Efficacy and limitations of peripheral nerve blocks in orthopaedic surgery. A systematic review of clinical implications and drawbacks

 

Nº de DOI: 10.34896/RSI.2026.42.20.001

 

 

AUTHORS

1. Valeria Valentina Satama Andrade. General Practitioner. Affiliated with Centro de Salud Casa Cuna Gangotena Posse. Graduate of Universidad Nacional de Loja. Based in Quito, Ecuador. https://orcid.org/0009-0003-0213-8492
2. Idelis Díaz Méndez. General Practitioner. Affiliated with Puesto de Salud Chalguayacu. Graduate of Universidad de Ciencias Médicas de Holguín. Based in Ibarra, Ecuador. https://orcid.org/0009-0000-2142-7458
3. Doménica Katherine Maya Venegas. General Practitioner with a Master’s Degree in Health Management. Affiliated with private healthcare institutions in Ecuador. Graduate of Universidad Técnica del Norte. Based in Andrade Marín, Ecuador. https://orcid.org/0000-0002-9140-796X
4. Jennifer Dayanara Tiban Changoluisa. General Practitioner. Affiliated with Clínica Pazmiño Narváez. Graduate of Universidad UTE. Based in Quito, Ecuador. https://orcid.org/0009-0006-3849-1492
5. Nadya Gabriela Patiño Realpe. General Practitioner with a Master’s Degree in Public Health, with a concentration in Comprehensive Emergency and Urgent Care. Affiliated with Hospital Delfina Torres de Concha. Graduate of Escuela Superior Politécnica de Chimborazo. Based in Esmeraldas, Ecuador. https://orcid.org/0009-0001-0836-973X

ABSTRACT

The role of new technologies, artificial intelligence and new block techniques, such as the popliteal plexus block, will also be considered in developing regional anesthesia. Nonetheless, we can determine that PNBs provide significant improvements in quality of recovery; however, efficacy is dependent on patient selection, anatomical area accuracy, and its role as a multimodal component.

KEY WORDS

Peripheral nerve block, orthopaedic surgery, regional anesthesia, analgesia, opioid-sparing.

RESUMEN

Se analizará el papel de las nuevas tecnologías, la inteligencia artificial y las nuevas técnicas de bloqueo como el bloqueo del plexo poplíteo en el desarrollo de la anestesia regional. No obstante, cabe señalar que los bloqueos de nervios periféricos (BNP) aportan mejoras significativas en la calidad de la recuperación; sin embargo, su eficacia depende de la selección del paciente, la precisión anatómica y su función como componente de un enfoque multimodal.

PALABRAS CLAVE

Bloqueo de nervio periférico, cirugía ortopédica, anestesia regional, analgesia, ahorro de opioides.

INTRODUCTION

The field of orthopaedic perioperative care has undoubtedly changed over the last few years due to Enhanced Recovery After Surgery (ERAS) protocols, which utilize multimodal analgesia to achieve improved outcomes for patients. Peripheral nerve blocks (PNBs) have become a key part of these protocols, and initiate the analgesic effect with specific pain control options and minimal systemic side effects with the use of traditional opioid-based regimens. This systematic review will assess clinical efficacy and the unavoidable limitations of PNBs in orthopaedic surgery, assessing the most current evidence gathered from clinical trials and meta-anlyses. The uptakes noted in the review include greater analgesic control in the early postoperative period, considerable reduction in opioid analgesia, and optimization of early mobilization in rehabilitation. Yet, the use of PNBs is not without complications. Technical challenges, risk of inadequate blockade, and neurological complications require high levels of skill and specific imaging. In addition, the «motor block paradox» warrants consideration, where the use of PNBs provides analgesia at the cost of muscle strength; this is particularly concerning with procedures on the lower extremity; where the risk of falls may be concerning after surgery.

OBJECTIVE

The main objective of this study is to conduct a comprehensive systematic review of the efficacy and limitations of peripheral nerve blocks (PNBs) in orthopaedic surgery.

METHODOLOGY

A systematic search of the literature published from 1980–2024 was conducted to identify relevant articles, with an emphasis on studies containing high-quality evidence from the past ten years. The search strategy was broad to include the full range of peripheral nerve blocks employed in the field of orthopaedic surgery. Major electronic databases were utilized, specifically MEDLINE (via PubMed), EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science. These databases are recognized as main repositories for clinical research and bibliometric data related to pain management³.

For the search terms, we included a combination of MeSH terms and keywords including «peripheral nerve block,» «orthopaedic surgery,» «regional anesthesia,» «analgesia,» «opioid-sparing,» «postoperative outcomes,» «total knee arthroplasty,» «total hip arthroplasty,» and «complications,» and the search was refined through the Boolean operators (AND, OR). To be comprehensive, we also screened the references of included studies and systematic reviews related to PNBs. The search was not limited by language, although priority was given to published articles in English and those that employed methods that we would consider to be high-quality.

The selection process was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The studies were included if they met the following criteria:

1. Type of Study: RCT, systematic review, meta-analysis, and large-scale prospective cohort study.
2. Population: Patients of any age undergoing some orthopaedic surgical procedure (e.g., arthroplasty, fracture repair, ligament reconstruction).
3. Intervention: A single-shot or continuous peripheral nerve block used as a primary or adjuvant analgesic technique.
4. Outcomes: Any study reporting at least one of the following outcomes: any pain score (VAS/NRS), opioids consumption, the hospital length of stay, any functional recovery outcome (i.e., range of motion, mobilization time), or any adverse event (nerve injury, falls, LAST).

We excluded studies that focused solely on neuraxial anesthesia (spinal/epidural) and did not have a PNB component, as well as case reports, letters to the editor, and those with inadequate data or poorly defined methodology. Titles and abstracts were screened by two independent reviewers, followed by full-text reviews of articles that were potentially relevant. Any discrepancies were resolved by consensus or by consulting a third, senior reviewer.

RESULTS

Orthopaedic surgery is synonymous with a high risk of postoperative pain, and if not managed appropriately, has the potential to limit recovery, prolong hospital length of stay, and develop chronic pain syndromes. Traditionally, the management of pain after orthopaedic procedures primarily relied on systemic opioids. The opioid crisis that has developed globally, in addition to well-known and documented effects associated with opioids, including respiratory depression, postoperative ileus, and cognitive impairment, has led to an effort to rethink and develop opioid-sparing techniques¹. Enhanced Recovery After Surgery (ERAS) protocols have been developed as a result, with a greater emphasis on a multidiscplinary plan, which brings together a diverse range of analgesic approaches, to target different pathways of the pain response².

In this setting, peripheral nerve blocks (PNbs) have emerged as a primary modality for these multimodal platforms. With the application of local anesthetics in close proximity to a specific nerve, or plexus, nerve blocks provide dense localized analgesia, acting as a means to effectively «turn off» nociceptive signaling from the surgical site. The changes in regional anesthesia have led to developments in block techniques that have transitioned from landmark techniques to ultrasound. The use of ultrasound techniques have led to both increased efficacy and safety. Recent bibliometric analyses have noted a significant increase in research within the topic area of PNBs, appropriately emphasizing their growing relevance in modern pain management³.

Even with their related advantages, a number of factors limit the benefits of PNBs. First, the duration of a single-shot block may not last long enough to cover the entire period of peak pain leading to «rebound pain» during the waning of the block. Additionally, the potential for motor blockade can place early physical therapy, which is especially an important part of recovery after total knee and hip arthroplasty, at risk. The safety of PNBs is generally good, but can be complicated by rare, albeit serious, events, such as local anesthetic systemic toxicity (LAST) and iatrogenic nerve injury⁴.

This systematic review aims to share a thorough exploration of the existing literature related to PNBs in the context of orthopaedic surgery. We will discuss the analgesic and functional benefits of different blocking techniques, identify related technical and safety limitations, and illustrate how the efficacy of PNBs is being optimized through technology and better surgical pathways.

Clinical Benefits of Peripheral Nerve Blocks:

Superior Analgesic Efficacy and Opioid-Sparing Effects:

The most consistently reported benefit of peripheral nerve blocks is the ability to provide high-quality analgesia in the immediate postoperative period. By blocking nociceptive impulses from the surgical site to the central nervous system, PNBs effectively stabilize the patient’s pain experience during the important 0-24 hour window⁵. This is particularly evident in more painful procedures such as total knee arthroplasty (TKA) or major shoulder surgery, where pain levels are often severe.

The opioid-sparing effect of PNBs is an essential pillar in modern perioperative care. By reducing the need for systemic narcotics, PNBs decrease the incidence of PONV, ileus, respiratory depression, which are substantial drivers of postoperative morbidity⁶. In pediatric population, where the potential neurotoxicity of general anesthetics raises concern, the use of regional techniques under USG decreases both the depth of general anesthesia and total dose of opioids administered⁸. For example, in elbow fracture surgery in the pediatric population, the application of a supraclavicular brachial plexus block (SCB) greatly decreased the number of patients requiring rescue opioids and total milligrams of morphine equivalents in the first 24 hours postoperatively¹².

PNBs extend beyond the simple reduction in the quantity of medication; they also prevent hyperalgesia and mitigate the surgical stress response. By blunting sympathetic and endocrine reactions to tissue injury, PNBs may lead to improved glycemic control, and decrease the addition of cardiac instability in higher risk populations. However, this effect is short lived and generally is temporary for only the duration of the local anesthetic, producing the phenomenon of «rebound pain» as the block wears off. This necessitates the careful timing of multimodal oral medications to allow for a seamless transition to systemic analgesia.

Promotion of Early Postoperative Mobilization and Rehabilitation:

Early mobilization is a primary goal in orthopaedic surgery to avoid deep vein thrombosis (DVT), pulmonary embolism, and muscle atrophy. PNBs serve both purposes: they promote mobilization by providing effective analgesia, but may hinder mobilization due to the possibility of motor blockade². Accordingly, the recent research in regional anesthesia has shifted to the development of «motor-sparing» blocks targeting sensory nerves while preserving the function of muscles needed for ambulation.

In the field of TKA, the development of the adductor canal block (ACB) and the potential to replace the femoral nerve block (FNB) as a means to avoid weakness of the quadriceps muscle demonstrates this trend. While the FNB provides excellent analgesia, a common adverse effect is quadriceps weakness, which may delay physical therapy and create risk factors for fall. The ACB is a motor-sparing block that targets the saphenous nerve and the nerve to vastus medialis at mid-thigh, providing sensory blockade anteriorly to the knee while sparing motor function of the quadriceps¹⁰.

Likewise, the popliteal plexus block (PPB) has also been investigated for the purpose of preserving motor strength of the foot and ankle compared to distal techniques like tibial nerve block (TNB). One randomized trial demonstrated that the PPB was non-inferior to TNB in rate of achieving rehabilitation goals, like knee flexion angles greater than 90 degrees and ambulatory status, and preserved better strength of plantar and dorsal isometric contraction at 6 hours post-block¹³. Functional advantages are necessary for patients to be able to safely conduct exercises needed to prevent stiffness and ensure long term function of the joint.

Reduced Length of Hospital Stay and Healthcare Costs:

The economic impact of PNBs is significant, and driven primarily from the impact on length of stay (LOS) in the hospital. The improved pain control and earlier mobilization allows many orthopaedic procedures to move from inpatient to outpatient, or shorter-length of stay². This is valuable in a health care economic sense, as reducing the burden on hospital resources decreases the overall cost to the healthcare system, which directly relates to value-based care.

In some cohorts, the impact on LOS is particularly pronounced in certain patients. For example, data comparing ACB with local infiltration (LA) in TKA patients, found that while the median LOS was unchanged across the whole cohort, the younger ACB population under age of 55 was statistically reduced by one day from previous cohorts receiving LA¹⁰. This clearly indicates the importance of patient selection and contributes to the idea that regional anesthesia can facilitate a quick turnaround for younger, more active populations.

While socioeconomic impact is valued, the costs to the healthcare system must be weighed against the costs of equipment (ultrasound, catheters), equipment, and time the anesthesiologist takes to perform the procedure. While the initial investment is higher, the secondary savings from reduced complications from opioids, PACU length of stay, and readmissions for uncontrolled pain per surgical episode of care typically favor the use of regional techniques. There are exploratory studies investigating artificial intelligence (AI) for pain management to assist with treatment planning and delivery, which may also aid in the efficiency and cost-benefit of programs¹¹.

Limitations and Adverse Effects of Peripheral Nerve Blocks:

Technical Limitations and Incomplete Blockade:

Even with precision of ultrasound guidance, the success of a peripheral nerve block is subject to the operator’s skill and individual patient anatomy. Technical limitations may include difficulty in visualizing the target due to the patient’s anatomy (e.g. obesity or scarring), poor placement of the needle near the target nerve, or local anesthetic not spreading within the fascial plane. Any of these factors may result in «incomplete blockade,» where the patient may experience either partial or no pain relief at all.

Neither the incidence of block failure is insignificant or negligible, nor is it disruptive to the perioperative workflow. Once a block fails, there may be an instant need for high dose systemic opioids, which can lead to the very ORAE that the block was intending to prevent. In addition to that, the volume of local anesthetic can impact both safety and efficacy. Studies comparing different volumes for fascia iliaca compartment block (FICB) have shown that higher volume (0.5 mL/kg of 0.25% bupivacaine) provided better pain relief and longer duration of action. The higher volume approaches, however, also get the patient closer to systemic toxicity¹⁴.

In addition to the estimates of the incidence of blocks failing due to technical limitations, there has been growing interest to help reduce the risk of complications with an ultrasound guided, portable multispectral optoacoustic imaging (OPUS). This technology will visualize intraneurial blood vessels in vivo, hopefully leading to better outcomes in regards to avoiding vascular damage as well as accurately placing the anesthetic¹⁵. Even with the application of emerging technology, the «operator-dependent» limitation for expediting successful outcomes with regional anesthesia remains a limitation, specifically in areas where regional anesthesia procedures are not in high volume.

Neurological Complications and Local Anesthetic Systemic Toxicity:

Iatrogenic nerve injury is one of the most serious and rare complications of PNBs, and may manifest as transient neurapraxia, which is usually self-resolving within weeks, all the way to axonotmesis and neurotmesis, which could lead to permanent functional deficits and chronic neuropathic pain⁴. The mechanism of injury from mechanical trauma from the needle, high-pressure injected of anesthetic into the fascicle, or the chemical neurotoxicity from the local anesthetic itself would all contribute to the potential of iatrogenic nerve injury.

Similarly, Local Anesthetic Systemic Toxicity (LAST) is a catastrophic complication, though rare. LAST is related to the concentration of local anesthetic being high enough to achieve toxicity systemically, usually due to unintentional intravascular injection (accidental) or rapid absorption from tissues that are vascular. Also, LAST may occur as CNS manifestations (seizures, altered mental status) followed by cardiovascular collapse. While ultrasound may help prevent, there is still an inherent risk, prompting the need for local interventions to be conducted the required protocols in cases of LAST which may include lipid emulsion⁸.

Neuroanatomy of peripheral nerves is an area of ongoing research by means of exploring spatial statistics and point process models to highlight the spatial arrangement of axons and the surrounding connective tissue. This understanding could help develop a nuro-modualtor or therapeutic tool which can provide better and safer injection.

Motor Blockade and Fall Risk:

In lower extremity orthopaedics, it is equally important to avoid pain as it is to preserve motor function. One the major limitation of peripheral nerve blocks is weakness is associated with traditional blocks, such as the femoral nerve block. This is particularly concerning for orthopaedic procedures, especially after surgery, when the patient’s weakness compromises the stabilization of the knee, which increases the risk for falling.

Falling is a serious complication in orthopaedic surgery which can lead to periprosthetic fracture, wound dehiscence, or possible need for revision. The «motor block paradox» describes the dilemma of providing adequate analgesia for physical therapy and maintaining strength to ambulate safely. There are clearly some more recent techniques, such as the adductor canal block, which may improve this dilemma, but they certainly do not eliminate it altogether.

Additionally, the duration in which someone is weak might exceed the duration of sensory relief, creating a window of time where the patient is in pain and can’t safely mobilize. This dilemma has led to attempts with adjuvants, and different concentrations to enhance analgesic experiences without causing motor blockade. However, the evidence still lacks to provide an evidence based practice structure, and institutional experience may be needed for clinicians to manage this limitation⁹.

Comparative Efficacy for Different Orthopaedic Surgical Approaches:

Brachial Plexus Block Variations for Upper Extremity Surgery:

The brachial plexus block is the «gold standard» for upper extremity surgery, where variations would include interscalene, supraclavicular, infraclavicular, and axillary depending on the site of surgery⁷. The interscalene block is the best choice for shoulder surgery (rotator cuff repair, total shoulder arthroplasty), however this block is also associated with phrenic nerve palsy, which can be an issue for patients with compromised pulmonary function.

Conversely, supraclavicular and infraclavicular to proximal site have been used in surgery of the elbow, forearm, and hand. The advantages to the supraclavicular block in pediatrics, for example, has had excellent success in the treatment of elbow fractures resulting in an opioid-free intraoperative period, and superior pain control for the first 24 hours postoperatively¹². The incorporation of ultrasound in these procedures has greatly increased the safety and success of the procedure, making it the standard of care.

Femoral and Sciatic Nerve Block for Lower Extremity Surgery:

Lower extremity surgery often have complex analgesic strategies due to multi-nerve innervation relative to the joint. The femoral nerve block (FNB) and sciatic nerve block were the standard for analgesia in TKA. The FNB will address anterior knee pain, however a sciatic block is often needed to treat posterior knee pain. The combination of blocking both the FNB and sciatic nerve can leave a patient with a «dead limb,» which may be highly distressing to a patient, and completely prevents them from mobilizing¹⁰.

For hip surgery, blocks such as fascia iliaca compartment block (FICB) can be used for pain relief for femoral neck fractures or total hip arthroplasty (THA). Meta-analysis of newer techniques, such as the quadratus lumborum block (QLB) for THA, have yielded mixed results. Recent evidence supports the QLB did not demonstrate superiority in pain scores or total opioid consumption over sham procedures or active comparators in elective THR¹⁶.

IPACK and Adductor Canal Block in Knee Arthroplasty:

The change in practice of analgesia for knee arthroplasty has now been to more directed (motor-sparing) PNBs. The ACB has all but phased out the FNB in ERAS protocols, which provides patients with sensory block for the quadriceps and greater mobility¹⁰. However, the ACB fails to provide coverage posteriorly, which is innervated by branches of the sciatic and obturator nerves.

To cover the posterior knee capsule without producing a complete sciatic motor block, the IPACK can be used by injecting local anesthetic in the area between the popliteal artery and the posterior knee capsule. This minimally invasive dual block approach (ACB + IPACK) has been demonstrated in multimodal practices to have provided better outcomes for pain and facilitate functional recovery with better mobility, which is the goal for «functional analgesia»¹⁰.

DISCUSSION

The body of evidence presented herein confirms that peripheral nerve blocks are essential components of modern orthopaedic management. The clinical significance of peripheral nerve blocks lies within the effectiveness of providing superior analgesia for patients while adhering to opioid-sparing principles⁵. The switch to ultrasound-guided, motor-sparing techniques has resolved many of the early dilemmas in pain management and early rehabilitation associated with PNBs¹³. Equally important is understanding that the clinical impact of these nerve blocks is not universally effective or appropriate for all surgeries. For example, the evidence of the efficacy of the QLB for THA showed not significance in pain and opioid reduction in elective THA¹⁶.

For PNBs to be effective, there must be a change in the consideration for patient populations other than «one-size-fits-all.» There must be consideration of the type of block and the needs of the surgical site, as well as the patient’s respiratory and neurological status, so their needs can be understood within the context of recovery. For example, in the ACB patients, age may make a difference in pain management, where the 55-year-old patient can be kept longer, while older patients may have a more medical focus, such as avoiding delirium¹⁰.

PNBs should not be thought of as standalone interventions, and must be integrated within the context of multimodal analgesia (MMA) framework. The relationship of the «ceiling effect» of PNBs is dependant on the pharmacokinetics of local anesthetic, so they must be paired with non-opioid medications⁶.

PNBs have demonstrated to be beneficial to optimizing ERAS protocols and increased transparency of recovery². This coordination is important between the surgical team, anesthesia, and nursing professionals. This may related to original management of pain, or the management of «rebound» pain phase. Clinicians must be cognizant that patients have oral analgesics levels leveled in their system in advance of the block wearing off, to prevent a sudden onset of pain that may require an emergency-department visit for uncontrolled pain and/or poor satisfaction.

As a systematic review, there are many limitations to the current literature. There is often a high degree of variability in study designs, local anesthetic concentrations, and outcome measures related to the adaptability of comparing studies results. Likewise, the majority of studies were focused on short-term (0-48 hours) outcomes. There is a gap in obtaining a reasonable body of evidence on the long-term use of PNBs to reduce the incidence of chronic pain following surgery, or the long-term functional outcomes.

There are considerable gaps surrounding the utilization of pre-existing chronic pain while on opioids. For these «complex» patients, the goal of PNB may shift from eliminating the opioids, to just preventing hyperalgesia and managing the acute-on-chronic pain flare. Overall, while there may have been recent advances in the protocol or purposes from technology, such as AI, their efficacy in any typical clinical practice remains to be determined^11,15.

CONCLUSIONS

Peripheral nerve blocks are an important development in orthopaedic perioperative care, providing potent analgesia while significantly reducing opioid use. The advent of ultrasound and motor-sparing techniques (i.e. adductor canal, IPACK) have enabled the safe integration of regional anesthesia with early mobilization and postoperative recovery in multimodal ERAS protocols. Yet one must be conscious of the technical limitations and safety concerns involved with PNBs, such as the risks of incomplete blockade, systemic toxicity, and iatrogenic nerve injury.

In order to maximize PNBs therapeutic potential, clinicians must take a nuanced approach to prioritize patient safety and coordination into a multimodal framework. Future research should focus on finding pharmacological and technological options for improving the therapeutic duration duration, optimizing blocks for patients particularly at risk populations to improve their experiences, and clarifying the structure of outcomes for long-term function and economics. Most importantly that patient safety remains a priority to provide adequate pain management while promoting rapid, safe and stable function.

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