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.).
Anesthesiology. 2017 May;126(5):923-937. doi: 10.1097/ALN.0000000000001607.
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.
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.
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.
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.
全膝关节置换术后的最佳镇痛仍然具有挑战性。已经使用了多种方法，包括外周神经阻滞、关节周围浸润和硬膜外镇痛。然而，各种方法的相对疗效尚不清楚。作者旨在量化并对各种具有临床意义的结果的有效镇痛方法进行排序。
作者搜索了多个数据库，每个数据库都从成立到 2016 年 7 月 15 日。作者使用随机效应网络荟萃分析。对于随时间重复的测量，如疼痛，作者考虑了所有时间点，以提高整体效果估计的可靠性。考虑的结果包括疼痛评分、阿片类药物消耗、康复情况、恢复质量和并发症。作者将最佳模式定义为在术后 72 小时内最佳平衡疼痛评分、阿片类药物消耗和运动范围的模式。
作者确定了 170 项试验（12530 名患者）评估了 17 种治疗方法。整体不一致性和异质性是可以接受的。根据累积排序曲线下面积，休息时疼痛的最佳前五种方法是股神经/闭孔神经、股神经/坐骨神经/闭孔神经、腰丛/坐骨神经、股神经/坐骨神经和股筋膜间隙阻滞。减少阿片类药物消耗的最佳前五种方法是股神经/坐骨神经/闭孔神经、股神经/闭孔神经、腰丛/坐骨神经、腰丛和股神经/坐骨神经阻滞。运动范围最佳的方法是股神经/坐骨神经阻滞。股神经/坐骨神经和股神经/闭孔神经阻滞最符合我们的最佳性能标准。仅考虑高质量的研究，股神经/坐骨神经似乎最好。
阻滞多根神经比阻滞任何单一神经、关节周围浸润或硬膜外镇痛更有效。股神经和坐骨神经联合阻滞似乎是一种总体上最佳的方法。康复参数仍然明显研究不足。
