The analgesic efficacy of pericapsular nerve group block in patients with intertrochanteric femur fracture: A randomized controlled trial

Comparison of proximal femoral nail antirotation internal fixation and artificial hip replacement for elderly patients with intertrochanteric fractures

OBJECTIVE

To compare the effects of proximal femoral nail antirotation (PFNA) internal fixation and artificial hip replacement (AHR) on serum inflammatory factors and hip function recovery in elderly patients with intertrochanteric fractures (IFs).

METHODS

One hundred and thirty patients with IFs who underwent surgery at the People's Hospital of Pingyang between July 2018 and July 2020 were enrolled. Sixty-five patients received PFNA internal fixation (fixation group) and 65 received AHR (replacement group). Surgical indicators and complications were recorded in both groups. The Harris Hip Scale was used to score hip joint function, the Visual Analog Scale (VAS) to assess pain, the MOS 36-Item Short-Form Health Survey (SF-36) to evaluate life quality, and enzyme-linked immunosorbent assay to measure serum tumor necrosis factor-α (TNF-α), interleukin (IL)-6, and IL-1β.

RESULTS

The replacement group experienced notably shorter hospitalization times, less complete weight-bearing time, and earlier time to walk compared to the fixation group (all P<0.05). The replacement group also showed a lower incidence of poor fracture healing and complications (both P<0.05). Additionally, on postoperative days 3, 15, and 45, the replacement group had notably lower VAS scores (all P<0.05). Furthermore, the replacement group exhibited higher Harris Hip Scale scores at 1, 2, and 3 months post-surgery (all P<0.05). Higher postoperative SF-36 scores were also observed in the replacement group (P<0.05). On postoperative day 30, both groups presented decreases in TNF-α, IL-6, and IL-1β levels compared to preoperative levels, with even lower levels in the replacement group (all P<0.05).

CONCLUSIONS

AHR can help elderly patients with IFs ambulate earlier, speed up hip function recovery, reduce inflammation, and improve life quality with fewer postoperative complications, making it worthy of clinical promotion.

Ultrasound-guided pericapsular nerve block compared with IV opioids in hip injuries: A randomised controlled trial

STUDY OBJECTIVES

The study aimed to compare the analgesic effect of USG-guided PENG (Peri capsular nerve group) block with Intravenous Nalbuphine hydrochloride (IVN) in patients with hip fracture coming to the emergency department (ED). The purpose was also to monitor the adverse effects and rescue analgesic requirements in both treatment modalities.

METHODS

The study was an open-label randomised controlled trial (RCT) comparing PENG block versus IVN in treating patients with femoral head and neck fractures, as well as pubic rami fracture of the hip (HF). The participants in the PENG group received a USG-guided PENG block by injection of 25 ml of 0.25% bupivacaine, whereas the IVN group received 0.15 mg/kg of nalbuphine. An emergency physician with expertise in ultrasound-guided nerve blocks performed the PENG blocks. The primary outcome was to measure the improvement of the NRS (Numerical rating scale) score at 30 min in both static position (Patient-chosen position for the best comfort) and dynamic position (15-degree passive affected lower limb elevation). Secondary outcomes were to measure static and dynamic NRS pain scores at 2 h, 4 h, and 6 h after intervention in both groups. The requirement for rescue analgesia, adverse events and any block-related complications were also recorded.

RESULTS

A total of 60 patients with HF were included in the final analysis. The static and dynamic NRS score was significantly lower in the PENG group compared to the IVN group at 30 min, 2 h, 4 h, and 6 h post-intervention. In the PENG group, the static NRS score was improved by 5.73 ± 1.17, while In the IVN group, the static NRS score was just improved by 2.13 ± 0.97 at 30 min. In the same duration, the Dynamic NRS score in the PENG group was improved by 6.13 ± 1.38, while In the IVN group, it improved just by 2.43 ± 1.28. Rescue analgesia was required in 50.0% of patients in the IVN group but none in the PENG group. Further, no block-related complications or adverse events were observed in the patients of the PENG group.

CONCLUSION

The study provides evidence that the ultrasound-guided PENG block has a better analgesic effect and has fewer adverse events than IV opioids in patients with HF.

Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis

STUDY OBJECTIVE

We conducted a systematic review and network meta-analysis to evaluate the comparative efficacy of peripheral nerve block types for preoperative pain management of hip fractures.

METHODS

We searched Cochrane, Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar for randomized clinical trials. We included participants aged more than 16 years with hip fractures who received peripheral nerve blocks or analgesics for preoperative pain management. The primary outcomes were defined as absolute pain score 2 hours after block placement, preoperative consumption of morphine equivalents, and length of hospital stay. We used a random-effects network meta-analysis conceptualized in the Bayesian framework. Confidence of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA).

RESULTS

We included 63 randomized controlled studies (4,778 participants), of which only a few had a low risk of bias. The femoral nerve block, 3-in-1 block, fascia iliaca compartment block, and pericapsular nerve group block yielded significantly lowered pain scores at 2 hours after block placement compared with those with no block (standardized mean differences [SMD]: -1.1; 95% credible interval [CrI]: -1.7 to -0.48, [confidence of evidence: low]; SMD: -1.8; 95% CrI: -3.0 to -0.55, [low]; SMD: -1.4; 95% CrI: -2.0 to -0.72, [low]; SMD: -2.3; 95% CrI: -3.2 to -1.4, [moderate], respectively). The pericapsular nerve group block, 3-in-1 block, fascia iliaca compartment block, and femoral nerve block resulted in lower pain scores than the no-block group. Additionally, the pericapsular nerve group block yielded a lower pain score than femoral nerve block or fascia iliaca compartment block (SMD: -1.21; 95% CrI: -2.18 to -0.23, [very low]: SMD: -0.92; 95% CrI: -1.70 to -0.16, [low]). However, both the fascia iliaca compartment block and femoral nerve block did not show a reduction in morphine consumption compared with no block. To our knowledge, no studies have compared the pericapsular nerve group block with other methods regarding morphine consumption. Furthermore, no significant difference was observed between peripheral nerve blocks and no block in terms of the length of hospital stay.

CONCLUSIONS

Compared with no block, preoperative peripheral nerve blocks for hip fractures appear to reduce pain 2 hours after block placement. Comparing different blocks, pericapsular nerve group block might be superior to fascia iliaca compartment block and femoral nerve block for pain relief, though the confidence evidence was low in most comparisons because of the moderate to high risk of bias in many of the included studies and the high heterogeneity of treatment strategies across studies. Therefore, further high-quality research is needed.

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.

Comparison of the Analgesic Efficacy between Levobupivacaine 0.25% and Ropivacaine 0.375% for PENG (Pericapsular Nerve Group) Block in the Context of Hip Fracture Surgery of Elderly Patients: A Single-Center, Randomized, and Controlled Clinical Trial

Previous studies have compared levobupivacaine versus ropivacaine in various peripheral nerve blocks in terms of block duration, quality of analgesia, and onset time, but this has not occurred in the PENG block. Here, a single-center, randomized, and controlled clinical trial is presented. One hundred and twenty patients older than 65 years suffering from hip fractures and surgically treated at our institution under spinal anesthesia were eligible for participation; of them, one hundred and eight were analyzed. Patients were randomized to receive ultrasound-guided PENG blocks using 20 mL of either 0.25% levobupivacaine or 0.375% ropivacaine (both of which are equipotent concentrations). The primary endpoint was to compare the analgesic duration (time to first rescue) and analgesic quality (pain scores using the VAS, PAINAD, and AlgoPlus scales) between the groups. Secondary endpoints included comparing the onset time, describing the need for and type of rescue analgesics, and possible associated adverse effects. There were no statistically significant differences in analgesic duration between levobupivacaine (median 861.0, IQR 960) and ropivacaine (median 1205.0, IQR 1379; p = 0.069). Likewise, the quality of analgesia and onset time were comparable among the groups. A small number of patients required opioids as rescue analgesics (4.6%). The possible associated adverse effects included postoperative infection (11.1%) and delirium (2.8%).

Comparison of analgesic effects of pericapsular nerve group block and fascia iliaca compartment block during hip arthroplasty: A systematic review and meta-analysis of randomised controlled trials

Background and Aims

Postoperative pain for patients having hip arthroplasty ranges from moderate to severe. Many regional anaesthesia procedures treat postoperative pain to improve functional ability and quality of life. Evidence comparing the analgesic effects of the pericapsular nerve group (PENG) block and fascia iliaca compartment block (FICB) remains unclear. The analgesic efficacies of PENG and FICB in hip arthroplasty were compared to determine which technique is associated with superior analgesia.

Methods

The electronic databases (PubMed, Cochrane Library, Google Scholar and Web of Sciences) were searched for published randomised controlled trials (RCTs) till 5 April 2023 comparing PENG block vs. FICB following hip arthroplasty. The primary outcome was pain scores [numerical rating scale (NRS) or visual analogue scale (VAS)] between 0 and 10 at rest and during movement at 24 h. Secondary outcomes included pain scores at rest and during movement within 30 min, at 6 h and 12 h, time to first rescue analgesia and cumulative postoperative opioid use in 24 h. We assessed the risk of bias using the Cochrane Collaboration Risk-of-Bias 2 tool. Using Grading of Recommendations Assessment, Development, and Evaluation (GRADE), the certainty of the evidence was assessed. Subgroup analysis was performed to explore the source of heterogeneity.

Results

We included 12 RCTs examining 644 patients. Pain scores at rest at 24 h (standardised mean differences (SMDs): 0.17; 95% confidence interval (CI): -0.90 to 1.23; P = 0.76, moderate certainty) and during movement at 24 h (SMD: -0.58, 95% CI: -1.53 to 0.38, P = 0.24, moderate certainty) were not different in both PENG block and FICB. Pain scores at rest and during movement within 30 min may be lower with PENG block than FICB. However, the pain score at rest and during movement at 6 h and the time to first rescue analgesia were not different between the two treatment arms. The mean opioid consumption in oral morphine equivalents (mg) in 24 h may be lower with PENG than FICB.

Conclusion

We observed no difference between the PENG block and the FICB at 24 h for pain at rest and movement with a moderate degree of certainty. However, PENG block showed improved analgesia within 30 min at rest and during movement, and reduce postoperative opioid consumption in 24 h with moderate certainty of evidence. Further large-scale and high-quality RCTs are required to supplement the present findings.