Does the Addition of iPACK Block to Adductor Canal Block Provide Improved Analgesic Effect in Total Knee Arthroplasty? A Systematic Review and Meta-Analysis

Abstract

The interspace between popliteal artery and the capsule of posterior knee (iPACK) block was proposed in recent years to relieve posterior knee pain. Since adductor canal block (ACB) and iPACK involve different branches of the sensory nerves, it is theoretically feasible to combine iPACK block and ACB to relief pain after total knee arthroplasty (TKA). We aim to validate the efficacy of adding iPACK block to ACB in the setting of a multimodal pain management protocol following TKA. A comprehensive literature review on Web of Science, Embase, the Cochrane Library, and PubMed was performed. Eight studies (N = 1,056) that compared the efficacy of iPACK block + ACB with ACB alone were included. Primary outcomes consisted of Visual Analogue Scale (VAS) score at rest or during activity at various time points. Secondary outcomes include opioids consumption, walking distance, and length of hospital stay (LOS). Compared to ACB alone, VAS scores at rest (standardized mean difference [SMD]: –1.18; 95% confidence interval [CI]: –2.05 to –0.30) and during activity (SMD: –0.26; 95% CI: –0.49 to –0.03) on the day of surgery were lower in the iPACK block + ACB group. However, the difference did not reach the minimal clinically important difference. Opioids consumption at postoperative 24 hours was lower in the iPACK + ACB group (SMD: –0.295; 95% CI: –0.543 to –0.048). VAS score on postoperative day (POD) 1 and POD2, opioids consumption from 24 to 48 hours, walking distance, and LOS were not different. In conclusion, the addition of iPACK block to ACB in a multimodal pain management protocol can effectively reduce opioids consumption in the early postoperative period. This is a level III, meta-analysis study.

Ultrasound Guided Infiltration of Popliteal Artery and Capsule of Knee [IPACK] versus IPACK with Adductor Canal Block [ACB] for Postoperative Knee Surgery Analgesia: A Comparative Study

“…Also, another study conducted by Sankineani et al [9] compared IPACK+ACB to ACB alone and showed statistically significant decreased VAS score with p-value <0.005. This goes in run with another systemic review analysis showed that ACB added to IPACK in total knee arthroplasty provides more effective analgesia with statistically significant decreased VAS score and lower doses of opioids consumed with p-value=0.048 [10] . In this study; there was statistically significant decreased total analgesia consumption in IPACK+ ACB group compared to IPACK group with p-value <0.001 with statistically significant increased 1st time for request analgesia in IPACK+ ACB compared to IPACK alone with p-value <0.001.…”

The effect of continuous adductor canal block combined with distal interspace between the popliteal artery and capsule of the posterior knee block for total knee arthroplasty: a randomized, double-blind, controlled trial

“…However, Kim DH reported that the consumption of opioid was decreased by the combination of ACB, IPACK and periarticular injection over the first 24 hours after surgery [ 21 ]. Coincidentally, a systematic review and meta-analysis indicated that IPACK block combined with ACB could reduce opioids consumption over the first 24 hours after surgery [ 22 ]. Interestingly, a recent systematic review and meta-analysis by Nasir H et al reported that IPACK block combined with ACB and periarticular infiltration could not improve analgesic effect after TKA.…”

The optimal choice of regional anesthesia in total knee arthroplasty: a prospective, double-blind, randomized, placebo-controlled study

“…и J.H. Wang и соавт., которые также проводили сравнения между группами БПК + айПАК и БПК [15,16]. В первой работе выраженность болевого синдрома по ВАШ была ниже в группе БПК + айПАК через 8, 12, 24 и 48 ч в покое (p <0,00001) и при движениях (p <0,00001), но не было зарегистрировано разницы в показателях при выписке.…”

“…Wang и соавт., напротив, не получили разницы в длительности пройденной дистанции. Остальные функциональные тесты в этом метаанализе не рассматривались [16]. R. Tak и соавт.…”