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Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 1 Early (4‐6 hours) postoperative pain relief at rest.
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Analysis 1.1

Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 1 Early (4‐6 hours) postoperative pain relief at rest.

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Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 2 Late (18‐24 hours) postoperative pain relief at rest.
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Analysis 1.2

Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 2 Late (18‐24 hours) postoperative pain relief at rest.

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Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 3 Early (4‐6 hours) postoperative dynamic pain relief.
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Analysis 1.3

Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 3 Early (4‐6 hours) postoperative dynamic pain relief.

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Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 4 Nausea or vomiting.
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Analysis 1.4

Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 4 Nausea or vomiting.

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Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 5 Sedation.
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Analysis 1.5

Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 5 Sedation.

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Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 6 Urinary retention.
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Analysis 1.6

Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 6 Urinary retention.

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Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 7 Pruritis.
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Analysis 1.7

Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 7 Pruritis.

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Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 8 Respiratory depression.
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Analysis 1.8

Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 8 Respiratory depression.

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Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 9 Hypotension.
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Analysis 1.9

Comparison 1 Epidural analgesia versus systemic analgesia, Outcome 9 Hypotension.

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Table 1. Classification of studies by type of joint replacement and anaesthesia

Anaesthetic

Hip

Knee

Hip or knee

All patients received neuraxial blockade

Bertini 1995; Gustafsson 1986

Sharrock 1994; Hendolin 1996; Klassen 1999

Weller 1991; Homeril 1994

Neuraxial blockade vs general anaesthesia

D'Ambrosio 1999; Wulf 1999

Jorgensen 1991; Singelyn 1998

Moiniche 1994

All patients received general anaesthesia

Capdevila 1999
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Table 1. Classification of studies by type of joint replacement and anaesthesia
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Table 2. Classification of studies by type of postoperative epidural analgesia

Epidural analgesia

Study

Local anesthetic

Jorgensen 1991; Wulf 1999

Narcotic

Gustafsson 1986; Weller 1991; Hommeril 1994; Hendolin 1996; Klasen 1999

Local anesthetic‐narcotic

Moiniche 1994; Sharrock 1994; Bertini 1995; Singelyn 1998; Capdevila 1999; D'Ambrosio 1999

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Table 2. Classification of studies by type of postoperative epidural analgesia
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Table 3. Summary of results on functional outcomes

Study

Outcome Measure

Results

Sharrock 1994

Number of days to reach seven rehabilitation milestones: ability to dangle legs over the side of bed unsupported, transfer from bed to walker unassisted, use a walker unassisted, use canes unassisted, climb stairs unassisted, achieve 90 degrees of knee flexion, and discharge from rehabilitation

No differences were seen between patients receiving epidural analgesia and patients receiving intravenous analgesia.

Singelyn 1998

Degree of knee flexion; number of days to reach 90 degrees of knee flexion

Degree of knee flexion, measured daily until discharge, was significantly (P<0.001) greater in patients receiving epidural analgesia compared to patients receiving intravenous analgesia. A statistically significant difference (P=0.03) in favour of the epidural analgesia group persisted at six weeks after knee replacement. There was no difference in degree of knee flexion between the two groups 3 months after knee replacement. Similarly, degree of knee flexion, measured daily until discharge, was significantly (P<0.001) greater in patients receiving 3‐in‐1 block compared to patients receiving intravenous analgesia. A statistically significant difference (P=0.03) in favour of the 3‐in‐1 block group persisted at six weeks after knee replacement. There was no difference in degree of knee flexion between the two groups 3 months after knee replacement. Epidural analgesia or 3‐in‐1 block permitted patients to reach 90 degrees of knee flexion faster than intravenous analgesia (P<0.001; 8+/‐5 days [epidural], 11+/‐6 days [3‐in‐1 block]; 17+/‐7 days [intravenous]).

Capdevila 1999

Maximal knee flexion at 5 days, 7 days (discharge), 1 month, and 3 months after knee replacement

Continuous epidural analgesia or continuous femoral block both resulted in greater degrees of knee flexion compared to intravenous patient controlled analgesia (P<0.05) at 5 days and 7 days after knee replacement. No differences were seen between the three groups 1 month and 3 months after knee replacement.

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Table 3. Summary of results on functional outcomes
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Table 4. Summary of results on length of stay

Study

Results

Moiniche 1994

No statistically significant differences in median length of hospital stay were observed in knee replacement (epidural 12 days; intravenous 13 days) or hip replacement (epidural 9 days; intravenous 9 days) patients.

Sharrock 1994

No statistically significant difference in mean length of hospital stay was observed between patients receiving epidural analgesia (16.7+/‐3.8 days) and patients receiving intravenous analgesia (15.6+/‐2.1 days).

Singelyn 1998

Compared to epidural analgesia (mean 16 days, SD 4 days) or 3‐in‐1 block (mean 17 days, SD 3 days), intravenous analgesia resulted in longer length of stay (mean 21 days, SD 3 days; p<0.001).

Capdevila 1999

Compared to continuous epidural analgesia (median 37 days, range 30 to 45 days) or continuous femoral block (median 40 days, range 31 to 60 days), intravenous PCA resulted in longer length of stay (median 50 days, range 30 to 80 days; p<0.05) in the rehabilitation center using objective discharge criteria.

Wulf 1999

No statistically significant difference in mean length of hospital stay was observed between patients receiving epidural analgesia (19+/‐5 days) and patients receiving intravenous analgesia (22+/‐10 days).

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Table 4. Summary of results on length of stay
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Comparison 1. Epidural analgesia versus systemic analgesia

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Early (4‐6 hours) postoperative pain relief at rest Show forest plot

7

236

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.77 [‐1.24, ‐0.31]

1.1 Studies evaluating total hip replacements only

1

50

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Studies evaluating total knee replacement only

4

122

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.66 [‐1.30, ‐0.02]

1.3 Studies evaluating total hip or total knee replacements

2

64

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.90 [‐1.57, ‐0.22]

2 Late (18‐24 hours) postoperative pain relief at rest Show forest plot

6

182

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.29 [‐0.73, 0.16]

2.1 Studies evaluating total hip replacements only

1

50

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.2 Studies evaluating total knee replacements only

4

102

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.47 [‐1.04, 0.10]

2.3 Studies evaluating total hip or total knee replacements

1

30

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.72, 0.72]

3 Early (4‐6 hours) postoperative dynamic pain relief Show forest plot

2

60

Std. Mean Difference (IV, Fixed, 95% CI)

‐2.45 [‐3.43, ‐1.48]

3.1 Studies evaluating total hip replacements only

1

30

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 Studies evaluating total knee replacements only

1

30

Std. Mean Difference (IV, Fixed, 95% CI)

‐2.45 [‐3.43, ‐1.48]

4 Nausea or vomiting Show forest plot

9

371

Odds Ratio (M‐H, Fixed, 95% CI)

0.95 [0.60, 1.49]

4.1 Studies using epidural local anaesthetic + narcotic

4

158

Odds Ratio (M‐H, Fixed, 95% CI)

0.88 [0.40, 1.94]

4.2 Studies using epidural narcotic

4

123

Odds Ratio (M‐H, Fixed, 95% CI)

2.10 [0.96, 4.59]

4.3 Studies using epidural local anaesthetic

1

90

Odds Ratio (M‐H, Fixed, 95% CI)

0.38 [0.16, 0.90]

5 Sedation Show forest plot

3

116

Odds Ratio (M‐H, Fixed, 95% CI)

0.30 [0.09, 0.97]

5.1 Studies using epidural local anaesthetic + narcotic

2

86

Odds Ratio (M‐H, Fixed, 95% CI)

0.32 [0.06, 1.68]

5.2 Studies using epidural narcotic

1

30

Odds Ratio (M‐H, Fixed, 95% CI)

0.29 [0.06, 1.45]

6 Urinary retention Show forest plot

5

166

Odds Ratio (M‐H, Fixed, 95% CI)

3.50 [1.63, 7.51]

6.1 Studies using epidural local anaesthetic + narcotic

2

66

Odds Ratio (M‐H, Fixed, 95% CI)

4.33 [0.71, 26.53]

6.2 Studies using epidural narcotic

3

100

Odds Ratio (M‐H, Fixed, 95% CI)

3.33 [1.43, 7.75]

7 Pruritis Show forest plot

6

209

Odds Ratio (M‐H, Fixed, 95% CI)

4.74 [1.76, 12.78]

7.1 Studies using epidural local anaesthetic + narcotic

2

86

Odds Ratio (M‐H, Fixed, 95% CI)

1.07 [0.17, 6.60]

7.2 Studies using epidural narcotic

4

123

Odds Ratio (M‐H, Fixed, 95% CI)

9.16 [2.45, 34.22]

8 Respiratory depression Show forest plot

5

204

Odds Ratio (M‐H, Fixed, 95% CI)

1.07 [0.45, 2.54]

8.1 Studies using epidural local anaesthetic + narcotic

2

101

Odds Ratio (M‐H, Fixed, 95% CI)

0.47 [0.15, 1.51]

8.2 Studies using epidural narcotic

3

103

Odds Ratio (M‐H, Fixed, 95% CI)

3.88 [0.78, 19.36]

9 Hypotension Show forest plot

4

137

Odds Ratio (M‐H, Fixed, 95% CI)

2.78 [1.15, 6.72]

9.1 Studies using epidural local anaesthetic + narcotic

3

117

Odds Ratio (M‐H, Fixed, 95% CI)

2.78 [1.15, 6.72]

9.2 Studies using epidural narcotic

1

20

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]
Figures and Tables -
Comparison 1. Epidural analgesia versus systemic analgesia
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