Network Meta-Analysis of Perioperative Analgesic Effects of Different Interventions on Postoperative Pain After Arthroscopic Shoulder Surgery Based on Randomized Controlled Trials

Abstract

Background: Shoulder arthroscopic surgery is a common surgical method used in orthopedics. However, severe postoperative pain can significantly limit the early joint movement of patients and adversely affect the impact of the surgery. At present, there is no consistent and effective analgesic scheme for the management of postoperative pain after arthroscopic surgery of the shoulder.

Purpose: The aim of this study was to search for the most effective analgesic scheme to control pain in the perioperative period of arthroscopic surgery of the shoulder.

Study design: Network meta-analysis.

Methods: We searched 5 different databases (i.e., Medline, PubMed, Embase, Web of Science, and the Cochrane Library) from January 2011 to January 2021 for English literature. Thereafter, we sifted out randomized controlled trials (RCTs), which compared different intervention schemes for pain management after shoulder arthroscopy and selected only 12 h, 24 h, or 48 h after the patient leaves the operating room as an optimal period for administration of analgesic intervention schemes. Only patients with shoulder disease who have undergone arthroscopic shoulder surgery were included in this study. The Cochrane "risk of bias" was used for the quality assessment. Moreover, some additional tests were performed to enhance the credibility of the results.

Results: Twenty-nine RCTs involving 1,885 patients were included in this frequentist network meta-analysis (NMA). These articles mainly were divided into two distinct groups, namely, the nerve block group and the non-nerve block group. Regarding the nerve block group, at postoperative 12 h, the intervention suprascapular nerve block + interscalene nerve block (SSNB + INB) was ranked first, whereas INB + intra-articular injection (INB + IAI) was ranked first at 24 h and 48 h postoperation. In the non-nerve block group, external application (EA) was ranked first at postoperative 12 h, but oral administration (OA) exhibited a better analgesic effect at postoperative 24 h and postoperative 48 h.

Conclusion: We conclude that the analgesic effect of SSNB+INB was the best at postoperative 12 h, and INB+IAI was the best at postoperative 24 h and 48 h in the nerve block group. For the non-nerve block group, the effect of EA was the best at postoperative 12 h, and the analgesic effect of OA at postoperative 24 h and 48 h was significantly better than any other interventions.

Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42021286777.

Keywords: arthroscopic shoulder surgery; network meta-analysis; pair-wise meta-analysis; postoperative pain; randomized controlled trials.

Figure 1

PRISMA flowchart of study selection.

Figure 2

Network plot of treatment comparisons. (A) (Network 1) Network plot of treatment comparisons for postoperative 12 h. The size of the blue area indicates the sample size of each group, and the thickness indicates the results of comparisons between two groups. (B) (Network 2) Network plot of treatment comparisons for postoperative 24 h. The size of the blue area indicates the sample size of each group, and the thickness indicates the results of comparisons between two groups. (C) (Network 3) Network plot of treatment comparisons for postoperative 48 h. The size of the blue area indicates the sample size of each group, and the thickness indicates the results of comparisons between two groups. INB, interscalene nerve block; SSNB, suprascapular nerve block; SCNB, supraclavicular nerve block; ICSCB, infraclavicular-suprascapular blocks; CCB, costoclavicular blocks; ANB, axillary nerve block; IAI, intra-articular injection; EA, external application; IVA, intravenous administration; SGB, stellate ganglion block; PL, placebo; HTESPB, high thoracic erector spinae plane block; CEB, cervical epidural block; ANB, axillary nerve block; OA, oral administration.

Figure 3

Quality assessment.

Figure 4

Quality assessment (ROB2.0).

Figure 5

(A) SUCRA for results of postoperative 12 h. (B) SUCRA for results of postoperative 24 h. (C) SUCRA for results of postoperative 48 h. The area under the curve represents the cumulative rank probability of each treatment; with larger areas signifying higher probabilities. INB, interscalene nerve block; SCNB, supraclavicular nerve block; SSNB, suprascapular nerve block; HTESPB, high thoracic erector spinae plane block; CEB, cervical epidural block; SGB, stellate ganglion block; ICSCB, infraclavicular-suprascapular blocks; CCB, costoclavicular blocks; ANB, axillary nerve block; IAI, intra-articular injection; OA, oral administration; EA, external application; IVA, intravenous administration; PL, placebo.

Figure 6

Loops analysis for inconsistency of network meta-analysis. [(A) postoperative 12 h., (B) postoperative 24 h]. When the 95% confidence interval (CI) includes 0; it means that inconsistency is low risk. INB, interscalene nerve block; SCNB, supraclavicular nerve block; SSNB, suprascapular nerve block; CEB, cervical epidural block; ANB, axillary nerve block; IAI, intra-articular injection; PL, placebo.

Figure 7

(A) SUCRA for results of postoperative 12 h. (B) SUCRA for results of postoperative 24 h. (C) SUCRA for results of postoperative 48 h. (After removing the article with less than 40 people). The area under the curve represents the cumulative rank probability of each treatment; with larger areas signifying higher probabilities. INB, interscalene nerve block; SCNB, supraclavicular nerve block; SSNB, suprascapular nerve block; HTESPB, high thoracic erector spinae plane block; CEB, cervical epidural block; ANB, axillary nerve block; IAI, intra-articular injection; OA, oral administration; EA, external application; IVA, intravenous administration; PL, placebo.

Figure 8

The comparison-adjusted funnel plot of network meta-analyses. [(A) postoperative 12 h, (B) postoperative 24 h, (C) postoperative 48 h]. INB, interscalene nerve block; SCNB, supraclavicular nerve block; SSNB, suprascapular nerve block; HTESPB, high thoracic erector spinae plane block; CEB, cervical epidural block; SGB, stellate ganglion block; ICSCB, infraclavicular-suprascapular blocks; CCB, costoclavicular blocks; ANB, axillary nerve block; IAI, intra-articular injection; OA, oral administration; EA, external application; IVA, intravenous administration; PL, placebo.