Combined femoral and sciatic nerve block versus femoral and local infiltration anesthesia for pain control after total knee arthroplasty: a meta-analysis of randomized controlled trials

Abstract

Background: The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the effect of combined femoral and sciatic nerve block (SNB) versus femoral and local infiltration anesthesia (LIA) after total knee arthroplasty (TKA).

Methods: The electronic databases PubMed, Embase, Cochrane Library, and Web of Science were searched from their inception to 15 June 2016. Articles comparing combined femoral and SNB versus femoral and LIA for pain control were eligible for this meta-analysis. This systematic review and meta-analysis was performed according to the PRISMA statement criteria. The primary endpoint was the visual analogue scale (VAS) score with rest at 12, 24, and 48 h, which represents the pain control after TKA. Data regarding active knee flexion, length of hospital stay, anesthesia time, and morphine use at 24 and 48 h were also compiled. The complications of postoperative nausea and vomiting (PONV) and fall were also noted to assess the safety of morphine-sparing effects. After testing for publication bias and heterogeneity across studies, the data were aggregated for random-effects modeling when necessary.

Results: Seven clinical trials with 615 patients were included in the meta-analysis. The pooled results indicated that SNB was associated with a lower VAS score at 12 h (MD = -6.96; 95% CI -8.36 to -5.56; P < 0.001) and 48 h (MD = -2.41; 95% CI -3.90 to -0.91; P < 0.001) after TKA. There was no significant difference between the SNB group and the LIA group in terms of the VAS score at 24 h (MD = 0.67; 95% CI -0.31 to 1.66; P = 0.182). The anesthesia time in the LIA group was shorter than in the SNB group, and the difference was statistically significant (MD = 4.31, 95% CI 1.34 to 7.28, P = 0.004). There were no significant differences between the groups in terms of active knee flexion, length of hospital stay, morphine use, PONV, and the occurrence of falls.

Conclusions: SNB may provide earlier anesthesia effects than LIA when combined femoral nerve block (FNB); however, there were no differences in morphine use, active knee flexion, and PONV between the groups. The LIA group spent less time under anesthesia, suggesting that LIA may offer a practical and potentially safer alternative to SNB.

Keywords: Local infiltration anesthesia; Meta-analysis; Sciatic nerve block; Total knee replacement.

Fig. 1

The flow diagram of the included studies. RCT randomized clinical trial

Fig. 2

The forest plot comparing SNB and LIA for VAS score after TKA. An inverse variance fixed-effects model was used. Mean differences with 95% CIs are reported. WMD weighted mean difference

Fig. 3

Funnel plot with pseudo 95% confidence limits

Fig. 4

The publication bias between the studies, indicated by the funnel plot. WMD weighted mean difference

Fig. 5

The result of Begg’s test for the VAS score after TKA

Fig. 6

The trial sequence analysis of the visual analogue scale (VAS) scores with rest at 12 h, showing that the accumulative Z-curve crossed the trial sequential monitoring boundary for harm and surpassed the required information size

Fig. 7

The forest plot comparing sciatic nerve block (SNB) and local infiltration anesthesia (LIA) for active knee flexion after TKA. An inverse variance fixed-effects model was used. Mean differences with 95% CIs are reported

Fig. 8

The forest plot comparing sciatic nerve block (SNB) and placebo in terms of morphine consumption at 24 and 48 h after TKA. An inverse variance fixed-effects model was used. Mean differences with 95% CIs are reported. WMD weighted mean difference

Fig. 9

Forest plot comparing the length of hospital stay between the SNB group and the LIA group. WMD weighted mean difference

Fig. 10

Forest plot comparing PONV between the SNB group and the LIA group. RR risk ratio

Fig. 11

Forest plot comparing the occurrence of fall between the two groups. Mean differences with 95% CIs are reported. RR risk ratio

Fig. 12

Forest plot comparing the anesthesia times of the two groups. Mean difference with 95% CIs are reported. WMD weighted mean difference