No difference in pain control and hospitalisation length between single-shot adductor canal block and periarticular injections following total knee arthroplasty: a meta-analysis

Filippo Migliorini; Ludovico Lucenti; Tommaso Bardazzi; Nicola Maffulli; Raju Vaishya; Jörg Eschweiler

doi:10.1016/j.jor.2026.02.024

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75 (); 177-183

doi:

10.1016/j.jor.2026.02.024

No difference in pain control and hospitalisation length between single-shot adductor canal block and periarticular injections following total knee arthroplasty: a meta-analysis

Filippo Migliorini^a,b,c,, Ludovico Lucenti^d, Tommaso Bardazzi^b, Nicola Maffulli^e,f,g, Raju Vaishya^h, Jörg Eschweiler^a,i

a Department of Trauma and Reconstructive Surgery, University Hospital of Halle, Martin-Luther University Halle-Wittenberg, 06097, Halle (Saale), Germany

b Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy

c Department of Life Sciences, Health, and Health Professions, Link Campus University, 00165, Rome, Italy

d Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, 90133, Palermo, Italy

e Department of Trauma and Orthopaedic Surgery, Faculty of Medicine and Psychology, University La Sapienza, 00185, Roma, Italy

f School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, ST4 7QB, UK

g Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, E1 4DG, UK

h Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospital, Sarita Vihar, 110076, New Delhi, India

i Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle GmbH, Halle (Saale), Germany

⁎Corresponding author: Filippo Migliorini. filippo.migliorini@uk-halle.de

Received: 2025-9-18, Accepted: 2026-2-3, Published: 2026-2-11

The Authors

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

This meta-analysis compared pain control and hospitalisation length between single-shot adductor canal block (ACB) versus periarticular injections (PAI) following total knee arthroplasty (TKA).

The 2020 PRISMA guidelines were followed. Embase, Web of Science, and PubMed were accessed in August 2025 without additional filters or temporal constraints. All randomised controlled trials (RCTs) comparing single-shot ACB versus PAI for pain management following TKA were considered. Data concerning the visual analogue scale (VAS) were collected for postoperative day (POD) 0, 1, 2, 3, and at discharge. Data on the length of the hospitalisation were also retrieved.

Data from 283 patients were retrieved, 75.3% of whom (213 of 283) were women. The mean length of follow-up was 2.8 ± 2.3 weeks. The mean age was 69.2 ± 1.9 years, and the mean BMI was 31.0 ± 1.1 kg/m². No difference was found in the length of the hospitalisation (P = 0.06). No difference was found in VAS at POD0 (P = 0.9), POD1 (P = 0.1), and POD2 (P = 0.5). No difference was found in pain control and hospitalisation length between single-shot adductor canal block and periarticular injections following total knee arthroplasty.

Obviously, when selecting one method over the other, consideration should be given to the fact that most surgeons are able to administer PAI, while ACB may require a specialised trained anaesthetist and the use of an ultrasound machine.

Keywords

replacement

visual analogue scale

recovery

surgery

orthopaedics

outcomes

Show Related Articles from PubMed

1 Introduction

Total knee arthroplasty (TKA) is commonly performed in patients with end-stage knee osteoarthritis to reduce pain, increase function, and improve the quality of life ^1–10. However, TKA is associated with moderate to severe postoperative pain 11–16. Establishing optimal pain management following TKA is crucial to ensure a good clinical outcome, fast recovery, and a reduced rate of complications ¹⁷^,¹⁸. Multimodal analgesia in lower limb arthroplasty minimises the need for narcotics, improves pain scores, raises satisfaction, and promotes early recovery ¹⁹^,²⁰. Single-shot adductor nerve block (ACB) is a common pain management strategy, as it selectively blocks sensory nerves while maintaining quadriceps muscle function ^21–23. Another frequently used method is periarticular injections (PAI) at the end of the surgery, which selectively target periarticular fields such as the posterior capsule, medial and lateral collateral ligaments, quadriceps mechanism and peripatellar tissue ²⁴^,²⁵. These procedures allow patients to undertake in early rehabilitation, critical for the best possible outcome after TKA ²⁶^,²⁷.

Although single-shot ACB and PAI are both widely used following TKA, the best pain management method following TKA remains debated. Moreover, whether a difference exists in the length of hospitalisation has yet to be fully clarified. Therefore, the present meta-analysis compares single-shot ACB versus PAI in pain control and hospitalisation length.

2 Methods

2.1

2.1 Eligibility criteria

All the clinical investigations comparing single-shot ACB versus PAI for pain management following TKA were considered. Only randomised controlled trials (RCTs) with levels I and II of evidence, according to the Oxford Centre of Evidence-Based Medicine (OCEBM),²⁸ were included. Reviews, opinions, editorials, and letters were excluded. According to the authors’ capabilities, only articles in the following languages were considered: German, English, French, Italian, and Spanish. Additionally, studies involving biomechanical assessments, computational analyses, in vitro experiments, animals, or cadaveric research were not eligible. Studies on monocompartmental knee arthroplasty and revision settings were also not considered.

2.2

2.2 Search strategy

The present systematic review followed the guidelines defined in the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.²⁹ The following framework (PICOD) was used for the search:•P (Problem): TKA;•I (Intervention): postoperative pain control and hospitalisation;•C (Comparison): Single-shot ACB vs PAI;•O (Outcomes): visual analogue scale and hospitalisation;•D (Design): RCTs.

2.3

2.3 Data source

EMBASE, Web of Science, and PubMed were accessed in August 2025 without additional filters or temporal constraints. The Medical Subject Headings (MeSH) used in the database search are reported in the Appendix.

2.4

2.4 Selection and data collection

Two authors (T.B. and J.E.) performed the database search. All the resulting titles were screened by hand, and the abstract was accessed if suitable. In case of a match, the full text was examined. If the full text was not accessible or available, the article was excluded. A cross reference of the bibliography of the full-text articles was also performed for inclusion. A third senior author (N. M.) took the final decision in case of disagreements.

2.5

2.5 Outcomes of interest

Two authors (T.B. and J.E.) independently conducted data extraction. For each study, the following generalities were collected: author, year of publication, journal, study design, and length of follow-up. The following data at baseline were extracted: number of patients, women, and BMI. Data concerning the hospitalisation length and VAS³⁰ were collected for postoperative days (POD) 0, 1, and 2. Extraction was performed using Microsoft Office Excel version 16.0 (Microsoft Corporation, Redmond, USA).

2.6

2.6 Methodology quality assessment

The methodological quality assessment was performed by two authors (T.B and J.E.). The revised Risk of Bias assessment tool (RoB2) ³¹^,³² of the Cochrane tool for assessing the Risk of Bias in randomised trials (RoB)³³ was used. The following endpoints were considered: bias arising from the randomisation process, bias from deviations from intended interventions, bias from missing outcome data, bias in the measurement of the outcome, and bias in the selection of the reported result. The figure of the RoB2 was elaborated using the Robvis Software (Risk-of-bias VISualization, Riskofbias.info, Bristol, UK).³⁴

2.7

2.7 Statistical analysis

The main author (F.M.) performed the statistical analyses following the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. The IBM SPSS software version 25 (International Business Machines Corporation, Armonk, USA) was used. Mean difference and standard deviation were used for descriptive statistics. The T-test was performed to assess baseline comparability, with values of P > 0.1 considered satisfactory. For the comparisons, the arithmetic mean and standard deviation were used for continuous data and the frequency (events/observations) for dichotomic variables. The meta-analyses were conducted using the software Review Manager 5.3 (The Nordic Cochrane Collaboration, Copenhagen). The inverse variance method with mean difference (MD) effect measure was used for continuous data. The CI was set at 95% in all the comparisons. Heterogeneity was evaluated through Higgins-I2 and χ² tests. If Pχ² >0.05, no statistically significant heterogeneity was found. If Pχ² <0.05, the heterogeneity was assessed following the values of the Higgins-I2: low (<30%), moderate (30% to 60%), and high (>60%). A fixed effect model was set as default. If high heterogeneity was detected, a random model effect was used. Overall values of P < 0.05 were considered statistically significant.

3 Results

3.1

3.1 Search result

The systematic literature search resulted in the identification of 3283 articles. After removing duplicates, the abstracts of 2196 articles were screened for eligibility. A total of 2004 articles were excluded for the following reasons: mismatch with the predefined study design criteria (N = 1123), full-text unavailability (N = 725), and language limitations (N = 156). Of the remaining 192 studies, another 189 were excluded after full-text evaluation. Consequently, a final selection of 3 studies was included in this systematic review. ^27–35 The literature search results are shown in Fig. 1.

3.2

3.2 Methodological quality assessment

The Cochrane risk of bias assessment tool (ROB 2) was used to evaluate the five included RCTs. The analysis suggested a low risk of bias across all domains for the two articles. One article presented some criticalities in measuring the outcome. The overall RoB was estimated to be low for two articles and high for one RCT, suggesting acceptable methodological quality. Fig. 2 shows the bias risk distribution across the included RCTs.

3.3

3.3 Patient demographics

Table 1 Characteristics and patient baseline of the included studies.

Author and Year	Journal	Follow-up (weeks)	Treatment Group	Patients (n)	Women (n)	Mean age (y)	Mean BMI
Cicekci et al., 2019²⁷	Sao Paulo Med J	6.0	Single-shot ACB	39	29	69.1	32.5
Cicekci et al., 2019²⁷	Sao Paulo Med J	6.0	PAI	40	30	68.5	32
Grosso et al., 2018³⁵	J Bone Joint Surg Am	3.0	Single-shot ACB	53	40	69	30.2
Grosso et al., 2018³⁵	J Bone Joint Surg Am	3.0	PAI	51	38	73	29.8
Kulkarni et al., 2019³⁶	J Arthroplasty	0.1	Single-shot ACB	50	38	67.4
Kulkarni et al., 2019³⁶	J Arthroplasty	0.1	PAI	50	38	67.7

3.4

3.4 Baseline comparability

Baseline comparability was evidenced in the mean length of follow-up, mean age, mean BMI, and female/male ratio (Table 2).

Table 2 Baseline comparability.

Endpoint	PAI (N = 141)	Single-shot ACB (N = 142)	P
Women	75.2% (106 of 141)	75.4% (107 of 142)	0.9
Mean follow-up (weeks)	2.8 ± 2.3	2.8 ± 2.3	0.5
Mean age	69.8 ± 2.4	68.5 ± 0.8	0.3
Mean-BMI	30.8 ± 1.1	31.2 ± 1.1	0.8

3.5

3.5 Hospitalisation

No difference was found in the length of the hospitalisation (MD 0.35; 95%CI -0.02 to 0.72; P = 0.06, Fig. 3).

Meta-analyses of the outcome: hospitalisation.

3.6

3.6 Visual analogue scale

No difference was found in VAS at POD0 (MD 0.09; 95%CI -1.45 to 1.62; P = 0.9), POD1 (MD -0.78; 95%CI -1.77 to 0.21; P = 0.1), and POD2 (MD -0.26; 95%CI -1.05 to 0.53; P = 0.5). The forest plots are reported in Fig. 4.

4 Discussion

The present meta-analysis found no difference in pain control and hospitalisation length between single-shot ACB and PAI in TKA. Both techniques have advantages, yet they appear similarly efficient for TKA postoperative pain management. Therefore, surgeons may choose either approach without altering patient comfort, recovery, or hospital stay. Obviously, when selecting one method over the other, consideration should be given to the fact that most surgeons are able to administer PAI, while ACB may require a specialised trained anaesthetist and the use of an ultrasound machine.

Despite not being statistically significant, some differences have been reported in postoperative pain levels and use of opioids in the included articles and relevant literature. Cicekci et al.,²⁷ in a RCT, analysed 79 patients (aged 40-85) dividing them into two groups (APC and PAI) and measured pain levels using VAS, morphine consumption, knee ROM, and 100-foot walking time. The authors found a better analgesia of the ACB with levobupivacaine in the first two postoperative days compared to PAI through an examination with VAS at rest and during the rehabilitation.²⁷ On the other hand, Kulkarni et al.,³⁶ in a single-blinded RCT with 100 patients, observed better pain control with PAI rather than ACB at 6, 12, and 24 h after surgery. The authors attributed the results to PAI targeting zones less accessible to ACB, such as posterior structures. However, the use of adjuvant drugs in PAI (such as epinephrine and ketorolac) may have impacted this result.³⁶

Grosso et al.³⁵ conducted an RCT with 155 patients divided into three groups (ACB, PAI, ACB + PAI) and reported that combining both techniques may be more efficient. They suggest this result may be attributed to the methods jointly targeting different pain pathways ^37–39.

Some researchers also support a lower necessity of opioids for the patients treated with PAI ³⁹^,⁴⁰. Indeed, Grosso et al.³⁵ observed a substantially higher opioid use in the ACB group compared to the PAI and ACB + PAI groups, especially on postoperative days two and three, indicating that PAI (whether used alone or in combination with ACB) may reduce the need for opioids ³⁹^,⁴⁰. Conversely, Cicekci et al.²⁷ detected a reduction in total morphine consumption in the ACB group compared to PAI patients. However, this decrease in opioid consumption was less noticeable than in studies that combined ACB and PAI, supporting that multimodal analgesia may be more effective ^37–40.

The present study has found no relevant differences in hospitalisation length or pain levels in PAI and ACB patients. Therefore, ROM and rehabilitation would be expected to be comparable.⁴¹ However, Cicekci et al.²⁷ found that PAI was associated with greater knee ROM during the first week after surgery, likely from less motor impairment compared to nerve blocks, facilitating better extension, flexion, and earlier ambulation ⁴²^,⁴³. Other researchers reported similar knee ROM three weeks after surgery, suggesting that early functional differences equalise as recovery progresses.³⁵ Therefore, choosing one method over the other may marginally impact early mobility but does not affect long-term rehabilitation²⁷ .⁴³ In contrast, Kulkarni et al.³⁶ showed lower VAS scores and faster recovery of mobility in patients treated with PAI, similar to other studies.⁴³ However, using numerous injections to specific areas may have enhanced the pain relief in unreachable zones via ACB.⁴⁴

The present analysis has reported no significant differences in the overall length of hospitalisation between ACB and PAI groups, but there are some variations among the studies. Grosso et al.³⁵ reported a trend towards a shorter stay in patients who underwent ACB + PAI compared to ACB alone, possibly from better pain control and reduced opioid need. The analysed studies did not report any adverse event or considerable complication associated with ACB or PAI. In the study of Kulkarni et al.,³⁶ the ACB group reported a marginally higher drop in haemoglobin levels after surgery. Ultrasound-guided injections improve reliability in these procedures as they may prevent complications ⁴⁵^,⁴⁶. Notable variations in the drugs and methodologies across the studies can justify the heterogeneity of the results. The volume and concentration of the anaesthetic used varied largely among the studies. For ACB, Cicekci et al.²⁷ have used 20 ml of 0.25% levobupivacaine. In comparison, Grosso et al.³⁵ used 15 ml of 0.5% bupivacaine, and Kulkarni et al.³⁶ used a solution with 30 mL of 0.5% ropivacaine and 100 mcg of clonidine. On the other hand, for PAI, the latter authors used a solution containing ropivacaine, ketorolac, adrenaline, clonidine, and normal saline according to the weight of the patient; Grosso et al.³⁵ used 50 mL of 0.25% bupivacaine, while Cicekci et al.²⁷ used 40 ml (0.125 mg) of levobupivacaine. The rationale for including adrenaline in the injection was to increase the analgesia through vasoconstriction, which may limit the absorption of anaesthetics⁴⁷ ^48–50.

This meta-analysis has several limitations. First, the sample size cannot capture crucial variabilities across different populations. Furthermore, the effectiveness of each technique and the accuracy of the findings in the included studies may be influenced by differences in patient demographics (such as age, sex, and BMI) and variations in comorbidities, used drugs, surgical approaches, and rehabilitation protocols. Larger, heterogeneous populations and standardised protocols are necessary to explore the analgesic strategies further and reinforce the results reported in this study. Future research should focus on extended follow-up periods, short and long-term functional recovery, and reliability. An improved comprehension of analgesic techniques can optimise pain management following TKA, thus obtaining early knee mobilisation and optimal rehabilitation and improving patient satisfaction.

5 Conclusion

No difference was found in pain control and hospitalisation length between single-shot ACB and PAI following TKA.

Ethical approval

This study complies with ethical standards.

Registration and protocol

The present study was not registered.

CRediT author statement

Filippo Migliorini: Conceptualization; Methodology; Formal analysis; Writing – original draft.JE: Supervision; Writing – review & editing; Validation; Data curation; Investigation (literature search; risk of bias assessment; data extraction).TB: Data curation; Investigation (literature search; risk of bias assessment; data extraction).RV: Writing – original draft.LL: Writing – original draft.NM: Writing – original draft.All authors read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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No difference in pain control and hospitalisation length between single-shot adductor canal block and periarticular injections following total knee arthroplasty: a meta-analysis

Abstract