Pericapsular Nerve Group (PENG) Block for Hip Fracture

Combined Pericapsular Nerve Group Block and Intrapelvic Lateral Femoral Cutaneous Nerve Block Is Associated With Decreased Opioid Consumption After Hip Arthroscopy: A Retrospective Cohort Study

Introduction

Ambulatory hip arthroscopies are associated with moderate-to-severe pain often requiring opioid analgesia. Novel motor-sparing blocks, the pericapsular nerve group (PENG) and lateral femoral cutaneous nerve (LFCN) block, have shown efficacy in hip surgery.

Purpose

We sought to investigate the analgesic benefits of these novel blocks in terms of opioid-sparing and discharge efficiency.

Methods

We conducted a retrospective cohort study with propensity score matching of 224 patients who underwent ambulatory elective unilateral hip arthroscopy. One group received a combined PENG and LFCN block (PENG/LFCN, n = 86), while a second group received only a PENG block (n = 26). A control group (n = 112) received no blocks. The primary outcome was postanesthesia care unit (PACU) mean opioid consumption. Secondary outcomes were maximum numeric rating scale (NRS) pain score, intravenous rescue analgesia, and PACU readiness-for-discharge times.

Results

The PENG/LFCN-block group required significantly less opioids than the control group in the PACU (25.98 ± 13.04 vs 14.58 ± 5.77, respectively) and were discharged earlier 2.72 ± 1.16 vs 4.42 ± 1.63 hours, respectively). The combined PENG/LFCN group also used less intravenous rescue opioids than the control group (0.47 ± 1.18 vs 1.44 ± 2.1 mg, respectively) and showed a significant difference in the highest NRS pain scores than the control group (6.01 ± 2.38 vs 6.77 ± 2.1 respectively). The PENG block alone group did not show a significant difference in opioid reduction (21.95 ± 15.83 vs 27.72 ± 15.01, respectively).

Conclusions

This retrospective study found that in patients who underwent ambulatory elective unilateral hip arthroscopy, a combined PENG and LFCN block was associated with expedited PACU discharge and a clinically significant reduction in postoperative opioid use. Further study is warranted.

Comparison of pericapsular nerve group and lateral quadratus lumborum blocks on cumulative opioid consumption after primary total hip arthroplasty: a randomized controlled trial

INTRODUCTION

Both the quadratus lumborum block (QLB) and the pericapsular nerve group (PENG) block provide effective postoperative analgesia after hip surgery while minimizing the impact on motor function. This study aimed to compare QLB and PENG in patients undergoing primary total hip arthroplasty (THA).

METHODS

This superiority trial randomized patients scheduled for elective THA to receive a lateral QLB or a PENG with a lateral femoral cutaneous nerve (LFC) block for postoperative analgesia. Perioperative analgesic protocols were standardized. The primary outcome was postoperative cumulative opioid consumption measured over time up to 72 hours. Secondary outcomes included postoperative pain scores in the first 72 hours, time to ambulation, length of stay, and patient-reported functional outcome measures (Hip disability and Osteoarthritis Outcome Score for Joint Replacement and Patient-Reported Outcome Measures Information System-10 scores).

RESULTS

This trial consented and randomized 106 subjects and 101 were included in the analysis: PENG (n=50), QLB (n=51). Mean (95% CI) opioid consumption in intravenous morphine milligram equivalents differed at 36 hours (mean difference (95% CI), 18.0 (0.80, 35.1); p=0.040), 48 hours (23.0 (5.20, 40.8); p=0.011), 60 hours (28.0 (9.24, 46.7); p=0.004), and 72 hours (33.0 (13.0, 53.0); p=0.001). There were no significant differences between treatment arms in average resting pain score, time to ambulation, rate of same-day discharge, length of stay, or patient-reported functional outcomes.

CONCLUSION

While both lateral QLB and PENG block+LFC block are effective analgesic methods for patients undergoing THA, patients receiving lateral QLB had decreased cumulative opioid consumption from 36 to 72 hours postoperative and lower pain scores with movement compared with patients receiving PENG+LFC blocks.

TRIAL REGISTRATION NUMBER

NCT05710107.

Utilization of the pericapsular nerve group block in preoperative rehabilitation of patients with femoral neck fractures -a case series

BACKGROUND

Elderly patients with femoral neck fractures, particularly those with severe comorbidities or living in regions with limited medical resources, may experience delays in surgical treatment. Although the benefits of preoperative rehabilitation (prehabilitation) in hip arthroplasty have been reported, pain management remains a challenge. The pericapsular nerve group (PENG) block, known for its exceptional analgesic effect and motor function preservation, may be a promising intervention during prehabilitation in these patients.

CASE

We enrolled ten patients with Garden classification 3-4 femoral neck fractures scheduled for hip arthroplasty. After receiving a PENG block with 20 ml of 0.375% ropivacaine, all patients underwent initial prehabilitation sessions comprising 9 mobility levels, ranging from bed-sitting to walking. One patient was excluded due to experiencing high blood pressure during prehabilitation. Six of the nine remaining patients (66.7%) were successfully transferred from bed to wheelchair.

CONCLUSIONS

The PENG block enhanced prehabilitation for patients with femoral neck fractures undergoing hip arthroplasty.

Retrospective Comparison of Quadratus Lumborum and Pericapsular Nerve Group Blocks for Postoperative Pain Management of Patients Undergoing Outpatient Hip Arthroscopy

Introduction

Hip arthroscopy is commonly performed as an outpatient procedure and effective postoperative pain management is important to provide quality patient care and enable timely discharge. Multiple regional nerve blocks have been described for pain relief after hip arthroscopy, but there is no consensus on the optimal technique. This retrospective investigation aimed to compare quadratus lumborum (QL) and pericapsular nerve group (PENG) blocks to determine if there are differences in analgesic outcomes after outpatient hip arthroscopy.

Methods

A total of 50 consecutive patients that received QL block and 50 that received PENG block for outpatient hip arthroscopy were identified and compared to determine if there were any differences in the primary outcome of total perioperative opioid consumption prior to discharge from the surgery center. Important secondary analgesic outcomes include postoperative opioid consumption, verbal rating scale (VRS) pain scores or total time in the recovery area. Summary statistics of relevant variables are compared and reported between study groups (QL versus PENG).

Results

For QL and PENG groups, no significant differences were observed in total perioperative oral morphine equivalents (OME) (69.5 vs 60mg; p=0.40), postoperative OME (15 vs 15.3mg; p=0.96) or maximum pain scores in the recovery area (7.0 vs 6.0; p=0.41). Postoperatively, QL block patients were in PACU for a greater length of time after surgery than PENG block patients (89.5 vs 72 minutes; p<0.001). No patients had uncontrolled pain requiring emergency room visits or hospital admission within 24 hours. No neurologic complications or instances of motor weakness were reported after QL or PENG blocks.

Conclusion

This retrospective study observed similar opioid requirements and pain scores for patients receiving QL versus PENG block for hip arthroscopy, though PENG block patients had shorter times in the recovery area. Prospective, controlled trials are required to further explore and confirm these findings.

Impact of Different Volumes of Pericapsular Nerve Group Block on Pain During Spinal Anesthesia Positioning and Postoperative Opioid Requirements in Femoral Fracture Surgeries; Randomized Prospective Study

Introduction

Hip fracture surgeries in patients present significant challenges, particularly in managing pain during spinal anesthesia positioning. The Pericapsular Nerve Group Block (PENG) has shown promise in addressing this issue, but the ideal volume of local anesthetic for PENG is still uncertain. In our study, we aimed to analyze the effects of administering PENG block with two different volumes on analgesic quality for patients undergoing hip fracture surgery.

Methods

In this prospective, randomized controlled trial, the effects of administering a PENG block with 20 mL versus 30 mL of local anesthetic in patients undergoing hip fracture surgery under spinal anesthesia were compared. The primary outcome was pain during spinal anesthesia positioning, and secondary outcomes included postoperative pain scores and opioid consumption.

Results

A total of 60 patients were analyzed, with 30 in each group. Critical parameters such as the time of spinal anesthesia administration and the satisfaction of the anesthesiologist showed no significant differences (p=0.918; p=0.741, respectively). NRS scores recorded before, during, and after the positioning for spinal anesthesia exhibited similar patterns (p=0.290; p=0.247; p=0.288, respectively). The cumulative opioid requirements did not exhibit a statistically significant difference at 24 hours (p = 0.098). Quadriceps weakness was significantly more in the PENG-30 group 6 hours after surgery but had recovered by the 9th hour (p= 0.004).

Conclusion

In patients undergoing hip fracture surgery, the effects of applying the PENG block with 20 mL or 30 mL of local anesthetic are comparable in terms of positioning for spinal anesthesia and postoperative analgesic requirements.

Ultrasound-Guided Suprainguinal Fascia Iliaca Compartment Block in Patients Undergoing Hip Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The use of fascia iliaca compartment block (FICB) has been widely encouraged for hip surgery; however, meta-analyses showed mixed results in terms of its efficacy in reduction in analgesic consumption and pain score. These meta-analyses included all forms of FICB approaches, which may diminish the effect size of the therapy. Suprainguinal FICB (s-FICB) has been shown to be superior to other FICB approaches including the ultrasound-guided infrainguinal approach and the landmark approach. This systematic review and meta-analysis aim to compare opioid consumption, pain score, and complications after s-FICB to control for patients undergoing hip surgery. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42023460377). We performed a systematic literature search in Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases from inception to 16 August 2023 to identify randomized controlled trials (RCTs) that evaluated the efficacy of s-FICB versus control for patients undergoing hip surgery. Data were independently extracted by two reviewers, and disagreements were resolved by consensus or by discussion with a third investigator. The primary outcome is the 24-hour oral morphine equivalent daily dose (oMMED). The secondary outcome includes oMMED at different timepoints, and pain score. The Cochrane risk of bias tool (Cochrane, London, England) was used to assess the risk of bias. The certainty of evidence was assessed via the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Data were synthesized using a random-effects model. Trial sequence analysis is performed on opioid consumption 24 hours post operation. Eleven randomized controlled trials were included. Arthroscopic hip surgery was performed in three studies involving 222 patients, hip and femur fracture surgeries were performed in three studies involving 149 patients, and total hip arthroplasty was performed in five studies involving 483 patients. In studies involving arthroscopic hip surgery, s-FICB did not improve intra-operative and post-operative opioid consumption and post-operative pain score. In studies involving hip and femur fracture surgeries, s-FICB was associated with a non-significant difference in opioid consumption at 24 hours after surgery and post-operative pain score at 12 hours and 24 hours after surgery. However, the result of the trial sequential analysis (TSA) was not definitive, indicating that additional research is necessary to draw conclusive outcomes. In studies involving total hip arthroplasty, s-FICB was associated with a significant reduction in post-operative opioid consumption at 24 and 48 hours with conclusive results in trial sequential analysis. In conclusion, s-FICB is superior to placebo for patients undergoing total hip arthroplasty. For patients undergoing arthroscopic hip surgery, s-FICB is unlikely to be beneficial. With regard to hip fracture surgery, additional research is necessary to draw conclusive outcomes.

The median effective concentration of ropivacaine for ultrasound-guided anterior iliopsoas muscle space block in the elderly undergoing hip surgery: a dose-finding study

Background

In order to improve perioperative pain and reduce the adverse outcome of severe pain in elderly hip fractures, anterior iliopsoas muscle space block (AIMSB) can be used clinically to reduce pain. The aim of the study is to investigate the 50% effective concentration (EC50) of ropivacaine for ultrasound-guided anterior iliopsoas space block in elderly with hip fracture.

Methods

A total of 27 patients were enrolled with aged ≥65 years, American society of Anesthesiologists (ASA) physical status classification II-III and undergoing Total Hip Arthroplasty (THA). We measured the EC50 using Dixon's up-and-down method. Ultrasound-guided AIMSB was performed preoperatively with an initial concentration of 0.2% in the first patient. After a successful or unsuccessful postoperative analgesia, the concentration of local anesthetic was decreased or increased 0.05%, respectively in the next patient. The successful block effect was defined as no sensation to pinprick in the area with femoral nerve, obturator nerve, and lateral femoral cutaneous nerve in 30 min. Meanwhile, the EC50 of ropivacaine was determined by using linear model, linear-logarithmic model, probit regression model, and centered isotonic regression.

Results

A total of 12 patients (48%) had a successful block. All patients with a successful block had a postoperative visual analog scale score of <4 in the 12 h. The estimated EC50 values in linear model, linear-logarithmic model, probit regression model, and centered isotonic regression (a nonparametric method) were 0.268%, 0.259%, 0.277%, and 0.289%. The residual standard error of linear model was the smallest (0.1245).

Conclusion

The EC50 of ropivacaine in anterior iliopsoas space block under ultrasound guidance is 0.259-0.289%.

Enhancing postoperative recovery in total hip arthroplasty: the role of pericapsular nerve group and lateral cutaneous nerve block under spinal anaesthesia

AIM OF THE STUDY

To compare the efficacy of spinal anaesthesia alone versus spinal anesthesia augmented with ultrasound-guided pericapsular nerve group (PENG) block combined with lateral femoral cutaneous nerve (LFCN) block in improving perioperative analgesia and functional recovery in patients undergoing THA.

METHODS

In a prospective, randomized clinical trial we included 66 patients scheduled for THA were divided into two groups: one receiving spinal anaesthesia alone (SA group; n = 32) and the other receiving spinal anaesthesia with regional analgesia blocks PENG + LFCN (SRAB group; n = 34). In the SRAB group, PENG followed by LFCN blocks were administered under ultrasound guidance before spinal anaesthesia.

RESULTS

There were significant differences between the two groups in the onset of postoperative pain (p < 0.01) and the total amount of analgesics required in the first 36 postoperative hours (p < 0.01).

CONCLUSION

The combined approach of spinal anaesthesia with PENG and LFCN blockade, enables opioid-free analgesia and may contribute to a safer and more comfortable postoperative experience for THA patients.

Ultrasound-Guided Fascia Iliaca Block Versus Pericapsular Nerve Group Block Before Positioning for Spinal Anesthesia in Patients Undergoing Surgery for Neck of Femur Fracture: A Comparative Study

Introduction Positioning patients with femur fractures for spinal anesthesia can be challenging due to pain. Regional anesthesia techniques, such as the fascia iliaca compartment block (FICB) and pericapsular nerve group block (PENG), have facilitated patient positioning and improved analgesia. This study compared the efficacy of ultrasound-guided FICB and PENG for pain management during the positioning of the patient for spinal anesthesia in neck of femur fracture surgeries. Aim of the study Ultrasound-guided fascia iliaca compartment block versus pericapsular nerve group block before positioning for spinal anesthesia in the neck of femur fracture surgeries. Materials and methods This prospective, randomized, single-blinded, and comparative study was conducted at Dr. DY Patil Hospital, Pune, from November 2022 to January 2024 and included 60 patients with neck and femur fractures scheduled for surgery under spinal anesthesia. Patients were randomly assigned to receive either ultrasound-guided FICB (n = 30) or PENG (n = 30) with 0.25% 20 ml of bupivacaine before positioning for spinal anesthesia. The primary outcome was to assess the Visual Analog Scale (VAS) score for pain before and after the block. Secondary outcomes included assessment of hemodynamic parameters, patient satisfaction, and adverse effects. Results The number of days since fracture in FICB was 2.73±0.98 and in PENG was 3.37±1.9 was comparable with no significant difference between them (p-value =0.11). The mean VAS score after the block was significantly lower in the PENG group compared to the FICB group (3.33±1.73 vs. 4.43±1.3, p = 0.007), indicating better pain relief with PENG. Both techniques were comparable in terms of hemodynamic stability. Patient satisfaction was high and similar in both groups. No significant adverse effects were reported. Conclusion This study observed that the ultrasound-guided pericapsular nerve group block was superior to the fascia iliaca block in providing better analgesia, good patient satisfaction, and hemodynamic stability during positioning for spinal anesthesia.

Comparison of Pericapsular Nerve Group and Lateral Quadratus Lumborum Blocks for Analgesia after Primary Total Hip Arthroplasty: A Randomized Controlled Trial

Introduction

The quadratus lumborum block (QLB) and the pericapsular nerve group (PENG) block both provide effective postoperative analgesia after hip surgery while minimizing impact on motor function. This study aimed to compare QLB and PENG in patients undergoing primary total hip arthroplasty.

Methods

This superiority trial randomized patients scheduled for elective total hip arthroplasty to receive a lateral QLB or PENG with lateral femoral cutaneous nerve blocks for postoperative analgesia. Perioperative analgesic protocols were standardized. The primary outcome was postoperative cumulative opioid consumption at 72 hours. Secondary outcome was postoperative pain scores. Additional outcomes of interest included time to first ambulation, length of stay, patient reported outcome measures, and opioid-related side effects.

Results

This trial consented and randomized 106 subjects and 101 were included in analysis: PENG (n=50), QLB (n=51). Mean (95% CI) opioid consumption (IV MME) in the first 72 hours did not differ between PENG [109.6 (93.6, 125.6)] and QL [92.3 (76.6, 107.9)] groups (p=0.129) There were no significant differences between treatment arms in average pain score, time to ambulation, distance ambulated, rate of same day discharge, or hospital length of stay. There were also no differences in patient reported outcomes using HOOS-JR and PROMIS-10 scores.

Conclusion

Patients undergoing primary THA receiving preoperative PENG vs QLB had similar opioid consumption, pain scores, time to ambulation, and hospital length of stay. Both QL and PENG blocks are analgesic options in patients undergoing primary THA.

Clinical Trials Registration

NCT05710107; www.ClinicalTrial.gov IRB Protocol ID: Pro00124880.

Key message

Pericapsular nerve group (PENG) block may provide analgesia after hip arthroplasty and improve early functional recovery. This study evaluated postoperative opioid consumption in patients randomized to PENG or lateral quadratus lumborum block (QLB).Opioid consumption, pain scores, motor recovery, and functional outcome measures did not differ in patients randomized to PENG vs lateral QLB.PENG and lateral QLBs are analgesic options following total hip arthroplasty with similar rates of same day discharge.

Pericapsular nerve group block: a 3D CT scan imaging study to determine the spread of injectate

BACKGROUND

Current understanding of the mechanism of action of the pericapsular nerve group (PENG) block is primarily based on cadaver studies. We performed an imaging study in patients undergoing hip surgery to enhance the understanding of the analgesic mechanisms following a PENG block.

MATERIALS AND METHODS

10 patients scheduled for hip surgery received an ultrasound-guided PENG block with 18 mL of 0.5% ropivacaine mixed with 2 mL of a contrast agent. After completion of the block, a high-resolution CT scan was performed to obtain a three-dimensional reconstruction of the injectate's dispersion.

RESULTS

The CT imaging revealed that injectate was mainly confined to the epimysium of the iliacus and the psoas muscle, with a minor spread to the hip capsule. Contrast dye was detected within the iliacus and/or the psoas muscle in all patients. No observed spread to either the subpectineal plane or the obturator foramen was detected.

CONCLUSION

Our study suggests that the analgesic effect of the PENG block may be related to the block of the branches of the femoral nerve traveling within the iliopsoas muscle without a spread pattern commensurate with the block of the obturator nerve.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT06062134).

Comparison of analgesic effect of pericapsular nerve group block and supra-inguinal fascia iliaca compartment block on dynamic pain in patients with hip fractures: a randomized controlled trial

BACKGROUND

Patients with hip fracture often experience severe pain, particularly during movement or slight positional change, prior to the occurrence of surgery. It is essential to explore the appropriate analgesic methods before surgery in patients with hip fracture, especially those capable of alleviating dynamic pain. Pericapsular nerve group (PENG) block was introduced as a useful technique for hip analgesia. In this study, we aimed to compare the reduction in dynamic pain between the PENG block and supra-inguinal fascia iliaca compartment block (SIFICB).

METHODS

This prospective trial included 80 hip fracture patients aged ≥19 years, with an American Society of Anesthesiologists Physical Status of 1-4 and a baseline dynamic pain score ≥4 on the numerical rating scale. The patients were randomly allocated into the PENG block (n=40) and SIFICB group (n=40). For the PENG block and SIFICB, 20 mL and 30 mL of 0.3% ropivacaine was used, respectively. The primary outcome was reduction in dynamic pain scores at 30 min following the peripheral nerve block. Dynamic pain score was evaluated when the leg was passively raised.

RESULTS

A total of 79 patients were included in the final analysis, and the reductions in pain score during hip flexion were 3.1±2.4 and 2.9±2.5 in the PENG block and SIFICB groups, respectively, which was statistically insignificant (p=0.75). Moreover, no significant differences were observed in any of the outcomes.

CONCLUSIONS

PENG block and SIFICB could effectively provide analgesia for dynamic pain in patients with hip fractures, with no significant difference between the two groups.

TRIAL REGISTRATION NUMBER

NCT04677348.

Chemical neurolysis for the conservative treatment of hip fractures

Aim: Hip fracture management is challenging when surgical risks outweigh benefits. Inadequate analgesia from conservative treatments prompted new procedures targeting hip capsule denervation. This study evaluates the efficacy and safety of single injection chemical hip neurolysis in the pericapsular nerve group plane.Materials & methods: In eligible patients, an ultrasound-guided diagnostic block was performed using 5 ml of 2% lidocaine in the pericapsular nerve group plane. If positive, 6 ml of 99.9% alcohol was administered.Results: From May 2022 to May 2023, five patients underwent hip neurolysis. None reported pain at day 5 or during follow-up. There were no adverse effects.Conclusion: Chemical neurolysis seems to provide effective and safe conservative treatment for hip fractures, offering reliable analgesia for nonsurgical candidates.

Regional Anesthesia for Hip Arthroscopy

Pain after hip arthroscopy can be severe, yet we lack a consensus method for non-narcotic analgesia. Here we describe anatomic elements of hip arthroscopy and our current understanding of the relevant sensory innervation as a prelude to the evaluation of locoregional analgesic techniques. Many regional nerve blocks and local anesthetic infiltration techniques are reviewed, including 2 newer ultrasound fascial plane blocks. Further study of targeted, motor-sparing approaches, either ultrasound-guided or under direct surgical visualization is needed.

Use and Clinical Relevancy of Pericapsular Nerve Block (PENG) in Total Hip Arthroplasty: A Systematic Review and Meta-analysis

BACKGROUND

Ultrasound-guided pericapsular nerve group (PENG) block is an emerging regional anesthesia technique that may provide analgesia for patients undergoing total hip arthroplasties (THA). There are clinical studies comparing this fascial plane block to other established methods; however, evidence on the actual efficacy of this block for THA continues to evolve.

OBJECTIVE

Available clinical studies conducted over the past 4 years were reviewed to evaluate the analgesic efficacy and effectiveness of PENG block in patients undergoing THAs.

METHODS

A meta-analysis of randomized controlled trials (RCTs) in patients undergoing THA, where PENG block was compared to no block, placebo/sham block (injection with saline), or other analgesic techniques including suprainguinal fascia iliaca block (FIB), or periarticular infiltration (PAI) was performed. Our primary outcome was opioid consumption during the first 24 hours. Secondary outcomes were postoperative rest and dynamic pain scores at 6-12, 24 and 48 hours, block performance time, sensory-motor assessment, quadriceps weakness, the incidence of postoperative falls, first analgesic request, block and opioid-related complications, surgical complications, patient satisfaction scores, postanesthesia care unit length of stay, hospital length of stay, and functional and quality of life outcomes.

RESULTS

We included 12 RCTs with a total of 705 patients. Data showed that PENG block decreased 24-hour oral morphine milligram equivalent consumption by a mean difference (MD) of 3.75 mg (95% CI: -5.96,-1.54; P =0.0009). No statistically significant differences in rest or dynamic pain were found, except for a modest MD reduction in dynamic pain score of 0.55 points (95% CI: -0.98, -0.12; P =0.01), measured 24 hours after surgery in favor of PENG block.

CONCLUSIONS

Our systematic review and meta-analysis suggest that PENG block provides better analgesia, measured as MME use, in the first 24 hours after THA, with no real impact on postoperative VAS scores. Despite statistical significance, the high heterogeneity across RCTs implies that PENG's benefits may not surpass the minimal clinically important difference threshold for us to recommend PENG as best practice in THA.

The efficacy of pericapsular nerve group block for reducing pain and opioid consumption after total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

Pericapsular nerve group block (PENG) is an emerging regional anesthesia technique for hip surgery. However, its efficacy in total hip arthroplasty (THA) isn't well defined. We perform this meta-analysis aiming to assess the effect of Pericapsular nerve group block on pain control and morphine consumption in patients with total hip arthroplasty.

METHODS

We searched four electronic databases (Pubmed, Embase, Cochrane Library, and Web of Science dated from 2018 to October 2023) for published eligible randomized controlled trials (RCTs) comparing PENG with placebo (no block/sham block) after THA. The outcome measurements consisted of pain score, opioid consumption, Time to first opioid, and postoperative complications. All data analyses were performed using STATA 12.0.

RESULTS

Five RCTs comprising 808 participants were included. Our meta-analysis showed that there were significant differences between two groups in terms of pain score in PACU (WMD =  - 0.598, 95% CI [- 0.886, - 0.310], P < 0.001), pain score at 6 h (WMD =  - 0.614, 95% CI [- 0.835, - 0.392], P < 0.001) and time to first opioid (WMD = 5.214, 95% CI [4.545, 5.883], P < 0.001). However, no significant differences were revealed from the pain score at 24 h after THA (WMD =  - 0.924, 95% CI [- 1.929, 0.081], P = 0.072). Meanwhile, the meta-analysis indicated that PENG significantly reduced 24-h opioid consumption (WMD =  - 6.168, 95% CI [- 6.667, - 5.668], P < 0.001) and 48-h opioid consumption (WMD =  - 7.171, 95% CI [- 8.994, - 5.348], P < 0.001).

CONCLUSION

Pericapsular nerve group block was effective for pain control up to postoperative 6 h and extending the time to the first opioid after THA. Moreover, it reduced postoperative opioid consumption when compared with a placebo group. Due to the high heterogeneity of the pain score after 24 h and the low-quality evidence, more high-quality RCTs are required to draw a definitive conclusion about pain control.

Evaluating Pain Management from Peripheral Nerve Block for Geriatric Patients following Bipolar Hemiarthroplasty for Displaced Femoral-Neck Fracture

INTRODUCTION

The purpose of this study was to evaluate peripheral nerve block (PNB) effectiveness in postoperative pain management and surgical outcomes for displaced femoral-neck fracture in geriatric patients (>70 years) who underwent bipolar hemiarthroplasty (BHA).

METHODS

From January 2017 to December 2021, 231 geriatric patients with displaced femoral-neck fracture who consecutively underwent BHA were retrospectively reviewed. Patients were divided into two groups: the patient-controlled analgesia (PCA) group (n = 132) who received only intravenous (IV) PCA for postoperative pain management, and all others who received PNB with IV PCA (PNB+PCA) such as femoral nerve block or fascia iliaca compartment block after surgery (n = 99). Primary outcomes were postoperative visual analog scale (VAS) at rest and during activity at 6, 24, and 48 h postoperatively. Secondary outcomes were postoperative complications, changes in hemoglobin, length of hospital stay, and total morphine usage after surgery.

RESULTS

Postoperative resting VAS at 6 h and 48 h was significantly lower in the PNB+PCA group compared with the PCA group (p = 0.075, p = 0.0318, respectively). However, there was no significant difference in either resting VAS at 24 h or active VAS. Complications of pneumonia and delirium until 1 month postoperative were significantly lower in the PNB + PCA group than the PCA group (p = 0.0022, p = 0.0055, respectively).

CONCLUSION

PNB with IV PCA seems to have a beneficial effect on geriatric femoral-neck patients who underwent BHA with postoperative analgesia for reducing postoperative resting pain and complications, especially pneumonia and delirium.

Bilateral pericapsular end nerve blocks for steroid-induced avascular necrosis following COVID-19 infection requiring bilateral total hip replacement

BACKGROUND

Osteonecrosis or avascular necrosis (AVN) of the hip was one of the dreaded complications of coronavirus disease 2019 (COVID-19), which emerged in patients who received steroid therapy. Corticosteroids have been a mainstay in the treatment protocol of COVID-19 patients. Popular corticosteroid drugs used in patients suffering from COVID-19 were intravenous (IV) or oral dexamethasone, methylprednisolone or hydrocortisone. The use of such high doses of corticosteroids has shown very positive results and has been lifesaving in many cases. Still, long-term consequences were drug-induced diabetes, osteoporosis, Cushing syndrome, muscle wasting, peripheral fat mobilization, AVN, hirsutism, sleep disturbances and poor wound healing. A significant number of young patients were admitted for bilateral total hip replacements (THR) secondary to AVN following steroid use for COVID-19 treatment.

AIM

To assess the efficacy of bilateral pericapsular end nerve group (PENG) blocks in patients posted for bilateral THR post-steroid therapy after COVID-19 infection and assess the time taken to first ambulate after surgery.

METHODS

This prospective observational study was conducted between January 2023 and August 2023 at Care Hospitals, Hyderabad, India. Twenty young patients 30-35 years of age who underwent bilateral THR were studied after due consent over 8 months. All the patients received spinal anaesthesia for surgery and bilateral PENG blocks for postoperative analgesia.

RESULTS

The duration of surgery was 2.5 h on average. Seventeen out of twenty patients (85%) had a Visual Analog Score (VAS) of less than 2 and did not require any supplementation. One patient was removed from the study, as he required re-exploration. The remaining two patients had a VAS of more than 8 and received IV morphine post-operatively as a rescue analgesic drug. Fifteen out of seventeen patients (88.2%) could be mobilized 12 h after the procedure.

CONCLUSION

Osteonecrosis or AVN of the hip was one of the dreaded complications of COVID-19, which surfaced in patients who received steroid therapy requiring surgical intervention. Bilateral PENG block is an effective technique to provide post-operative analgesia resulting in early mobilization and enhanced recovery after surgery.

Efficacy and safety of pericapsular nerve group block in total hip arthroplasty: a meta-analysis and systematic review

INTRODUCTION

Ensuring effective perioperative pain control is a crucial aspect of rehabilitation programs following total hip arthroplasty. This study presents a comprehensive meta-analysis and systematic review to assess the efficacy and safety of pericapsular nerve group block (PENG) in the context of total hip arthroplasty.

EVIDENCE ACQUISITION

A systematic search was conducted in multiple databases, including PubMed, Embase, Cochrane Library, and Web of Science, to identify relevant randomized controlled studies investigating the efficacy and safety of PENG for total hip arthroplasty. The search was conducted up until 1st June 2023. Data analysis was performed using Stata v. 15.0.

EVIDENCE SYNTHESIS

A total of 721 individuals participated in this study, which included 13 randomized controlled trials. Among them, 377 individuals were assigned to the experimental group, while 344 individuals were assigned to the control group. The findings from the meta-analysis indicated that the application of PENG yielded favorable outcomes in terms of reducing six-hour pain scores (SMD=-0.63, 95% CI -1.18, -0.09) and 24-hour pain scores (SMD=-1.45, 95% CI -2.51, -0.29). Moreover, it was found to decrease opioid consumption (SMD=-0.84, 95% CI -1.35, -0.34), without causing a significant increase in nausea and vomiting (RR=0.75, 95% CI 0.45, 1.23) or urinary retention (RR=2.46, 95% CI 0.49, 12.31).

CONCLUSIONS

Based on the latest findings, PENG has been shown to effectively decrease pain scores within six and 24 hours following total hip arthroplasty. However, its effectiveness in pain control diminishes after 48 hours. Additionally, PENG has demonstrated the ability to reduce opioid consumption without an accompanying increase in adverse drug events.

[Old and New Regional Anesthesia Procedures Under Review - Abdomen to Toe]

Ultrasound (US) technology has significantly expanded the spectrum of regional anesthesiological procedures in recent years. Abdominal wall blocks are becoming an increasingly integral part of a multimodal postoperative pain concept after abdominal surgery, gynecological or urological interventions. Thoracic epidural analgesia remains the gold standard for extensive surgery. The requirement for rapid postoperative mobilization and discharge after lower extremity surgery has led to the abandonment of neuroaxial or plexus blocks in favor of selective, peripheral blocks such as the PENG block or adductor canal block. The following article is intended to show the reader the change in the use of regional anesthesiological procedures for abdominal wall and lower extremity blocks using selected blockages.

Comparative Evaluation of Analgesic Efficacy of Ultrasound-Guided Pericapsular Nerve Group Block and Femoral Nerve Block During Positioning of Patients With Hip Fractures for Spinal Anesthesia: A Prospective, Double-Blind, Randomized Controlled Study

INTRODUCTION

Hip fractures cause severe pain during positioning for spinal anesthesia (SA). Intravenous systemic analgesics can lead to various complications in elderly patients, hence peripheral nerve blocks are emerging as a standard of care in pain management for hip fractures, among which femoral nerve block (FNB) is widely known and practiced. Pericapsular nerve group (PENG) block is a recently described technique that blocks the articular nerves of the hip with motor-sparing effects and is used to manage positional pain in hip fractures. This study aims to evaluate the analgesic efficacy of PENG block over FNB in managing pain during positioning before SA in hip fractures.

MATERIALS AND METHODS

This was a prospective, randomized, double-blinded study. After ethical clearance, 70 patients undergoing hip fracture surgery under SA in a tertiary-care hospital were recruited and randomized to receive either ultrasound-guided PENG block or FNB with 20 ml of 0.25% bupivacaine before performing SA. We compared pain severity using the visual analog scale (VAS) 15 and 30 minutes after the block and during positioning. The sitting angle, requirement of rescue analgesia for positioning, and anesthesiologist and patient satisfaction scores were also analyzed. Continuous data were analyzed with an unpaired t-test while the chi-square test was used for categorical data.

RESULTS

There was a significant reduction in VAS scores after PENG block (PENG: 0.66 ± 1.05 and FNB: 1.94 ± 1.90; p = 0.001) with lesser requirement of rescue analgesia for positioning compared to FNB. The anesthesiologist and patient satisfaction scores were also significantly better in the PENG group.

CONCLUSION

PENG block offers better analgesia for positioning before SA than FNB without any significant side effects, and improves patient and anesthesiologist satisfaction, thus proving to be an effective analgesic alternative for painful hip fractures.

Effect of Pericapsular Nerve Group Block with Different Concentrations and Volumes of Ropivacaine on Functional Recovery in Total Hip Arthroplasty: A Randomized, Observer-Masked, Controlled Trial

Purpose

The pericapsular nerve group (PENG) block provides satisfactory postoperative analgesia without hampering motor function for total hip arthroplasty (THA); however, unexpected motor block has been observed clinically. It is unknown whether this motor block is related to the dose of ropivacaine. We aimed to conduct a prospective randomized trial to test whether reducing the volume or concentration of ropivacaine was better for less motor block after PENG block.

Patients and Methods

Ninety-nine patients with fracture or femoral head necrosis scheduled for THA were randomly allocated to receive 20 mL 0.5% ropivacaine (Group A), 20 mL 0.25% ropivacaine (Group B), and 10 mL 0.5% ropivacaine (Group C). The primary outcome was the incidence of postoperative quadriceps motor block at 6 hours. Secondary outcomes were the incidence of postoperative quadriceps motor block at 0, 12, 24 and 48 hours; pain scores on the numeric rating scale (NRS) at all postoperative time points (0, 6, 12, 24, and 48 hours); the time to first walk; the incidence of rescue analgesia; side effects such as dizziness, ache, nausea, and vomiting; and patient satisfaction.

Results

Compared with Group A, Group C resulted in a lower incidence of quadriceps motor block at 0 hours, 6 hours and 12 hours postoperatively (P < 0.05), while Group B only resulted in a lower incidence of motor block at 12 hours postoperatively (P < 0.05). No intergroup differences were found in terms of postoperative pain scores, the incidence of rescue analgesia, adverse events or patient satisfaction (P > 0.05).

Conclusion

A higher incidence of motor blockade was observed when 20 mL of 0.5% ropivacaine was administered, which was mainly caused by the excessive volume. Therefore, we recommend performing PENG block with 10 mL 0.5% ropivacaine.

Combination of Pericapsular Nerve Group (PENG) and Sacral Erector Spinae Plane (S-ESP) Blocks for Hip Fracture Pain and Surgery: A Case Series

A hip fracture is a serious injury with life-threatening complications, and its risk rises with increasing age. A hip fracture can be a very painful condition, and prompt surgical treatment is recommended to reduce pain and complications. Pain management is considered integral to the management of a broken hip. The choice between general and regional anesthesia in hip fracture surgery continues to be a topic of debate because risks are potentially associated with both approaches. Nerve blockades have proven to be effective in reducing acute pain after a hip fracture and in the perioperative period. For this reason, many regional techniques have been introduced, such as the lumbar plexus block, fascia iliac block, femoral nerve block, and recently, the pericapsular nerve group (PENG) block. Hip joint innervation is complex, not limited to the lumbar plexus but also depending on the sciatic nerve and branches of the sacral plexus (superior and inferior gluteal nerves and an articular branch from the quadratus femoris nerve). We hypothesized that a combination of two emerging regional anesthesia techniques, such as the PENG block and sacral erector spinae plane (S-ESP) block, could represent a good option to obtain pain control of the whole hip joint without opioid administration intraoperatively and postoperatively. Here, we report the cases of three frail patients with significant comorbidities who underwent hip fracture surgery (two cases of intramedullary nailing and one hemiarthroplasty), in which we preoperatively performed PENG and S-ESP blocks. We registered optimal intraoperative and postoperative pain control up to 48 hours after surgery without complications and without opioid administration, allowing the surgery to be performed with intravenous sedation or laryngeal mask general anesthesia. The surgeries were uneventful, and no complications were reported. This approach warrants further investigation in hip fracture surgery.

Iliopsoas plane block does not improve pain after primary total hip arthroplasty in the presence of multimodal analgesia: a single institution randomized controlled trial

BACKGROUND

The clinical analgesic efficacy of iliopsoas plane block remains a subject of discussion. This study aimed to assess the analgesic efficacy of iliopsoas plane block under general anesthesia using multimodal analgesia.

METHODS

Fifty-six adult patients who underwent elective primary hip arthroplasty were enrolled. Patients were randomized to receive either a single-shot iliopsoas plane block (10 mL 0.75% ropivacaine with 1:200 000 epinephrine) or a sham block (10 mL normal saline). All patients received general anesthesia, multimodal analgesia (preoperative buprenorphine patch, 5 µg/h), intraoperative intravenous dexamethasone (8 mg) and nefopam (20 mg), and round-the-clock acetaminophen and celecoxib. The primary outcome was the numeric rating scale pain score at rest 6 hour after surgery.

RESULTS

Iliopsoas plane block did not have a notable advantage over the sham block in terms of pain relief at rest, as assessed by the numeric rating scale score, 6 hour after total hip arthroplasty (iliopsoas plane block: median, 4.0; IQR, 2.0-5.8; sham: median, 5.5; IQR, 2.3-6.8; median difference, -1.0; 95% CI -2.0 to 0.0; p≥0.999). Linear mixed model analysis showed no differences in pain scores, opioid consumption, quadriceps strength, or quality of recovery between the groups.

CONCLUSIONS

Iliopsoas plane block did not improve postoperative analgesia following total hip arthroplasty under general anesthesia with a multimodal analgesic regimen. The blockade of sensory femoral branches supplying the anterior hip capsule using iliopsoas plane block may not yield additional benefits concerning patient outcomes in the aforementioned clinical context.

TRIAL REGISTRATION NUMBER

NCT05212038, https://clinicaltrials.gov/ct2/show/NCT05212038.

Ultrasound-Guided Peripheral Nerve Blocks for Hip Surgery: A Concise Perspective

Ultrasound implementation for the facilitation of peripheral nerve blocks is well established. Ultrasound-guided lumbar plexus, femoral, fascia iliaca and supra-inguinal fascia iliaca compartment, pericapsular nerve group and quadratus lumborum nerve blocks have been employed for analgesia purposes in hip surgery. The combination of motor-sparing regional anesthesia strategies for optimal postoperative pain control with recovery protocols targeting to early and safe patients' mobilization constitute the current dogma of orthopedic surgery. Therefore, this editorial sets out to revisit the role of peripheral nerve blocks in postoperative pain management of hip surgery patients, under the prism of current orthopedic practice.

Comparison of the pericapsular nerve group block with the intra-articular and quadratus lumborum blocks in primary total hip arthroplasty: a randomized controlled trial

BACKGROUND

The pericapsular nerve group (PENG) block, quadratus lumborum block (QLB), and intra-articular (IA) local anesthetic injection have been shown to provide effective analgesia in total hip arthroplasty (THA). This randomized study aimed to compare the analgesic efficacy, motor protection, and quality of recovery associated with the PENG block, QLB, and IA injection.

METHODS

Eighty-nine patients who underwent a unilateral primary THA under spinal anesthesia were randomly assigned to the PENG (n=30), QLB (n=30), or IA (n=29) group. The primary outcome was the numerical rating scale (NRS) score over the first 48 h postoperatively. The secondary outcomes were postoperative opioid consumption, quadriceps and adductor muscle strength, and quality of recovery (QoR-40).

RESULTS

The dynamic (with movement) NRS scores at 3 and 6 h postoperatively were significantly lower in the PENG and QLB groups compared to the IA group (P = 0.002 and P < 0.001, respectively). The time to first opioid analgesia requirement was longer in the PENG and QLB groups than in the IA group (P = 0.009 and P = 0.016, respectively). A provided better preservation was found in the the PENG group than in the QLB group in terms of quadriceps muscle strength at 3 h postoperatively (P = 0.007) and time to mobilization (P = 0.003). No significant differences in the QoR-40 scores were seen.

CONCLUSIONS

The PENG and QLB groups showed similar analgesic effects and both showed more effective analgesia 6 h postoperatively than the IA group. All the groups showed similar postoperative quality of recovery.

Comparison of Pericapsular Nerve Group (PENG) Block Versus Quadratus Lumborum (QL) Block for Analgesia After Primary Total Hip Arthroplasty Under Spinal Anesthesia: A Retrospective Study

BACKGROUND

Total hip arthroplasty (THA) is one of the most common operative procedures performed. Controlling postoperative pain following THA remains a challenge due to the complex innervation of the hip joint and the recent desire to preserve motor function following nerve blockade. Several nerve block techniques have been used for THA in the past, but the quadratus lumborum (QL) block and the blockade of the pericapsular nerve group (PENG) have emerged as opiate-sparing regional anesthesia techniques that preserve motor function. To date, little data comparing the two block techniques exists. The purpose of our study was to compare outcomes following these techniques in patients undergoing primary THA.

MATERIALS AND METHODS

This retrospective analysis utilized data from three distinct groups who underwent primary THA at our institution: 45 patients who received PENG block, 38 patients who received QL block, and 77 control patients. Chart review analysis was performed by authorized personnel to obtain cumulative oral morphine equivalent (OME) data at 24 and 48 hours postoperatively (primary outcomes). In addition, visual analog pain scale (VAS) scores in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours, ambulation distance, and length of hospital stay data were obtained (secondary outcomes). Group comparisons were conducted using either analysis of variance (ANOVA) with Tukey's multiple comparison test for parametric data or Krustal-Wallis with Dunn's multiple comparison tests for nonparametric endpoints.

RESULTS

This study found a statistically significant difference in cumulative OME usage across all groups at 24 and 48 hours. Significant difference in OMEs was found between QL and control and PENG and control; however, no difference was found in OMEs between PENG and QL groups at either time point. There was a statistically significant difference in VAS scores in the PACU across all groups; QL showed significantly lower VAS scores in the PACU compared to PENG and control, while PENG only showed significantly lower VAS scores compared to control. There was a statistically significant difference in VAS scores at 24 hours across all groups; however, only QL showed significantly lower VAS scores compared to control at 24 hours. QL was associated with a statistically significant increase in the length of hospital stay compared to PENG.

CONCLUSION

This study showed no difference between OME usage in patients who received PENG or QL nerve blocks for primary THA. VAS scores were similar between groups with the exception of QL outperforming PENG in the PACU. Optimizing postoperative pain via multi-approach strategies should remain a priority for patients undergoing THA. Future research is warranted in order to provide guidance on best practice for these patients.

Efficacy of iliopsoas plane block for patients undergoing hip arthroscopy: a prospective, triple-blind, randomized, placebo-controlled trial

BACKGROUND

Intraoperative stretching of the hip joint capsule often generates severe pain during the first 3 hours after hip arthroscopy. The short-lived severe pain mandates high opioid consumption, which may result in adverse events and delay recovery. The femoral nerve nociceptors are located anteriorly in the hip joint capsule. A femoral nerve block reduces pain and opioid demand after hip arthroscopy. It impedes, however, ambulation and home discharge after outpatient surgery. The iliopsoas plane block selectively anesthetizes the femoral sensory nerve branches innervating the hip joint capsule without compromising ambulation. We aimed to assess reduction of opioid consumption after iliopsoas plane block during the short-lived painful postsurgical period of time after hip arthroscopy.

METHODS

In a randomized, triple-blind trial, 50 patients scheduled for hip arthroscopy in general anesthesia were allocated to active or placebo iliopsoas plane block. The primary outcome was opioid consumption during the first three postoperative hours in the postanesthesia care unit. Secondary outcomes included pain, nausea, and ability to ambulate.

RESULTS

Forty-nine patients were analyzed for the primary outcome. The mean 3-hour intravenous morphine equivalent consumption in the iliopsoas plane block group was 10.4 mg vs 23.8 mg in the placebo group (p<0.001). No intergroup differences were observed for the secondary outcomes during the postoperative follow-up.

CONCLUSION

An iliopsoas plane block reduces opioid consumption after hip arthroscopy. The reduction of opioid consumption during the clinically relevant 3-hour postsurgical period of time was larger than 50% for active versus placebo iliopsoas plane block in this randomized, triple-blind trial.

Cadaveric study investigating the femoral nerve-sparing volume for pericapsular nerve group (PENG) block

BACKGROUND

This cadaveric study investigated the maximum effective volume of dye in 90% of cases (MEV90) required to stain the iliac bone between the anterior inferior iliac spine (AIIS) and the iliopubic eminence (IPE) while sparing the femoral nerve during the performance of pericapsular nerve group (PENG) block.

METHODS

In cadaveric hemipelvis specimens, the ultrasound transducer was placed in a transverse orientation, medial and caudal to the anterior superior iliac spine in order to identify the AIIS, the IPE and the psoas tendon. Using an in-plane technique and a lateral-to-medial direction, the block needle was advanced until its tip contacted the iliac bone. The dye (0.1% methylene blue) was injected between the periosteum and psoas tendon. Successful femoral-sparing PENG block was defined as the non-staining of the femoral nerve on dissection. Volume assignment was carried out using a biased coin design, whereby the volume of dye administered to each cadaveric specimen depended on the response of the previous one. In case of failure (ie, stained femoral nerve), the next one received a lower volume (defined as the previous volume with a decrement of 2 mL). If the previous cadaveric specimen had a successful block (ie, non-stained femoral nerve), the next one was randomized to a higher volume (defined as the previous volume with an increment of 2 mL), with a probability of b=1/9, or the same volume, with a probability of 1-b=8/9.

RESULTS

A total of 32 cadavers (54 cadaveric hemipelvis specimens) were included in the study. Using isotonic regression and bootstrap CI, the MEV90 for femoral-sparing PENG block was estimated to be 13.2 mL (95% CI: 12.0 to 20.0). The probability of a successful response was estimated to be 0.93 (95% CI: 0.81 to 1.00).

CONCLUSION

For PENG block, the MEV90 of methylene blue required to spare the femoral nerve in a cadaveric model is 13.2 mL. Further studies are required to correlate this finding with the MEV90 of local anesthetic in live subjects.

Pericapsular nerve group (PENG) block for early pain management of elderly patients with hip fracture: a single-center double-blind randomized controlled trial

BACKGROUND

The pericapsular nerve group block (PENG) is a novel technique that blocks the articular branches of the hip joint. This study aimed to compare its effectiveness to a sham block in elderly patients with hip fractures.

METHOD

A randomized double-blind controlled trial was conducted in elderly patients with intertrochanteric and neck of femur fractures. Patients were randomized to receive either PENG block or a sham block. Postblock, systemic analgesia was titrated using a standardized protocol of acetaminophen, oral morphine or patient-controlled analgesia. The primary outcome was the dynamic pain score (Numerical Rating Scale 0-10) at 30 min postblock. Secondary outcomes included pain scores at multiple other time points and 24-hour opioid consumption.

RESULTS

60 patients were randomized and 57 completed the trial (PENG n=28, control n=29). Patients in PENG group had significantly lower dynamic pain scores at 30 min compared with control group (median (IQR) 3 (0.5-5) vs 5 (3-10), p<0.01). For the secondary outcomes, dynamic pain scores were lower in PENG group at 1 hour (median (IQR) 2 (1-3.25) vs 5 (3-8), p<0.01) and 3 hours postblock (median (IQR) 2 (0-5) vs 5 (2-8), p<0.05). Patients in PENG group had lower 24-hour opioid consumption (median (IQR) oral morphine equivalent dose 10 (0-15) vs 15 (10-30) mg, p<0.05).

CONCLUSION

PENG block provided effective analgesia for acute traumatic pain following hip fracture. Further studies are required to validate the superiority of PENG blocks over other regional techniques.

TRIAL REGISTRATION NUMBER

NCT04996979.

The Analgesic Effects of Preemptive Ultrasound-Guided Pericapsular Nerve Group Block in Comparison with Erector Spinae Plane Block in Elderly Undergoing Hip Arthroplasty: A Randomized Controlled Trial

Background

Perioperative pain management strategies in the elderly undergoing hip arthroplasty need special and safe preemptive care.

Objectives

The primary aim of this study was to compare the analgesic effects of preemptive ultrasound-guided pericapsular nerve group (PENG) block and lumbar erector spinae plane block (L-ESPB) in the elderly undergoing hip arthroplasty. The time to the first postoperative rescue analgesia was measured. The secondary aim was to assess the ease of spinal positioning (EOSP), onset of sensory block, block performance time, and patient satisfaction.

Methods

Before positioning for spinal anesthesia, 69 elderly patients undergoing hip arthroplasty were randomized into three groups (n = 23 per group). The first intervention group received ultrasound-guided PENG block with 20 mL bupivacaine 0.25%; the second intervention group received ultrasound-guided L-ESPB using the same dose of bupivacaine. In the control group, patients received spinal anesthesia without any block.

Results

The time to first postoperative rescue analgesic (morphine) was significantly prolonged in the PENG group (13.3 ± 3.5 h) compared to the L-ESPB (9.5 ± 2.3 h) and control (2.6 ± 0.4 h) groups. The EOSP score was significantly higher in the PENG group compared to the L-ESPB and control groups (P < 0.001). The block performance time and oneset of the sensory block were significantly shorter in the PENG group compared to the L-ESPB group. The highest patient satisfaction scores were observed in the PENG group.

Conclusions

Preemptive pericapsular nerve group block postponed the need for postoperative analgesia and eased spinal positioning compared to L-ESPB in the elderly undergoing hip arthroplasty.

Randomized clinical trial comparing pericapsular nerve group (PENG) block and periarticular local anesthetic infiltration for total hip arthroplasty

BACKGROUND

This randomized trial compared pericapsular nerve group block and periarticular local anesthetic infiltration in patients undergoing primary total hip arthroplasty. We hypothesized that, compared with pericapsular nerve group block, periarticular local anesthetic infiltration would decrease the postoperative incidence of quadriceps weakness at 3 hours fivefold (ie, from 45% to 9%).

METHODS

Sixty patients undergoing primary total hip arthroplasty under spinal anesthesia were randomly allocated to receive a pericapsular nerve group block (n=30) using 20 mL of adrenalized bupivacaine 0.50%, or periarticular local anesthetic infiltration (n=30) using 60 mL of adrenalized bupivacaine 0.25%. Both groups also received 30 mg of ketorolac, either intravenously (pericapsular nerve group block) or periarticularly (periarticular local anesthetic infiltration), as well as 4 mg of intravenous dexamethasone.Postoperatively, a blinded evaluator carried out sensory assessment and motor assessment (knee extension and hip adduction) at 3, 6 and 24 hours. Furthermore, the blinded observer also recorded static and dynamic pain scores at 3, 6, 12, 18, 24, 36 and 48 hours; time to first opioid request; cumulative breakthrough morphine consumption at 24 hours and 48 hours; opioid-related side effects; ability to perform physiotherapy at 6, 24 and 48 hours; as well as length of stay.

RESULTS

There were no differences in quadriceps weakness at 3 hours between pericapsular nerve group block and periarticular local anesthetic infiltration (20% vs 33%; p=0.469). Furthermore, no intergroup differences were found in terms of sensory block or motor block at other time intervals; time to first opioid request; cumulative breakthrough morphine consumption; opioid-related side effects; ability to perform physiotherapy; and length of stay. Compared with pericapsular nerve group block, periarticular local anesthetic infiltration resulted in lower static pain scores (at all measurement intervals) and dynamic pain scores (at 3 and 6 hours).

CONCLUSION

For primary total hip arthroplasty, pericapsular nerve group block and periarticular local anesthetic infiltration result in comparable rates of quadriceps weakness. However, periarticular local anesthetic infiltration is associated with lower static pain scores (especially during the first 24 hours) and dynamic pain scores (first 6 hours). Further investigation is required to determine the optimal technique and local anesthetic admixture for periarticular local anesthetic infiltration.

TRIAL REGISTRATION NUMBER

NCT05087862.

Pericapsular Nerve Group Block as an Effective Intervention for Pain Relief and Improving Functional Mobility in Cancer Patients: A Case Series

Pericapsular nerve group block (PENG) is an ultrasound-guided regional block technique that blocks the articular branches of the femoral nerve, accessory obturator nerve and obturator nerve. These nerves richly innervate the anterior capsule of the hip joint and blocking these nerves helps in hip analgesia. PENG block is commonly used in hip fracture pain perioperatively. In this case series, we have used PENG block in cancer patients with hip pain. PENG block was given to six patients with bupivacaine and triamcinolone, out of which five patients had good pain relief and their functional mobility to activities of daily living improved.

Efficacy of Pericapsular Nerve Group Block for Pain Reduction and Opioid Consumption after Total Hip Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

The aim of this study was to conduct a meta-analysis of randomized controlled trials (RCTs) for comparison of the effectiveness of pericapsular nerve group (PENG) block with that of other analgesic techniques for reduction of postoperative pain and consumption of opioids after total hip arthroplasty (THA). A search of records in the PubMed, Embase, and Cochrane Library, and ClinicalTrials.gov databases was conducted in order to identify studies comparing the effect of the PENG block with that of other analgesics on reduction of postoperative pain and consumption of opioids after THA. Determination of eligibility was based on the PICOS (participants, intervention, comparator, outcomes, and study design) criteria as follows: (1) Participants: patients who underwent THA. (2) Intervention: patients who received a PENG block for management of postoperative pain. (3) Comparator: patients who received other analgesics. (4) Outcomes: numerical rating scale (NRS) score and opioid consumption during different periods. (5) Study design: clinical RCTs. Five RCTs were finally included in the current meta-analysis. Significantly lower postoperative opioid consumption at 24 hours after THA was observed in the group of patients who received the PENG block compared with the control group (standard mean difference=-0.36, 95% confidence interval -0.64 to -0.08). However, no significant reduction in NRS score at 12, 24, and 48 hours after surgery and opioid consumption at 48 hours after THA was observed. The PENG block showed better results for opioid consumption at 24 hours after THA compared with other analgesics.

Novel use of continuous pericapsular nerve group (PENG) block technique for traumatic superior and inferior pubic rami fractures: a case report

BACKGROUND

Pubic rami fractures are painful injuries more commonly seen in the elderly with osteoporosis after high velocity trauma. In the most cases, management is conservative and non-operative with the goal to provide optimal pain relief to facilitate early mobilization and hospital discharge. Unfortunately, opioids remain the mainstay analgesic option and regional anesthesia techniques are limited but may include lumbar epidural anesthesia.

CASE PRESENTATION

A female patient in her 80s presented to the emergency department of a level 1 trauma center following a high-speed motor vehicle collision. The patient suffered multiple non-life-threatening injuries. Notably, the patient was experiencing severe right groin and leg pain secondary to superior and inferior pubic rami fractures. Due to the severity of this pain, the patient was unable to mobilize or participate with physiotherapy. A lumbar epidural anesthesia technique was not deemed suitable and instead, we inserted a continuous pericapsular nerve group (PENG) block with a programmed intermittent bolus regimen. Immediate relief of pain was achieved and 48 hours later, the patient still reported satisfactory pain control and started to independently mobilize.

CONCLUSION

Analgesia options are limited in pubic rami fractures. We present the first published case of a novel use of the PENG block with a continuous catheter technique for the analgesic management of a traumatic superior and inferior pubic rami fracture. The clinical utility of this technique in pubic ramus fractures warrants further clinical investigation.

A Novel Approach to Improving Post-Operative Pain and Minimizing Opioid Consumption After a Hip Arthroscopy

Background

There have been many different approaches to controlling pain in patients undergoing hip arthroscopy. These include medications, nerve blocks, and intra-articular injections among many others. We introduced a combination of a pre-operative pericapsular nerve group (PENG) block, and intra-operative pericapsular injection of BKK (bupivacaine, ketamine, and ketorolac).

Methods

Patients undergoing primary hip arthroscopy were identified. There were three patient cohorts based on type of anesthesia: general anesthesia only (GA), general anesthesia and a pericapsular Marcaine injection (GA/Marcaine), or GA with pre-operative PENG block and an intraoperative BKK pericapsular injection (GA+PENG/BKK). Data collected included post-operative pain scores in the PACU (Post-Anesthesia Care Unit), time spent in the PACU, inpatient opioid consumption (both PACU and inpatient), and outpatient opioid prescriptions filled.

Results

20 patients received GA, 11 patients received GA/Marcaine, and 20 patients received GA+PENG/BKK. The GA+PENG/BKK group had average PACU pain score of 3.9 out of 10 compared to 7.7 in the GA group (p<.001) and 6.6 in the GA/Marcaine injection group (p=.048). The GA+PENG/BKK group had shorter mean PACU times than either other group (p<.001). The GA+PENG/BKK also consumed less opioids than the GA or GA/Marcaine groups in the PACU (p<.001), and in the total inpatient stay (p=.002, p=.003), as well as outpatient (p=.019, p=.040).

Conclusion

In patients undergoing a hip arthroscopy, performing a pre-operative PENG block and intra-operative BKK pericapsular injection will result in decreased postoperative pain, PACU time, and inpatient and outpatient opioids compared to general anesthesia only and general anesthesia with intracapsular Marcaine.

Combining Pericapsular Nerve Group (PENG) Block With the Supra-Inguinal Fascia Iliaca Block (SIFICB) for Perioperative Analgesia and Functional Recovery in Patients Undergoing Hip Surgeries: A Retrospective Case Series

BACKGROUND

The complex innervation of the hip joint may require a combined peripheral nerve block technique for perioperative effective analgesia and early recovery. The pericapsular nerve group (PENG) and suprainguinal fascia iliaca compartment blocks (SIFICB) are interfascial plane blocks aiming to involve the femoral, obturator, accessory obturator, and lateral femoral cutaneous nerves. The data still lacks in providing the standard of care for patients undergoing hip surgery. In this case series, we studied the efficacy of ultrasound-guided combined PENG block and SIFICB for perioperative analgesia and functional recovery in patients posted for hip surgery.

METHOD

We studied 10 adults of either gender who underwent close reduction and internal fixation of hip fracture. Before receiving spinal anesthesia, all patients had PENG block and SIFICB with 10 ml and 20 ml of local anesthetics respectively. Patients were observed for ease of giving sitting position for spinal anesthesia (EOSP), visual analogue score (VAS) at rest and 15° leg elevation, duration of postoperative analgesia, the cumulative requirement of rescue analgesic at 48 hours and ability of patients to undergo weight-bearing trial postoperatively.

RESULT

The static and dynamic VAS before receiving spinal anesthesia and postoperatively, was reduced compared to pre-block. The optimal position for delivering spinal anesthesia was possible to achieve as the patients were able to sit comfortably after 10 minutes of receiving both blocks. Duration of postoperative analgesia also extended up to 18 hours with the cumulative requirement of injection tramadol restricted to two doses postoperatively. All were able to walk down a minimum of 55 steps after 48 hours of completion of surgery.

CONCLUSION

Combining PENG block along with SIFICB is effective in the provision of perioperative analgesia with a considerable reduction in opioids and enhanced functional recovery due to motor sparing effect after surgical repair of the hip fracture.

Efficacy of pericapsular nerve group block vs. fascia iliaca compartment block for Hip surgeries: A systematic review and meta-analysis

Objective

The review aimed to compare outcomes of pericapsular nerve group block (PENG) vs. fascia iliaca compartment block (FICB) for patients undergoing hip surgeries.

Methods

Randomized controlled trials (RCTs) published in the databases of PubMed, CENTRAL, Embase, and Web of Science comparing PENG vs. FICB for pain control after hip surgeries were included in the review.

Results

Six RCTs were included. 133 patients received PENG block and were compared with 125 patients receiving FICB. Our analysis showed no difference in 6 h (MD: -0.19 95% CI: -1.18, 0.79 I 2 = 97% p = 0.70), 12 h (MD: 0.04 95% CI: -0.44, 0.52 I 2 = 72% p = 0.88) and 24 h (MD: 0.09 95% CI: -1.03, 1.21 I 2 = 97% p = 0.87) pain scores between PENG and FICB groups. Pooled analysis showed that mean opioid consumption in morphine equivalents was significantly less with PENG as compared to FICB (MD: -8.63 95% CI: -14.45, -2.82 I 2 = 84% p = 0.004). Meta-analysis of three RCTs showed no variation in the risk of postoperative nausea and vomiting in the two groups. The quality of evidence on GRADE was mostly moderate.

Conclusion

Moderate quality of evidence suggests that PENG may result in better analgesia than FICB in patients undergoing hip surgeries. Data on motor-sparing ability and complications are scarce to draw conclusions. Further large-scale and high-quality RCTs should be conducted to supplement current findings.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022350342.

Addition of Pericapsular Nerve Group and Transversus Abdominis Plane Blocks Significantly Reduces Opioid Use in Patients Undergoing Concomitant Hip Arthroscopy and Periacetabular Osteotomy

INTRODUCTION

Previous studies have evaluated the effect of the pericapsular nerve group block for hip arthroscopy and the transverse abdominis plane block for periacetabular osteotomy and have shown decreased narcotic consumption in both groups. No published study has evaluated the effectiveness of combining the blocks when performing hip arthroscopy and periacetabular osteotomy under the same general anesthesia. It was hypothesized that patients treated for hip dysplasia with hip arthroscopy and concomitant periacetabular osteotomy using a pericapsular nerve group block, transverse abdominis plane block, and general anesthesia would have decreased postoperative pain and require less narcotic consumption than those undergoing the procedure with general anesthetic alone.  Methods: A single surgeon performed a retrospective analysis of consecutive patients undergoing concomitant hip arthroscopy and periacetabular osteotomy between 11/2020 and 6/2021. Fifteen consecutive patients undergoing the procedure with a general anesthetic alone (no-block group) were compared to 15 patients undergoing the same procedure with a combined pericapsular nerve group block, transverse abdominis plane block, and general anesthetic (block group). Hip arthroscopy was performed utilizing a post-free technique, and a rectus sparing approach was used for the periacetabular osteotomy. The nerve blocks were performed by multiple anesthesiologists using previously published methods. Operating room time, length of stay, visual analog scale pain scores, and total narcotic consumption in morphine milliequivalents were analyzed. Groups were compared using the chi-squared test for non-continuous demographic variables and a two-tailed t-test for continuous variables utilizing Microsoft Excel (Microsoft, Redmond, WA, USA), p-value set at 0.05 for significance.  Results: The no-block group consisted of 14 females and one male, while the block group was all females. No significant differences were observed between age, sex, BMI, surgery time, length of stay, or procedures performed, p>0.05. The maximal visual analog scale score in the post-anesthesia care unit was 8 ± 1.3 vs. 7 ± 1.9 in the no-block vs. block groups, respectively, p=0.15. The average hospital floor visual analog scale score was 5.7 ± 1.3 vs. 4.8 ± 1.3 in the no-block vs. block groups, respectively, p=0.07. Total pain medications required were 217.6 ± 54.6 vs. 154 ± 41.9 morphine milliequivalents in the no-block vs. block groups, respectively, p=0.001. No complications were reported in either group, and no patient in the block group demonstrated motor nerve palsy or postoperative fall.

CONCLUSION

 This study demonstrated that patients undergoing combined hip arthroscopy and periacetabular osteotomy for symptomatic acetabular dysplasia who had pericapsular nerve group, transverse abdominal plane block, and general anesthesia required fewer narcotics in the first 24 hours after surgery compared to those who had general anesthesia alone.

The efficacy of pericapsular nerve group block for postoperative analgesia in patients undergoing hip surgery: A systematic review and meta-analysis of randomized controlled trials

Background

As an optional regional anesthesia approach, pericapsular nerve group (PENG) block has been successfully utilized to manage pain for hip surgeries without affecting motor function. The present meta-analysis aimed to verify the efficacy of PENG block for postoperative analgesia in patients undergoing hip surgery.

Methods

A total of 497 academic articles were identified after a systematic search in the databases of PubMed, Embase, Web of Science, and Cochrane Library up to 25 August 2022. The primary outcome was postoperative 24-h morphine consumption. Secondary outcomes included the time of the first request for rescue analgesia, static and dynamic pain scores 6 and 24 h after surgery, and incidence of postoperative nausea and vomiting (PONV). We calculated mean differences (MDs) with 95% confidence intervals (CIs) for postoperative 24-h morphine consumption, time of the first request for rescue analgesia, static and dynamic pain scores 6 and 24 h after surgery, and odds ratios (ORs) with 95% CIs for incidence of PONV. The chi-square test was used for heterogeneity analysis, and heterogeneity was assessed by I ². Statistical analysis was performed using Review Manager 5.4.

Results

Numerous electronic databases were searched, and finally, nine studies were identified. There was no significant difference in morphine consumption during the postoperative 24 h [MD: -2.57, 95% CI: (-5.42, 0.27), P = 0.08] and the time of the first request for rescue analgesia [MD: 1.79, 95% CI: (-1.06, 4.64), P = 0.22] between the PENG block and control groups. PENG block did not reveal a significant difference in 6 h [MD: -0.17, 95% CI: (-0.92, 0.57), P = 0.65] [MD: -0.69, 95% CI: (-1.58, 0.21), P = 0.13] and 24 h [MD: -0.25, 95% CI: (-1.54, 1.05), P = 0.71], [MD: 0.05, 95% CI: (-0.84, 0.93), P = 0.91] static and dynamic pain scores compared with other nerve block methods. Moreover, the two groups have a similar risk of PONV (OR: 1.29, 95% CI = 0.53-3.10, P = 0.57).

Conclusion

This review shows that PENG block can act as an alternative multimodal analgesia for hip surgery, and compared with the other kinds of nerve block, there was no significant difference in the postoperative analgesic effect of PENG block.

Systematic review registration

Supplementary Datasheet 1, identifier: CRD 42022356496.

Effectiveness of a PENG catheter and the implications and a complication of tunnelling

Pericapsular nerve group (PENG) block is a recently developed technique for analgesia for hip surgeries. We chose to use a PENG catheter for effective analgesia perioperatively. In this case report, we performed PENG catheter for a patient posted for hip hemiarthroplasty. During the process of tunnelling after securing the catheter, we accidentally sheared the catheter and had to redo the procedure. The patient was comfortable during their stay with minimal pain. This case report emphasises the importance of securing a catheter in providing prolonged analgesia and also the importance of dealing with complications due to the procedure itself.

Pericapsular nervegroup (PENG) block—a scoping review

The obturator nerve and its accessory branch supplying the hip region, unlike the femoral nerve, are not adequately anaesthetized by conventional regional anaesthetic techniques targeting the hip region. With advancements in ultrasound-guided regional anaesthetic techniques, interests are revived in the field and efforts are being made to block them together. One such successful attempt is the novel peri-capsular nerve group (PENG) block. Consequently, further research on the PENG block began to explore its versatilities. The present study undertakes a scoping review of research on the PENG block in humans for any indication to determine the extent of the research done, the methodologies used, and other practical issues addressed in the research. This will help to identify potential research gaps that should be addressed in the future. PubMed, Google Scholar, Cochrane Library, KoreaMed, Latin American and Caribbean Health Science Literature, and the directory of open access journals were searched with the keyword “PENG block” and “pericapsular nerve group”. Manual search of electronically retrieved papers was also carried out. Among the 67 articles selected in our review, eighteen are case series; twenty-nine are case reports; two are randomized studies; one each of prospective cohort study, review, and cadaveric study; and 15 are editorials. However, only 64 articles were included later due to the retraction of three case reports. Data is insufficient to provide firm recommendations for or against different aspects of the block. The review encourages future work addressing different aspects of the PENG block.

A Retrospective Study of Ultrasound-Guided Pericapsular Nerve Group Block With Dexamethasone: An Excellent Option for Early Mobility Following Total Hip Replacement Surgery

Background Severe postoperative pain and immobility increase the length of hospital stay and immobility-related life-threatening complications after total hip replacement (THR). Pericapsular nerve group (PENG) block is a recent addition to pain management of neck of femur (NoF) fracture, the use of which has been incorporated into THR as alternative analgesia or as an adjunct with other regional analgesia techniques. The present study primarily aims to assess postoperative mobility. Secondary outcomes measured were the length of hospital stay, pain score, opioid consumption, and side effects. Methods This is a retrospective study of 50 patients who underwent primary THR. Twenty-eight patients received PENG block after spinal anesthesia (PENG Group), seven patients had general anesthesia (GA) with patient-controlled analgesia (PCA) postoperatively (PCA Group), and the remaining 15 received spinal anesthesia with fascia iliaca block (FIB Group). Mobilization was attempted in all patients (ability to stand and walk a few steps with a walker) 10 hours after the end of surgery. Data was collected for average postoperative pain score, time of mobilization, total opioid consumption (till discharge from the hospital), opioid-related side effects, and time of discharge. Results Mobilization was attempted in all patients 10 hours after the end of the surgery, irrespective of their anesthetic technique. In the PENG Group, 26 patients (n=28) could be mobilized after the first 10 hours without opioids. The total morphine requirement until discharge was significantly less in the PENG Group of patients compared to the FIB and GA+PCA patients. The average time of discharge (hours) from the hospital (22.1+/-4.9) was also significantly lower in the PENG Group compared to all other groups (31.7 +/- 3.4, p=<0.01). The average postoperative pain score was significantly low in the PENG Group within the first 48 hours. Conclusion The PENG block helps in early mobilization and enhanced recovery after THR.

Pericapsular nerve group block for hip fracture is feasible, safe and effective in the emergency department: A prospective observational comparative cohort study

OBJECTIVES

The pericapsular nerve group (PENG) block was first described for analgesia of hip fracture in 2018. We hypothesised that the PENG block is safe and effective for patients with hip fracture when provided by emergency physicians and trainees in the ED.

METHODS

This was an observational study of routine care. Consecutive patients receiving regional anaesthesia for hip fracture at a single ED were prospectively enrolled. Pain scores were assessed prior to regional anaesthesia then at 15, 30 and 60 min after administration. Maximal reduction in pain scores within 60 min were assessed using the Visual Analogue Scale (at rest and on movement) or the Pain Assessment IN Advanced Dementia tool (at rest). Patients were followed for opioid use for 12 h after regional anaesthesia and adverse events over the duration of admission.

RESULTS

There were 67 eligible patients during the enrolment period, with 52 (78%) prospectively enrolled. Thirty-three received femoral blocks (19 fascia iliaca compartment blocks, 14 femoral nerve blocks) and 19 received a PENG block. Inexperienced providers were able to successfully perform the PENG block. There was no difference in maximum pain score reduction between the groups. There was no difference in adverse effects between groups. Opioid use was similar between the groups. More patients were opioid-free after a PENG block.

CONCLUSIONS

The present study demonstrated that the PENG block can be provided safely and effectively to patients with hip fracture in the ED. On the basis of this pilot study, a larger randomised controlled study should now be designed.