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Duan L, Li J, Chen Z, Wen T, He J, Zhang A. Posterior Hip Pericapsular Block (PHPB) with pericapsular nerve group (PENG) block for hip fracture: a case series. BMC Anesthesiol 2024; 24:352. [PMID: 39354374 PMCID: PMC11443933 DOI: 10.1186/s12871-024-02731-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Accepted: 09/16/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND Pain after total hip arthroplasty (THA) for femoral neck fracture (FNF) can be severe, potentially leading to serious complications. PENG block has become an optional local analgesic strategy in hip fracture surgery, but it cannot provide effective pain relief for the posterior capsule of the hip joint. Therefore, we modified the traditional sacral plexus nerve block and named it Posterior Hip Pericapsule Block (PHPB) to complement the blockade of the relevant nerves innervating the posterior hip capsule region. Thereby, we detail the analgesic effect of PHPB combined with PENG block on five hip fracture patients and the effect on their hip motor function. METHODS This case series was conducted from December 2023 to February 2024. We performed ultrasound-guided PHPB combined with PENG block on five patients with hip fractures. Numerical Rating Scale (NRS) pain scores at rest and maximum NRS pain scores during limb movement of the five patients were recorded within 48 h after surgery. Their hip flexion, abduction, adduction, keen flexion and quadriceps muscle strength were also recorded. Serious postoperative complications, including wound infection, hematoma formation, or nerve injury, were recorded. RESULTS They experienced effective pain control within 48 h postoperatively, with NRS pain scores at rest decreasing from 3.0 (3.0, 4.5) to 0.0 (0.0, 1.0) and maximum NRS pain scores during limb movement from 8.0 (7.5, 8.5) to 1.0 (0.5, 2.0). They can autonomously perform hip flexion, abduction, adduction, and knee flexion within 48 h postoperatively without any signs of movement disorders or quadriceps muscle weakness. No severe postoperative complications, such as wound infections, hematoma formation or nerve damage, were observed in any of the patients. CONCLUSIONS Ultrasound-guided PENG block combined with PHPB provided effective analgesia for hip fracture patients in the perioperative period. It maintained hip joint motor function and quadriceps muscle strength within 24 h after THA.
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Affiliation(s)
- Lei Duan
- Department of Anesthesiology, Xi'an Aerospace General Hospital, Xi'an City, China
| | - Jianzhong Li
- Department of Anesthesiology, Norinco General Hospital, Xi'an City, 710065, China
| | - Zhe Chen
- Department of Joint Surgery, Xi'an Aerospace General Hospital, Xi'an City, China
| | - Tao Wen
- Department of Anesthesiology, Xi'an Aerospace General Hospital, Xi'an City, China
| | - Junyang He
- Department of Anesthesiology, Xi'an Aerospace General Hospital, Xi'an City, China
| | - Afeng Zhang
- Department of Anesthesiology, Xidian Group Hospital, No.97 Fengdeng Road, Lianhu District, Xi'an, 710077, Shaanxi Province, China.
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Atalay YO, Ciftci B, Tekin B, Ansen G, Sakul BU, Cacan MA, Azboy I, Yilmaz B, Alici HA. A Case Series of Deep Subgluteal Block: A New Block Targeting the Missed Portion of the Hip for Analgesia After Total Hip Replacement. A A Pract 2024; 18:e01848. [PMID: 39250338 DOI: 10.1213/xaa.0000000000001848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
The study aimed to evaluate the effectiveness of deep subgluteal block (DSGB) for pain relief after posterolateral-approached total hip replacement. The cadaver study and observational case series assessed the spread and outcomes of ultrasound-guided DSGB. Results showed low postoperative pain scores, minimal opioid requirements, and no complications related to DSGB. Anatomical dissection revealed effective spread of the injected substance. These findings suggest that DSGB could be a promising regional analgesic technique for postoperative pain management after posterolateral-approached total hip replacement.
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Affiliation(s)
| | | | | | | | | | | | | | - Bilge Yilmaz
- Cardiovascular Surgery, Istanbul Medipol University, Istanbul, Turkiye
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Cho TH, Jun B, Yang HM, Kim SH. Comparison of Dye Spread Pattern and Nerve Involvement between Suprainguinal and Infrainguinal Fascia Iliaca Blocks with Different Injectate Volumes: A Cadaveric Evaluation. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1391. [PMID: 39336432 PMCID: PMC11433574 DOI: 10.3390/medicina60091391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 08/13/2024] [Accepted: 08/22/2024] [Indexed: 09/30/2024]
Abstract
Background and Objectives: Fascia iliaca compartment block (FICB) is an effective and relatively safe technique in perioperative pain management for hip surgery. However, blockade of the obturator nerve (ON) using this technique remains controversial. This study aimed to compare dye spread patterns and nerve involvement in the suprainguinal FICB (S-FICB) and infrainguinal FICB (I-FICB) approaches using different volumes of dye. Materials and Methods: Following randomization, 6 S-FICBs and 6 I-FICBs were performed on the left or right sides of 6 unembalmed cadavers. For each block, 30 mL or 60 mL of dye solution was injected. The extent of dye spreading and the staining pattern in the lumbar plexus branches were investigated using anatomical dissection. Results: Twelve injections were successfully completed. The lateral femoral cutaneous nerve (LFCN) and femoral nerve (FN) were consistently stained in all injections. Extended dye spread toward lumbar plexus branches was observed volume-dependently in S-FICBs. However, I-FICBs with an increased volume only showed dye spreading in the caudad direction limited to within the fascia iliaca. When 30 mL of dye was used, the ON was not stained with either approach. A stained ON was only observed in S-FICBs when 60 mL of dye was used. Conclusions: In this cadaveric evaluation, the ON was not stained in either FICB approach with the volume of injectate commonly used in clinical practice. The S-FICBs but not I-FICBs using a high volume of injectate resulted in extended spreading to the lumbar plexus branches.
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Affiliation(s)
- Tae-Hyeon Cho
- Department of Anatomy, College of Korean Medicine, Semyung University, Jecheon-si 27136, Republic of Korea
- Translational Research Unit for Anatomy and Analgesia, Seoul 03722, Republic of Korea
| | - Byongnam Jun
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hun-Mu Yang
- Translational Research Unit for Anatomy and Analgesia, Seoul 03722, Republic of Korea
- Translational Laboratory for Clinical Anatomy, Department of Anatomy, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Surgical Anatomy Education Center, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Shin Hyung Kim
- Translational Research Unit for Anatomy and Analgesia, Seoul 03722, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Safa B, Trinh H, Lansdown A, McHardy PG, Gollish J, Kiss A, Kaustov L, Choi S. Ultrasound-guided suprainguinal fascia iliaca compartment block and early postoperative analgesia after total hip arthroplasty: a randomised controlled trial. Br J Anaesth 2024; 133:146-151. [PMID: 38762396 PMCID: PMC11213984 DOI: 10.1016/j.bja.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Hip replacement surgery can be painful; postoperative analgesia is crucial for comfort and to facilitate recovery. Regional anaesthesia can reduce pain and postoperative opioid requirements. The role of ultrasound-guided suprainguinal fascia iliaca block for analgesia after elective total hip arthroplasty is not well defined. This randomised trial evaluated its analgesic efficacy. METHODS Consenting participants (134) scheduled for elective primary total hip arthroplasty under spinal anaesthesia were randomly allocated to receive ultrasound-guided fascia iliaca block with ropivacaine 0.5% or sham block with saline. The primary outcome was opioid consumption in the first 24 h after surgery. Additional outcomes included pain scores at 4, 8, 12, and 16 h, opioid-related side-effects (nausea, vomiting, pruritis), ability to perform physiotherapy on the first postoperative day, and physiotherapist-assessed quadriceps weakness. RESULTS There were no significant differences in 24-h opioid consumption (block vs sham block, mean difference -3.2 mg oral morphine equivalent, 95% confidence interval -15.3 to 8.1 mg oral morphine equivalent, P=0.55) or any other prespecified outcomes. CONCLUSIONS In patients undergoing primary total hip arthroplasty, ultrasound-guided suprainguinal fascia iliaca block with ropivacaine did not confer a significant opioid-sparing effect compared with sham block. There were no differences in other secondary outcomes including pain scores, opioid-related side-effects, or ability to perform physiotherapy on the first postoperative day. CLINICAL TRIAL REGISTRATION www. CLINICALTRIALS gov (NCT03069183).
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Affiliation(s)
- Ben Safa
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
| | - Hawn Trinh
- University of New South Wales, Sydney, NSW, Australia
| | | | - Paul G McHardy
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jeffrey Gollish
- Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Alex Kiss
- Institute for Evaluative Clinical Sciences, University of Toronto, Toronto, ON, Canada
| | - Lilia Kaustov
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Stephen Choi
- Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
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Huzum RM, Hînganu MV, Huzum B, Hînganu D. Advances in Molecular Research on Hip Joint Impingement-A Vascular Perspective. Biomolecules 2024; 14:784. [PMID: 39062498 PMCID: PMC11275018 DOI: 10.3390/biom14070784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/19/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
With the rise in longevity within the population, medicine continues to encounter fresh hurdles necessitating prompt actions, among which are those associated with hip joint aging. Age-related arthropathies encompass damage to bones' articulating extremities and their supporting structures, such as articular cartilage, and alterations in the quantity and quality of synovial fluid. This study aims to summarize the biomolecular methods of hip joint evaluation focused on its vascularization, using data correlated with biomolecular research on other joints and tissues, in order to reach an objective opinion of the study prospects in this field. Following a retrospective study on most modern biomolecular research methods on the synovium, the capsule, and the articular cartilage of the hip joint, we have hereby concretized certain future research directions in this field that will improve the qualitative and morphofunctional management of the hip joint at an advanced age, even within population categories at risk of developing various degenerative joint pathologies.
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Affiliation(s)
- Riana Maria Huzum
- Department of Radiology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 400347 Iasi, Romania;
| | - Marius Valeriu Hînganu
- Department of Morpho-Functional Sciences I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 400347 Iasi, Romania;
| | - Bogdan Huzum
- Department of Orthopedics and Traumatology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 400347 Iasi, Romania;
| | - Delia Hînganu
- Department of Morpho-Functional Sciences I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 400347 Iasi, Romania;
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Wen H, Zhang W, Wang Y, Lu M. Effects of Different Volumes of Ropivacaine for Pericapsular Nerve Group Block on Incidence of Quadriceps Weakness and Analgesic Efficacy Following Hip Arthroplasty: A Randomized Controlled Trial. Pain Ther 2024; 13:533-541. [PMID: 38478173 PMCID: PMC11111422 DOI: 10.1007/s40122-024-00590-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/28/2024] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION The pericapsular nerve group (PENG) block has been shown to be an effective approach to alleviating pain and reducing the need for opioids among older adults following hip surgery, with possible motor-sparing effects. No reports to date, however, have described appropriate ropivacaine volumes for use in the context of PENG block. The present prospective randomized controlled study was thus developed to assess the quadriceps muscle strength and analgesic efficacy associated with PENG block performed using three different volumes of 0.33% ropivacaine following general anesthesia in older adults undergoing hip arthroplasty. METHODS In this prospective randomized double-blind controlled clinical study, 60 patients were assigned at random to undergo ultrasound-guided PENG block for hip arthroplasty using different volumes of ropivacaine. Specifically, these patients were administered 10 ml (Group A, n = 20), 20 ml (Group B, n = 20), or 30 ml (Group C, n = 20) of 0.33% ropivacaine. Quadriceps muscle strength was evaluated at 6 h post-surgery. Visual analog scale (VAS) scores at rest and with movement were assessed at 4, 6, 12, and 24 h post-surgery. Block duration, adverse event incidence, and patient satisfaction were evaluated at 24 h post-surgery. RESULTS Quadriceps motor block incidence rates at 6 h post-surgery in the 10 ml, 20 ml, and 30 ml groups were 5%, 20%, and 75%, respectively. Quadriceps muscle weakness at 6 h post-surgery was significantly more common in the 30 ml group relative to the others (p < 0.001). Patients administered 10 ml 0.33% ropivacaine exhibited significantly higher VAS pain scores at rest and with movement relative to those patients in the 20 ml and 30 ml treatment groups at all time points (p < 0.05). No apparent differences in analgesic efficacy were observed when comparing the 20 ml and 30 ml groups at 4, 6, 12, and 24 h post-surgery. No significant differences in block duration, satisfaction, or adverse event incidence were observed among groups. CONCLUSIONS The preservation of motor function in the 20 ml 0.33% ropivacaine group was superior to that in the 30 ml 0.33% ropivacaine group. Relative to the group that received 10 ml 0.33% ropivacaine during PENG block, those elderly patients administered 20 ml and 30 ml volumes of 0.33% ropivacaine experienced superior postoperative pain relief following hip arthroplasty.
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Affiliation(s)
- Huaichang Wen
- Department of Anesthesiology, First Affiliated Hospital of Wannan Medical College, No. 2 Zhe Shan Street, Wuhu, 241000, Anhui, China
| | - Weihua Zhang
- Department of Anesthesiology, First Affiliated Hospital of Wannan Medical College, No. 2 Zhe Shan Street, Wuhu, 241000, Anhui, China
| | - Yi Wang
- Department of Anesthesiology, First Affiliated Hospital of Wannan Medical College, No. 2 Zhe Shan Street, Wuhu, 241000, Anhui, China
| | - Meijing Lu
- Department of Anesthesiology, First Affiliated Hospital of Wannan Medical College, No. 2 Zhe Shan Street, Wuhu, 241000, Anhui, China.
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Scott EJ. Editorial Commentary: Hip Arthroscopy Pain Management With Surgeon-Administered Pericapusular Injection Is Fast, Safe, Inexpensive, and Effective. Arthroscopy 2023; 39:2464-2465. [PMID: 37981388 DOI: 10.1016/j.arthro.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 11/21/2023]
Abstract
Regional pain management after hip arthroscopy is challenging. The hip capsule alone has a complex and highly variable innervation, including contributions from articular branches of the femoral, obturator, accessory obturator, accessory femoral, superior gluteal, accessory superior gluteal, inferior gluteal, sciatic, and posterior femoral cutaneous nerves, nerve to the quadratus femoris, as well as a direct supply from the lumbosacral plexus. Thus, it is unrealistic to expect a traditional peripheral nerve block, including blocks of the proximal lumbar plexus, femoral nerve, and fascia iliaca region to provide thorough hip analgesia without inducing quadriceps weakness that could result in a patient experiencing a fall during the postoperative period. In addition, newer, sensory-only blocks, such as quadratus lumborum or pericapsular nerve group blocks, have not been shown to be superior to simple pericapsular injection (PCI). Hip arthroscopy pain management using surgeon administered PCI is fast, safe, inexpensive, and effective. While not perfect, PCI is the best option among current choices.
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Uchida S, Kizaki K, Arjuna MS, Murata Y, Shimozono Y, Miura K, Nakagawa K, Nakamae A, Nakamura T, Sakai T, Kikugawa K, Mae T, Tsuda E, Tohyama H. Arthroscopic Hip Capsular Repair Improves Patient-Reported Outcome Measures and Is Associated With a Decreased Risk of Revision Surgery and Conversion to Total Hip Arthroplasty. Arthrosc Sports Med Rehabil 2023; 5:100800. [PMID: 37854131 PMCID: PMC10579288 DOI: 10.1016/j.asmr.2023.100800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/08/2023] [Indexed: 10/20/2023] Open
Abstract
Purpose To perform a systematic review to assess the effect of capsular repair compared with nonrepair on patient-reported outcome measures (PROMs) and conversion to total hip arthroplasty (THA) after hip arthroscopy in patients with femoroacetabular impingement syndrome. Methods We initially searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PubMed databases, as well as ongoing clinical trials (https://clinicaltrials.gov), on December 15, 2022. The eligibility criteria were randomized controlled trials (Level Ⅰ) and prospective comparative studies (Level II) of patients who underwent capsular repair and nonrepair via hip arthroscopy with a minimum follow-up period of 2 years. We registered this protocol a priori on PROSPERO (identification No. CRD42021239306). We assessed the risk of bias using the Methodological Index for Non-randomized Studies (MINORS) appraisal tool. Results This review included 5 studies with a total of 639 patients (270 with capsular repair [average age, 35.4 years; 41% female patients] and 369 with nonrepair [average age, 37.3 years; 38% female patients]). In the included studies, surgical procedures consisting of labral repair and pincer or cam osteoplasty were performed via hip arthroscopy. The modified Harris Hip Score was measured in all the included studies, and the standardized mean difference in PROMs for capsular repair versus nonrepair in the included studies was 0.42 (95% confidence interval [CI], 0.20 to 0.63). A sensitivity analysis of randomized controlled trials achieved consistent results (standardized mean difference in PROMs, 0.31; 95% CI, 0.02 to 0.60). Capsular repair was not associated with a reduction in revision surgery (risk difference, -0.02; 95% CI, -0.06 to 0.03; 26 of 270 patients with capsular repair vs 42 of 369 with nonrepair) but was associated with a reduction in conversion to THA (risk difference, -0.05; 95% CI -0.09 to -0.01; 12 of 270 patients with capsular repair vs 38 of 369 with nonrepair). The average Methodological Index for Non-randomized Studies (MINORS) score in the included studies was 20. Conclusions Patients who undergo capsular repair in conjunction with other arthroscopic hip preservation techniques have better PROMs and a lower incidence of THA conversion. Level of Evidence Level II, systematic review of Level I and II investigations.
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Affiliation(s)
- Soshi Uchida
- Department of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuha Kizaki
- Department of Surgery, Division of Arthroscopy & Sports Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Maharaj S. Arjuna
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yoichi Murata
- Department of Orthopaedic Surgery, Wakamatsu Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | - Kazutomo Miura
- Department of Orthopaedic Surgery, Kensei Hospital, Hirosaki, Japan
| | - Koichi Nakagawa
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Atsuo Nakamae
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshiyasu Nakamura
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Tokyo, Japan
| | - Tadahiro Sakai
- Department of Orthopaedic Surgery, Toyota Memorial Hospital, Nagoya, Japan
| | | | - Tatsuo Mae
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Nuthep L, Klanarong S, Tangwiwat S. The Analgesic effect of adding ultrasound-guided pericapsular nerve group block to suprainguinal fascia iliaca compartment block for hip fracture surgery: A prospective randomized controlled trial. Medicine (Baltimore) 2023; 102:e35649. [PMID: 37932971 PMCID: PMC10627608 DOI: 10.1097/md.0000000000035649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/22/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Both suprainguinal ultrasound-guided fascia iliaca compartment block (FICB) and pericapsular nerve group (PENG) block have been used to treat pain after hip surgery. Motor-sparing PENG block may further expedite early postoperative rehabilitation. This study aimed to compare the analgesic efficacy and recovery outcome of suprainguinal ultrasound-guided FICB alone with FICB combined with PENG block for hip fracture surgery. METHODS In this study, 59 elderly patients undergoing hip fracture surgery were randomized to receive either FICB alone or combined FICB + PENG block. The primary outcome was pain score at rest 12 hours after surgery as measured by the numerical rating scale (NRS, 0-10) and secondary outcomes were pain scores at rest and with movement measured at other time points within 48 hours, time to first sit up without pain, rescue morphine requirements, opioid-related side effects, incidence of delirium, in-hospital morbidities and mortality, and length of hospital stay. RESULTS Both patient groups had similar demographic profile and postoperative pain scores at rest and with movement. Median NRS pain scores at rest between FICB alone or combined FICB + PENG block at 4, 8, 12, 24, 36 and 48 hours after surgery were 3 versus 3 (P = .31), 3 versus 3 (P = .21) and 3 versus 3 (P = .69), 2 versus 2 (P = .35), 2 versus 3 (P = .17), 3 versus 2 (P = .18) respectively and NRS during movement at 12, 24, 48 hours were 10 versus 8 (P = .30), 6 versus 5 (P = .54) and 3.5 versus 2.0 (P = .64), respectively. There was also no significant difference in the time for patients to first sit up without pain (17.50 vs 19.37 hours vs h; P = .058) or any other secondary outcome measures. The procedure time was, however, significantly longer for the FICB + PENG block (10 vs 5 minutes, P < .001). CONCLUSION Addition of ultrasound-guided PENG block to FICB did not improve postoperative analgesic or recovery outcomes in elderly patients undergoing hip fracture surgery.
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Affiliation(s)
- Luckapa Nuthep
- Department of Anesthesiology, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - Suwattana Klanarong
- Department of Anesthesiology, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - Suwimon Tangwiwat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Tomlinson JCL, Zwirner J, Oorschot DE, Morawski M, Ondruschka B, Zhang M, Hammer N. Microstructural analysis on the innervation of the anterior, medial, and lateral human hip capsule: Preliminary evidence on its neuromechanical contribution. Osteoarthritis Cartilage 2023; 31:1469-1480. [PMID: 37574111 DOI: 10.1016/j.joca.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 06/16/2023] [Accepted: 07/05/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE Capsular repair aims to minimize damage to the hip joint capsular complex (HJCC) and subsequent dislocation risk following total hip arthroplasty (THA). Numerous explanations for its success have been advocated, including neuromuscular feedback loops originating from within the intact HJCC. This research investigates the hypothesis that the HJCC contributes to hip joint stability by analyzing HJCC innervation. METHOD Twenty-nine samples from the anterior, medial, and lateral aspects of the midportion HJCC of 29 individuals were investigated stereologically and immunohistochemically to identify encapsulated mechanoreceptors according to a modified Freeman and Wyke classification, totaling 11,745 sections. Consecutive slices were observed to determine the nerve course within the HJCC. RESULTS Few encapsulated mechanoreceptors were found in the HJCC subregions and overlying tissues across the cohort studied. Of regions studied, no significant regional differences in the density of mechanoreceptors were found. No significant difference in mechanoreceptor density was found between sides (left, 10.2×10-4/mm3, 4.0×10-4 - 19.0×10-4/mm3; right 12.9×10-4/mm3, 5.0×10-4 - 22.0×10-4/mm3; mean, 95% confidence intervals) sexes (female 10.4×10-4/mm3, 4.0×10-4 - 18.0×10-4/mm3; male 11.6×10-4/mm3, 5.0×10-4 - 20.0×10-4/mm3; mean, 95% confidence intervals), nor in correlation with age demographics. Myelinated nerves coursed consistently within the HJCC in various orientations. CONCLUSION Sparse mechanoreceptor density suggests that the HJCC contributes to a limited extent to hip joint stabilization. HJCC nerve terminals may potentially contribute to neuromuscular feedback loops with associated muscles to mediate joint stability in tandem with the active and passive components of the joint.
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Affiliation(s)
- Joanna C L Tomlinson
- School of Anatomy, University of Bristol, Bristol, United Kingdom; Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, Otago, New Zealand.
| | - Johann Zwirner
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Oral Sciences, University of Otago, Dunedin, Otago, New Zealand
| | - Dorothy E Oorschot
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, Otago, New Zealand
| | - Markus Morawski
- Paul Flechsig Institute for Brain Research, Medical Faculty, University of Leipzig, Leipzig, Saxony, Germany
| | - Benjamin Ondruschka
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ming Zhang
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, Otago, New Zealand
| | - Niels Hammer
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Graz, Styria, Austria; Division of Biomechatronics, Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Dresden, Saxony, Germany; Department of Orthopaedic and Trauma Surgery, University of Leipzig, Germany
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Chan A, Ng TKT, Tang BYH. Single-Shot Lumbar Erector Spinae Plane Block in Total Hip Replacement: A Randomized Clinical Trial. Anesth Analg 2022; 135:829-836. [PMID: 35913722 DOI: 10.1213/ane.0000000000006162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Lumbar erector spinae plane block (ESPB) has been proposed to relieve pain after total hip replacement (THR), but high-quality evidence is scarce. METHODS This double-blinded (patient and assessor) randomized clinical trial, performed in 2 tertiary centers in Hong Kong, recruited patients undergoing primary unilateral THR under general anesthesia (GA) who received either single-shot ESPB at L1 (treatment arm) or no block (control arm). Patients were followed up on the first day postoperatively. We hypothesized that compared to no block, a single-shot lumbar ESPB at L1 would reduce postoperative fentanyl use and postoperative pain scores. Primary outcomes were intravenous fentanyl use at 12 and 24 hours postoperatively, along with pain intensity in numeric rating scale (0-10) at rest and upon movement on the first day postoperatively. Per-protocol analysis was performed. Mann-Whitney U test was used to compare the outcomes between both groups, and median difference was derived from the Hodges-Lehmann estimator. RESULTS Seventy-one patients were randomized (n = 36 in treatment arm, n = 35 in control arm). The median amount of fentanyl consumed at 12 hours postoperatively was 210 (quartiles, 140.5-363) μg for the ESPB group and 165 (quartiles, 77.5-330.5) μg for the control group, while at 24 hours postoperatively, it was 409 (quartiles, 221-636.5) μg for the former and 349 (quartiles, 114-626.5) μg for the latter. The median differences in fentanyl consumption 12 and 24 hours postoperatively were 39 μg (95% confidence interval [CI], -40 to 116; P = .463) and 41 μg, respectively (95% CI, -83.5 to 199.5; P = .474), which were statistically insignificant. The median pain score at rest was 3 for both the ESPB group (quartiles, 0-5) and the control group (quartiles, 0-4.5), while upon movement, it was 7 for both the former (quartiles, 6-8) and the latter (quartiles, 4.5-8.5). The median difference in pain scores between both groups was 0 at rest (95% CI, -1 to 1; P = .890) and upon movement (95% CI, -1 to 1; P = .509). CONCLUSIONS This trial did not demonstrate that ESPB at L1 improved analgesia following THR.
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Affiliation(s)
- Anyon Chan
- From the Department of Anesthesia and Operating Theatre Services, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | - Tony K T Ng
- From the Department of Anesthesia and Operating Theatre Services, Tuen Mun Hospital, Tuen Mun, Hong Kong.,Department of Anesthesiology, LKS Faculty of Medicine, the University of Hong Kong, Tuen Mun, Hong Kong.,Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Bruce Y H Tang
- Department of Orthopedics and Traumatology, Tuen Mun Hospital, Tuen Mun, Hong Kong
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A Preliminary Analysis of a Modified Anterior Approach to Hip Pericapsular Neurolysis for Inoperable Hip Fracture Using the IDEAL Framework. Healthcare (Basel) 2022; 10:healthcare10061002. [PMID: 35742053 PMCID: PMC9222877 DOI: 10.3390/healthcare10061002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/09/2022] [Accepted: 05/23/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction: With an increasingly ageing population, there is a growing impact of fragility hip fracture on the healthcare system and on society as a whole. Oral and injectable analgesics are often insufficient whilst traction and regional blocks do not allow patients to be discharged easily. While the conventional approach of ultrasound-guided anterior hip pericapsular neurolysis can help a lot of inoperable hip fracture patients to relieve their fracture pain and facilitate subsequent nursing care, enormous technical challenges are encountered in some cases. In this retrospective case study, we evaluated the overall pain and functional outcomes of our modified approach of anterior hip pericapsular neurolysis for inoperable hip fractures using the IDEAL framework. Method: This retrospective case series studied patients with acute inoperable hip fracture who received the modified approach of anterior hip pericapsular neurolysis from January 2018 to June 2019 according to the IDEAL recommendations. The modified approach consisted of pericapsular nerve group (PENG) injection, iliopsoas plane infiltration, and the sagittal approach of obturator nerve articular branches (ONAB) injection. Subsequent alcohol neurolysis would be performed in the same setting if there were positive diagnostic blocks. Assessments were carried out on post-intervention day 5. The primary outcome was pain intensity during hip flexion at 80 degrees in the recumbent position and during gentle hip internal and external rotation using an appropriate pain scoring tool. The secondary outcomes were the range of tolerable hip flexion and occurrence of any lower limb neurological deficit because of the procedure. Interim outcomes were also briefly evaluated. Results: Among the 74 patients who were reviewed in the study period, the median dynamic pain at hip flexion 80° (p < 0.001) and on gentle hip external and internal rotation (p < 0.001) was significantly reduced from a composite score of 3 (severe pain) to 1 (mild pain) on post-intervention day 5 after the modified approach of hip neurolysis. This translated to 72% of patients achieving satisfactory pain control, which was defined as a composite pain score of ≤1 on hip flexion at 80°. Functionally, the mean range of tolerable hip flexion significantly improved from 39.7° at baseline to 74° on post-intervention day 5 (p < 0.001). Transient and reversible hypotension was seen in about 10% of the patients. No other major procedural adverse event was noted. Interim follow-up at 4−6 months post-intervention revealed that more than 95% of patients continued to have satisfactory dynamic pain control (i.e., composite pain score ≤ 1). According to the IDEAL classification, this study could be ranked as stage 2a (development). Conclusions: Our findings suggested that anterior hip pericapsular neurolysis using a modified approach could offer consistent and satisfactory analgesic and functional benefits to a majority of patients with inoperable hip fractures during the interim of the fracture healing process, and it was potentially safer than the conventional approach. This technique might have achieved its readiness to proceed to the next stage of research according to the IDEAL framework.
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Abd-Elsayed A, Martens JM, Fiala KJ, Schatman ME. Radiofrequency Ablation of the Trochanteric Branches of the Femoral Nerve for the Treatment of Greater Trochanteric Syndrome. J Pain Res 2022; 15:115-122. [PMID: 35058713 PMCID: PMC8765535 DOI: 10.2147/jpr.s343165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/21/2021] [Indexed: 11/23/2022] Open
Abstract
Background Approximately 10–15% of the population over the age of 60 suffers from hip pain. Greater trochanteric pain syndrome (GTPS) is one of the most common diagnoses in patients with chronic hip pain, includes a number of disorders, and has a broad differential diagnosis. Conservative managements of GTPS, including pharmacologic interventions, physical therapy, chiropractic intervention, acupuncture, and more invasive techniques, such as intra-articular injections, commonly fail to provide patients with sufficient, long-term relief. While radiofrequency ablation (RFA) has been used to treat intra-articular hip pain in the past, there is little evidence for the feasibility of RFA for managing patients with GTPS. This case series builds on previous evidence that cooled radiofrequency ablation (CRF) of the trochanteric branch of the femoral nerve may offer patients with GTPS effective, safe, and lasting pain improvement. Cases A series of eight patients with GTPS underwent CRF of the nervus females to the trochanter. CRF procedures were either targeted at the left, right, or bilateral nerves. Conclusion This case series provides additional evidence for the safety and effectiveness of CRF of the nervus femoralis to the trochanter for offering long-term pain relief in patients with GTPS. All patients experienced at least two months of relief, with most patients experiencing ongoing relief from the procedure.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Correspondence: Alaa Abd-Elsayed Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USATel +1 608 263 6039 Email
| | - Joshua M Martens
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kenneth J Fiala
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA
- School of Social Work, North Carolina State University, Raleigh, NC, USA
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Ng TKT, Peng P, Chan WS. Posterior hip pericapsular neurolysis (PHPN) for inoperable hip fracture: an adjunct to anterior hip pericapsular neurolysis. Reg Anesth Pain Med 2021; 46:1080-1084. [PMID: 34686579 DOI: 10.1136/rapm-2021-103023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/02/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The development of anterior hip neurolysis has made an appreciable impact on the management of patients with inoperable hip fracture. Nonetheless, suboptimal analgesic benefit was still observed in some patients. We therefore developed a novel posterior hip pericapsular neurolysis (PHPN) to complement anterior hip neurolysis in inoperable hip fracture. METHODS In this retrospective review, we analyzed patients who responded suboptimally (defined as composite pain score moderate or higher on hip flexion 80°) to the anterior hip neurolysis from July 2019 to March 2021. The patients received additional PHPN if the composite pain score was suboptimal. The percentage of patients with dynamic composite pain scores on hip flexion to 80° and on gentle hip external and internal rotation on post-intervention day 5 was then evaluated. RESULTS Among the 70 patients who were reviewed in the study period, 20 patients who partially responded to anterior hip neurolysis received an addition of diagnostic posterior hip pericapsular block. Eighteen patients were the positive responders and PHPN was then performed. Among the PHPN recipients, a high percentage with satisfactory dynamic pain control was observed with 78% on hip flexion 80° and 83% on hip external/internal rotation on day 5 following the intervention. No procedural adverse event was noted. CONCLUSIONS While most patients responded satisfactorily to anterior hip neurolysis, we concluded PHPN could be an effective adjunct to manage suboptimal pain control after anterior hip neurolysis in inoperable hip fracture. TRIAL REGISTRATION NUMBER NTWC/REC/21061.
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Affiliation(s)
- Tony Kwun-Tung Ng
- Department of Anaesthesia and Operating Theatre Services, Tuen Mun Hospital, Tuen Mun, Hong Kong .,Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Anaesthesiology, the University of Hong Kong, Pokfulam, Hong Kong
| | - Philip Peng
- Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Wing-Sang Chan
- Frankston Pain Management, Melbourne, Victoria, Australia
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