Analgesic efficacy of regional and local analgesic techniques for anterior cruciate ligament reconstruction in adults undergoing general anesthesia: a systematic review and network meta-analysis

Acute pain after anterior cruciate ligament reconstruction (ACLR) can impair early mobility and rehabilitation. This network meta-analysis (NMA) compared regional and local analgesic techniques in adults undergoing ACLR under general anesthesia. PubMed, Embase, the Cochrane Library, and Web of Science were searched from inception to February 18, 2026, for randomized controlled trials. Risk of bias was assessed utilizing the revised Cochrane risk-of-bias tool (RoB2), and a Bayesian random-effects NMA was performed. Thirty-one studies involving 2,470 patients were included. Only six were at low risk of bias. For oral morphine milligram equivalents (OMME) at 24 h postoperatively, femoral nerve block (FNB) [mean difference (MD) = − 30.31, 95% credible interval (CrI) − 58.02, − 6.79] and FNB with sciatic nerve block (SNB) [MD = − 40.42, 95% CrI − 80.42, − 5.79] were associated with lower estimated opioid consumption than control. FNB with SNB ranked highest for lower 24-h OMME [surface under the cumulative ranking curve (SUCRA) = 87.44%]. FNB with graft donor-site infiltration was associated with lower estimated pain scores in the post-anesthesia care unit (PACU) than local infiltration analgesia (MD = − 2.46, 95% CrI: −4.67, − 0.21). At 24 h, adductor canal block (ACB) with graft donor-site infiltration had lower estimated pain scores than ACB (MD = − 1.50, 95% CrI: −2.43, − 0.61). At 48 h, the 95% CrIs for all pain comparisons included 0. ACB with infiltration between the popliteal artery and capsule of the posterior knee (iPACK) had a longer estimated time to first analgesic request (TFAR) than ACB (MD = 7.50, 95% CrI: 1.92, 13.01). Regarding postoperative nausea and vomiting (PONV), the 95% CrIs for all comparisons included 1. In sensitivity analyses excluding high-risk studies, the CrIs for key comparisons regarding OMME and TFAR widened and included 0. Some treatment nodes were missing from certain outcome networks, and the rankings for PONV changed. Potential analgesic benefits varied across outcomes, but key estimates became less precise after high-risk studies were excluded. Functional outcomes were not systematically synthesized, and adverse event assessment was limited to PONV. These findings do not establish the overall clinical superiority of any single strategy. Not applicable.