title: Is Local Infiltration Analgesia Superior to Peripheral Nerve Blockade for Pain Management After THA: A Network Meta-analysis.
abstract: BACKGROUND
  Local infiltration analgesia and peripheral nerve blocks are common methods for pain management in patients after THA but direct head-to-head, randomized controlled trials (RCTs) have not been performed. A network meta-analysis allows indirect comparison of individual treatments relative to a common comparator; in this case placebo (or no intervention), epidural analgesia, and intrathecal morphine, yielding an estimate of comparative efficacy.
  
  
  OBJECTIVE
  We asked, when compared with a placebo, (1) does use of local infiltration analgesia reduce patient pain scores and opioid consumption, (2) does use of peripheral nerve blocks reduce patient pain scores and opioid consumption, and (3) is local infiltration analgesia favored over peripheral nerve blocks for postoperative pain management after THA?
  
  
  METHODS
  We searched six databases, from inception through June 30, 2014, to identify RCTs comparing local infiltration analgesia or peripheral nerve block use in patients after THA. A total of 35 RCTs at low risk of bias based on the recommended Cochrane Collaboration risk assessment tool were included in the network meta-analysis (2296 patients). Primary outcomes for this review were patient pain scores at rest and cumulative opioid consumption, both assessed at 24 hours after THA. Because of substantial heterogeneity (variation of outcomes between studies) across included trials, a random effect model for meta-analysis was used to estimate the weighted mean difference (WMD) and 95% CI. The gray literature was searched with the same inclusion criteria as published trials. Only one unpublished trial (published abstract) fulfilled our criteria and was included in this review. All other studies included in this systematic review were full published articles. Bayesian network meta-analysis included all RCTs that compared local infiltration analgesia or peripheral nerve blocks with placebo (or no intervention), epidural analgesia, and intrathecal morphine.
  
  
  RESULTS
  Compared with placebo, local infiltration analgesia reduced patient pain scores (WMD, -0.61; 95% CI, -0.97 to -0.24; p = 0.001) and opioid consumption (WMD, -7.16 mg; 95% CI, -11.98 to -2.35; p = 0.004). Peripheral nerve blocks did not result in lower pain scores or reduced opioid consumption compared with placebo (WMD, -0.43; 95% CI, -0.99 to 0.12; p = 0.12 and WMD, -3.14 mg, 95% CI, -11.30 to 5.02; p = 0.45). However, network meta-analysis comparing local infiltration analgesia with peripheral nerve blocks through common comparators showed no differences between postoperative pain scores (WMD, -0.36; 95% CI, -1.06 to 0.31) and opioid consumption (WMD, -4.59 mg; 95% CI, -9.35 to 0.17), although rank-order analysis found local infiltration analgesia to be ranked first in more simulations than peripheral nerve blocks, suggesting that it may be more effective.
  
  
  CONCLUSIONS
  Using the novel statistical network meta-analysis approach, we found no differences between local infiltration analgesia and peripheral nerve blocks in terms of analgesia or opioid consumption 24 hours after THA; there was a suggestion of a slight advantage to peripheral nerve blocks based on rank-order analysis, but the effect size in question is likely not large. Given the slight difference between interventions, clinicians may choose to focus on other factors such as cost and intervention-related complications when debating which analgesic treatment to use after THA.
  
  
  METHODS
  Level I, therapeutic study.
authors.affiliation: Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY, USA.|Mayo Clinic Graduate School, Rochester, MN, USA.
authors.forename: José H
authors.initials: JH
authors.lastname: Jiménez-Almonte
authors.affiliation: Mayo Clinic Medical School, Rochester, MN, USA.
authors.forename: Cody C
authors.initials: CC
authors.lastname: Wyles
authors.affiliation: Mayo Clinic Medical School, Rochester, MN, USA.
authors.forename: Saranya P
authors.initials: SP
authors.lastname: Wyles
authors.affiliation: Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
authors.forename: German A
authors.initials: GA
authors.lastname: Norambuena-Morales
authors.affiliation: Mayo Clinic Graduate School, Rochester, MN, USA.
authors.forename: Pedro J
authors.initials: PJ
authors.lastname: Báez
authors.affiliation: Division of Preventive Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Murad
authors.affiliation: Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA. Sierra.Rafael@mayo.edu.
authors.forename: Rafael J
authors.initials: RJ
authors.lastname: Sierra
mesh_terms: D000701:Analgesics, Opioid / Q000627:therapeutic use; D000772:Anesthesia, Local / Q000009:adverse effects / Q000379:methods*; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D016009:Chi-Square Distribution; D006621:Hip Joint / Q000601:surgery*; D006801:Humans; D009407:Nerve Block / Q000009:adverse effects / Q000379:methods*; D016017:Odds Ratio; D059408:Pain Management / Q000009:adverse effects / Q000379:methods*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D010525:Peripheral Nerves / Q000187:drug effects*; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local