Pericapsular nerve group block results in a longer analgesic effect and shorter time to discharge than femoral nerve block in patients after hip fracture surgery: a single-center double-blinded randomized trial

Use of Peripheral Nerve Blocks for Total hip Arthroplasty

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent literature regarding regional anesthesia (RA) techniques and outcomes for total hip arthroplasty (THA) in the face of changing surgical techniques and perioperative considerations.

RECENT FINDINGS

Based on large meta-analyses, peripheral nerve blocks are indicated for THA. Each block has its own risks and benefits and data for outcomes for particular techniques are limited. New surgical techniques, improved use of multimodal analgesia, and improved ultrasound guided regional anesthetics lead to better pain control for patients undergoing THA with less associated risks. Block selection continues to be influenced by provider comfort, surgical approach, patient anatomy, and postoperative goals. Head-to-head studies of particular nerve blocks are warranted.

Peripheral Nerve Blocks for Hip Fractures

The incidence of hip fractures has continued to increase as life expectancy increases. Hip fracture is one of the leading causes of increased morbidity and mortality in the geriatric population. Early surgical treatment (<48 h) is often recommended to reduce morbidity/mortality. In addition, adequate pain management is crucial to optimize functional recovery and early mobilization. Pain management often consists of multimodal therapy which includes non-opioids, opioids, and regional anesthesia techniques. In this review, we describe the anatomical innervation of the hip joint and summarize the commonly used peripheral nerve blocks to provide pain relief for hip fractures. We also outline literature evidence that shows each block's efficacy in providing adequate pain relief. The recent discovery of a nerve block that may provide adequate sensory blockade of the posterior capsule of the hip is also described. Finally, we report a surgeon's perspective on nerve blocks for hip fractures.

The Effects of the Pericapsular Nerve Group Block on Postoperative Pain in Patients with Hip Fracture: A Multicenter Study

BACKGROUND

An adequate early mobilization followed by an effective and pain-free rehabilitation are critical for clinical and functional recovery after hip and proximal femur fracture. A multimodal approach is always recommended so as to reduce the administered dose of analgesics, drug interactions, and possible side effects. Peripheral nerve blocks should always be considered in addition to spinal or general anesthesia to prolong postoperative analgesia. The pericapsular nerve group (PENG) block appears to be a less invasive and more effective analgesia technique compared to other methods.

METHODS

We conducted multicenter retrospective clinical research, including 98 patients with proximal femur fracture undergoing osteosynthesis surgery within 48 h of occurrence of the fracture. Thirty minutes before performing spinal anesthesia, 49 patients underwent a femoral nerve (FN) block plus a lateral femoral cutaneous nerve (LCFN) block, and the other 49 patients received a PENG block. A non-parametric Wilcoxon-Mann-Whitney (α = 0.05) test was performed to evaluate the difference in resting and dynamic numerical rating scale (NRS) at 30 min, 6 h, 12 h, and 24 h.

RESULTS

the PENG block administration was more effective in reducing pain intensity compared to the FN block in association with the LFCN block, as seen in the resting and dynamic NRS at thirty minutes and 12 h follow-up.

CONCLUSION

the PENG block was more effective in reducing pain intensity than the femoral nerve block associated with the lateral femoral cutaneous nerve block in patients with proximal femur fracture undergoing to osteosynthesis.

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.

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

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.

The Efficiency of Ultrasound-Guided Pericapsular Nerve Group Block for Pain Management after Hip Surgery: A Meta-analysis

INTRODUCTION

Patients with hip surgery often experience moderate to severe postoperative pain, and need large doses of opioids to relieve it, which is not conducive to patient rehabilitation. Pericapsular nerve group (PENG) block is a new regional block technique that is considered to reduce postoperative pain and the use of opioids. The purpose of this study was to evaluate the efficacy and safety of PENG block for postoperative analgesia after hip surgery.

METHODS

We searched multiple databases for randomized controlled trials (RCTs) published in English, which compared PENG block with fascia iliaca compartment block (FICB). The primary outcome was 24 h postsurgical opioid consumption (OC). The secondary outcomes were pain scores (PSs) at different timepoints after surgery and the incidence of postoperative nausea and vomiting (PONV).

RESULTS

Five RCTs involving 234 patients were selected for our analysis. Our results show that the 24 h OC was drastically lower in PENG block versus FICB patients (SMD -0.60, 95% CI -1.08 to -0.11); P < 0.05, I² = 69%). At the same time, there were no significant difference in postsurgical PSs between the two cohorts (6 h: MD -0.07, 95% CI -0.67 to 0.53; P = 0.82, I² = 43%; 12 h: MD -0.60, 95% CI -1.40 to 0.19; P = 0.14, I² = 31%; 24 h: MD 0.17, 95% CI -0.87 to 1.21; P = 0.75, I² = 76%; 36 h: MD 0.80, 95% CI -0.92 to 2.51; P = 0.36, I² = 73%; 48 h: MD -0.06, 95% CI -0.75 to 0.63; P = 0.86, I² = 0%) and the incidence of PONV (RR 1.00, 95% CI 0.40-2.50, P = 1.00, I² = 35%).

CONCLUSIONS

Our research shows that PENG block can reduce the use of opioids after hip surgery and is effective in postoperative analgesia. Future research should explore the injection method, concentration, and dosage.

Efficacy of pericapsular nerve group (PENG) block on perioperative pain management in elderly patients undergoing hip surgical procedures: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

An increasing number of elderly patients suffer from hip diseases associated with moderate to severe perioperative pain during the accelerating global ageing process. Optimal analgesia can decrease perioperative complications and facilitate elderly patients' perioperative recovery. Pericapsular nerve group (PENG) block is a relatively new, analgesia adequate and motor-sparing block technique for perioperative pain management of hip diseases. However, the efficacy of PENG block remains unclear as the limited clinical evidence. Then, we will perform a protocol for a systematic review and meta-analysis to identify the efficacy of PENG block for perioperative pain management.

METHODS AND ANALYSIS

PubMed, Ovid Medline, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Chinese BioMedical Literature, Wanfang and VIP databases will be searched from inception to August 2022 to identify randomised controlled trials of elderly patients accepting PENG block for hip diseases. The primary outcome will be the pain intensity after pain management. Secondary outcomes will be quadriceps strength, perioperative rescue analgesia information and perioperative complications. Assessment of heterogeneity will be primarily inspected by forest plots. If there is no indication of funnel plot asymmetry, a random-effects meta-analysis will be performed. The Cochrane risk-of-bias tool, Grading of Recommendations Assessment, Development and Evaluation and trial sequential analysis will be conducted to evaluate the evidence quality and control the random errors. Funnel plots and Egger's regression test will be performed to evaluate publication bias.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42022313895.

The Pericapsular Nerve Group (PENG) block combined with Local Infiltration Analgesia (LIA) compared to placebo and LIA in hip arthroplasty surgery: a multi-center double-blinded randomized-controlled trial

BACKGROUND

The PEricapsular Nerve Group (PENG) block is a novel regional analgesia technique that provides improved analgesia in patients undergoing hip surgery while preserving motor function. In this study the PENG block was investigated for analgesia in elective total hip arthroplasty (THA).

METHODS

In this multi-centre double-blinded randomized-controlled trial, in addition to spinal anesthesia and local infiltration analgesia (LIA), THA patients received either a PENG block or a sham block. The primary outcome was pain score (numeric rating scale 0-10) 3 h postoperatively (Day 0). Secondary outcomes were postoperative quadriceps muscle strength, postoperative Day 1 pain scores, opiate use, complications, length of hospital stay, and patient-reported outcome measures.

RESULTS

Sixty patients were randomized and equally allocated between groups. Baseline demographics were similar. Postoperative Day 0, the PENG group experienced less pain compared to the sham group (PENG: 14 (47%) patients no pain, 14 (47%) mild pain, 2 (6%) moderate/severe pain versus sham: 6 (20%) no pain, 14 (47%) mild pain, 10 (33%) moderate/severe pain; p = 0.03). There was no difference in quadriceps muscle strength between groups on Day 0 (PENG: 23 (77%) intact versus sham: 24 (80%) intact; p = 0.24) and there were no differences in other secondary outcomes.

CONCLUSIONS

Patients receiving a PENG block for analgesia in elective THA experience less postoperative pain on Day 0 with preservation of quadriceps muscle strength. Despite these short-term benefits, no quality of recovery or longer lasting postoperative effects were detected.