title: Pain Management Modalities after Total Knee Arthroplasty: A Network Meta-analysis of 170 Randomized Controlled Trials.
abstract: BACKGROUND
  Optimal analgesia for total knee arthroplasty remains challenging. Many modalities have been used, including peripheral nerve block, periarticular infiltration, and epidural analgesia. However, the relative efficacy of various modalities remains unknown. The authors aimed to quantify and rank order the efficacy of available analgesic modalities for various clinically important outcomes.
  
  
  METHODS
  The authors searched multiple databases, each from inception until July 15, 2016. The authors used random-effects network meta-analysis. For measurements repeated over time, such as pain, the authors considered all time points to enhance reliability of the overall effect estimate. Outcomes considered included pain scores, opioid consumption, rehabilitation profile, quality of recovery, and complications. The authors defined the optimal modality as the one that best balanced pain scores, opioid consumption, and range of motion in the initial 72 postoperative hours.
  
  
  RESULTS
  The authors identified 170 trials (12,530 patients) assessing 17 treatment modalities. Overall inconsistency and heterogeneity were acceptable. Based on the surface under the cumulative ranking curve, the best five for pain at rest were femoral/obturator, femoral/sciatic/obturator, lumbar plexus/sciatic, femoral/sciatic, and fascia iliaca compartment blocks. For reducing opioid consumption, the best five were femoral/sciatic/obturator, femoral/obturator, lumbar plexus/sciatic, lumbar plexus, and femoral/sciatic blocks. The best modality for range of motion was femoral/sciatic blocks. Femoral/sciatic and femoral/obturator blocks best met our criteria for optimal performance. Considering only high-quality studies, femoral/sciatic seemed best.
  
  
  CONCLUSIONS
  Blocking multiple nerves was preferable to blocking any single nerve, periarticular infiltration, or epidural analgesia. The combination of femoral and sciatic nerve block appears to be the overall best approach. Rehabilitation parameters remain markedly understudied.
authors.affiliation: From the Department of Anesthesiology (A.S.T., E.C.N.) and Claude Moore Health Sciences Library (M.S.N.), University of Virginia, Charlottesville, Virginia; Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia (A.S.T., K.S.D.); Outcomes Research Consortium, Cleveland, Ohio (A.S.T.); Department of Primary School Education and Department of Hygiene and Epidemiology (D.M., M.P.), University of Ioannina, Ioannina, Greece; Department of Outcomes Research, Anesthesiology Institute, Cleveland, Ohio (D.I.S.); Department of Surgery, Sanad Hospital, Riyadh, Saudi Arabia (R.S.T.); and Faculty of Medicine, Umm Durman University, Khartoum, Sudan (Y.S.T.).
authors.forename: Abdullah Sulieman
authors.initials: AS
authors.lastname: Terkawi
authors.forename: Dimitris
authors.initials: D
authors.lastname: Mavridis
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
authors.forename: Megan S
authors.initials: MS
authors.lastname: Nunemaker
authors.forename: Khaled S
authors.initials: KS
authors.lastname: Doais
authors.forename: Rayan Sulieman
authors.initials: RS
authors.lastname: Terkawi
authors.forename: Yazzed Sulieman
authors.initials: YS
authors.lastname: Terkawi
authors.forename: Maria
authors.initials: M
authors.lastname: Petropoulou
authors.forename: Edward C
authors.initials: EC
authors.lastname: Nemergut
mesh_terms: D000698:Analgesia / Q000379:methods*; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D004359:Drug Therapy, Combination; D006801:Humans; D059408:Pain Management / Q000379:methods*; D010149:Postoperative Pain / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic; D015203:Reproducibility of Results