Reframing Hip Fracture Analgesia in the ED: Is It Time to Consider the PENG Block?

Comparaison du bloc du groupe nerveux péricapsulaire (PENG) avec le bloc du compartiment fascia iliaque (FICB) pour le contrôle de la douleur dans les fractures autour de la hanche: Essai clinique contrôlé randomisé prospectif en double aveugle

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

The PENG block is a recently described ultrasound-guided technique for the blockade of the sensory nerve branches to the anterior hip joint capsule. It was described as an analgesic block for the acute pain management after hip fracture, while subsequent studies expanded the original indication. The aim of this narrative review was to summarize the existing knowledge about the PENG block from the anatomical bases and to provide an up-to-date description of the technique, applications and effects. We reviewed the following medical literature databases for publications on PENG block: PubMed, Google Scholar, EMBASE, and Web of science until August 31st, 2020. Data regarding anatomy, indications, drugs and technique were also collected, reported and discussed. From our search result we selected 57 relevant publications. Among them, 36 were case reports or case series and 12 publication were letters or correspondence; no RCT was identified. The main indication is the hip-related analgesia. The most commonly injected drug is a 20ml long-acting local anesthetic. There are some cases of femoral and obturator nerve block, but no major complication such as hematoma/bleeding or needle-related organ injury has been reported yet. The PENG block is a promising technique. Randomized controlled trials of high methodological quality are required to further elaborate the role of this block.

P180 PENG block associated with intra-articular block for perioperative analgesia in hip surgery

EP022 Efficacy of PENG block over sedation during positioning in sub-arachnoid block for hemiarthroplasty of the hip: an observational study

Total hip arthroplasty (THA) is a highly effective treatment for end-stage osteoarthritis and hip fractures, significantly enhancing patients' quality of life. However, substantial postoperative pain remains a challenge, potentially impeding rehabilitation, prolonging hospitalization, and increasing the risk of chronic pain and subsequent revision surgeries. Multimodal analgesia (MA), which combines two or more analgesic methods with different mechanisms, is commonly employed in clinical practice to manage postoperative pain in THA. Among these methods, regional nerve blocks and local infiltration analgesia (LIA) have gained increasing attention due to their excellent analgesic effects and relatively few adverse reactions. This article reviews the two primary analgesic methods for postoperative THA: regional nerve blocks, including the emerging pericapsular nerve group block (PENG block), and LIA. Regional nerve blocks, such as femoral nerve block (FNB) and PENG block, have demonstrated efficacy in reducing postoperative pain and opioid consumption while preserving quadriceps muscle strength, thereby promoting rapid postoperative recovery. The PENG block, in particular, has shown promise as a preferred nerve block option for THA due to its ability to effectively block multiple nerves supplying the hip joint without affecting lower limb muscle strength. LIA, involving the infiltration of a high-volume local anesthetic solution around the joint capsule and surgical incision, has also proven to be a simple, cost-effective, and efficacious method for acute pain control after THA. Its analgesic effects are comparable to those of intrathecal morphine injection or peripheral nerve blocks, and it does not affect lower limb muscle strength. Combining LIA with nerve blocks such as PENG and FNB can further enhance multimodal analgesia. However, there is currently no unified formula for the drug composition of LIA, and research on liposomal bupivacaine, a sustained-release formulation of bupivacaine, has yielded varying results regarding its benefits. Overall, current evidence supports the use of regional nerve blocks, particularly the PENG block, and LIA as effective analgesic methods for postoperative THA, with the potential for further optimization through combination therapies and standardized protocols.

Introduction. Intertrochanteric fractures are defined as extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter. Bipolar hip arthroplasty is one of the most common major orthopaedic procedures to improve patient’s functional status and quality of life. Spinal anesthesia is a regional anesthetic technique that is performed by injecting local anesthetic drugs into the subarachnoid space to obtain dermatome-level analgesia and skeletal muscle relaxation. Pain after hip replacement originates mainly from the anterior pelvic capsule. The main target for pelvic analgesia is the anterior capsule which is the most richly innervated part of the joint. PENG block is used to block the articular branches to the pelvis. The patient was assessed with an NRS (numeric rating scale) instrument pre and post operative.
 Case presentation. A-74 year old woman admitted with complaints of pain in the right hip and diagnosed with a closed fracture of the right intertrochanter and planned for bipolar hip arthroplasty with PENG block and spinal anesthesia. Preoperatively the patient was assessed with an NRS (numeric rating scale) instrument with a score of 6. After the procedure, we reevaluated the pain score using NRS was 2 post operative.
 Conclusion. Patients receiving a PENG block and spinal anesthesia for intraoperative and postoperative analgesia during hip fracture surgery. Prior to spinal anesthesia, PENG block can be performed as a multimodal analgesia in the patient, PENG block expected to facilitate a sitting position during spinal anesthesia and for postoperative pain management

Analgesia and anesthesia using the pericapsular nerve group block in hip surgery and hip fracture: a scoping review

Translated article] Benefits of analgesic blocks, PENG block (PEricapsular Nerve Group), in fast recovery after hip surgery

BackgroundPain after total hip arthroplasty (THA) for femoral neck fracture (FNF) can be severe, potentially leading to serious complications. PENG block has become an optional local analgesic strategy in hip fracture surgery, but it cannot provide effective pain relief for the posterior capsule of the hip joint. Therefore, we modified the traditional sacral plexus nerve block and named it Posterior Hip Pericapsule Block (PHPB) to complement the blockade of the relevant nerves innervating the posterior hip capsule region. Thereby, we detail the analgesic effect of PHPB combined with PENG block on five hip fracture patients and the effect on their hip motor function.MethodsThis case series was conducted from December 2023 to February 2024. We performed ultrasound-guided PHPB combined with PENG block on five patients with hip fractures. Numerical Rating Scale (NRS) pain scores at rest and maximum NRS pain scores during limb movement of the five patients were recorded within 48 h after surgery. Their hip flexion, abduction, adduction, keen flexion and quadriceps muscle strength were also recorded. Serious postoperative complications, including wound infection, hematoma formation, or nerve injury, were recorded.ResultsThey experienced effective pain control within 48 h postoperatively, with NRS pain scores at rest decreasing from 3.0 (3.0, 4.5) to 0.0 (0.0, 1.0) and maximum NRS pain scores during limb movement from 8.0 (7.5, 8.5) to 1.0 (0.5, 2.0). They can autonomously perform hip flexion, abduction, adduction, and knee flexion within 48 h postoperatively without any signs of movement disorders or quadriceps muscle weakness. No severe postoperative complications, such as wound infections, hematoma formation or nerve damage, were observed in any of the patients.ConclusionsUltrasound-guided PENG block combined with PHPB provided effective analgesia for hip fracture patients in the perioperative period. It maintained hip joint motor function and quadriceps muscle strength within 24 h after THA.

Background and Aims:We hypothesised that blocking the lateral femoral cutaneous nerve (LFCN) separately may provide an additional advantage to the peri-capsular nerve group (PENG) block in terms of duration of analgesia and patient comfort. Therefore, we conducted a prospective, double-blinded, randomised study comparing the effect of PENG with that of the PENG Plus LFCN block on the duration of analgesia in fractured hip surgery. Rest and Dynamic pain scores for 24 hours were recoded as primary objectives. The duration of analgesia, the time of administration of the block until numerical rating scale (NRS) ≥ 4, the ease of spinal positioning, and side effects were recorded as secondary outcomes.Methods:A total of 124 patients of age group 18 to 80 years, American Society of Anesthesiologists grade 1–3, were randomised into two groups. The ultra-sound-guided PENG block with ropivacaine 0.5% 30 ml and dexamethasone 8 mg was given in group A and ropivacaine 0.5% 25 ml and 5 ml at LFCN separately was given in group B. The NRS after 20 minutes, 25 minutes, and 30 minutes was noted. The ease of spinal positioning was also noted. The NRS at 4, 6, 8, 12, and 24 hours was noted in resting and movement. Any side effects were documented and treated as a hospital protocol. All patients were given a combined spinal epidural with injection bupivacaine 0.5 per cent 1.6 ml with fentanyl 20 µg. Injection paracetamol 1 gram was added 8 hourly in both the groups as a part of multi-modal analgesia. Injection tramadol 25 mg was given if NRS exceeded 4 through a patient-controlled analgesia only bolus dose, a lock-out of 10 minutes, 4 hourly, limit 100 mg, as rescue analgesia.Results:NRS at rest and movement in group A (PENG) mean [inter-quartile range (IQR)] = 3 (3-2), group B (PENG+LFCN) 2 (2-1), respectively. Time to first analgesic request mean (IQR) group A 9.04 (12.5-0), group B 12.12 (14-0), ease of spinal positioning group A 3 (3-2), group B 3 (3-2).Conclusion:The PENG block is an effective block for fractured hip surgeries in providing ease of spinal positioning and post-operative analgesia, and if PENG is combined with the LFCN block, the post-operative analgesia is enhanced by increasing the duration and reduction in the pain score.TableNRS at rest and movement in both groups at 24 hMedian (IQR)PNRS at rest at 24 h Group A3 (3-2)0.00001 Group B2 (3-2)0.0026NRS at movement at 24 h Group A3 (3-3)0.00001 Group B2.5 (3-2)0.00092

Background: The peri-capsular nerve group block (PENG) has reported the ability to decrease pain in hip fractures and minimize the use of opioids for postoperative analgesia. We conducted this trial to assess the efficacy of varying volumes of local anesthetic solution in PENG block in alleviating post-operative pain at rest and on dynamic hip movement after hip surgeries. Material & Methods: A prospective, double-blinded interventional trial was conducted on 70 adult ASA I-III patients undergoing hip surgeries under general anesthesia. Enrolled subjects were divided into two groups A and B to receive either 10ml of 0.2% ropivacaine or 20ml of 0.2% ropivacaine respectively in an ultrasound-guided (USG) PENG block after administration of general anesthesia. The primary outcome was the duration of analgesia. VAS scores (at rest and on dynamic hip movement), the cumulative amount of rescue analgesic needed in the 24-hour post-operative period and patient satisfaction scores were secondary outcomes. Data thus collected were statistically analyzed. Results: Mean duration of analgesia was significantly prolonged in group B (12.24±5.14 hours) as compared to group A (2.77±1.06 hours). There were statistically significant decreased VAS scores at rest and on dynamic hip movement in group B. Median total rescue analgesic consumption in 24 hours and patient satisfaction score was significantly reduced in group B than in group A (p=0.001). Conclusion: In PENG block, 20 ml of 0.2% ropivacaine provides a significantly longer duration of analgesia, a statistically significant reduction in pain scores on rest and dynamic hip movement with substantially decreased 24-hour total rescue analgesic consumption, and improved patient satisfaction in patients undergoing hip surgeries. Keywords: Pericapsular nerve group block (PENG), Hip surgeries, Ropivacaine, Visual analogue scale (VAS)

Background Proximal femur fractures are most common fractures especially in elderly population. Regional anaesthesia is preferred during surgery in these patients. However, the severe pain associated with these injuries makes appropriate positioning difficult for the regional anaesthesia, thus altering their overall success rate, also the majority of patients often experience moderate to severe postoperative pain. Aim of the Work The study aimed to compare between ultrasound guided PENG and FNB using VAS score to assess the overall efficacy for pain relief during patient positioning for spinal anesthesia. Patients and Methods After approval of anaesthesiology department scientific and ethical committees in Ain Shams University Hospitals, 50 patients were included in the study, and were divided into two groups (n = 25; each); group PENG and FNB group. The two groups were adequately monitored and assessed before spinal anesthesia and post-operatively and they were compared regarding analgesic outcome by using the visual analogue scaling system, besides, recording time for first call for rescue analgesia and total amount of analgesia required. Results This study documented that PENG block is comparable to femoral block for postoperative pain control. The PENG block has been described very first in 2018 for preoperative management of femur neck fracture. We observed no statistically significant difference in pain scores during positioning for spinal anesthesia and for first 24 hrs post-operative. Similarly, no significant difference was also found in first rescue analgesia time and Cumulative nalbuphine consumption at 24 hours after surgery between the two groups. Conclusion In the management of hip fractures, PENG block is not associated in the present study with a significant change in pain score during positioning for spinal anesthesia compared to femoral nerve block.

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.

Beneficios de los bloqueos analgésicos, PENG (PEricapsular Nerve Group), en la recuperación precoz tras la cirugía de cadera