Combining various acupuncture therapies with multimodal analgesia to enhance postoperative pain management following total knee arthroplasty: a network meta-analysis of randomized controlled trials

Total knee arthroplasty (TKA) is one of the most effective orthopedic procedures for treating advanced knee osteoarthritis. With population aging and rising obesity, the need for this surgery has grown significantly, affecting more than 13% of older adults in some regions of China. Although TKA is highly effective at relieving pain and improving joint function long-term, severe postoperative pain remains a major challenge, directly affecting recovery and the patient's ability to participate in early rehabilitation.

Pain management after TKA is fundamental to treatment success. Severe pain not only causes physical discomfort but can also lead to anxiety, depression, and kinesiophobia, creating a harmful cycle that delays recovery. Traditionally, pain control is achieved through multimodal analgesia, which combines different medications and techniques such as anti-inflammatory drugs, opioids, and nerve blocks. However, these conventional methods can cause significant adverse effects including nausea, vomiting, dizziness, somnolence, and — in the case of opioids — risk of dependence and respiratory depression.

This study used a network meta-analysis methodology to compare the efficacy of four different acupuncture therapies when combined with multimodal analgesia in TKA postoperative pain treatment. The investigators analyzed 41 randomized clinical trials including 3,003 patients, comparing the effects of traditional acupuncture, electroacupuncture, transcutaneous electrical acupoint stimulation (TEAS), and auricular therapy — all combined with multimodal analgesia — versus multimodal analgesia alone. The search was performed across nine different databases in both English and Chinese, covering studies published through November 2023.

Main results showed interesting differences between acupuncture modalities. For pain assessed on postoperative day 3, there were no significant differences among the five interventions tested. However, on postoperative day 7, TEAS combined with multimodal analgesia was more effective than analgesia alone for pain reduction. When evaluating knee-function improvement using the HSS scale, three acupuncture modalities — traditional acupuncture, electroacupuncture, and TEAS — were superior to conventional treatment alone.

For knee range of motion, traditional acupuncture showed the best results, superior to all other modalities tested.

A particularly relevant aspect was adverse-event evaluation. Auricular therapy combined with multimodal analgesia was the most effective for preventing postoperative nausea, vomiting, dizziness, and somnolence. Overall, all acupuncture modalities significantly reduced the incidence of nausea and vomiting compared with conventional treatment. As for dizziness and somnolence, both TEAS and auricular therapy were superior to conventional treatment, while traditional acupuncture showed slightly higher rates of these symptoms compared with auricular therapy.

The clinical implications of these results are promising for both patients and clinicians. For patients, it means there is a safe and effective option that can be added to conventional treatment to improve pain control and accelerate recovery after knee surgery. Acupuncture may reduce the need for stronger medications and their associated adverse effects, allowing more active participation in rehabilitation exercises from the first days after surgery. For clinicians, these data provide robust scientific evidence for incorporating different acupuncture modalities into postoperative recovery protocols, choosing the technique most appropriate to the specific treatment goal.

The study suggests that electroacupuncture and TEAS may be the best options for postoperative pain control, while traditional acupuncture would be the ideal choice for promoting functional recovery. Auricular therapy, in turn, would be particularly valuable for patients with greater susceptibility to adverse effects such as nausea and dizziness.

It is important to acknowledge several study limitations. Most included studies were conducted in China and published in Chinese, which may introduce cultural bias. In addition, due to the nature of acupuncture, fully blinded studies were not possible, since both therapist and patient know that acupuncture is being applied. The methodological quality of some studies was also considered low to moderate, and the studies focused mainly on short-term effects, leaving questions about long-term benefits unresolved.

In conclusion, this study provides solid scientific evidence that different acupuncture modalities, when combined with multimodal analgesia, offer significant benefits in pain control and functional recovery after total knee arthroplasty. The choice of specific modality can be individualized to treatment goals and patient profile, representing a valuable integrative approach that combines the best of traditional Chinese medicine with modern medical care.