PENG block associated with dexmedetomidine sedation for intramedullary femoral fixation in high-risk elderly patients: a case series and review of the literature

BACKGROUND

Hip fracture is a major cause of hospitalization among the elderly population. The standard surgical treatment involves early repair to reduce mortality and morbidity. One type of treatment in the case of intertrochanteric and subtrochanteric fractures is intramedullary nailing, as it decreases soft tissue damage and permits early weight bearing. The most common anesthesia technique combines spinal anesthesia with a peripheral block. In cases where spinal anesthesia is contraindicated, general anesthesia is preferred. However, both techniques can lead to significant complications, especially in patients with multiple comorbidities. Pain management after hip surgery, particularly in elderly and frail individuals, poses a challenge. The pericapsular nerve group block (PENG) targets the innervation of the anterior portion of the hip joint and is increasingly used for pain management related to hip surgery.

CASE SERIES

This paper presents a case series of three elderly patients who underwent pericapsular nerve group block (PENG) block combined with dexmedetomidine sedation for intramedullary femoral fixation.

CONCLUSIONS

The PENG block can be effectively used as the sole anesthetic technique for managing elderly patients undergoing intramedullary femoral fixation while on antiplatelet drugs. This procedure effectively controlled pain during both the surgical and postoperative periods. The addition of dexmedetomidine for sedation enables comfortable and safe procedures, minimizing the risk of perioperative neurocognitive dysfunctions and without adverse effects on cardiorespiratory function.

Comparative Evaluation of Two Different Post-Operative Analgesia after Hallux Valgus Correction in Day Surgery Patients

Introduction

The aim of this study was the evaluation of two different techniques on post-operative analgesia and motor recovery after hallux valgus correction in one-day surgery patients.

Material and Methods

We enrolled 26 patients scheduled for hallux valgus surgery and treated with the same surgical technique (SCARF osteotomy). After subgluteal sciatic nerve block with a short acting local anaesthetic (Mepivacaine 1.5%, 15ml), each patient received an ultrasound-guided Posterior Tibialis Nerve Block (PTNB) with Levobupivacaine 0.5% (7-8ml). We measured the postoperative intensity of pain using a Visual Analogue Scale (VAS), the consumption of oxycodone after operative treatment and the motor recovery. VAS was detected at baseline (time 0, before the surgery) and at 3, 6, 12 and 24 hours after the operative procedure (T1, T2, T3, T4 respectively). Control group of 26 patients were treated with another post-operative analgesia technique: local infiltration (Local Infiltration Anaesthesia, LIA) with Levobupivacaine 0.5% (15ml) performed by the surgeon.

Results

PTNB group showed a significant reduction of VAS score from the sixth hour after surgery compared to LIA group (p<0.028 at T2, p<0.05 at T3 and p<0.002 at T4, respectively). Instead, no significant differences were found in terms of post-operative oxycodone consumption and motor recovery after surgery.Conclusions: PTNB resulted in a valid alternative to LIA approach for post-operative pain control due to its better control of post-operative pain along the first 24 hours. In a multimodal pain management according to ERAS protocol, both PTNB and LIA should be considered as clinically effective analgesic techniques.

Enhanced recovery after surgery (ERAS) in hip and knee replacement surgery: description of a multidisciplinary program to improve management of the patients undergoing major orthopedic surgery

PURPOSE

Enhanced recovery after surgery (ERAS) protocols aim to develop peri-operative multidisciplinary programs to shorten length of hospital stay (LOS) and reduce complications, readmissions and costs for patients undergoing major surgery. The aim of this study is to evaluate the effects of an ERAS pathway for total hip (THR) and knee (TKR) replacement surgery in terms of length of stay, incidence of complications and patient satisfaction.

METHODS

Patients scheduled for hip and knee replacement were included in the study. The main aspects of this program were preoperative education/physical therapy, rational choice of the anesthetic technique, optimization of multimodal analgesia, reduction of incidence of urinary retention and catheterization, active management of risk for blood loss and deep vein thrombosis, and early mobilization of the patients. All patients had 6 months predicted and planned follow-up appointments. Primary outcomes of the study were the mean LOS, readmission and complication rates. Secondary Outcomes were percentage of Knee Injury & Osteoarthritis Outcome Score (KOOS) and Hip disability and Osteoarthritis Outcome Score (HOOS) increase and patient's satisfaction.

RESULTS

We consecutively enrolled 207 patients who underwent total joint arthroplasty, 78 hip and 129 knee joint replacements. The mean length of stay (LOS) for patients of the two groups was 4.3 days for ASA 3-4 patients subjected to TKR and THR, in ASA 1-2 patients 3.6 days for TKR and 3.9 days for THR respectively. Postoperative satisfaction level was higher than 7 (very satisfied) in 94.4% of the cases. All patients were discharged home: 61.8% continued physical therapy in complete autonomy, 23.7% supported by a home-physiotherapist and only 14.5% needed the attendance to a physiotherapy center on a daily basis. The overall incidence of major complications was 3.4%.

CONCLUSIONS

The implementation of an ERAS program for hip and knee replacement surgery allows early patient's discharge and a quick return to independency in the daily activities.

LEVEL OF EVIDENCE

IV.