Evaluating the pericapsular nerve group block in hip fracture patients:  A prospective observational cohort study.

Lesedi Mothiba; Grace Manjooran; Mathabe  Sehlapelo

doi:10.51168/sjhrafrica.v7i2.2527

Authors

Lesedi Mothiba BSc (Wits), MBBCH (Wits), DA (SA), Department of Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand.
Grace Manjooran MBBCh (Wits), DA (SA), FCA (SA), MMed (Anaes) (Wits), PG Dip HSE (Wits), Department of Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand.
Mathabe Sehlapelo MBChB (UP), DA (SA), FCA (SA), MMed (Anaes) (Wits), DTM&H (Wits), DipHivMan (SA), Higher Cert HSM (Regent), PG Dip HSE (Wits), Department of Anaesthesiology at Witwatersrand University, Chris Hani Baragwanath Academic Hospital, RSA.

DOI:

https://doi.org/10.51168/sjhrafrica.v7i2.2527

Keywords:

hip fracture, PENG block, Analgesic efficacy, Arthroplasty, Postoperative analgesia

Abstract

Background

This study aimed to assess the pericapsular nerve group (PENG) block combined with a spinal anaesthetic compared to only a spinal anaesthetic in patients presenting for hip fracture surgery. The objectives were to determine the ability of a patient to sit for a spinal anaesthetic, rest, dynamic hip pain scores, and the incidence of lower limb motor blockade following the block. Furthermore, time to first request for opioid analgesia post-operatively and the total opioid consumption in morphine equivalents were determined.

Methods

A prospective, observational study with 40 participants who were recruited via purposive sampling. Participants receiving the PENG block combined with a spinal anaesthetic were allocated to the PENG block (Group P, n = 20) and those receiving only a spinal anaesthetic (Group C, n = 20). Group P received bupivacaine 0.25% 20ml injected into the target site in the block area, followed by spinal after 30 minutes in theatre. Group C received a spinal only.

Results

There were no significant differences in participants’ characteristics. Group P had 90% of the participants able to sit adequately without IV analgesia for a spinal versus 45% in Group C. Group P had statistically significantly lower rest (p<0.001) and dynamic (p<0.001) pain scores compared to Group C at 30 minutes following PENG block injection (T1). Thirteen (65%) participants in Group P did not have motor blockade as they were able to lift the blocked leg to 15 degrees at T1. A longer duration to first opioid analgesia required was found in Group P (p <0.001). The total IV morphine equivalent analgesic requirement for Group C was almost double that required for Group P (p = 0.009).

Conclusion

PENG block combined with spinal anaesthesia is better compared to spinal anaesthesia only.

Recommendations

A randomised controlled trial with a larger sample size is recommended.

Author Biographies

Lesedi Mothiba, BSc (Wits), MBBCH (Wits), DA (SA), Department of Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand.

is an anaesthetist in private practice. She completed her registrar training in anaesthesiology at Chris Hani Baragwanath Academic Hospital and the University of the Witwatersrand, South Africa. She has a keen interest in the management of acute pain, orthopaedic surgery, and anaesthesia for non-cardiac surgery in cardiac patients.

Grace Manjooran, MBBCh (Wits), DA (SA), FCA (SA), MMed (Anaes) (Wits), PG Dip HSE (Wits), Department of Anaesthesia, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand.

is a senior anaesthesiologist at Chris Hani Baragwanath Academic Hospital and a Lecturer in the Department of Anaesthesiology, University of the Witwatersrand, Johannesburg, South Africa. Her research interests include postgraduate education, paediatric anaesthesia, and perioperative pain management.

Mathabe Sehlapelo, MBChB (UP), DA (SA), FCA (SA), MMed (Anaes) (Wits), DTM&H (Wits), DipHivMan (SA), Higher Cert HSM (Regent), PG Dip HSE (Wits), Department of Anaesthesiology at Witwatersrand University, Chris Hani Baragwanath Academic Hospital, RSA.

is a senior anaesthesiologist at Chris Hani Baragwanath Academic Hospital and Lecturer in the Department of Anaesthesiology, University of the Witwatersrand, Johannesburg, South Africa. She is the domain head of airway management, breast, and endocrine. She is committed to health sciences education through innovative pedagogy, student mentorship, health system management, and community engagement.

References

Dela SS, Paruk F, Brown SL, Lukhele M, et al. Ethnic and gender-specific incidence rates for hip fractures in South Africa: A multi-centre study. Bone. 2020;133:115253.https://doi.org/10.1016/j.bone.2020.115253 PMid:31987987

Fernandez MA, Griffin XL, Costa ML. Management of hip fracture. Br Med Bull. 2015;115(1):165-72. https://doi.org/10.1093/bmb/ldv036 PMid:26311503

Krickl J, Ittermann T, Thannheimer A, Schmidt W, et al. The rising problem of hip fractures in geriatric patients: analysis of surgical influences on the outcome. Journal of Personalized Medicine. 2023;13(8). https://doi.org/10.3390/jpm13081271 PMid:37623521 PMCid:PMC10455730

Pincus D, Ravi B, Wasserstein D, Huang A, et al. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA. 2017;318(20):1994-2003.https://doi.org/10.1001/jama.2017.17606

PMid:29183076 PMCid: PMC5820694

Mid-year population estimates. Republic of South Africa: Statistics South Africa; 2024. Available from: https://www.statssa.gov.za/?page_id=1854&PPN=P0302&SCH=73952%20

Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, et al. Assessment of pain. British Journal of Anaesthesia. 2008;101(1):17-24. https://doi.org/10.1093/bja/aen103 PMid:18487245

Shmukler D, Griffiths A, Fourtunas M, Anamourlis C, Pegu K. SASA arthroplasty guidelines 2024: South African Society of Anaesthesiologists 2024. Available from: https://www.sasaweb.com/wp-content/uploads/2024/02/SASA-Arthroplasty-Guidelines-2024-FINAL-with-Cover.pdf.

Chetty S, Hodgson E, Milner A, Travers A, et al. Guidelines for the management of acute pain in specific scenarios: South African Society of Anaesthesiologists 2022. Available from: https://sasaweb.com/wp-content/uploads/2024/05/SASA-Acute-Pain-Guidelines-2022.pdf.

Sinatra R. Causes and consequences of inadequate management of acute pain. Pain Medicine. 2010;11(12):1859-71. https://doi.org/10.1111/j.1526-4637.2010.00983.x PMid:21040438

NICE. Hip fracture: Management: National Institute for Health and Care Excellence; 2011. Available from: https://www.nice.org.uk/guidance/cg124.

Wainwright TW, Gill M, McDonald DA, G Middleton R, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced recovery after surgery (ERAS®) society recommendations. Acta Orthopaedica. 2019;91(1):3-19. https://doi.org/10.1080/17453674.2019.1683790 PMid:31663402 PMCid:PMC7006728

Li S, An J, Qian C, Wang Z. Efficacy and safety of pericapsular nerve group block for hip fracture surgery under spinal anesthesia: A meta-analysis. International Journal of Clinical Practice. 2024;2024:6896066. https://doi.org/10.1155/2024/6896066 PMid:38510561 PMCid:PMC10954362

Dizdarevic A, Farah F, Ding J, Shah S, et al. A comprehensive review of analgesia and pain modalities in hip fracture pathogenesis. Curr Pain Headache Rep. 2019;23(10):72. https://doi.org/10.1007/s11916-019-0814-9 PMid:31388846

Kukreja P, Avila A, Northern T, Dangle J, et al. A retrospective case series of pericapsular nerve group (PENG) block for primary versus revision total hip arthroplasty analgesia. Cureus. 2020;12(5):e8200. https://doi.org/10.7759/cureus.8200

Kamel HK, Iqbal MA, Mogallapu R, Maas D, Hoffmann RG. Time to ambulation after hip fracture surgery: Relation to hospitalization outcomes. The Journals of Gerontology: Series A. 2003;58(11):M1042-M5. https://doi.org/10.1093/gerona/58.11.M1042 PMid:14630887

Short AJ, Barnett JJG, Gofeld M, Baig E, et al. Anatomic study of innervation of the anterior hip capsule: Implications for image-guided intervention. Reg Anesth Pain Med. 2018;43(2):186-92. https://doi.org/10.1097/AAP.0000000000000701 PMid:29140962

Giron-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular nerve group (PENG) block for hip fracture. Reg Anesth Pain Med. 2018;43(8):859-63. https://doi.org/10.1097/ AAP.0000000000000847 PMid:30063657 PMCid:PMC11459890

Alrefaey AK, Abouelela MA. Pericapsular nerve group block for analgesia of positioning pain during spinal anesthesia in hip fracture patients, a randomized controlled study. Egyptian Journal of Anaesthesia. 2020;36(1):234-9. https://doi.org/10.1080/11101849.2020.1828017.

Lin X, Liu CW, Goh QY, Sim EY, et al. Pericapsular nerve group (PENG) block for early pain management of elderly patients with hip fracture: A single-center double-blind randomized controlled trial. Reg Anesth Pain Med. 2023;48(11):535-9. https://doi.org/10.1136/rapm-2022-104117 PMid:37055189

Pagano T, Scarpato F, Chicone G, Carbone D, et al. Analgesic evaluation of ultrasound-guided pericapsular nerve group (PENG) block for emergency hip surgery in fragile patients: A case series. Arthroplasty. 2019;1(1):18.

https://doi.org/10.1186/s42836-019-0018-0 PMid:35240764 PMCid:PMC8796512

Pascarella G, Costa F, Del Buono R, Pulitanò R, et al. Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: A randomised, observer-masked, controlled trial. Anaesthesia. 2021;76(11):1492-8. https://doi.org/10.1111/anae.15536 PMid:34196965 PMCid:PMC8519088

Pai P, Amor D, Lai YH, Echevarria GC. Use and clinical relevance of pericapsular nerve block (PENG) in total hip arthroplasty: A systematic review and meta-analysis. Clin J Pain. 2024;40(5):320-32. https://doi.org/10.1097/AJP.0000000000001196 PMid:38268183

Sheldon J, Nejthardt M, Quan C, Retief F, et al. SASA guidelines for regional anaesthesia in South Africa, South African Society of Anaesthesiologists; 2016. Available from: https://sasaweb.com/wp-content/uploads/2022/07/SASRA-guidelines-2016.pdf.

Kolli S, Nimma SR, Kukreja P, P. How I do it: Pericapsular nerve group (peng) block. ASRA Pain Medicine News [Internet]. 2023; 48. Available from: https://doi.org/10.52211/asra080123.007.

AAOS. Management of hip fractures in older adults: evidence-based clinical practice guideline.American Academy of Orthopaedic Surgeons; 2021. Available from: https://www.aaos.org/globalassets/quality-and-practice-resources/hip-fractures-in-the-elderly/hipfxcpg.pdf.

Aliste J, Layera S, Bravo D, Jara A, et al. Randomized comparison between pericapsular nerve group (PENG) block and suprainguinal fascia iliaca block for total hip arthroplasty. Reg Anesth Pain Med. 2021;46(10):874-8.

https://doi.org/10.1136/rapm-2021-102997 PMid:34290085

Et T, Korkusuz M. Comparison of the pericapsular nerve group block with the intra-articular and quadratus lumborum blocks in primary total hip arthroplasty: A randomized controlled trial. Korean J Anesthesiol. 2023;76(6):575-85. https://doi.org/10.4097/kja.23064 PMid:37013389 PMCid:PMC10718628

Farag A, Hendi NI, Diab RA. Does the pericapsular nerve group block have limited analgesia in the initial post-operative period? Systematic review and meta-analysis. J Anesth. 2023;37(1):138-53. https://doi.org/10.1007/s00540-022-03129-5. PMid:36342537 PMCid: PMC9870839