There were nine high quality studies (Chan 2012, Liu 2014, Sahin 2014, Hinarejos 2016, Ortiz-Gomez 2017, Biswas 2018, Leung 2018, Rousseau-Saines 2018, Dimaculangan 2019) and one low quality study (Wyatt 2015) evaluating whether the use of peripheral nerve blockade reduces complications or improves outcomes in adult patients undergoing knee arthroplasty compared to no peripheral nerve block use. The included literature investigated Femoral Nerve Block (Chan 2012, Sahin 2014, Hinarejos 2016, Ortiz-Gomez 2017, Dimaculangan 2019, Wyatt 2015), Adductor Nerve Block (Leung 2018, Rousseau-Saines 2018, Ortiz-Gomez 2017), Sciatic Block (Liu 2014, Hinarejos 2016), and Lumbar Plexus Block (Liu 2014).
Four high quality studies (Chan 2012, Liu 2014, Hinarejos 2016, Rousseau-Saines 2018) demonstrated significantly lower VAS pain scores, and three high quality studies (Biswas 2018, Rousseau-Saines 2018, Dimaculangan 2019) demonstrated significantly lower opioid requirements during the postoperative period when peripheral nerve blockade was utilized compared to parenteral opioids alone.
Three high quality (Sahin 2014, Biswas 2018, Rousseau-Saines 2018) studies demonstrated no difference in adverse effects (nausea, vomiting, pruritis, urinary retention) between peripheral nerve blockade and no block.
Two high quality (Leung 2018, Dimaculangan 2019) studies and one low quality (Wyatt 2015) study showed no significant difference in early postoperative range of motion compared to no block. However, one high quality study (Chan 2012) demonstrated significantly better overall range-of-motion and a reduction in opioid-related side effects with the use of peripheral nerve blockade when compared to no peripheral nerve block use. Another high quality study (Liu 2014) demonstrated that peripheral nerve block use improved the Quality of Recovery (e.g., Emotive, Nociceptive and Cognitive domains) during the immediate postoperative period.
Benefits/ Harms of Implementation
The risks associated with peripheral nerve blockade may include bleeding, infection, and associated neural injury. Although rare, these potential risks need to be balanced with the documented benefits of peripheral nerve blockade. Depending upon clinical circumstances, peripheral nerve blockade may also be associated with postoperative motor weakness. Under these conditions, care must be taken to minimize the risk of patient falls or delayed mobilization during the hospitalization.
Future Research
Additional prospective studies may be needed to evaluate the long-term (>24-hour) analgesic benefits of peripheral nerve blockade, as well as their impact on functional outcomes. In addition, higher quality studies are also needed to compare specific peripheral nerve block techniques and to compare other modalities of perioperative analgesia (e.g., periarticular injection, neuraxial anesthesia). Future studies comparing the effectiveness of a single perioperative peripheral nerve block versus continuous infusion should be performed for standard outcomes. The scope of this guideline does not include the combination of. Future guidelines should investigate the combination of PNB and Periarticular Local Infiltration (PAI) / Periarticular Block (PAB), as it was not included in the scope of this guideline.
- Wyatt, M. C., Wright, T., Locker, J., Stout, K., Chapple, C., Theis, J. C. Femoral nerve infusion after primary total knee arthroplasty: A prospective, double-blind, randomised and placebo-controlled trial. Bone and Joint Research 2015; 2: 11-16
- Sahin, L., Korkmaz, H. F., Sahin, M., Atalan, G. Ultrasound-guided single-injection femoral nerve block provides effective analgesia after total knee arthroplasty up to 48 hours. Agri Dergisi 2014; 3: 113-8
- Rousseau-Saine, N., Williams, S. R., Girard, F., Hebert, L. J., Robin, F., Duchesne, L., Lavoie, F., Ruel, M. The Effect of Adductor Canal Block on Knee Extensor Muscle Strength 6 Weeks After Total Knee Arthroplasty: A Randomized, Controlled Trial. Anesthesia & Analgesia 2018; 3: 1019-1027
- Ortiz-Gómez, J. R., Perepérez-Candel, M., Vázquez-Torres, J. M., Rodriguez-Delrío, J. M., Torrón-Abad, B., Fornet-Ruiz, I., Palacio-Abizanda, F. J. Postoperative analgesia for elective total knee arthroplasty under subarachnoid anesthesia with opioids: Comparison between epidural, femoral block and adductor canal block techniques (with and without perineural adjuvants). Aprospective, randomized, clinical trial. Minerva Anestesiologica 2017; 1: 50-58
- Liu, J., Yuan, W., Wang, X., Royse, C. F., Gong, M., Zhao, Y., Zhang, H. Peripheral nerve blocks versus general anesthesia for total knee replacement in elderly patients on the postoperative quality of recovery. Clinical Interventions In Aging 2014; 0: 341-50
- Leung, P., Dickerson, D. M., Denduluri, S. K., Mohammed, M. K., Lu, M., Anitescu, M., Luu, H. H. Postoperative continuous adductor canal block for total knee arthroplasty improves pain and functional recovery: A randomized controlled clinical trial. Journal of Clinical Anesthesia 2018; 0: 46-52
- Hinarejos, P., Capurro, B., Santiveri, X., Ortiz, P., Leal, J., Pelfort, X., Torres-Claramunt, R., Sanchez-Soler, J., Monllau, J. C. Local infiltration analgesia adds no clinical benefit in pain control to peripheral nerve blocks after total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy 2016; 10: 3299-3305
- Dimaculangan, D., Chen, J. F., Borzio, R. B., Jauregui, J. J., Rasquinha, V. J., Maheshwari, A. V. Periarticular injection and continuous femoral nerve block versus continuous femoral nerve block alone on postoperative opioid consumption and pain control following total knee arthroplasty: Randomized controlled trial. Journal of Clinical Orthopaedics and Trauma 2019; 1: 81-86
- Chan, M. H., Chen, W. H., Tung, Y. W., Liu, K., Tan, P. H., Chia, Y. Y. Single-injection femoral nerve block lacks preemptive effect on postoperative pain and morphine consumption in total knee arthroplasty. Acta Anaesthesiol Taiwan 2012; 2: 54-8
- Biswas, A., Perlas, A., Ghosh, M., Chin, K., Niazi, A., Pandher, B., Chan, V. Relative Contributions of Adductor Canal Block and Intrathecal Morphine to Analgesia and Functional Recovery After Total Knee Arthroplasty: a Randomized Controlled Trial. Regional Anesthesia and Pain Medicine 2018; 2: 154-160