Table 2 The baseline characteristics

El-Emam2020

Egypt

N/A

IPACK + SACB

SACB

28

28

52 (15)

54 (13)

8 (28.57%)

9 (32.14%)

Hu2020

China

N/A

IPACK + SACB

SACB

40

40

74.7 (6.3)

73.9 (4.9)

N/A

N/A

Kim2019

America

2017.03–2017.10

IPACK + SACB + mPAI

PAI

43

43

68.3 (7)

67.1 (8.1)

23 (53.48%)

30 (69.77%)

Kertkiatkachorn2020

Thailand

2019.05–2019.11

IPACK + SACB + CACB

CACB + PAI

38

38

70.6 (6.9)

68.7 (8.5)

29 (85.29%)

29 (82.85%)

Kampitak2020(Comparison A)

Thailand

2018.02–2019.01

Proximal IPACK + CACB

TNB + CACB

33

32

68.6 (6.1)

68.8 (6.5)

28 (84.84%)

28 (87.5%)

Kampitak2020(Comparison B)

Thailand

2018.02–2019.01

Distal IPACK + CACB

TNB + CACB

33

32

69.9 (6.6)

68.8 (6.5)

27 (81.8%)

28 (87.5%)

Li2019

China

2017.11–2018.04

IPACK + SACB

SACB

30

30

66 (6)

69 (6)

21 (70%)

16 (53.33%)

Li2020(Comparison A)

China

2018.05–2019.04

IPACK + SACB + LFCNB

SACB + LFCNB

50

50

66.26 (4.69)

66.40 (6.42)

33 (66%)

32 (64%)

Li2020(Comparison B)

China

2018.05–2019.04

IPACK + SACB

SACB

50

50

66.82 (6.17)

65.56 (6.34)

40 (80%)

31 (62%)

Ochroch2020

America

2018.11–2019.07

IPACK + CACB

CACB

60

59

67.7 (7.8)

65.6 (8.2)

34 (57%)

35 (60%)

Patterson2020

America

2016.11–2018.01

IPACK + CACB

CACB

35

34

67 (3.511)

68 (3.476)

21 (60%)

21 (62%)

Sankineani2018

India

2016.09–2017.03

IPACK + SACB

SACB

60

60

60

61

38 (63.33%)

42 (70%)

Tak2020(Comparison A)

India

2019.03–2019.06

IPACK + SACB

CACB

56

57

65.5

63.3

29 (51.8%)

38 (66.7%)

Tak2020(Comparison B)

India

2019.03–2019.06

IPACK + SACB

SACB

56

57

65.5

64.1

29 (51.8%)

37 (63.8%)

Vichainarong2020

Thailand

2018.07–2019.05

IPACK + CACB + LIA

CACB + LIA

33

32

70.7 (8.2)

68.7 (7.9)

29 (87.87%)

27 (84.37%)

Zheng2020

China

N/A

IPACK + SACB

FNB + SNB

30

30

62 (6)

61 (7)

21 (63.64%)

20 (66.66%)

El-Emam2020

Egypt

N/A

8 (28.57%)

9 (32.14%)

29.1 (2.7)

28.5 (3)

Age > 45 years; ASA I–III; Be competent to understand the study protocol; Radiographic evidence of OA (> Grade II); Chronic pain for at least 6 months; Conservative therapies were useless during the last 6 months;

Patient refusal; Bleeding or coagulation disorders; Local skin infection or any other medical problem in the affected limb; Psychiatric problems lead to difficult communication with the patients; Previous chronic opioid use; Contraindications to steroid injection as diabetes or hypertension

Combined SACB and IPACK block provide more effective analgesia and better functional outcomes compared to the SACB alone

Hu2020

China

N/A

N/A

N/A

21.2 (1.9)

20 (4.2)

Age between 65 to 89; ASA I-III; BMI18.5–23.7 kg/m²; Selective unilateral primary TKA;

Severe cardiovascular disease; Severe pulmonary dysfunction; Diseases of the central nervous system; Fail to communicate and cooperate; Coagulation disorders; Puncture site infection; Allergic to local anesthetic drugs;

IPACK group decreased postoperative remedial analgesia and the use of vasoactive drugs, but the postoperative VAS scores are similar after 24 h and 48 h; Ultra-guided IPACK and ACB are safe and effective in old patients with primary TKA;

Kim2019

America

2017.03–2017.10

23 (53.48%)

30 (69.77%)

28.3 (4.1)

29.9 (4.8)

Patients with OA scheduled for primary unilateral TKA with a participating surgeon; Age 18–80 years old, planned use of regional anesthesia, able to follow study protocol, and English speaking;

Hepatic or renal insufficiency, age < 18 or > 80 years old, patients undergoing general anesthesia, allergy or intolerance to one of the study medications, BMI > 40, diabetes mellitus, ASA IV, chronic gabapentin or pregabalin use (regular use for > 3 months), chronic opioid use (taking opioids for > 3 months, or daily oral morphine equivalent of > 5 mg/d for 1 month), and patients with severe valgus deformity and flexion contracture

We conclude that the addition of IPACK and ACB to PAI for pain management in TKA patients improves postoperative pain, opioid consumption, and measures of pain-related patient satisfaction

Kertkiatkachorn2020

Thailand

2019.05–2019.11

29 (85.29%)

29 (82.85%)

27.2 (3.8)

28 (4.2)

Ages between 18 and 80 years; ASA I to III; Scheduled to undergo the first two elective TKAs of the day were screened for eligibility

Exclusion criteria were a varus-valgus deformity of > 20°, knee flexion deformity > 30°, known allergy to the drugs used in this trial, body mass index < 18 or > 40 kg/m2, contraindication for neuraxial or regional anesthesia, contraindication for NSAIDs, chronic opioid use (defined as a history of regular opioid use for more than 3 months or a history of oral morphine use equivalent of > 60 mg/month), failure to perform the Timed Up and Go test and, inability to communicate or unwilling to give informed consent

The combination of ACB and IPACK block provides noninferior analgesia compared with PAI when combined with CACB during part of postoperative multimodal analgesia regimens for patients undergoing TKA. However, the ACB + IPACK block may be associated with a higher level of opioid consumption and lower ambulatory ability on the day of surgery

Kampitak2020(Comparison A)

Thailand

2018.02–2019.01

28 (84.84%)

28 (87.5%)

27.6 (4.2)

28.6 (3.9)

Inclusion criteria were age > 18 years; ASA I–III; BMI:18–40 kg/m2

Exclusion criteria were inability to cooperate, allergy to any drug administered in this study, contraindications to neuraxial and/or regional anesthesia, lower limb neuropathy involving the operative site, intolerance to non-steroidal anti-inflammatory drugs, chronic opioid drug use (daily or almost daily use of opioid drugs for at least 3 months, or morphine use greater than or equal to 60 mg/day for at least 1 month, or diagnosis of neuropathic pain), and inability to perform the timed up- and- go (TUG) test

Distal IPACK block were better able to preserve the normal motor function of the common peroneal nerve and tibial nerve compared with those who received the proximal IPACK block or TNB;

Kampitak2020(Comparison B)

Thailand

2018.02–2019.01

27 (81.8%)

28 (87.5%)

26.3 (3.8)

28.6 (3.9)

See in Kampitak2020 (Comparison A)

See in Kampitak2020 (Comparison A)

See in Kampitak2020 (Comparison A)

Li2019

China

2017.11–2018.04

21 (70%)

16 (53.33%)

21.9 (2.2)

21.7 (2)

Primary unilateral TKA; Age between 55 to 78 years; ASA I-III;

Severe cardiovascular disease; Severe pulmonary dysfunction; Diseases of the central nervous system; Fail to communicate and cooperate; Coagulation disorders; Puncture site infection; Allergic to local anesthetic drugs;

IPACK plus SACB added to multimodal analgesic methods could provide satisfied effect

Li2020(Comparison A)

China

2018.05–2019.04

33 (66%)

32 (64%)

24.82 (2.58)

24.81 (3.15)

Aged between 50 and 80 years; BMI 19–30 kg/m2; ASA I-III; Scheduled to have primary unilateral TKA for osteoarthritis;

Exclusion criteria included the following: (1) knee flexion deformity ≥ 30°, varus-valgus deformity ≥ 30°, and inability to walk; (2) allergy to morphine or had a past history of opioid consumption; (3) had any contraindications to regional anesthesia, local infiltration, general anesthesia, and the drugs used in this study; (4) diagnosis of septic arthritis, rheumatic arthritis, traumatic arthritis, and other non-OA; and (5) patients with a medical history of psychiatric illness, cognitive impairment, recognized neuromuscular disorder, narcotic dependency, knee infection, knee surgery, or thromboembolic event including myocardial infarction, cerebrovascular accident, deep vein thrombosis, and pulmonary embolus. Additionally, patients with a language barrier, or those who refused to sign informed consent, were also excluded

ACB with IPACK block and LFCNB may decrease the early postoperative pain scores and prolong analgesic duration following TKA. Compared to ACB with IPACK, ACB with LFCNB, or ACB alone, this method produced optimal outcomes without increased complications

Li2020(Comparison B)

China

2018.05–2019.04

40 (80%)

31 (62%)

24.68 (2.60)

24.97 (3.18)

see in Li (Comparison A)

see in Li (Comparison A)

see in Li (Comparison A)

Ochroch2020

America

2018.11–2019.07

34 (57%)

35 (60%)

31.9 (6.4)

31.3 (7.0)

Patients with ASA I-III undergoing primary TKA; Age 18–80 years;

Patients were excluded from the study if they had an allergy to any of the study medications, BMI > 45, coagulopathy, chronic kidney disease or recent chronic opioid therapy, defined as the use of regular daily doses of systemic opioids for the past 3 months prior to the surgery. Revision knee replacement procedures were also excluded

IPACK block reduced the incidence of posterior knee pain 6 h postoperatively. Given the relative ease and safety profile, it may have a potential role as part of the multimodal analgesia after knee arthroplasty, particularly as a distinct alternative to sciatic nerve blockade that does not affect motor function. The IPACK block can also be considered as a more consistent and reproducible alternative to surgical PAI of the posterior capsule of the knee, but more studies are needed

Patterson2020

America

2016.11–2018.01

21 (60%)

21 (62%)

31 (1.732)

30 (1.450)

Eligible patients with elective unilateral, primary TKA; Age > 18 years old; English speaking; ASAI-III

Exclusion criteria were contraindication to regional anesthesia or peripheral nerve blocks, allergy to local anesthetics, nonsteroidal anti-inflammatory drugs (NSAIDs), chronic renal insufficiency (Cr > 1.4 mg/dL or glomerular filtration rate < 60 mL/min), chronic pain not related to the knee joint, chronic opiate consumption (daily or almost daily use for ≥ 3 months), pre-existing peripheral neuropathy involving the operative site, and body mass index > 40 kg/m2

IPACK and CACB improved pain scores in the immediate postoperative period but otherwise provided no additional benefit in pain scores, opioid consumption, physical therapy performance, the frequency of opioid-related side effects, and hospital length of stay were not affected by the addition of the IPACK. Therefore, IPACK and CACB may not provide a significant clinical benefit in TKA patients

Sankineani2018

India

2016.09–2017.03

38 (63.33%)

42 (70%)

29.36

28.88

N/A

Patients undergoing bilateral or revision total knee replacement, with history of bleeding diathesis or prior vascular surgery on femoral vessels on operated site, severe renal insufficiency, history of arrhythmia or seizures, sepsis, preexisting lower extremity neurological abnormality and difficulties in comprehending visual analog scale (VAS) pain scores, were excluded from the study

ACB + IPACK is a promising technique that offers improved pain management in the immediate postoperative period without affecting the motor function around the knee joint resulting in better ROM and ambulation compared to ACB alone

Tak2020(Comparison A)

India

2019.03–2019.06

29 (51.8%)

38 (66.7%)

26

26

Unilateral tricompartmental TKA for primary OA; Age 45–80 years; ASA I–III

Exclusion criteria included patients who underwent bilateral or revision TKA, knee flexion deformity of ≥ 30°, varus–valgus deformity of ≥ 30°, arthritis due to rheumatoid disease or trauma or septic arthritis, creatinine > 1.2, renal or hepatic dysfunction, known allergy to any study medication, chronic opioid use, BMI > 40, chronic pain unrelated to knee joint, pre-existing neuropathy, arrhythmia, epilepsy, had a history of bleeding diathesis or prior vascular surgery on femoral vessels on operated site and difficulty in comprehending VAS pain scores

CACB provides better pain control, decreased opioid consumption and superior ambulation capacity in the immediate postoperative period compared to SACB + IPACK without any significant adverse side effects

Tak2020(Comparison B)

India

2019.03–2019.06

29 (51.8%)

37 (63.8%)

26

26.6

See in TAK (comparison A)

See in TAK (comparison A)

This study also concludes that the addition technique of IPACK to SACB may not add any additional benefit in postoperative pain control, ambulation, opioid consumption or rehabilitation compared to SACB alone

Vichainarong2020

Thailand

2018.07–2019.05

29 (87.87%)

27 (84.37%)

27 (4.4)

28.2 (4.2)

Adult patients with ASA I–III scheduled for elective primary TKA using standard spinal anesthesia

Age < 18 or > 80 years; BMI > 40 kg/m²; inability to provide informed consent; cognitive or psychiatric history that may interfere with assessment; a varus-valgus knee deformity > 20°; knee flexion deformity > 30°; contraindication for spinal anesthesia or peripheral nerve block; allergy or intolerance to local anesthetic drugs or any component of the multimodal analgesic regimen; pre-existing chronic pain or opioid drug use (daily or almost daily use of opioid drugs for ≥ 3 months or morphine use ≥ 60 mg/day for ≥ 1 month); Pre-existing neuropathy or neurological deficit in the lower extremities

The addition of an IPACK block to the LIA and CACB does not reduce the postoperative opioid consumption nor improve analgesia. However, it may improve immediate functional performance and reduce the length of hospitalization after TKA

Zheng2020

China

N/A

21 (63.64%)

20 (66.66%)

27.1 (3.4)

26.7 (2.7)

Age between 18 to 65 years; BMI between 18–24 kg/m²; ASA I or II;

Infection diseases; Nerve damage on operation side; Coagulation dysfunction; Liver or kidney diseases; Analgesic allergy; mental disfunction

IPACK and SACB could help improve the postoperative function recovery