{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,3]],"date-time":"2026-11-03T21:19:30Z","timestamp":1793740770594,"version":"4.6.1"},"reference-count":44,"publisher":"BMJ","issue":"8","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"accepted":{"date-parts":[[2021,4,14]]},"published-print":{"date-parts":[[2021,8]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>When combined with adductor canal block (ACB), local anesthetic infiltration between popliteal artery and capsule of knee (iPACK) is purported to improve pain following total knee arthroplasty (TKA). However, the analgesic benefits of adding iPACK to ACB in the setting of surgeon-administered periarticular local infiltration analgesia (LIA) are unclear.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To evaluate the analgesic benefits of adding iPACK to ACB, compared with ACB alone, in the setting of LIA following TKA.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Evidence review<\/jats:title>\n                    <jats:p>We conducted a meta-analysis of randomized trials comparing the effects of adding iPACK block to ACB versus ACB alone on pain severity at 6\u2009hours postoperatively in adult patients undergoing TKA. We a priori planned to stratify analysis for use of LIA. Opioid consumption at 24\u2009hours, functional recovery, and iPACK-related complications were secondary outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>\n                      Fourteen trials (1044 patients) were analyzed. For the primary outcome comparison in the\n                      <jats:italic>presence<\/jats:italic>\n                      of LIA (four trials, 273 patients), adding iPACK to ACB did not improve postoperative pain at 6\u2009hours. However, in the\n                      <jats:italic>absence<\/jats:italic>\n                      of LIA (eight trials, 631 patients), adding iPACK to ACB reduced pain by a weighted mean difference (WMD) (95% CI) of \u22121.33\u2009cm (\u22121.57 to \u20131.09) (p&lt;0.00001). For the secondary outcome comparisons in the\n                      <jats:italic>presence<\/jats:italic>\n                      of LIA, adding iPACK to ACB did not improve postoperative pain at all other time points, opioid consumption or functional recovery. In contrast, in the\n                      <jats:italic>absence<\/jats:italic>\n                      of LIA, adding iPACK to ACB reduced pain at 12\u2009hours, and 24\u2009hours by a WMD (95%\u2009CI) of \u22120.98 (\u22121.79 to \u20130.17) (p\n                      <jats:italic>=<\/jats:italic>\n                      0.02) and \u22120.69 (\u22121.18 to \u20130.20) (p=0.006), respectively, when compared with ACB alone, but did not reduce opioid consumption. Functional recovery was also improved by a log(odds ratio) (95% CI) of 1.28 (0.45 to 2.11) (p=0.003). No iPACK-related complications were reported.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Adding iPACK to ACB in the setting of periarticular LIA does not improve analgesic outcomes following TKA. In the absence of LIA, adding iPACK to ACB reduces pain up to 24\u2009hours and enhances functional recovery. Our findings do not support the addition of iPACK to ACB when LIA is routinely administered.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/rapm-2021-102705","type":"journal-article","created":{"date-parts":[[2021,5,14]],"date-time":"2021-05-14T11:19:12Z","timestamp":1620991152000},"page":"713-721","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":82,"title":["Does the addition of iPACK to adductor canal block in the presence or absence of periarticular local anesthetic infiltration improve analgesic and functional outcomes following total knee arthroplasty? A systematic review and meta-analysis"],"prefix":"10.1136","volume":"46","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0353-1002","authenticated-orcid":false,"given":"Nasir","family":"Hussain","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7708-8843","authenticated-orcid":false,"given":"Richard","family":"Brull","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Toronto Western Hospital, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brendan","family":"Sheehy","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Dasu","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tristan","family":"Weaver","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2435-6186","authenticated-orcid":false,"given":"Faraj W","family":"Abdallah","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Anesthesia, University of Ottawa, Ottawa, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2021,5,14]]},"reference":[{"key":"2025101109214530000_46.8.713.1","doi-asserted-by":"crossref","first-page":"2277","DOI":"10.1111\/pme.12751","article-title":"The incidence and severity of postoperative pain following inpatient surgery","volume":"16","author":"Buvanendran","year":"2015","journal-title":"Pain Med"},{"key":"2025101109214530000_46.8.713.2","doi-asserted-by":"crossref","first-page":"1049","DOI":"10.1093\/pm\/pnz355","article-title":"Aaapt diagnostic criteria for acute knee arthroplasty pain","volume":"21","author":"Abdallah","year":"2020","journal-title":"Pain Med"},{"key":"2025101109214530000_46.8.713.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.arth.2014.06.010"},{"key":"2025101109214530000_46.8.713.4","doi-asserted-by":"publisher","DOI":"10.1093\/bja\/aer255"},{"key":"2025101109214530000_46.8.713.5","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.N.00642"},{"key":"2025101109214530000_46.8.713.6","doi-asserted-by":"publisher","DOI":"10.1213\/ANE.0b013e3182536193"},{"key":"2025101109214530000_46.8.713.7","doi-asserted-by":"crossref","first-page":"1271","DOI":"10.1007\/s12630-020-01652-1","article-title":"The safety and efficacy of the IPACK block in primary total knee arthroplasty: a retrospective chart review","volume":"67","author":"Biehl","year":"2020","journal-title":"Can J Anaesth"},{"key":"2025101109214530000_46.8.713.8","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-2020-101558"},{"key":"2025101109214530000_46.8.713.9","doi-asserted-by":"crossref","first-page":"3554","DOI":"10.1016\/j.arth.2020.06.060","article-title":"Efficacy of adductor canal block combined with additional analgesic methods for postoperative analgesia in total knee arthroplasty: a prospective, double-blind, randomized controlled study","volume":"35","author":"Li","year":"2020","journal-title":"J Arthroplasty"},{"key":"2025101109214530000_46.8.713.10","doi-asserted-by":"crossref","first-page":"S173","DOI":"10.1016\/j.arth.2020.01.014","article-title":"The effect of the ipack block on pain after primary tka: a double-blinded, prospective, randomized trial","volume":"35","author":"Patterson","year":"2020","journal-title":"J Arthroplasty"},{"key":"2025101109214530000_46.8.713.11","article-title":"Continuous adductor canal block is superior to adductor canal block alone or adductor canal block combined with IPACK block (interspace between the popliteal artery and the posterior capsule of knee) in postoperative analgesia and ambulation following total knee arthroplasty: randomized control trial","author":"Tak","year":"2020","journal-title":"Musculoskelet Surg"},{"key":"2025101109214530000_46.8.713.12","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-2020-101396"},{"key":"2025101109214530000_46.8.713.13","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2009.06.005"},{"key":"2025101109214530000_46.8.713.14","first-page":"950","article-title":"Application of ultrasound-guided adductor canal block combined with ipack in total knee arthroplasty for the elderly patients","volume":"36","author":"Ling","year":"2020","journal-title":"The Journal of Practical Medicine"},{"key":"2025101109214530000_46.8.713.15","unstructured":"Zadoroznijs S . Ipack (interspace between the popliteal artery and the capsule of the posterior knee) block efficiency as aid for acb (adductor canal block) in postoperative analgesia after total knee arthroplasty (pilot study). German clinical trials register, DRKS00019069: drks.de."},{"key":"2025101109214530000_46.8.713.16","first-page":"730","article-title":"Adductor canal block combined with ipack block after total knee arthroplasty: a randomized controlled trial","volume":"9","author":"Wang","year":"2020","journal-title":"Chinese Journal of Bone and Joint"},{"key":"2025101109214530000_46.8.713.17","first-page":"1004","article-title":"The effect of ultrasound-guided adductor block combined with ipack block combined general anesthesia in analgesia after total knee arthroplasty","volume":"25","author":"Zhou","year":"2020","journal-title":"Zhejiang Journal of Traumatic Surgery"},{"key":"2025101109214530000_46.8.713.18","unstructured":"Chia P , Wang K , Grogan T . Ipack block has no additional benefit to patients who receive an adductor canal catheter and intraarticular injection for tka. San Francisco, CA: ASRA 45th Annual Regional Anesthesiology & Acute Pain Medicine Meeting, 2020."},{"key":"2025101109214530000_46.8.713.19","first-page":"47","article-title":"Comparing continuous adductor canal block alone, with combined continuous adductor canal block with ipack in terms of early recovery and ambulation in patients undergoing unilateral total knee replacement - a prospective randomized double blinded study","volume":"7","author":"Vijay","year":"2020","journal-title":"Journal of Evidenced Based Medicine"},{"key":"2025101109214530000_46.8.713.20","doi-asserted-by":"crossref","unstructured":"Amin M , Abotaleb U . Value of IPACK block (interspace between the popliteal artery and the capsule of the posterior knee) with adductor canal block in total knee arthroplasty. 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The Cochrane collaboration 2011."},{"key":"2025101109214530000_46.8.713.25","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2005.06.006"},{"key":"2025101109214530000_46.8.713.26","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2288-14-135"},{"key":"2025101109214530000_46.8.713.27","doi-asserted-by":"publisher","DOI":"10.1037\/1082-989X.8.4.448"},{"key":"2025101109214530000_46.8.713.28","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.k4817"},{"key":"2025101109214530000_46.8.713.29","doi-asserted-by":"publisher","DOI":"10.1016\/0197-2456(86)90046-2"},{"key":"2025101109214530000_46.8.713.30","doi-asserted-by":"publisher","DOI":"10.2307\/4615733"},{"key":"2025101109214530000_46.8.713.31","doi-asserted-by":"publisher","DOI":"10.1179\/106698108790818512"},{"key":"2025101109214530000_46.8.713.32","doi-asserted-by":"publisher","DOI":"10.1093\/bja\/aew466"},{"key":"2025101109214530000_46.8.713.33","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.315.7109.629"},{"key":"2025101109214530000_46.8.713.34","doi-asserted-by":"crossref","unstructured":"Amer N . Combined adductor canal and i-PAK blocks is better than combined adductor canal and periarticular injection blocks for painless ACL reconstruction surgery. JACCOA 2018;10.doi:10.15406\/jaccoa.2018.10.00381","DOI":"10.15406\/jaccoa.2018.10.00381"},{"key":"2025101109214530000_46.8.713.35","article-title":"Comparison of analgesic effect of adductor block combined with iPACK and periarticular injection after total knee arthroplasty","author":"Fan","year":"2020","journal-title":"Minerva Med"},{"key":"2025101109214530000_46.8.713.36","doi-asserted-by":"crossref","DOI":"10.1016\/j.arth.2020.06.086","article-title":"Adductor canal block combined with ipack (interspace between the popliteal artery and the capsule of the posterior knee) block vs periarticular injection for analgesia after total knee arthroplasty: a randomized noninferiority trial","volume":"36","author":"Kertkiatkachorn","year":"2021","journal-title":"J Arthroplasty"},{"key":"2025101109214530000_46.8.713.37","article-title":"Decreased opioid consumption and length of stay using an ipack and adductor canal nerve block following total knee arthroplasty","author":"Eccles","year":"2019","journal-title":"J Knee Surg"},{"key":"2025101109214530000_46.8.713.38","doi-asserted-by":"crossref","first-page":"1391","DOI":"10.1007\/s00590-018-2218-7","article-title":"Comparison of adductor canal block and IPACK block (interspace between the popliteal artery and the capsule of the posterior knee) with adductor canal block alone after total knee arthroplasty: a prospective control trial on pain and knee function in immediate postoperative period","volume":"28","author":"Sankineani","year":"2018","journal-title":"Eur J Orthop Surg Traumatol"},{"key":"2025101109214530000_46.8.713.39","doi-asserted-by":"crossref","first-page":"127","DOI":"10.4103\/aer.AER_109_19","article-title":"Ultrasound-Guided adductor canal block versus combined adductor canal and infiltration between the popliteal artery and the posterior capsule of the knee block for osteoarthritis knee pain","volume":"14","author":"El-Emam","year":"2020","journal-title":"Anesth Essays Res"},{"key":"2025101109214530000_46.8.713.40","first-page":"1","article-title":"Comparison of adductor canal block and ipack block with adductor canal block alone for postoperative pain control in patients undergoing total knee arthroplasty","volume":"47","author":"Singtana","year":"2020","journal-title":"Thai Journal of Anesthesiology"},{"key":"2025101109214530000_46.8.713.41","unstructured":"Okunlola O , Lai Y , Hebbalasankatte PPB , et al . Addition of ipack block technique to adductor canal block and periarticular local infiltration for knee replacement surgery. ASRA 45th annual regional anesthesiology and acute pain medicine meeting, San Francisco, Ca."},{"key":"2025101109214530000_46.8.713.42","unstructured":"Regional anesthesia and pain medicine. Instructions for authors. Available: https:\/\/rapm.bmj.com\/pages\/authors\/ [Accessed 20 Mar 2021]."},{"key":"2025101109214530000_46.8.713.43","doi-asserted-by":"crossref","first-page":"221???226","DOI":"10.1097\/00003086-199404000-00034","article-title":"Innervation of the human knee joint and implications for surgery","author":"Horner","year":"1994","journal-title":"Clin Orthop Relat Res"},{"key":"2025101109214530000_46.8.713.44","first-page":"233","article-title":"Novel regional techniques for total knee arthroplasty promote reduced Hospital length of stay: an analysis of 106 patients","volume":"17","author":"Thobhani","year":"2017","journal-title":"Ochsner J"}],"container-title":["Regional Anesthesia &amp; Pain Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/rapm-2021-102705","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T16:21:58Z","timestamp":1760199718000},"score":1,"resource":{"primary":{"URL":"https:\/\/rapm.bmj.com\/lookup\/doi\/10.1136\/rapm-2021-102705"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,5,14]]},"references-count":44,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2021,7,20]]},"published-print":{"date-parts":[[2021,8]]}},"alternative-id":["10.1136\/rapm-2021-102705"],"URL":"https:\/\/doi.org\/10.1136\/rapm-2021-102705","relation":{},"ISSN":["1098-7339","1532-8651"],"issn-type":[{"value":"1098-7339","type":"print"},{"value":"1532-8651","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,5,14]]}}}