Analgesia for total knee arthroplasty: a meta-analysis comparing local infiltration and femoral nerve block

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"identificador" => "aff1" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Corresponding author:" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig4" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 499 "Ancho" => 780 "Tamanyo" => 35803 ] ] "descripcion" => array:1 [ "en" => "Sensitivity analysis of each end point. (A) NRS value for pain at rest in the first 24 hours; (B) NRS value for pain upon movement in the first 24 hours; (C) opioid consumption (mg) in the first 24 hours." ] ] ] "textoCompleto" => "INTRODUCTIONEvery year, approximately 130,000 patients receive knee replacements in the United States <a class="elsevierStyleCrossRef" href="#bib1">1</a>. Modern medical techniques offer substantial benefits for the increasing number of patients undergoing total knee arthroplasty <a class="elsevierStyleCrossRef" href="#bib2">2</a>,<a class="elsevierStyleCrossRef" href="#bib3">3</a>. However, postoperative pain after total knee arthroplasty noticeably affects patients' quality of life. Clinical studies and hospital records have indicated that severe postoperative pain is associated with an increased risk of complications and that it slows the rehabilitation process, delays the improvement of persistent pain states, prolongs the length of hospital stay, and raises overall costs <a class="elsevierStyleCrossRef" href="#bib4">4</a>. Thus, greater attention should be paid to analgesia after total knee arthroplasty.Pain management after total knee arthroplasty is a multipart strategy. It often includes intravenous opioids, epidural analgesia, or peripheral nerve blocks in combination with oral analgesics and cryotherapy <a class="elsevierStyleCrossRef" href="#bib5">5</a>. These treatments can have a number of side effects, such as nausea, emeses, excessive sedation, hypotension, inhibition of respiration, and urinary retention. A femoral nerve block is seen as the gold standard for total knee arthroplasty <a class="elsevierStyleCrossRef" href="#bib6">6</a>. However, local infiltration is becoming popular because it has fewer side effects and is easier to administer. Therefore, choosing effective analgesia methods is a topic of interest.Using systematic review methods and meta-analysis, our objective is to synthesize evidence from randomized controlled trials to compare the effectiveness of local infiltration with that of a femoral nerve block for pain control in patients undergoing total knee arthroplasty.METHODSSearch strategy and selection criteriaWe searched articles in three electronic databases, Pubmed, EMBASE, and the Cochrane Library, for reports published between January 1, 2000, and January 26, 2015. The search terms included femoral nerve block, local infiltration, total knee arthroplasty, pain, analgesia, and randomized controlled trial. We removed duplicate articles that were located in more than one database. We included randomized controlled trials that compared the use of local infiltration with the use of a femoral nerve block for patients who underwent primary unilateral total knee arthroplasty. We excluded trials about bilateral total knee arthroplasty.Data collection and extractionTwo reviewers (Shuya Mei, Shuqing Jin) screened the relevant titles, abstracts, and full papers according to the previously mentioned criteria. If these two reviewers did not agree on a selection, a third reviewer (Quan Li) was consulted.Information was extracted regarding study characteristics, participant characteristics, the anesthesia procedures common to randomized groups, intervention (methods for local infiltration and femoral nerve block and the concentration, volume, and dose of medicine), and analgesia assessment (numeric rating scale [NRS] values for pain at rest and upon movement and opioid consumption in the first 24 hours).OutcomesThree aspects were assessed to compare the effectiveness of local infiltration and femoral nerve block for pain management in patients after total knee arthroplasty: 1. The NRS value for pain at rest in the first 24 hours; 2. The NRS value for pain upon movement in the first 24 hours; and 3. opioid consumption in the first 24 hours.Study qualityPossible biases were recorded in a Cochrane risk of bias table <a class="elsevierStyleCrossRef" href="#bib7">7</a>. Random sequence generation, allocation concealment, blinding of participants and personnel, blind outcome assessment, incomplete outcome data, selective reporting, and other sources of bias were measured with care. We classified the overall quality of each article as low, unclear or high risk of bias.Meta-analysisReview Manager Software (Revman 5.0, Cochrane Collaboration, Oxford, United Kingdom) was used for the meta-analysis. The heterogeneity of the studies was tested using the I2 statistic and chi-squared tests. A fixed-effects model was used when the heterogeneity test did not reveal statistical significance (I2<50%, p>0.1). Otherwise, the random effects model was used. Three continuous variables were included in this meta-analysis (NRS value for pain at rest, NRS value for pain upon movement and opioid consumption in first 24 hours) and the mean difference (MD) and 95% confidence interval (95% CI) were determined. All tests of statistical significance were two-sided <a class="elsevierStyleCrossRef" href="#bib8">8</a>. A sensitivity analysis was performed using Stata 11.0 (StataCorp., College Station, TX, USA) to explore the effect of an individual study.RESULTSSearch resultsOriginally, 23 records were identified through the PubMed, EMBASE, and Cochrane Library databases. The full text of all articles except one <a class="elsevierStyleCrossRef" href="#bib9">9</a> was available <a class="elsevierStyleCrossRef" href="#bib5">5</a>, but only 8 of the articles <a class="elsevierStyleCrossRef" href="#bib5">5</a>, met the inclusion criteria. Among these, 1 article <a class="elsevierStyleCrossRef" href="#bib24">24</a> was excluded because the study compared a femoral nerve block combined with periarticular anesthetic infiltration to local infiltration analgesia. One article <a class="elsevierStyleCrossRef" href="#bib30">30</a> did not include data that could be extracted for our analyses. Ultimately, 6 articles were included in our meta-analysis. The specific electronic search strategy used is shown in <a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>.<elsevierMultimedia ident="fig1"></elsevierMultimedia>Characteristics of the included trials<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a> shows the detailed characteristics of the included trials, and <a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a> shows risk of bias assessment results. All of the included randomized controlled trials had a low risk of bias and a moderate methodological quality. In all, 306 patients were included in the meta-analysis and were randomly allocated to receive either local infiltration or a femoral nerve block. The variety, concentration, volume, time, velocity and location of local anesthetics varied among the trials. Among the 6 included studies, all surgeries were primary unilateral total knee arthroplasties.<elsevierMultimedia ident="tbl1"></elsevierMultimedia><elsevierMultimedia ident="fig2"></elsevierMultimedia>Primary end pointsThe results of the NRS for pain at rest in the first 24 hours showed no differences between local infiltration and femoral nerve block (MD-0.42; 95%CI:-1.32 to 0.47; p=0.35; <a class="elsevierStyleCrossRef" href="#fig3">Figure 3A</a>). However, significant differences were found in the NRS for pain upon movement in the first 24 hours (MD-0.62; 95%CI: -1.13 to -0.12; p=0.02; <a class="elsevierStyleCrossRef" href="#fig3">Figure 3B</a>).<elsevierMultimedia ident="fig3"></elsevierMultimedia>Secondary end pointsThere were no differences in total opioid consumption in the first 24 hours between local infiltration and a femoral nerve block (MD 2.92; 95%CI:-1.32 to 7.16; p=0.18; <a class="elsevierStyleCrossRef" href="#fig3">Figure 3C</a>).Sensitivity analysisA sensitivity analysis of the three end points (NRS value for pain at rest, NRS value for pain upon movement and total opioid consumption in the first 24 hours) was conducted. No individual study significantly affected the heterogeneity results (<a class="elsevierStyleCrossRef" href="#fig4">Figure 4</a> A-C).<elsevierMultimedia ident="fig4"></elsevierMultimedia>DISCUSSIONWe selected articles from various databases to obtain relatively fair and objective results. Ultimately, 6 out of 23 articles were included for analysis, most of which were randomized, controlled and double-blind experiments, except for two <a class="elsevierStyleCrossRef" href="#bib27">27</a>,<a class="elsevierStyleCrossRef" href="#bib28">28</a> whose design was not clear.In comparing local infiltration and femoral nerve block for pain control after total knee arthroplasty, different studies drew different conclusions. Toftdahl K et al. <a class="elsevierStyleCrossRef" href="#bib5">5</a> and Moghtadaei M et al. <a class="elsevierStyleCrossRef" href="#bib29">29</a> proposed that local infiltration offered greater advantages for early analgesia after total knee arthroplasty. However, Carli F et al. <a class="elsevierStyleCrossRef" href="#bib25">25</a> concluded that femoral nerve block was better for recovery from total knee arthroplasty. The remaining 3 studies <a class="elsevierStyleCrossRefs" href="#bib26">26–28</a> determined that both local infiltration analgesia and a femoral block provided good analgesia for total knee arthroplasty.Our systematic review and meta-analysis provide a substantial evaluation of the effectiveness of local infiltration and femoral nerve block for pain control after total knee arthroplasty. Our data indicate that the two analgesic regimens offer a similar quality of pain relief at rest and are associated with similar levels of opioid consumption during the first 24 hours after total knee arthroplasty. The NRS value for pain upon movement was significantly lower in the femoral nerve block group.Meftah M et al. <a class="elsevierStyleCrossRef" href="#bib27">27</a> combined a femoral nerve block and patient-controlled epidural analgesia; they used bupivacaine for the block and infiltration, while others <a class="elsevierStyleCrossRef" href="#bib5">5</a>,<a class="elsevierStyleCrossRef" href="#bib25">25</a>,<a class="elsevierStyleCrossRef" href="#bib26">26</a>,<a class="elsevierStyleCrossRef" href="#bib28">28</a>,<a class="elsevierStyleCrossRef" href="#bib29">29</a> used ropivacaine. Theodosiadis P et al. compared the efficacy and safety of ropivacaine and bupivacaine for a 3-in-1 block during total knee arthroplasty and found that ropivacaine and bupivacaine had similar analgesic effects <a class="elsevierStyleCrossRef" href="#bib31">31</a>. Muldoon T et al. determined that ropivacaine was associated with slightly higher pain scores than bupivacaine was, but the mean value of the difference might not reflect a significant clinical difference <a class="elsevierStyleCrossRef" href="#bib32">32</a>.Patients in the study of Ng FY et al. <a class="elsevierStyleCrossRef" href="#bib28">28</a> underwent general anesthesia, while patients in other studies <a class="elsevierStyleCrossRef" href="#bib5">5</a>,<a class="elsevierStyleCrossRefs" href="#bib25">25–27</a>, used spinal anesthesia. Liguori GA reported that the choice of anesthetic will affect not only the short-term success of post-operative analgesia but also the patient's ability to achieve certain physical therapy milestones <a class="elsevierStyleCrossRef" href="#bib3">33</a>.Moghtadaei M et al. <a class="elsevierStyleCrossRef" href="#bib29">29</a> employed a single-injection femoral nerve block, while others <a class="elsevierStyleCrossRef" href="#bib5">5</a>, employed continuous femoral nerve blocks. Francis et al. observed that a continuous femoral nerve block could extend the analgesic effect of a single-injection femoral nerve block after total knee arthroplasty <a class="elsevierStyleCrossRef" href="#bib34">34</a>. Chan EY et al. found that patients with continuous femoral nerve blocks had lower pain scores on movement at 24 h and consumed less opioids compared with patients who received single-injection femoral nerve blocks <a class="elsevierStyleCrossRef" href="#bib35">35</a>.Although these three studies <a class="elsevierStyleCrossRefs" href="#bib27">27–29</a> had differences that may have affected the analgesic effects, only one article noted these differences. Therefore, subgroup analyses could not be performed. Our sensitivity analysis showed that no individual study significantly affected the heterogeneity results.Our study has the following limitations: 1. Because of language and database limitations, only published full-text articles in English were included, and this resulted in small number of included studies; 2. No data about postoperative movement functions were extracted for analysis, so the assessment of analgesia for total knee arthroplasty was not comprehensive.In summary, local infiltration provides analgesia comparable to that of a femoral nerve block for patients receiving total knee arthroplasty based on pain at rest and opioid consumption, but a femoral nerve block reduces pain upon movement.AUTHOR CONTRIBUTIONSMei S and Jin S searched articles, extracted data and wrote this manuscript. Chen Z, Ding X, Zhao X and Li Q examined the original study data, reviewed the analysis of data, and approved the final manuscript. Li Q is the author responsible for archiving the study files." 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It is unclear whether local infiltration or a femoral nerve block offers a better analgesic effect after total knee arthroplasty.We performed a systematic review and meta-analysis of randomized controlled trials to compare local infiltration with a femoral nerve block in patients who underwent a primary unilateral total knee arthroplasty. We searched Pubmed, EMBASE, and the Cochrane Library through December 2014. Two reviewers scanned abstracts and extracted data. The data collected included numeric rating scale values for pain at rest and pain upon movement and opioid consumption in the first 24 hours. Mean differences with 95% confidence intervals were calculated for each end point. A sensitivity analysis was conducted to evaluate potential sources of heterogeneity.While the numeric rating scale values for pain upon movement (MD-0.62; 95%CI: -1.13 to -0.12; p=0.02) in the first 24 hours differed significantly between the patients who received local infiltration and those who received a femoral nerve block, there were no differences in the numeric rating scale results for pain at rest (MD-0.42; 95%CI:-1.32 to 0.47; p=0.35) or opioid consumption (MD 2.92; 95%CI:-1.32 to 7.16; p=0.18) in the first 24 hours.Local infiltration and femoral nerve block showed no significant differences in pain intensity at rest or opioid consumption after total knee arthroplasty, but the femoral nerve block was associated with reduced pain upon movement." ] ] "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "#" "nota" => "co-first authors" "identificador" => "fn1" ] 1 => array:1 [ "nota" => "No potential conflict of interest was reported." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1225 "Ancho" => 760 "Tamanyo" => 62061 ] ] "descripcion" => array:1 [ "en" => "Flow chart of study selection." ] ] 1 => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 999 "Ancho" => 650 "Tamanyo" => 88747 ] ] "descripcion" => array:1 [ "en" => "Risk of bias assessment for included studies." ] ] 2 => array:7 [ "identificador" => "fig3" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 554 "Ancho" => 780 "Tamanyo" => 90904 ] ] "descripcion" => array:1 [ "en" => "Meta-analysis results of local infiltration compared with femoral nerve block after total knee arthroplasty. (A) NRS value for pain at rest in the first 24 hours; (B) NRS value for pain upon movement in the first 24 hours; (C) opioid consumption (mg) in the first 24 hours." ] ] 3 => array:7 [ "identificador" => "fig4" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 499 "Ancho" => 780 "Tamanyo" => 35803 ] ] "descripcion" => array:1 [ "en" => "Sensitivity analysis of each end point. (A) NRS value for pain at rest in the first 24 hours; (B) NRS value for pain upon movement in the first 24 hours; (C) opioid consumption (mg) in the first 24 hours." ] ] 4 => array:7 [ "identificador" => "tbl1" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" scope="col">Author \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Year of publication \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Anesthesia \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Number of patients \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Femoral nerve block \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="middle" scope="col">Local infiltration \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Toftdahl K \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">spinal anesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">continuous femoral nerve block \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">local infiltration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Carli F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">spinal anesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">continuous femoral nerve block \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">local infiltration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Affas F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">spinal anesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">continuous femoral nerve block \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">local infiltration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Ng FY \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">general anesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">continuous femoral nerve block \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">local infiltration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Meftah M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">spinal anesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">combine patient-controlled epidural  analgesia and femoral nerve block \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">local infiltration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Moghtadaei M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">spinal anesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">single-injection femoral nerve block \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="middle">local infiltration \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of eligible trials." ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Total Knee Arthroplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => 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] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:1 [ "link" => "Available: http://www.hss.edu/professional-conditions_anesthesia-analgesia-for-total-knee-hip-replacement.asp#.VJpW1REJBA" ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib34" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effect of single-injection femoral nerve block versus continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery within an established clinical pathway" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ FV Salinas \n \t\t\t\t\t\t\t\t """ 1 => """ SS Liu \n \t\t\t\t\t\t\t\t """ 2 => """ MF Mulroy \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1213/01.ane.0000198675.20279.81" "Revista" => array:7 [ "tituloSerie" => "Anesth Analg" "fecha" => "2006" "volumen" => "102" "numero" => "4" 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array:2 [ "doi" => "10.1016/j.arth.2012.06.039" "Revista" => array:7 [ "tituloSerie" => "J Arthroplasty" "fecha" => "2013" "volumen" => "28" "numero" => "4" "paginaInicial" => "608" "paginaFinal" => "613" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23142441" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1016/j.arth.2012.06.039" "WWW" => array:1 [ "link" => "http://dx.doi.org/10.1016/j.arth.2012.06.039" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack639194" "titulo" => "ACKNOWLEDGEMENTS" "texto" => "We are grateful for the support of the National Natural Science Foundation. We also thank all authors of the publications included in this study for providing the information we requested." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/18075932/0000007000000009/v1_202212011309/S1807593222013412/v1_202212011309/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/18075932/0000007000000009/v1_202212011309/S1807593222013412/v1_202212011309/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222013412?idApp=UINPBA00004N"]

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ShuYa Mei#, ShuQing Jin#, ZhiXia Chen, XiBing Ding, Xiang Zhao, Quan Li

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liquantongji@163.com

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Tongji University School of Medicine, Shanghai East Hospital, Department of Anesthesiology, Shanghai, China.

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Every year&#44; approximately 130&#44;000 patients receive knee replacements in the United States <a class="elsevierStyleCrossRef" href="#bib1">1</a>&#46; Modern medical techniques offer substantial benefits for the increasing number of patients undergoing total knee arthroplasty <a class="elsevierStyleCrossRef" href="#bib2">2</a>&#44;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#46; However&#44; postoperative pain after total knee arthroplasty noticeably affects patients&#39; quality of life&#46; Clinical studies and hospital records have indicated that severe postoperative pain is associated with an increased risk of complications and that it slows the rehabilitation process&#44; delays the improvement of persistent pain states&#44; prolongs the length of hospital stay&#44; and raises overall costs <a class="elsevierStyleCrossRef" href="#bib4">4</a>&#46; Thus&#44; greater attention should be paid to analgesia after total knee arthroplasty&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">Pain management after total knee arthroplasty is a multipart strategy&#46; It often includes intravenous opioids&#44; epidural analgesia&#44; or peripheral nerve blocks in combination with oral analgesics and cryotherapy <a class="elsevierStyleCrossRef" href="#bib5">5</a>&#46; These treatments can have a number of side effects&#44; such as nausea&#44; emeses&#44; excessive sedation&#44; hypotension&#44; inhibition of respiration&#44; and urinary retention&#46; A femoral nerve block is seen as the gold standard for total knee arthroplasty <a class="elsevierStyleCrossRef" href="#bib6">6</a>&#46; However&#44; local infiltration is becoming popular because it has fewer side effects and is easier to administer&#46; Therefore&#44; choosing effective analgesia methods is a topic of interest&#46;</p><p id="para30" class="elsevierStylePara elsevierViewall">Using systematic review methods and meta-analysis&#44; our objective is to synthesize evidence from randomized controlled trials to compare the effectiveness of local infiltration with that of a femoral nerve block for pain control in patients undergoing total knee arthroplasty&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">METHODS</span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">Search strategy and selection criteria</span><p id="para40" class="elsevierStylePara elsevierViewall">We searched articles in three electronic databases&#44; Pubmed&#44; EMBASE&#44; and the Cochrane Library&#44; for reports published between January 1&#44; 2000&#44; and January 26&#44; 2015&#46; The search terms included femoral nerve block&#44; local infiltration&#44; total knee arthroplasty&#44; pain&#44; analgesia&#44; and randomized controlled trial&#46; We removed duplicate articles that were located in more than one database&#46; We included randomized controlled trials that compared the use of local infiltration with the use of a femoral nerve block for patients who underwent primary unilateral total knee arthroplasty&#46; We excluded trials about bilateral total knee arthroplasty&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle50">Data collection and extraction</span><p id="para50" class="elsevierStylePara elsevierViewall">Two reviewers &#40;Shuya Mei&#44; Shuqing Jin&#41; screened the relevant titles&#44; abstracts&#44; and full papers according to the previously mentioned criteria&#46; If these two reviewers did not agree on a selection&#44; a third reviewer &#40;Quan Li&#41; was consulted&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">Information was extracted regarding study characteristics&#44; participant characteristics&#44; the anesthesia procedures common to randomized groups&#44; intervention &#40;methods for local infiltration and femoral nerve block and the concentration&#44; volume&#44; and dose of medicine&#41;&#44; and analgesia assessment &#40;numeric rating scale &#91;NRS&#93; values for pain at rest and upon movement and opioid consumption in the first 24 hours&#41;&#46;</p></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">Outcomes</span><p id="para70" class="elsevierStylePara elsevierViewall">Three aspects were assessed to compare the effectiveness of local infiltration and femoral nerve block for pain management in patients after total knee arthroplasty&#58; 1&#46; The NRS value for pain at rest in the first 24 hours&#59; 2&#46; The NRS value for pain upon movement in the first 24 hours&#59; and 3&#46; opioid consumption in the first 24 hours&#46;</p></span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">Study quality</span><p id="para80" class="elsevierStylePara elsevierViewall">Possible biases were recorded in a Cochrane risk of bias table <a class="elsevierStyleCrossRef" href="#bib7">7</a>&#46; Random sequence generation&#44; allocation concealment&#44; blinding of participants and personnel&#44; blind outcome assessment&#44; incomplete outcome data&#44; selective reporting&#44; and other sources of bias were measured with care&#46; We classified the overall quality of each article as low&#44; unclear or high risk of bias&#46;</p></span><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">Meta-analysis</span><p id="para90" class="elsevierStylePara elsevierViewall">Review Manager Software &#40;Revman 5&#46;0&#44; Cochrane Collaboration&#44; Oxford&#44; United Kingdom&#41; was used for the meta-analysis&#46; The heterogeneity of the studies was tested using the I<span class="elsevierStyleSup">2</span> statistic and chi-squared tests&#46; A fixed-effects model was used when the heterogeneity test did not reveal statistical significance &#40;I<span class="elsevierStyleSup">2</span>&#60;50&#37;&#44; <span class="elsevierStyleItalic">p</span>&#62;0&#46;1&#41;&#46; Otherwise&#44; the random effects model was used&#46; Three continuous variables were included in this meta-analysis &#40;NRS value for pain at rest&#44; NRS value for pain upon movement and opioid consumption in first 24 hours&#41; and the mean difference &#40;MD&#41; and 95&#37; confidence interval &#40;95&#37; CI&#41; were determined&#46; All tests of statistical significance were two-sided <a class="elsevierStyleCrossRef" href="#bib8">8</a>&#46; A sensitivity analysis was performed using Stata 11&#46;0 &#40;StataCorp&#46;&#44; College Station&#44; TX&#44; USA&#41; to explore the effect of an individual study&#46;</p></span></span><span id="cesec80" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">RESULTS</span><span id="cesec90" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">Search results</span><p id="para100" class="elsevierStylePara elsevierViewall">Originally&#44; 23 records were identified through the PubMed&#44; EMBASE&#44; and Cochrane Library databases&#46; The full text of all articles except one <a class="elsevierStyleCrossRef" href="#bib9">9</a> was available <a class="elsevierStyleCrossRef" href="#bib5">5</a>&#44; but only 8 of the articles <a class="elsevierStyleCrossRef" href="#bib5">5</a>&#44; met the inclusion criteria&#46; Among these&#44; 1 article <a class="elsevierStyleCrossRef" href="#bib24">24</a> was excluded because the study compared a femoral nerve block combined with periarticular anesthetic infiltration to local infiltration analgesia&#46; One article <a class="elsevierStyleCrossRef" href="#bib30">30</a> did not include data that could be extracted for our analyses&#46; Ultimately&#44; 6 articles were included in our meta-analysis&#46; The specific electronic search strategy used is shown in <a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia></span><span id="cesec100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle110">Characteristics of the included trials</span><p id="para110" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a> shows the detailed characteristics of the included trials&#44; and <a class="elsevierStyleCrossRef" href="#fig2">Figure 2</a> shows risk of bias assessment results&#46; All of the included randomized controlled trials had a low risk of bias and a moderate methodological quality&#46; In all&#44; 306 patients were included in the meta-analysis and were randomly allocated to receive either local infiltration or a femoral nerve block&#46; The variety&#44; concentration&#44; volume&#44; time&#44; velocity and location of local anesthetics varied among the trials&#46; Among the 6 included studies&#44; all surgeries were primary unilateral total knee arthroplasties&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><elsevierMultimedia ident="fig2"></elsevierMultimedia></span><span id="cesec110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle120">Primary end points</span><p id="para120" class="elsevierStylePara elsevierViewall">The results of the NRS for pain at rest in the first 24 hours showed no differences between local infiltration and femoral nerve block &#40;MD-0&#46;42&#59; 95&#37;CI&#58;-1&#46;32 to 0&#46;47&#59; <span class="elsevierStyleItalic">p&#61;</span>0&#46;35&#59; <a class="elsevierStyleCrossRef" href="#fig3">Figure 3A</a>&#41;&#46; However&#44; significant differences were found in the NRS for pain upon movement in the first 24 hours &#40;MD-0&#46;62&#59; 95&#37;CI&#58; -1&#46;13 to -0&#46;12&#59; <span class="elsevierStyleItalic">p&#61;</span>0&#46;02&#59; <a class="elsevierStyleCrossRef" href="#fig3">Figure 3B</a>&#41;&#46;</p><elsevierMultimedia ident="fig3"></elsevierMultimedia></span><span id="cesec120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle130">Secondary end points</span><p id="para130" class="elsevierStylePara elsevierViewall">There were no differences in total opioid consumption in the first 24 hours between local infiltration and a femoral nerve block &#40;MD 2&#46;92&#59; 95&#37;CI&#58;-1&#46;32 to 7&#46;16&#59; <span class="elsevierStyleItalic">p&#61;</span>0&#46;18&#59; <a class="elsevierStyleCrossRef" href="#fig3">Figure 3C</a>&#41;&#46;</p></span><span id="cesec130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle140">Sensitivity analysis</span><p id="para140" class="elsevierStylePara elsevierViewall">A sensitivity analysis of the three end points &#40;NRS value for pain at rest&#44; NRS value for pain upon movement and total opioid consumption in the first 24 hours&#41; was conducted&#46; No individual study significantly affected the heterogeneity results &#40;<a class="elsevierStyleCrossRef" href="#fig4">Figure 4</a> A-C&#41;&#46;</p><elsevierMultimedia ident="fig4"></elsevierMultimedia></span></span><span id="cesec140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle150">DISCUSSION</span><p id="para150" class="elsevierStylePara elsevierViewall">We selected articles from various databases to obtain relatively fair and objective results&#46; Ultimately&#44; 6 out of 23 articles were included for analysis&#44; most of which were randomized&#44; controlled and double-blind experiments&#44; except for two <a class="elsevierStyleCrossRef" href="#bib27">27</a>&#44;<a class="elsevierStyleCrossRef" href="#bib28">28</a> whose design was not clear&#46;</p><p id="para160" class="elsevierStylePara elsevierViewall">In comparing local infiltration and femoral nerve block for pain control after total knee arthroplasty&#44; different studies drew different conclusions&#46; Toftdahl K et al&#46; <a class="elsevierStyleCrossRef" href="#bib5">5</a> and Moghtadaei M et al&#46; <a class="elsevierStyleCrossRef" href="#bib29">29</a> proposed that local infiltration offered greater advantages for early analgesia after total knee arthroplasty&#46; However&#44; Carli F et al&#46; <a class="elsevierStyleCrossRef" href="#bib25">25</a> concluded that femoral nerve block was better for recovery from total knee arthroplasty&#46; The remaining 3 studies <a class="elsevierStyleCrossRefs" href="#bib26">26&#8211;28</a> determined that both local infiltration analgesia and a femoral block provided good analgesia for total knee arthroplasty&#46;</p><p id="para170" class="elsevierStylePara elsevierViewall">Our systematic review and meta-analysis provide a substantial evaluation of the effectiveness of local infiltration and femoral nerve block for pain control after total knee arthroplasty&#46; Our data indicate that the two analgesic regimens offer a similar quality of pain relief at rest and are associated with similar levels of opioid consumption during the first 24 hours after total knee arthroplasty&#46; The NRS value for pain upon movement was significantly lower in the femoral nerve block group&#46;</p><p id="para180" class="elsevierStylePara elsevierViewall">Meftah M et al&#46; <a class="elsevierStyleCrossRef" href="#bib27">27</a> combined a femoral nerve block and patient-controlled epidural analgesia&#59; they used bupivacaine for the block and infiltration&#44; while others <a class="elsevierStyleCrossRef" href="#bib5">5</a>&#44;<a class="elsevierStyleCrossRef" href="#bib25">25</a>&#44;<a class="elsevierStyleCrossRef" href="#bib26">26</a>&#44;<a class="elsevierStyleCrossRef" href="#bib28">28</a>&#44;<a class="elsevierStyleCrossRef" href="#bib29">29</a> used ropivacaine&#46; Theodosiadis P et al&#46; compared the efficacy and safety of ropivacaine and bupivacaine for a 3-in-1 block during total knee arthroplasty and found that ropivacaine and bupivacaine had similar analgesic effects <a class="elsevierStyleCrossRef" href="#bib31">31</a>&#46; Muldoon T et al&#46; determined that ropivacaine was associated with slightly higher pain scores than bupivacaine was&#44; but the mean value of the difference might not reflect a significant clinical difference <a class="elsevierStyleCrossRef" href="#bib32">32</a>&#46;</p><p id="para190" class="elsevierStylePara elsevierViewall">Patients in the study of Ng FY et al&#46; <a class="elsevierStyleCrossRef" href="#bib28">28</a> underwent general anesthesia&#44; while patients in other studies <a class="elsevierStyleCrossRef" href="#bib5">5</a>&#44;<a class="elsevierStyleCrossRefs" href="#bib25">25&#8211;27</a>&#44; used spinal anesthesia&#46; Liguori GA reported that the choice of anesthetic will affect not only the short-term success of post-operative analgesia but also the patient&#39;s ability to achieve certain physical therapy milestones <a class="elsevierStyleCrossRef" href="#bib3">33</a>&#46;</p><p id="para200" class="elsevierStylePara elsevierViewall">Moghtadaei M et al&#46; <a class="elsevierStyleCrossRef" href="#bib29">29</a> employed a single-injection femoral nerve block&#44; while others <a class="elsevierStyleCrossRef" href="#bib5">5</a>&#44; employed continuous femoral nerve blocks&#46; Francis et al&#46; observed that a continuous femoral nerve block could extend the analgesic effect of a single-injection femoral nerve block after total knee arthroplasty <a class="elsevierStyleCrossRef" href="#bib34">34</a>&#46; Chan EY et al&#46; found that patients with continuous femoral nerve blocks had lower pain scores on movement at 24 h and consumed less opioids compared with patients who received single-injection femoral nerve blocks <a class="elsevierStyleCrossRef" href="#bib35">35</a>&#46;</p><p id="para210" class="elsevierStylePara elsevierViewall">Although these three studies <a class="elsevierStyleCrossRefs" href="#bib27">27&#8211;29</a> had differences that may have affected the analgesic effects&#44; only one article noted these differences&#46; Therefore&#44; subgroup analyses could not be performed&#46; Our sensitivity analysis showed that no individual study significantly affected the heterogeneity results&#46;</p><p id="para220" class="elsevierStylePara elsevierViewall">Our study has the following limitations&#58; 1&#46; Because of language and database limitations&#44; only published full-text articles in English were included&#44; and this resulted in small number of included studies&#59; 2&#46; No data about postoperative movement functions were extracted for analysis&#44; so the assessment of analgesia for total knee arthroplasty was not comprehensive&#46;</p><p id="para230" class="elsevierStylePara elsevierViewall">In summary&#44; local infiltration provides analgesia comparable to that of a femoral nerve block for patients receiving total knee arthroplasty based on pain at rest and opioid consumption&#44; but a femoral nerve block reduces pain upon movement&#46;</p></span><span id="cesec150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle160">AUTHOR CONTRIBUTIONS</span><p id="para240" class="elsevierStylePara elsevierViewall">Mei S and Jin S searched articles&#44; extracted data and wrote this manuscript&#46; Chen Z&#44; Ding X&#44; Zhao X and Li Q examined the original study data&#44; reviewed the analysis of data&#44; and approved the final manuscript&#46; Li Q is the author responsible for archiving the study files&#46;</p></span></span>"
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        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><p id="spara60" class="elsevierStyleSimplePara elsevierViewall">Patients frequently experience postoperative pain after a total knee arthroplasty&#59; such pain is always challenging to treat and may delay the patient&#39;s recovery&#46; It is unclear whether local infiltration or a femoral nerve block offers a better analgesic effect after total knee arthroplasty&#46;</p><p id="spara70" class="elsevierStyleSimplePara elsevierViewall">We performed a systematic review and meta-analysis of randomized controlled trials to compare local infiltration with a femoral nerve block in patients who underwent a primary unilateral total knee arthroplasty&#46; We searched Pubmed&#44; EMBASE&#44; and the Cochrane Library through December 2014&#46; Two reviewers scanned abstracts and extracted data&#46; The data collected included numeric rating scale values for pain at rest and pain upon movement and opioid consumption in the first 24 hours&#46; Mean differences with 95&#37; confidence intervals were calculated for each end point&#46; A sensitivity analysis was conducted to evaluate potential sources of heterogeneity&#46;</p><p id="spara80" class="elsevierStyleSimplePara elsevierViewall">While the numeric rating scale values for pain upon movement &#40;MD-0&#46;62&#59; 95&#37;CI&#58; -1&#46;13 to -0&#46;12&#59; <span class="elsevierStyleItalic">p</span>&#61;0&#46;02&#41; in the first 24 hours differed significantly between the patients who received local infiltration and those who received a femoral nerve block&#44; there were no differences in the numeric rating scale results for pain at rest &#40;MD-0&#46;42&#59; 95&#37;CI&#58;-1&#46;32 to 0&#46;47&#59; <span class="elsevierStyleItalic">p&#61;</span>0&#46;35&#41; or opioid consumption &#40;MD 2&#46;92&#59; 95&#37;CI&#58;-1&#46;32 to 7&#46;16&#59; <span class="elsevierStyleItalic">p&#61;</span>0&#46;18&#41; in the first 24 hours&#46;</p><p id="spara90" class="elsevierStyleSimplePara elsevierViewall">Local infiltration and femoral nerve block showed no significant differences in pain intensity at rest or opioid consumption after total knee arthroplasty&#44; but the femoral nerve block was associated with reduced pain upon movement&#46;</p></span>"
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="middle" scope="col">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="middle" scope="col">Year of publication&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="middle" scope="col">Anesthesia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle" scope="col">Number of patients&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle" scope="col">Femoral nerve block&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="middle" scope="col">Local infiltration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Toftdahl K&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">spinal anesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">continuous femoral nerve block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">local infiltration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Carli F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">spinal anesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">continuous femoral nerve block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">local infiltration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Affas F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">spinal anesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">continuous femoral nerve block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">local infiltration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Ng FY&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">general anesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">continuous femoral nerve block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">local infiltration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Meftah M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">spinal anesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">combine patient-controlled epidural &#8195;analgesia and femoral nerve block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">local infiltration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">Moghtadaei M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">spinal anesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="middle">single-injection femoral nerve block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="middle">local infiltration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spara50" class="elsevierStyleSimplePara elsevierViewall">Characteristics of eligible trials&#46;</p>"
        ]
      ]
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      "titulo" => "REFERENCES"
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          "identificador" => "cebibsec10"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Total Knee Arthroplasty"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => """
                              H Palmer Simon \n
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                              """
                            1 => """
                              J Cross Mervyn \n
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                              """
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "WWW" => array:1 [
                        "link" => "Available from URL&#58; http&#58;&#47;&#47;emedicine&#46;medscape&#46;com&#47;article&#47;1250275-overview&#35;showall"
                      ]
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                  ]
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "What&#39;s new in adult reconstructive knee surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => """
                              CA Deirmengian \n
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                            1 => """
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                          ]
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                    ]
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                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.2106/JBJS.H.01106"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Bone Joint Surg Am"
                        "fecha" => "2008"
                        "volumen" => "90"
                        "numero" => "11"
                        "paginaInicial" => "2556"
                        "paginaFinal" => "2565"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18978439"
                            "web" => "Medline"
                          ]
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                      ]
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                      "doi" => "10.2106/JBJS.H.01106"
                      "WWW" => array:1 [
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                      "titulo" => "Current state and future of joint replacements in the hip and knee"
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                            0 => """
                              K Lee \n
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                      "Revista" => array:7 [
                        "tituloSerie" => "Expert Rev Med Devices"
                        "fecha" => "2008"
                        "volumen" => "5"
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                        "paginaInicial" => "383"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18452388"
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              "referencia" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
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                              TM Halaszynski \n
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                        "volumen" => "43"
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                            0 => """
                              K Toftdahl \n
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                              L Nikolajsen \n
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                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1080/17453670710013645"
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            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9432252"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Periarticular infiltration of 0&#46;25&#37; bupivacaine on top of femoral nerve block and intrathecal opioid improves quality of pain control after total knee arthroplasty&#58; a randomized double-blind placebo controlled clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              T Chinachoti \n
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                            1 => """
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                            2 => """
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "J Med Assoc Thai"
                        "fecha" => "2012"
                        "volumen" => "95"
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              "etiqueta" => "10"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Local infiltration analgesia is comparable to femoral nerve block after anterior cruciate ligament reconstruction with hamstring tendon graft&#58; a randomised controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => """
                              PK Kristensen \n
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                              """
                            1 => """
                              M Pfeiffer-Jensen \n
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                              """
                            2 => """
                              JO Storm \n
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                              """
                            3 => """
                              TM Thillemann \n
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                              """
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                            1 => """
                              M Fransen \n
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                            2 => """
                              S Sathappan \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              NH Chua \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              YH Chan \n
                              \t\t\t\t\t\t\t\t
                              """
                            5 => """
                              N Chua \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1016/j.arth.2012.06.039"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Arthroplasty"
                        "fecha" => "2013"
                        "volumen" => "28"
                        "numero" => "4"
                        "paginaInicial" => "608"
                        "paginaFinal" => "613"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23142441"
                            "web" => "Medline"
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                    1 => array:2 [
                      "doi" => "10.1016/j.arth.2012.06.039"
                      "WWW" => array:1 [
                        "link" => "http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;arth&#46;2012&#46;06&#46;039"
                      ]
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            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:4 [
        "identificador" => "xack639194"
        "titulo" => "ACKNOWLEDGEMENTS"
        "texto" => "<p id="para250" class="elsevierStylePara elsevierViewall">We are grateful for the support of the National Natural Science Foundation&#46; We also thank all authors of the publications included in this study for providing the information we requested&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/18075932/0000007000000009/v1_202212011309/S1807593222013412/v1_202212011309/en/main.assets"
  "Apartado" => null
  "PDF" => "https://static.elsevier.es/multimedia/18075932/0000007000000009/v1_202212011309/S1807593222013412/v1_202212011309/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1807593222013412?idApp=UINPBA00004N"
]

Article information

ISSN: 18075932
Original language: English

DOI:10.6061/clinics/2015(09)09

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	14	3	17
2024 October	41	27	68
2024 September	45	21	66
2024 August	44	23	67
2024 July	73	34	107
2024 June	33	18	51
2024 May	38	15	53
2024 April	47	12	59
2024 March	40	11	51
2024 February	50	17	67
2024 January	33	15	48
2023 December	17	17	34
2023 November	35	21	56
2023 October	29	16	45
2023 September	34	9	43
2023 August	11	2	13
2023 July	19	8	27
2023 June	18	1	19
2023 May	43	4	47
2023 April	35	1	36
2023 March	25	1	26
2023 February	6	1	7
2023 January	9	1	10
2022 December	47	3	50

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