Efficacy of popliteal plexus block for opioid sparing and pain management after lower extremity surgery: a meta-analysis

Abstract

Background

Postoperative pain management often depends on opioids, despite the associated adverse effects. The popliteal plexus block (PPB) presents a promising technique to reduce opioid consumption in surgeries.

Methods

This meta-analysis evaluates the effectiveness of PPB when added to other nerve blocks, as well as its comparative efficacy against other block techniques, in improving postoperative recovery. Randomized controlled trials (RCTs) investigating the effect of PPB in adults undergoing lower extremity surgery were included. The primary outcome was 24-hour opioid consumption; secondary outcomes included pain scores at 12 and 24 hours, and the incidence of postoperative nausea and vomiting (PONV). The pooled effect size was quantified using mean difference (MD), standardized MD (SMD), or relative risk (RR) with a 95% confidence interval (CI).

Results

Quantitative synthesis was restricted to studies evaluating PPB as an add-on to another nerve block technique. Compared with the standalone comparator, PPB significantly reduced 24-hour opioid consumption (5 studies; SMD –1.32; 95% CI –2.29 to –0.34), pain scores at 12 hours (4 studies; MD –1.32; 95% CI –2.25 to –0.39) and 24 hours (4 studies; MD –0.52; 95% CI –1.02 to –0.02), and the incidence of PONV (3 studies; RR 0.21; 95% CI 0.08 to 0.55). Three additional single-trial head-to-head comparisons (vs. other blocks) were not pooled and are reported narratively.

Conclusions

As an add-on, PPB reduces opioid consumption, pain scores, and PONV incidence. Head-to-head evidence against other blocks remains limited and inconsistent; further high-quality RCTs are warranted to clarify comparative efficacy and address heterogeneity.

INTRODUCTION

Postoperative pain management is crucial for recovery, with opioids commonly used for pain control, despite their associated risks such as respiratory depression, nausea, and dependency. The ongoing opioid crisis has highlighted the need for alternative pain management strategies to minimize reliance on opioids and reduce associated risks [1]. In response to this, regional anesthesia techniques, such as nerve blocks, have gained considerable attention for their potential to reduce opioid consumption while providing effective pain control [2]. These techniques not only help mitigate opioid-related side effects but also align with the goals of enhanced recovery after surgery (ERAS) protocols, which emphasize multimodal analgesia and faster recovery times [3]. Among these regional anesthesia techniques, the popliteal plexus block (PPB) has emerged as an effective option for providing anesthesia and analgesia during lower extremity surgeries, offering a promising solution to manage postoperative pain while minimizing opioid use [4].

PPB provides effective analgesia for lower extremity surgeries, such as knee arthroplasty and arthroscopic knee surgery, with a relatively low incidence of side effects, offering benefits in reducing opioid consumption and improving recovery [5,6]. However, the overall efficacy of PPB in improving postoperative outcomes remains debated. While studies generally support the analgesic benefits of PPB in reducing opioid consumption [7,8], comparative trials have reported varying results [9]. These discrepancies likely reflect the distinct anatomical targets and potential sensory overlap of different regional anesthesia techniques, rather than inconsistencies in the inherent efficacy of PPB. Such variations highlight the need to examine the comparative role of PPB within the context of specific anatomical coverage and multimodal analgesic protocols.

This meta-analysis hypothesizes that PPB improves postoperative recovery by reducing opioid consumption, pain, and postoperative nausea and vomiting (PONV). The aim is to compare the combination effect of PPB with other nerve blocks and the individual effect of PPB compared to other nerve blocks, to evaluate their effectiveness in optimizing recovery following lower extremity surgeries.

MATERIALS AND METHODS

The study protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO; ID: CRD420261278673) on January 5, 2026. While initial title and abstract screening of the literature search result (conducted on November 24, 2025) preceded formal registration, full-text eligibility assessment, data extraction, and statistical analyses were initiated on January 7, 2026, strictly following the registered protocol. No deviations from the predefined protocol occurred throughout the review process. This meta-analysis was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA 2020) guidelines.

1. Eligible criteria

Study eligibility was determined through the application of the PICOS (population, intervention, comparison, outcomes, and study design) framework. Only randomized controlled trials (RCTs) were included. The population was defined as adult participants (aged 18 years or older) who were undergoing elective lower extremity surgery. For the intervention, the use of PPB was required. Eligible comparators (Comparison) were restricted to either placebo or other nerve blocks. Finally, inclusion was granted only if a study reported at least one of the prespecified outcomes: opioid consumption 24 hours after surgery, pain scores at 12 and 24 hours postoperatively, or the incidence of PONV.

2. Search strategy

A detailed and comprehensive search strategy was established to identify all potentially eligible studies. The following databases were searched from their inception up to November 24, 2025: PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. To enhance the breadth of the search, keywords such as “popliteal plexus,” “block,” and “block*” were combined using Boolean operators (AND/OR). Crucially, no restrictions were applied regarding language or geographical region during the search process. Popliteal plexus block has been the sole term used in the literature for this specific technique since its original description by Runge et al. [4,10]. Broader descriptors such as posterior knee block or IPACK (infiltration between the popliteal artery and capsule of the knee) refer to anatomically and procedurally distinct techniques rather than to PPB itself; the search was therefore restricted to this specific term to preserve technique specificity and avoid conflating heterogeneous interventions. The full details of the specific search syntax are documented in Supplementary Table 1.

3. Study selection and data extraction

All records retrieved from the systematic search were first imported into a reference management software (EndNote 20; Clarivate) to facilitate the removal of duplicate entries. The initial screening of titles and abstracts was conducted independently by two reviewers. The full-text articles of those potentially eligible studies were subsequently assessed to confirm final inclusion based on the predefined criteria. Any disagreements regarding eligibility were resolved via consensus-based discussion or through consultation with a third independent reviewer.

Data extraction was performed independently by two investigators using a standardized form. The following key data were extracted from each included study: study characteristics (i.e., author, publication year), participant demographics (i.e., age, sample size), clinical details (i.e., type of surgery, specific nerve blocks applied, type and dose of local anesthetics), and relevant outcome data. When outcomes were presented using medians and interquartile ranges, they were converted to means and standard deviations following the methodology established by Wan et al. [11]. For instances where results were reported solely in graphical form, data values were retrieved using the WebPlotDigitizer software (https://apps.automeris.io/wpd/).

4. Outcome measures

The primary outcome of interest was designated as the total opioid consumption measured at 24 hours following the surgical procedure. Secondary outcomes included assessments of pain scores at 12 hours and 24 hours postoperatively, as well as the reported incidence of PONV. Opioid consumption reported in different formulations and routes across studies (e.g., fentanyl, morphine, tramadol) was converted to intravenous morphine milligram equivalents using standard equianalgesic conversion ratios [12] prior to pooling.

5. Assessment of risk of bias and quality of evidence

The methodological quality and internal validity of each included study were assessed using the Cochrane Risk of Bias tool version 2 (RoB 2) [13]. This assessment was carried out independently by two reviewers and focused on the following critical domains: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in measurement of the outcome, and bias in selection of the reported result. Each specific domain was categorized as having “low risk,” “some concerns,” or “high risk” of bias.

The certainty of the evidence for each outcome was subsequently evaluated utilizing the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach [14]. This comprehensive evaluation was based upon five key factors: the risk of bias (as determined by RoB 2), inconsistency, indirectness, imprecision, and the potential for publication bias.

6. Statistical analysis

All statistical analyses were performed utilizing Stata® SE version 19.0 (StataCorp LLC). For continuous outcomes, the pooled effect size was quantified using standardized mean differences (SMDs) or MDs along with their 95% confidence intervals (CIs). Conversely, relative risk (RR) with 95% CIs were calculated for dichotomous outcomes. A random-effects model was uniformly implemented across all meta-analyses to appropriately incorporate anticipated methodological and clinical heterogeneity. Statistical heterogeneity across studies was quantified using the I² statistic and Cochran’s Q test. I² values of 25%, 50%, and 75% were interpreted as indicating low, moderate, and high heterogeneity, respectively. To investigate the robustness of the findings, leave-one-out sensitivity analyses were conducted to examine the specific influence of each individual study on the overall pooled effect size. Since the number of included studies for each outcome was fewer than 10, funnel plots were not constructed to assess publication bias.

Quantitative pooling was restricted to comparisons represented by two or more independent trials sharing a directionally comparable comparator. Comparisons represented by only a single trial were reported narratively rather than pooled.

RESULTS

1. Study selection

A total of 151 records were initially identified through database searches, including CENTRAL (n = 39), Embase (n = 51), PubMed (n = 18), Scopus (n = 24), and Web of Science (n = 19). After removing 75 duplicate records, 76 reports remained for title and abstract screening. Of these, 61 records were excluded based on their titles (n = 34) and abstracts (n = 27). Among the 15 reports sought for retrieval, one report could not be retrieved. Consequently, 14 reports were assessed for full-text eligibility. During this final stage, 6 reports were excluded because one was a non-RCT design, four were abstract-only publications, and one had an inappropriate group composition (Supplementary Table 2). Ultimately, 8 studies met all inclusion criteria and were included in this meta-analysis. The detailed procedure for study identification and selection is depicted in the flowchart (Fig. 1).

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram of study selection. A total of 151 articles were identified through the electronic databases. After excluding 75 studies for duplication, 34 and 27 articles were removed from the article pool based on the fitness of the title and abstract, respectively. After removing one study that could not be retrieved, the full texts of remained 14 articles were reviewed. Finally, a total of 8 RCTs were included in the meta-analysis. CENTRAL: Cochrane Central Register of Controlled Trials, RCT: randomized controlled trial.

Of these eight studies, five evaluated PPB as an add-on to another nerve block technique and were pooled in meta-analysis; the remaining three compared PPB against an active comparator (fascia iliaca block [FIB], IPACK, and tibial nerve block [TNB], respectively) in single trials and are therefore reported narratively.

2. Characteristics of study and participants

Table 1 provides a comprehensive overview of the baseline characteristics for the eight trials included in this synthesis. A total of 684 adult participants were involved, with 342 individuals equally distributed between the PPB and control groups. Six studies [6–9,15,16] focused on participants undergoing total knee arthroplasty, while the remaining two studies [5,17] involved arthroscopic anterior cruciate ligament reconstruction. The anesthesia methods employed included general anesthesia [6–8,16,17] and spinal anesthesia [5,9,15]. Various analgesic strategies were investigated in relation to PPB: five studies [5,6,15–17] evaluated PPB as an additive component to other nerve blocks, such as femoral triangle block [15], femoral nerve block [16], or adductor canal block [5,6,17], while the remaining three studies [7–9] compared PPB directly against alternative techniques, including FIB [9], IPACK block [7], or TNB [8]. Local anesthetics, such as ropivacaine or bupivacaine, with volumes ranging from 10 to 40 mL, were used across the studies. Most procedures were performed under ultrasound guidance to ensure block precision.

Table 1.

Characteristics of study and participant

Author, year	Participant			Age		Surgery	Anesthesia	Group			Local anesthetic
	N1	N2		A1	A2			Treatment	Control		Treatment	Control
Abdelraheem et al. [9], 2023	30	30		57	56	TKA	Spinal	PPB	FIB		0.5% bupivacaine 10 mL	0.25% bupivacaine 40 mL
Behery et al. [5], 2024	55	55		29	30	Arthroscopic ACL reconstruction	Spinal	PPB + ACB	ACB		0.25% bupivacaine 15 mL + 0.25% bupivacaine 15 mL	0.25% bupivacaine 15 mL
Fujino et al. [7], 2025	43	43		70	73	TKA	General	PPB + FTB	IPACK + FTB		0.25% levobupivacaine 10 mL + 15 mL	0.25% levobupivacaine 10 mL + 15 mL
Jiang et al. [6], 2024	30	30		63	64	TKA	General	PPB +cACB	Sham + cACB		0.5% ropivacaine 20 mL + 15 mL	0.9% Saline 20 mL + 0.5% ropivacaine 15 mL
Mahmoud et al. [17], 2021	30	30		24	24	Arthroscopic ACL reconstruction	General	PPB + ACB	ACB		0.5% bupivacaine 1 mg/kg	0.5% bupivacaine 1 mg/kg
Sakai et al. [8], 2024	67	65		76	75	TKA	General	PPB + ACB	TNB + ACB		0.25% levobupivacaine 10 mL + 10 mL	0.25% levobupivacaine 10 mL + 10 mL
Sørensen et al. [15], 2025	55	55		69	71	TKA	Spinal	PPB + FTB	Sham + FTB		0.5% bupivacaine 10 mL + 10 mL	0.5% bupivacaine 10 mL
Stebler et al. [16], 2026	32	34		69	69	TKA	General	PPB + cFNB	cFNB		0.5% bupivacaine 15 mL + 0.2% ropivacaine infusion	0.2% ropivacaine infusion

N1: number of participants in the treatment group, N2: number of participants in the control group, A1: mean age in the treatment group, A2: mean age in the control group, TKA: total knee arthroplasty, PPB: popliteal plexus block, FIB: fascia iliaca block, ACL: anterior cruciate ligament, ACB: adductor canal block, FTB: femoral triangle block, IPACK: infiltration between the popliteal artery and capsule of the knee, cACB: continuous adductor canal block, TNB: tibial nerve block, cFNB: continuous femoral nerve block.

3. 24-hour postoperative opioid consumption

Among the five studies [5,6,15–17] evaluating PPB as an add-on to another nerve block technique, PPB was associated with a significant reduction in 24-hour opioid consumption compared with the standalone comparator. The pooled effect size (SMD, Hedges’s g) was –1.32 (95% CI: –2.29 to –0.34; P = 0.008; I² = 94.83%; Fig. 2).

Fig. 2.

Forest plot for 24-hour opioid consumption (MME). The pooled estimate showed a significant reduction in opioid consumption in the PPB group compared with the standalone comparator group. SD: standard deviation, CI: confidence interval, ACB: adductor canal block, cACB: continuous adductor canal block, FTB: femoral triangle block, cFNB: continuous femoral nerve block, PPB: popliteal plexus block, MME: morphine milligram equivalents.

Separately, three trials [7–9] compared PPB against an active comparator, with inconsistent findings. PPB was associated with significantly higher 24-hour opioid consumption than FIB (8.8 ± 2.6 mg vs. 6.8 ± 1.4 mg) [9], significantly lower opioid consumption than IPACK (5.6 ± 6.9 mg vs. 11.7 ± 10.3 mg) [7], and significantly lower opioid dose equivalents than TNB (1.6 ± 0.2 mg vs. 2.0 ± 0.2 mg) [8]. As each comparator was represented by a single trial, these results were not pooled; full effect sizes are provided in Supplementary Table 3.

A leave-one-out sensitivity analysis confirmed the robustness of the pooled effect for 24-hour opioid consumption among the five add-on studies. The direction of effect consistently favored PPB, with the pooled SMD ranging from –1.60 to –0.96 across single-study omissions (Supplementary Fig. 1). Exclusion of the study by Mahmoud et al. [17] alone rendered the pooled estimate borderline non-significant (P = 0.052), though the consistent magnitude and direction across omissions support the robustness of the finding that PPB reduces opioid consumption.

4. Postoperative pain score at 12 hours

Pooling the four add-on studies reporting this outcome yielded a MD of –1.32 (95% CI: –2.25 to –0.39; P = 0.005; I² = 94.70%), indicating that PPB significantly reduced pain scores at 12 hours relative to the standalone comparator (Fig. 3).

Fig. 3.

Forest plot for pain scores at 12 hours post-surgery. The pooled estimate indicated a significant reduction in pain scores favoring the PPB group. SD: standard deviation, MD: mean difference, CI: confidence interval, ACB: adductor canal block, cACB: continuous adductor canal block, cFNB: continuous femoral nerve block, PPB: popliteal plexus block.

Two head-to-head trials assessed this outcome. Pain scores were significantly higher with PPB than with FIB in Abdelraheem et al. [9] (MD: 1.50; 95% CI: 0.03 to 2.97). Sakai et al. [8], however, found no significant difference between PPB and TNB (MD: 0.00; 95% CI: –0.51 to 0.51). Given that each comparator was evaluated in only one trial, pooling was not performed (Supplementary Table 4).

Sensitivity analysis using the leave-one-out method showed that the pooled MD remained between –1.96 and –1.07 regardless of which study was excluded (Supplementary Fig. 2), indicating a robust effect. The most pronounced shift followed exclusion of Behery et al. [5] (MD: –1.96; 95% CI: –2.22 to –1.71; P < 0.001), whereas omission of Jiang et al. [6] or Mahmoud et al. [17] each yielded a non-significant result (P = 0.067 and 0.068, respectively). As the effect direction was preserved across every iteration, the reduction in 12-hour pain scores associated with add-on PPB can be considered stable.

5. Postoperative pain score at 24 hours

PPB significantly reduced pain scores at 24 hours when added to another nerve block, based on pooled data from four trials (4 RCTs [5,6,16,17]; MD: –0.52; 95% CI: –1.02 to –0.02; P = 0.042; I² = 59.80%; Fig. 4).

Fig. 4.

Forest plot for pain scores at 24 hours after surgery. The pooled estimate indicated a significant reduction in pain scores favoring the PPB group. SD: standard deviation, MD: mean difference, CI: confidence interval, ACB: adductor canal block, cACB: continuous adductor canal block, cFNB: continuous femoral nerve block, PPB: popliteal plexus block.

Three trials directly compared PPB with an active comparator at this time point—FIB (Abdelraheem et al. [9]), IPACK (Fujino et al. [7]), and TNB (Sakai et al. [8])—and none demonstrated a significant between-group difference. As each comparator was assessed in only a single study, pooling was not undertaken; full results are compiled in Supplementary Table 5.

Leave-one-out analysis indicated that this pooled effect depended heavily on the inclusion of three of the four add-on studies: removing Behery et al. [5], Jiang et al. [6], or Stebler et al. [16] individually eliminated statistical significance (P = 0.172, 0.143, and 0.105, respectively). By contrast, removing Mahmoud et al. [17] alone left the estimate significant and, if anything, strengthened it (MD: –0.74; 95% CI: –1.14 to –0.33; P < 0.001; Supplementary Fig. 3). Given this dependence on individual studies, the statistically significant reduction in 24-hour pain scores should be interpreted with caution.

6. Incidence of postoperative nausea and vomiting

Pooling the three add-on studies [6,16,17] reporting this outcome, PPB significantly lowered the incidence of PONV relative to the comparator alone (RR: 0.21; 95% CI: 0.08 to 0.55; P = 0.002; I² = 0%; Fig. 5).

Fig. 5.

Forest plot for the incidence of PONV. The pooled estimate indicated a significantly lower incidence of PONV in the PPB group compared with the standalone comparator group. RR: relative risk, CI: confidence interval, cACB: continuous adductor canal block, ACB: adductor canal block, cFNB: continuous femoral nerve block, PPB: popliteal plexus block, PONV: postoperative nausea and vomiting.

At the level of individual comparators, findings were mixed. PPB carried a numerically higher, though non-significant, risk of PONV relative to FIB (Abdelraheem et al. [9]; RR: 2.67; 95% CI: 0.78 to 9.09) and to TNB (Sakai et al. [8]; RR: 1.94; 95% CI: 0.18 to 20.88), whereas PPB was associated with a significantly lower risk of PONV compared with IPACK (Fujino et al. [7]; RR: 0.14; 95% CI: 0.03 to 0.59). As with the other outcomes, each comparator was evaluated in a single trial, precluding pooling; results are summarized in Supplementary Table 6.

Leave-one-out sensitivity analysis demonstrated that the statistically significant reduction in PONV incidence favoring PPB was robust, as the pooled effect remained significant regardless of the exclusion of any individual study (Supplementary Fig. 4).

7. Risk of bias

The risk of bias summary is presented in Supplementary Figs. 5 and 6. Most included studies were judged to have a low risk of bias across all domains. However, the study by Behery et al. [5] was rated as having “some concerns” in the overall assessment. This was specifically due to unclear blinding of outcome assessors (Domain 4: Bias in measurement of the outcome), which could potentially introduce detection bias. Aside from this specific concern, the remaining seven studies met the criteria for a low risk of bias in all assessed categories.

8. Certainty of evidence

The certainty of evidence for the included outcomes was evaluated using the GRADE approach, with results categorized by their assessed certainty levels (Supplementary Table 7). The incidence of PONV was the only outcome classified as having high certainty, as no serious limitations were identified across any of the assessed domains. The postoperative pain score at 24 hours was rated as having moderate certainty, having been downgraded by one level due to serious risk of bias specifically attributed to the unclear blinding of outcome assessors. Finally, the certainty of evidence for 24-hour postoperative opioid consumption and the postoperative pain score at 12 hours was rated as low. These two outcomes were downgraded by two levels due to a combination of serious risk of bias regarding unclear blinding and serious inconsistency arising from high heterogeneity among the included studies.

DISCUSSION

This meta-analysis evaluated the effect of PPB on opioid consumption, pain scores, and PONV after lower extremity surgery. The authors’ findings suggest that PPB, particularly when utilized in conjunction with other nerve block techniques, significantly reduces opioid consumption, improves pain scores, and lowers the incidence of PONV.

One of the primary benefits of PPB identified in this analysis is its ability to reduce opioid consumption within the first 24 hours after surgery. The reduction in opioid use is particularly important given the growing concerns around opioid-related side effects and the opioid crisis [18]. The robust analgesic efficacy of PPB via regional anesthesia facilitates an opioid-sparing approach, potentially reducing the clinical dependency on high-dose opioid regimens [19]. This reduction in opioid use could lead to fewer opioid-related complications such as nausea, vomiting, and sedation, which are common with general anesthesia and systemic opioid administration [20]. The clinical implications of reducing opioid consumption extend beyond the immediate postoperative period. Decreased opioid use can shorten recovery times, reduce the risk of opioid dependency, and decrease the likelihood of long-term adverse effects related to opioid use, including chronic pain and addiction [21,22]. For healthcare providers, this suggests that PPB, especially when combined with other nerve blocks, could be integrated into multimodal pain management strategies to improve patient outcomes and enhance recovery.

The results of this meta-analysis demonstrate that PPB significantly enhances analgesic efficacy when used in combination with other nerve blocks. This is crucial for postoperative care, as effective pain management during the early recovery phase is essential for improving patient comfort and facilitating mobilization [23]. The clinical benefit of PPB in managing postoperative pain is particularly relevant for patients undergoing lower extremity surgeries, as these procedures are often associated with significant discomfort during the early recovery phase [24]. Effective pain control not only enhances the overall patient experience but also contributes to faster rehabilitation and shorter hospital stays [25]. Therefore, incorporating PPB into anesthesia protocols for such surgeries could lead to improved patient satisfaction, reduced need for rescue analgesia, and quicker mobilization, ultimately benefiting both patients and healthcare systems.

PPB concurrently applied with other nerve block techniques was associated with a reduced incidence of PONV. PONV remains a common and distressing complication following surgery, particularly in patients who receive general anesthesia or opioids for pain management [26]. The potential of PPB to reduce PONV suggests that PPB could be an important tool in enhancing postoperative recovery. Reducing PONV not only improves patient comfort but also reduces the need for antiemetic medications, which can have their own side effects. As such, the combination of PPB with other techniques could serve as an effective strategy for minimizing both pain and PONV, improving overall recovery outcomes.

Beyond the add-on comparisons, three trials directly compared PPB against other nerve block techniques (FIB, IPACK, and TNB). As each comparator was evaluated in only a single trial, a meaningful quantitative synthesis was not feasible. Notably, the direction of effect varied significantly across these studies: PPB was associated with higher opioid consumption and pain scores compared to FIB; lower opioid consumption and reduced PONV compared to IPACK; and lower opioid consumption relative to TNB. This heterogeneity indicates that head-to-head evidence remains preliminary and comparator-specific. Consequently, further replication is required before definitive conclusions can be drawn regarding the relative efficacy of PPB against any individual alternative technique.

While this meta-analysis provides valuable insights into the effectiveness of PPB, several limitations should be acknowledged. First, the high heterogeneity observed in some comparisons suggests that the effects of PPB may vary depending on factors such as the type of surgical procedure, the specific combination of anesthesia techniques used, and patient characteristics. This variability makes it difficult to draw definitive conclusions about the superiority of PPB over other regional blocks. Second, the inclusion of studies with different methodologies and varying quality of evidence may have influenced the results. Some studies included in this meta-analysis had small sample sizes, which can increase the risk of bias and affect the generalizability of the findings. The potential for publication bias should also be considered, as studies with positive results are more likely to be published. Finally, the studies varied in terms of the types of additional nerve blocks or anesthesia techniques combined with PPB. The combination of PPB with different anesthetic methods may have influenced the outcomes, making it difficult to isolate the specific effect of PPB alone. Standardized protocols and further research are needed to determine the most effective combinations for optimizing patient recovery.

In conclusion, this meta-analysis demonstrates that PPB is a promising regional anesthesia technique for improving postoperative recovery. When utilized as an add-on to other nerve block techniques, PPB provides significant clinical benefits by reducing 24-hour opioid consumption, improving pain scores at both 12 and 24 hours, and effectively lowering the incidence of PONV. These findings support the integration of PPB into multimodal analgesic protocols for lower extremity surgeries. While head-to-head evidence against other nerve blocks remains preliminary and heterogeneous, the consistent benefits observed with add-on PPB highlight its potential as an effective analgesic tool. Further high-quality, large-scale studies are warranted to clarify the comparative efficacy of PPB against other nerve blocks and to standardize its clinical application.

SUPPLEMENTARY MATERIALS

Supplementary materials can be found via https://doi.org/10.3344/kjp.26265.