection or continuous sciatic nerve block in addition to a continuous femoral nerve block in patients undergoing total knee arthroplasty: a prospective, randomized, controlled trial. Regional Anesthesia & Pain Medicine 2011;36(5):481‐8. [PUBMED: 21857273] - PubMed
Weston‐Simons 2012 {published data only}
    1. Weston‐Simons JS, Pandit H, Haliker V, Dodd CA, Popat MT, Murray DW. Intra‐articular local anaesthetic on the day after surgery improves pain and patient satisfaction after unicompartmental knee replacement: a randomised controlled trial. Knee 2012;19:352‐5. [PUBMED: 21669534] - PubMed
Zhang 2010 {published data only}
    1. Zhang HH, Yan SH, Li X, Jin Y, Liu ZC. Analgesia following artificial joint replacement joint replacement: nerve block based on gait analysis. Journal of Clinical Rehabilitative Tissue Engineering Research 2010;14(22):4018‐22.
Ziwenga 2010 {published data only}
    1. Ziwenga O, Tsui B, Sriramatr D. Comparison of quadriceps weakness following total knee arthroplasty using analgesia by femoral nerve block: continuous vs patient controlled techniques. Regional Anesthesia and Pain Medicine 2010;35(5):E194.

References to studies awaiting assessment

Grider 2011 {published data only}
    1. Grider JS, Harned ME, Paul S, Mauro G. Comparison of single shot versus continuous femoral local anesthetic nerve block in patients undergoing knee arthroplasty. Regional Anesthesia and Pain Medicine 2011;36(5):508‐20.
Mullen 2008 {published data only}
    1. Mullen M, Rooney BP, Kelly MP, Storey N. 24 hour infusion femoral and sciatic nerve block following total knee arthroplasty. Scottish Medical Journal 2008;2:59.
Tobin 2011 {published data only}
    1. Tobin R, Singh MK, Sharma P, Girotra G, Arora D, Panigrahi B. Ultrasound guided in‐plane continuous femoral nerve block for postoperative analgesia & early mobilisation in patients undergoing unilateral total knee arthroplasty—an Indian experience. Regional Anesthesia and Pain Medicine 2011;36(5):E263.
Yuksel 2011 {published data only}
    1. Yuksel BE, Doger C, Erdogan N, Ornek D, Kadiogullari N. Continuous epidural analgesia versus combination of single dose sciatic nerve block and continuous femoral analgesia in total knee arthroplasty. Regional Anesthesia and Pain Medicine 2011;36(5):E183‐E4.

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References to other published versions of this review

Chan 2012
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