The analgesic efficacy of local infiltration analgesia vs femoral nerve block after total knee arthroplasty: a systematic review and meta-analysis

Abstract

Many consider femoral nerve block the gold standard in pain management following knee arthroplasty. Local infiltration analgesia is an alternate approach that applies the concept of surgical wound infiltration with local anaesthetics. This meta-analysis aims to compare both analgesic treatments for analgesia and functional outcomes after total knee arthroplasty. This meta-analysis was performed according to the PRISMA statement guidelines. The primary outcomes were cumulative i.v. morphine consumption, pain scores at rest and on movement on postoperative day one (analogue scale,0-10). Secondary outcomes included range of motion, quadriceps muscle strength, length of stay and rates of complications (neurologic events, cardiovascular events, falls and knee infections). Fourteen trials, including 1122 adult patients were identified. There was no difference in i.v. morphine consumption (mean difference: -2.0 mg; 95% CI: -4.9, 0.9 mg; I(2)=69%; P=0.19), pain scores at rest (mean difference: -0.1; 95% CI: -0.4, 0.3; I(2)=72%; P=0.80) and pain scores on movement (mean difference: 0.2; 95% CI: -0.5, 0.8; I(2)=80%; P=0.64) on postoperative day one (a negative mean difference favours local infiltration analgesia). The qualities of evidence for our primary outcomes were moderate according to the GRADE system. There were no clinical differences in functional outcomes or rates of complications. Complication rates were captured by three trials or fewer with exception of knee infection, which was sought by eight trials. Local infiltration analgesia provides similar postoperative analgesia after total knee arthroplasty to femoral nerve block. Although this meta-analysis did not capture any difference in rates of complications, the low number of trials that specifically sought these outcomes dictates caution.

Adjuncts to Local Anaesthetics in Total Knee Arthroplasty

“…This highlights the often under-appreciated role of local infiltration analgesia (LIA) in the management of early post-operative pain. In 2016 Albrecht et al [3] published a meta-analysis of 1,112 patients sourced from fourteen randomised controlled trials, comparing LIA with femoral nerve block (FNB) in total knee arthroplasty (TKA) [3]. This study showed LIA to be equivalent to FNB in regard to 24 hour post-operative pain scores, morphine consumption and complications such as infection and falls.…”

Adductor Canal Block Combined with Sciatic Nerve Block Vs. Local Analgesic Infiltration for Pain Control after Total Knee Arthroplasty

“…This surgery is mostly associated with moderate to severe pain [1,2]. Good post-operative analgesia after TKR facilitates of early mobilization, reduction of length of hospital stay, less postoperative complications, prevents progression of acute pain to chronic pain and provides a hemodynamic stability [3].…”

“…LAI usually administrates as periarticular or with intra-articular infiltration. Meanwhile, the efficacy of LAI was comparable to that of epidural anesthesia, femoral nerve block (FNB) [2], adductor canal block (ACB) [5], and intrathecal morphine [6]. Sciatic nerve block (SNB) and LAI are two major options to supplement FNB in relieving of pain after TKR, However, its short duration of action limited its clinical application [7][8][9].…”

CORR Insights®: No Difference in Early Analgesia Between Liposomal Bupivacaine Injection and Intrathecal Morphine After TKA

“…More recently, it was reported that PAI might be better than continuous femoral nerve block in terms of pain relief after TKA in retrospective [17,23] and prospective trials [12,19], and might even improve the time for discharge from the hospital [9]. One recent meta-analysis of 14 randomized controlled trials confirmed that femoral nerve block was not superior to PAI in terms of opioid consumption, pain scores (at rest or movement), ROM, muscle strength and length of stay [1]. Continuous PAI was also reported to be equivalent to continuous femoral nerve block in terms of analgesic profiles after TKA [21], or even better and allowed for better function and less risk of motor weakness [18].…”