Analgesic efficacy of adding the IPACK block to multimodal analgesia protocol for primary total knee arthroplasty: a meta-analysis of randomized controlled trials

Abstract

Background: Total knee arthroplasty (TKA) is a standard treatment for end-stage degenerative knee disease. Most patients will experience moderate-to-severe postoperative knee pain, significantly affecting rehabilitation. However, controversy remains regarding the efficacy of adding the interspace between the popliteal artery and capsule of the knee (IPACK) into multimodal analgesia protocol. Methods: PubMed, Medline, Embase, Cochrane Library, and other databases were searched from inception to February 1, 2021. Studies comparing patients receiving IPACK to patients not receiving IPACK were included. The primary outcome was the ambulation pain score on a visual analogue scale (VAS) of 0–10. Secondary outcomes included pain score at rest, morphine usage, functional recovery, clinical outcomes, and complications. Results: Thirteen RCTs involving 1347 knees were included. IPACK was associated with lower ambulation pain scores (weight mean difference [WMD] − 0.49, 95% confidence interval [CI] − 0.72 to − 0.26). The benefits were observed from 2 to 4 h, 6 to 12 h, and beyond one week. IPACK also significantly reduced rest pain scores (WMD − 0.49, 95% CI − 0.74 to − 0.24), and the benefits were observed from 6 to 12 h and beyond one week. IPACK reduced the overall morphine consumption (WMD − 2.56, 95% CI − 4.63 to − 0.49). Subgroup analysis found reduced oral morphine consumption from 24 to 48 h (WMD − 2.98, 95% CI − 5.71 to − 0.24) and reduced rate of morphine requirement from 12 to 24 h (relative risk [RR] = 0.51, 95% CI 0.31 to 0.83). Functional recovery outcomes regarding ambulation distances (on the second postoperative day [POD2]) (WMD = 1.74, 95% CI 0.34 to 3.15) and quadriceps muscle strength (at 0 degree) (WMD = 0.41, 95% CI 0.04 to 0.77) favored IPACK. And IPACK reduced the rate of sleep disturbance (on POD 1) (RR = 0.39, 95% CI 0.19 to 0.81). There was no significant difference in the other outcomes. Conclusions: Moderate-level evidence confirmed that IPACK was related to better results in pain scores, morphine usage, and functional recovery without increasing the risk of complications. Registration: CRD42021252156.