Functional Recovery After Knee

Eur J Anaesthesiol 2019; 36:418–426
ORIGINAL ARTICLE
Functional recovery after knee arthroplasty with

regional analgesia
A systematic review and meta-analysis of randomised
controlled trials
Thomas Osinski, Samir Bekka, Jean-Philippe Regnaux, Dominique Fletcher and Valeria Martinez
BACKGROUND Regional analgesia (RA) has been widely systemic analgesia (0.90 days, 95% confidence interval
evaluated for pain relief after total knee arthroplasty (TKA). 0.3 to 1.4). Subgroup analyses found that only infiltration
Its impact on functional recovery is less well known. analgesia decreased the LOS. ROM during the first
week was significantly higher for all techniques of RA
OBJECTIVES To evaluate the functional benefits of RA than for systemic analgesia (9.238, 95% confidence
after TKA.
interval 4.6 to 13.9). No impact of regional analgesia
DESIGN Systematic review with a random-effects meta- techniques on global function in the longer term was
analysis of randomised controlled trials comparing LRA demonstrated. No difference in serious adverse effects
with systemic analgesia on function in adults undergoing was found between RA and systemic analgesia.
TKA for osteoarthritis.
CONCLUSION RA techniques compared with systemic
DATABASE SOURCES MEDLINE, EMBASE, LILAC, analgesia have a beneficial impact on the LOS and the
Cochrane, CTRD databases. ROM achieved in the early postoperative period. Global
function in the longer term after surgery seems
OUTCOMES Length of stay (LOS) in hospital and early unaffected by peri-operative RA.
knee flexion range of motion (ROM), early and long-term
knee function, serious adverse effects. TRIAL REGISTRATION CRD42014013995.
RESULTS Twenty-three studies (1246 patients) were Published online 3 April 2019
included. LOS was significantly shorter for RA than for
Introduction
Osteoarthritis, the most common type of arthritis, is essential to allow the patient to exercise and regain
estimated to affect more than 40 million people across mobility, thereby facilitating recovery and decreasing the
1
Europe and has a lifetime risk of 45% for knee osteoar- length of hospital stay. Several techniques of regional
2
thritis. Symptomatic knee osteoarthritis has a prevalence analgesia (RA) have been developed for postoperative pain
of 16.7% in subjects over the age of 45 years, and more relief. RA has been widely evaluated and several
than 500 000 knee replacements are performed annually in systematic reviews have shown its benefit for pain relief
3,4 6–13
the USA. This number was projected to grow by 673% after TKA. However, the impacts on functional
4
from 2005 to 2030. Total knee arthroplasty (TKA) is recovery and adverse effects are less well known. We
widely performed to improve mobility and quality of life. undertook a systematic review of randomised controlled
5
TKA is a very painful surgical procedure. Effective trials that compared RA with systemic analgesia in adults
analgesia in the immediate postoperative phase is undergoing major knee surgery for osteoarthritis. We
From the Service d’anesthesie, Hoˆpital Raymond Poincare, Garches, Assistance Publique Hoˆpitaux de Paris (SB, DF, VM), INSERM, U-987, Hoˆpital Ambroise Pare, Centre
d’Evaluation et de Traitement de la Douleur (TO, DF, VM), Universite Versailles Saint-Quentin, Paris (DF, VM) and Departement sciences infirmie`res et
paramedicales Ecole des Hautes Etudes en sante publique, Rennes, France (J-PR)
Correspondence to Valeria Martinez, MD, PhD, Service d’anesthesie, Hoˆpital Raymond Poincare, Garches, Assistance Publique Hoˆpitaux de Paris, Paris,
France E-mail: valeria.martinez@aphp.fr
0265-0215 Copyright 2019 European Society of Anaesthesiology. All rights reserved. DOI:10.1097/EJA.0000000000000983
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

Functional recovery after knee arthroplasty 419
assessed length of hospital stay, range of motion (ROM), adverse events (SAEs) corresponding to the definition of
global function and severe adverse effects. 17
Food and Drug Administration (FDA). We expected only
small total numbers of SAEs to be reported. We therefore
Method analysed specific adverse effects corresponding to the FDA
The systematic review of randomised controlled trials definition and reported in the trials included in the meta-
(RCTs) was reported in accordance with the criteria of the analysis. Three experts independently pre-determined
Preferred Reporting Items for Systematic Reviews and which adverse effects frequently reported in previous
Meta-Analyses (PRISMA) statement and the current studies corresponded to SAEs. Following discussion to
14,15 resolve any conflicts/disagreements, we classified the
recommendations of the Cochrane Collaboration. The
study was registered at PROSPERO (CRD42014013995). following adverse effects as SAEs: haemo-dynamic
instability, respiratory depression, venous thrombosis,
We searched the Cochrane Central Register of Con-trolled wound infection or necrosis (whatever the site), arrhythmia
Trials, MEDLINE, EMBASE and LILACS, from the or bradycardia, syncope, knee infection, falls, pneumonia,
inception of each database to January 2017. The search cerebral stroke, myocardial infarction or death.
equation is available in Supplementary data 1,
http://links.lww.com/EJA/A194. The articles identified had
to be published in English. We also searched the Cochrane Pairs of authors independently reviewed and extracted data
Database of Systematic Reviews and the Data-base of from each study. Disagreements were resolved by
Abstracts of Reviews of Effects for previous relevant consensus with a third author. We extracted information
systematic reviews. We hand-searched the annual about the general characteristics of the study (first author,
conference proceedings of the American Society of number of arms in the study, country, sponsorship), parti-
Anesthesiologists and the European Society of Anaes- cipants [age, BMI, American Society of Anesthesiologists’
thesiology from June 2013 to June 2017 and searched for (ASA) physical status, characteristics of the population,
completed trials in ClinicalTrials.gov and the WHO population randomised and analysed], experimental inter-
International Clinical Trials Registry Platform. We iden- vention (local anaesthetic used, administration route, tim-
tified randomised trials with the highly sensitive search ing of administration and doses), the use of discharge
strategy of the Cochrane Collaboration.
16 criteria, the existence of an enhanced recovery programme
and all functional outcomes evaluated. Dichotomous out-
We included all RCTs on adults undergoing TKA for comes were extracted as the presence or absence of an
osteoarthritis. For trials on mixed populations, we con- effect. For continuous data, we calculated mean and SD. If
sidered only those in which more than 50% of the patients necessary, means and measures of dispersion were approx-
were suffering from osteoarthritis. The interventions of imated from figures generated with dedicated software
interest were: epidural analgesia, peripheral nerve block, (http://www.datathief.org/). If not reported, the SDs were
local infiltration analgesia (LIA), regardless of the anaes- obtained from the confidence intervals (CIs) or P values for
16,18
thetic drug, volume administered, type of block or type of the differences between the means of two groups. If
local infiltration (peri-articular tissue and/or intra-articu-lar medians with ranges were reported, we obtained the mean
space). The control group of interests was either a group 19
and SD as described by Hozo. If only means were
with a sham technique with saline administration or a reported, we contacted the authors. We followed the
group with no RA. In either case, systemic analgesia had to recommendations of the Cochrane group to manage mul-
be clearly defined. We excluded trials in which functional 20
tiple groups. First, we selected only interventions of
outcomes were not provided. Two authors (TO and SB) interest in our meta-analysis. Second when possible, we
independently screened titles, abstracts and full texts for combined groups to create a single pair-wise comparison.
the inclusion criteria. Any disagreement between these two Third, when we needed to include each pair-wise compar-
authors was settled by discussion with a third author (VM) ison separately, we split the ‘shared’ group into two groups
until a consensus was reached. with smaller sample size, and include two comparisons.
For dichotomous outcomes, both the number of events and
The primary outcomes assessed were length of stay (LOS) the total number of patients were recorded.
in hospital in days, and knee flexion ROM in degrees on
day 4 after surgery (if this value was not provided, we used Two of the authors (TO, SB) independently assessed the
the ROM recorded for the week closest to this time point). methodological quality of the trials with the Cochrane Risk
The secondary outcomes were: time to first ambulation (in of Bias tool, with any discrepancies resolved by
days), knee flexion ROM at least 1 month after surgery, 21
consensus. We documented the methods used for gen-
number of patients achieving active straight leg raising erating allocation sequences, allocation concealment, the
(SLR), patient satisfaction and functional score [Western blinding of investigators and participants, the blinding of
Ontario and McMaster Uni-versities Osteoarthritis Index outcome assessors, and for dealing with incomplete out-
(WOMAC), Knee Oxford Score, knee society score] in the come data. Each item was classified as having a low,
first week and at least 1 month after surgery. We assessed unclear or high risk of bias. The overall risk of bias was
the incidence of severe defined as the highest risk of bias documented.

420 Osinski et al.
Data synthesis and analysis was used for the meta-analysis. We rated the quality of
We calculated risk ratios with 95% CIs for dichotomous evidence for each outcome following the Grades of Rec-
data and mean differences with 95% CI for continuous ommendation, Assessment, Development, and Evaluation
24
data. We expected there to be heterogeneity (because of the (GRADE) Working Group system. sufficient evidence
diverse populations included), and we therefore used the had been accrued. We rated the quality of evidence for each
Dersimonian and Lairs random effects meta-analysis outcome following the GRADE Working Group system.
24
modules. We used the Wells calculator to obtain the
number needed to treat for an additional beneficial
outcome for continuous measures (available at the Results
Cochrane Musculoskeletal Group editorial office There were 463 potentially eligible reports. We exam-ined
https://musculoskeletal.cochrane.org/). We assumed a 65 full-text articles, and we selected 23 studies on a total of
minimal clinically importance difference (MCID) of 1 day 1246 patients (Fig. 1). All the studies involved single sites.
for LOS and 108 for ROM to interpret the clinical The median target sample size was 60 (range 16 to 210)
22
importance of our results. We assessed statistical hetero- patients. The median publication date was 2009 (range
geneity by a visual inspection of graphs and by using the I
2 1990 to 2015). Participants were adults with ASA physical
statistic, which describes the proportion of variability in status classes 1 or 2. The characteristics of the selected
effect estimates due to heterogeneity rather than sampling trials are reported in Supplemental data Table 1,
2 23 http://links.lww.com/EJA/A194.
error (I > 50% indicates substantial heterogeneity). The
software RevMan 5.30 (Review Manager (RevMan) [Com- Seven trials (30%) were classified as being at low risk of
puter program]. Version 5.3. Copenhagen: The Nordic bias, eight (33%) at an unclear risk of bias and eight (33%)
Cochrane Centre, The Cochrane Collaboration, 2014)
Fig. 1
Studies found in electronic databases Studies from other sources:

Identification
- Conferences (n = 40)
(n = 636)
- Register of ongoing studies (n = 24)
- References in other studies (n = 63)
Studies found
(n = 463)
Selection
Studies excluded:
- Study design (n = 397)
Eligibility
Selection on full text
(n = 65)
Studies excluded on full text (n = 42):
- Study design (n = 35)
- Inadequate data (n = 5)
- Language (n = 2)
Inclusion Studies included in
qualitative review
(n = 23)
Studies included in quantitative analysis

- Length of stay (n = 13)
- Range of flexion the first week (n = 16)
- SAE (n = 17)
- First deambulation (n = 3)
- Range of flexion after 1 month (n = 4)
- Function at distance (n = 5)
PRISMA flow diagram showing literature search results.

at high risk of bias. The randomisation procedure was
adequately described in 16 trials (66%) and the con-
cealment of treatment allocation was described in 12 trials
Fig. 2
(50%). Eleven (48%) were double-blind. Four studies
(17%) had an unclear or high risk of incomplete data
Blinding of participants and personnel (performance bias)
Incomplete outcome data (attrition bias)
Overall risk of biais

Random sequence generation (selection bias)
Allocation concealment (selection bias)
Blinding of outcome assessment (detection bias)

outcomes (Fig. 2 details the risk of bias for each trial).
Primary outcomes
27–39
Thirteen studies, including 872 patients, reported data
for LOS, which was found to be shorter for RA than for
2
systemic analgesia by 0.9 days (range 0.36 to 1.45, I ¼
82%). Subgroup analysis by type of RA showed that this
small but significant difference concerned only the
2
LIA group [1.05 days (range 0.46 to 1.64, I ¼ 60%)].
29–32,34–36,39–47
Sixteen studies, including 958 patients,
reported data for range of flexion on day 4 after surgery.
ROM was significantly higher for patients given RA than
for those receiving systemic analgesia, regardless of the
2
type of RA [9.28 (range 4.7 to 13.7, I ¼ 95%)]. The effect
estimates for both outcomes met our criteria for MCID (i.e.
1 day for LOS and 108 for ROM) and were statisti-cally Baranovic 2011 + ? – – – –
significant (P < 0.05). The number needed to treat for a
beneficial outcome was four (range 2.5 to 10) for LOS and Busch 2006 + ? ? ? ? ?
two (range 1.5 to 3.7) for ROM. The level of quality of Chan 2014
+ + – + + –
evidence was downgraded twice for both out-comes due to
2 Chen 2012
inconsistency (I > 50%) and insufficient quality of data, so + + + + + +
the quality of evidence is low (Fig. 3). Essving 2010 + + + + + +
Secondary outcomes Fu 2009 + + + + + +

33,34,48
Three studies, including 155 patients, reported data Fu 2010 + + + + + +
for time to first ambulation. There was no significant Gomez 2010
global difference in this time between LIA and systemic + + + + + +
2
analgesia [ 0.29 days (range 0.82 to 0.2), I ¼ 73%]. Only Good 2007 ? + + + + ?
one study reported a significant difference in the time to Kadic 2009 +
ambulation between epidural analgesia and sys- + ? ? + ?
34 Kardash 2007 +
temic analgesia [0.80 (range 0.08 to 1.52), P ¼ 0.03]. ? + + + ?
45,46,49
Three studies comparing LIA and systemic anal- Mahoney 1990 ? ? ? ? + ?
gesia, including 261 patients, evaluated the time until the
patient could perform SLR after surgery. The time to first McDonald 2016 + + – – + –
SLR was significantly shorter for LIA than for systemic
2 Ng 2001 ? ? + + ? ?
analgesia [20.6 h (range 17.7 to 23.5), I ¼ 91%]. Four
35,45,46,50 Niemlainen 2014 +
studies comparing LIA and systemic analgesia, + + + + +
including 310 patients, reported data for ROM in the longer Ong 2010 ? ? – – + –
term. No difference in median ROM was found between
LIA and systemic analgesia 3 months after surgery [1.58 Seet 2006 ? ? – – + –
(range 1.1 to 4.2)], with a median ROM
Shum 2009 ? ? – + + –
for the control group of 1088 at this time point. Two
41,51
studies indicated no difference in long-term Singelyn 1998 + ? – – + –
WOMAC score between femoral nerve block and sys-
41,48,52 Vaishya 2015 + + + + + +
temic analgesia. Three studies showed no differ-
ence in long-term Knee Society Score (KSS) between Venditolli 2006 + + – – + –
femoral nerve block and systemic analgesia. One study
Wang 2002 + ? + + + ?
showed no difference in long-term KSS and WOMAC
27 33,41,48 Zhang 2011 ?
scores between LIA and systemic analgesia. Three ? ? + ? ?
33,41,48,53,54
of five studies reported higher
satisfaction in the peripheral nerve block group than in
Risk of bias.

422 Osinski et al.
Fig. 3
(a) RA SA Mean difference Mean difference

Study or subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.1.1 Epidural analgesia
Mahoney 1990 9.6 1.34 56 11.2 1.94 42 9.2% –1.60 (–2.28, –0.92)
Singelyn 1998 16 4 15 21 3 7 2.5% –5.00 (–8.01, –1.99)
Subtotal (95% Cl) 71 49 11.7% –2.97 (–6.24, 0.30)
2 2 2
Heterogeneity:Tau = 4.54; Chi = 4.67, df = 1 (P = 0.03); I = 79%
Test for overall effect: Z = 1.78 (P = 0.07)
1.1.1 Femoral block
Chan 2014 5.71 1.77 134 5.4 1.4 66 10.0% 0.31 (–0.14, 0.76)
Kardash 2007 6.46 1.33 39 6.1 1.34 20 9.1% 0.36 (–0.36, 1.08)
Ng 2001 9.2 3.19 36 8.8 2.9 12 4.6% 0.40 (–1.54, 2.34)
Seet 2006 6.51 1.94 35 7 2.22 20 7.2% –0.49 (–1.66, 0.68)
Singelyn 1998 17 3 15 21 3 8 3.2% –4.00 (–6.57, –1.43)
Wang 2002 3.5 1.15 15 4.25 1 15 8.9% –0.75 (–1.52, 0.02)
Subtotal (95% Cl) 274 141 42.9% –0.29 (–1.00, 0.43)
2 2 2
1.1.3 Infiltration analgesia
Busch 2006 5.2 1.34 32 5.1 1.94 32 8.7% 0.10 (–0.72, 0.92)
Essving 2010 4.5 2 24 6.25 2.08 23 7.2% –1.75 (–2.92, –0.58)
Gomez 201 0 5.72 1.34 25 7.32 1.94 25 8.2% –1.60 (–2.52, –0.68)
Ong 2010 5.39 1.51 37 7.25 4.04 17 4.5% –1.86 (–3.84, 0.12)
Vaishya 2015 4.5 0.67 40 5.7 0.64 40 10.5% –1.20 (–1.49, –0.91)
Venditolli 2006 4.8 2.1 22 5.2 2.5 20 6.3% –0.40 (–1.80, 1.00)
Subtotal (95% Cl) 180 157 45.3% –1.051–1.64, –0.46)
2 2 2
Total (95% Cl) 525 347 100.0% –0.90 (–1.45, –0.36)
2 2 2
Heterogeneity:Tau = 0.72; Chi = 72.54, df = 13 (P < 0.00001); I = 82%
Test for overall effect: Z = 3.24 (P = 0.001) –10 –5 0 5 10
2 2 Favour (RA) Favour (SA)
Test for subgroup differences: Chi = 4.37, df = 2 (P = 0.11), I = 54.2%
Forest plots. Comparison between regional analgesia and systemic analgesia. (a) Length of stay, (b) range of motion, (c) severe adverse effects.
the systemic analgesia group. Two studies compared postoperative function or the recovery process in the long
patient satisfaction between LIA and systemic analgesia term after surgery.
and reported conflicting results.27,29 Fifteen studies27,30–
34,36,39–41,45,46,49,50,53,55 including 1221 patients, com- Overall, the randomised clinical trials reported that all RA
pared the occurrence of SAEs between systemic analge-sia techniques slightly increased ROM in the early postoper-
and RA groups. The incidence of SAEs tended to be ative period but had no impact on long-term function. It
smaller in the RA group but failed to achieve signifi-cance has been suggested that peripheral nerve blocks provide
2
with a risk ratios of 0.75 (range 0.52 to 1.08, I ¼ 11%) better pain control, particularly for pain on movement, than
7,10
(Fig. 3). The level of quality of evidence was downgraded systemic analgesia alone. Better pain management
for imprecision because the optimal information size was probably improves mobility, as indicated by the greater
not reached. The quality of evi-dence was moderate (Fig. ROM recorded in the early postoperative period. How-
3). Falls were not reported in the included studies. ever, this benefit does not seem to be systematically
sustained beyond the period covered by the peripheral
nerve block, with conflicting results reported for functional
35,45,46,50
outcomes after discharge and no impact on long-
56
Discussion term functional recovery. Although, the decrease in LOS
The systematic review summarises the available evi-dence was very small, it reached the minimal clinical importance
concerning the impact of regional analgesia on functional difference and was similar to that reported in other sys-
11,12
recovery after TKA. It shows that all RA techniques tematic reviews. However, this decrease in LOS is
provide a similar transient improvement in knee ROM in much lower than the 2 to 3 days reported in cohort studies
55,57,58
the first week over that observed in patients receiving including an enhanced recovery programme. It
systemic analgesia. However, none of the regional could be explained by the lack of standardised discharge
analgesia techniques influenced global criteria in more than two-third of trials included.

Fig. 3
(b) RA SA Mean difference Mean difference

Study or subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.1.1 Epidural analgesia
Mahoney 1990 84.3 14.3 56 66.2 6.8 42 6.7% 18.10 (13.83, 22.37)
Singelyn 1998 79 12 15 62 18 7 4.1 % 17.00 (2.35, 31.65)
Subtotal (95% Cl) 71 49 10.8% 18.01 (13.91, 22.12)
2 2 2
Test for overall effect: Z = 8.61 (P < 0.0001)
1.1.2 Femoral block
Chan 2014 85.59 1 0.92 41 85.24 9.88 41 6.7% 0.35 (–4.16, 4.86)
Good 2007 67 16 19 62 10 19 5.7% 5.00 (–3.48, 13.48)
Kadic 2009 87.5 7.41 16 75 11.12 16 6.2% 12.50 (5.95, 19.05)
Kardash 2007 61.03 19.88 39 55 17.89 20 5.3% 6.03 (–3.99, 16.05)
Singelyn 1998 81 7 15 62 18 8 4.5% 19.00 (6.03, 31.97)
Wang 2002 76.7 9.5 15 71 10.2 15 6.1 % 5.70 (–1.35, 12.75)
Subtotal (95% Cl) 145 119 34.5% 7.04 (11.92, 12.16)
2 2 2
1.1.3 Infiltration
Essving 2010 80 17.56 22 64.75 14.11 22 5.5% 15.25 (5.84, 24.66)

Fu 2009 63.9 8.9 40 57.2 10 40 6.8% 6.70 (2.55, 10.85)
Fu 2010 64.4 8.9 50 56.9 10 50 6.8% 7.50 (3.79, 11.21)
Gomez 201 0 102.8 8.9 25 93.5 10 25 6.5% 9.30 (4.05, 14.55)
Niemlainen 2014 75.8 22 22 76 18 22 4.8% –0.20 (–12.08, 11.68)
Ong 2010 76.42 18.52 37 75 28.43 17 4.0% 1.42 (–13.35, 16.19)
Vaishya 2015 90.125 10 40 59.25 10 40 6.7% 30.88 (26.49, 35.26)
Venditolli 2006 90 8.9 22 94 10 20 6.4% –4.00 (–9.75, 1.75)
Zhang 2011 93.15 4.76 54 87.5 5.7 26 7.0% 5.65 (3.12, 8.18)
Subtotal (95% Cl) 312 262 54.6% 8.48 (1.73, 15.23)
2 2 2
Total (95% Cl) 528 430 100.0% 9.20 (4.70, 13.69)
2 2 2
Heterogeneity:Tau = 73.25; Chi = 167.01, df = 16 (P < 0.00001); I = 90%
Test for overall effect: Z = 4.01 (P = 0.0001) –20 –10 0 10 20
2 2 Favour (SA) Favour (RA)
(continued)
Our systematic review was based on numerous small knowledge concerning the contribution of regional anal-
single-site trials. There was therefore a risk of overesti- gesic techniques to functional recovery after knee
mation of treatment effects and underreporting of rele-vant arthroplasty compared with systemic analgesia. This anal-
severe adverse effects. We observed a significant ysis could therefore be used to develop a rational basis for
imbalance in terms of the amount of evidence available for future research. Based both on the frequency of outcomes
individual types of intervention, with an underrepre- reported in this systematic review and on the unmet needs
sentation of epidural analgesia. In addition, the included for which future clinical research is required, we suggest
trials reported many different nonstandardised end-points, the following evaluation of function after TKA. Global
precluding the comparison of trial results and the pooling function should be evaluated before surgery and in the
of data from independent studies. The retrieved trials dealt longer term after surgery, by calculating the WOMAC
with highly diverse drug regimens (volume, dose, timing score. Maximal flexion of the knee and SLR tests could be
and molecule administered), and the limited functional used as intermediate functional outcomes in the imme-diate
outcome data reported made it impossible to carry out postoperative period. The lack of standardised crite-ria of
more detailed subgroup analyses. discharge is an issue and precludes the evaluation of the
LOS based on a combination of criteria used in the studies
Our study has several strengths. First, we conducted a included in this review and cohort studies regard-
rigorous and extensive literature search, including registry ing the addition of an enhanced recovery program for
55,57
searches, contact with the authors of the studies considered TKA could be proposed. We suggest that the following
and searches of the abstract proceedings for the two main criteria should be considered; to standardise LOS endpoint
congresses in the field for up to 5 years. Second, our meta- in trials independently mobile with sticks or elbow
analysis provides a complete overview of current scientific crutches, ability to climb or descend a single flight of stairs

424 Osinski et al.
Fig. 3
(c) RA SA Risk ratio Risk ratio

Study or subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
1.3.1 Epidural
Mahoney 1990 5 56 1 42 2.8% 3.75 (0.45, 30.91)
Singelyn 1998 1 15 0 8 1.3% 1.69 (0.08, 37.26)
Subtotal (95% Cl) 71 50 4.2% 2.91 (0.51, 16.63)
Total events 6 1
2 2 2
1.3.2 Femoral block
Baranovic 2011 6 35 23 36 16.6% 0.27 (0.12, 0.58)

Good 2007 2 19 3 19 4.4% 0.67 (0.13, 3.55)
Kadic 2009 0 27 0 26 Not estimable
Kardash 2007 13 39 4 20 11.3% 1.67 (0.62, 4.45)
Seet 2006 4 35 3 20 6.2% 0.76 (0.19, 3.07)
Singelyn 1998 0 15 1 7 1.4% 0.17 (0.01, 3.65)
Subtotal (95% Cl) 170 128 39.8% 0.60 (0.25, 1.46)
Total events 25 34
2 2 2
1.3.3 Infiltration analgesia
Busch 2006 5 32 5 32 8.8% 1.00 (0.32, 3.12)

Chen 2012 1 40 2 40 2.3% 0.50 (0 .05, 5.30)
Fu 2009 9 40 10 40 16.1 % 0.90 (0.41,1.98)
Fu 2010 11 50 12 50 18.4% 0.92 (0.45, 1.88)
McDonald 2016 0 113 0 109 Not estimable
Ong 2010 0 37 0 17 Not estimable
Vaishya 2015 0 40 1 40 1.3% 0.33 (0.01,7.95)
Venditolli 2006 1 22 3 20 2.7% 0.30 (0.03, 2.68)
Zhang 2011 5 54 3 26 6.5% 0.80 (0.21, 3.10)
Subtotal (95% Cl) 428 374 56.0% 0.84 (0.54,1.29)
Total events 32 36
2 2 2
Heterogeneity:Tau = 0.00; Chi = 1.55, df = 6 (P = 0.96); I =
0% Test for overall effect: Z = 0.80 (P = 0.42)
Total (95% Cl) 669 552 100.0% 0.75 (0.52, 1.08)

Total events 63 71
2 2 2
Heterogeneity:Tau = 0.05; Chi = 14,63, df = 13 (P < 0.33); I =
0.01 0.1 1 10 100
11% Test for overall effect: Z = 1.54 (P = 0.12)
2 2 Favour (RA) Favour (SA)
(continued)
safely, 908 knee flexion, satisfactory analgesia (maximum regional analgesia techniques on global function in the
30 mm on a visual analogue scale) and good quadriceps longer term has been demonstrated.
strength (able to stand up from a sitting position and to
55
maintain knee extension while weight-bearing). The Acknowledgements relating to this article
achievement of discharge criteria should be the gold Assistance with the study: none.
standard in all studies evaluating analgesia approaches in
Financial support and sponsorship: none.
postoperative care.
Conflicts of interest: none.
Presentation: none.
Conclusion
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Eur J Anaesthesiol 2019; 36:418–426