title: Systematic review and meta-analysis of the efficacy of perineural local anaesthetic catheters after major lower limb amputation.
abstract: OBJECTIVE
  The aim of this systematic review and meta-analysis was to evaluate the effects of using an intraoperatively placed perineural catheter (PNC) with a postoperative local anaesthetic infusion on immediate and long-term outcomes after lower limb amputation.
  
  
  METHODS
  A systematic review of key electronic journal databases was undertaken from inception to January 2015. Studies comparing PNC use with either a control, or no PNC, were included. Meta-analysis was performed for postoperative opioid use, pain scores, mortality, and long-term incidence of stump and phantom limb pain. Sensitivity analysis was performed for opioid use. Quality of evidence was assessed using the GRADE system.
  
  
  RESULTS
  Seven studies reporting on 416 patients undergoing lower limb amputation with PNC usage (n = 199) or not (n = 217) were included. Approximately 60% were transtibial amputations PNC use reduced postoperative opioid consumption (standardised mean difference: -0.59, 95% CI -1.10 to -0.07, p = .03), maintained on sensitivity analysis for large (p = .03) and high-quality (p = .003) studies, but was marginally lost (p = .06) on studies enrolling patients with peripheral arterial disease only. PNC treatment did not affect postoperative pain scores (p = .48), in-hospital mortality (p = .77), phantom limb pain (p = .28) or stump pain (p = .37). GRADE quality of evidence for all outcomes was very low.
  
  
  CONCLUSIONS
  There is poor-quality evidence that PNC usage significantly reduces opioid consumption following lower limb amputation, without affecting other short- or long-term outcomes. Well-performed randomised studies are required.
authors.affiliation: South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, UK. Electronic address: davebosanquet@hotmail.com.
authors.forename: D C
authors.initials: DC
authors.lastname: Bosanquet
authors.affiliation: South East Wales Regional Vascular Network, University Hospital of Wales, Cardiff, UK.
authors.forename: J C D
authors.initials: JC
authors.lastname: Glasbey
authors.affiliation: South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, UK.
authors.forename: A
authors.initials: A
authors.lastname: Stimpson
authors.affiliation: South East Wales Regional Vascular Network, University Hospital of Wales, Cardiff, UK.
authors.forename: I M
authors.initials: IM
authors.lastname: Williams
authors.affiliation: South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, UK.
authors.forename: C P
authors.initials: CP
authors.lastname: Twine
mesh_terms: D000671:Amputation, Surgical / Q000009:adverse effects* / Q000401:mortality; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D002404:Catheterization / Q000295:instrumentation*; D002408:Catheters, Indwelling; D016009:Chi-Square Distribution; D006801:Humans; D007263:Infusions, Parenteral; D035002:Lower Extremity / Q000601:surgery*; D016017:Odds Ratio; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D010591:Phantom Limb / Q000209:etiology / Q000517:prevention & control; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local
keywords: Amputation; Meta analysis; Nerve sheath catheter; Perineural; Phantom limb; Postoperative pain