Pericapsular Nerve Group Block vs Femoral Nerve Block for Perioperative Pain Management in Patients With Hip Fracture.

Study Overview
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Brief Summary
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The aim of this work is to compare between the use of PENG block and femoral nerve block for perioperative pain management in patients with hip fracture.

Detailed Description
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Hip fractures are common orthopaedic problem especially in elderly population which is associated with significant morbidity and mortality. Early surgical reduction and fixation is the preferred treatment in most patients. Significant pain, if inadequately controlled, can impair early rehabilitation and functional recovery and can reduce patient satisfaction after surgery . Combinations of systemic analgesics, intra-articular injection, and neuraxial and peripheral nerve blocks should be considered as the integral components of the perioperative pain management plan. Among these, intra-articular local anaesthetic injections have been shown to play a potential role in providing analgesia after hip arthroplasty. The risks of this procedure include hematoma, nerve damage, local anaesthetics toxicity, intravenous injection of local anesthetics and septic osteoarthritis, but their occurrence is very rare. Several peripheral nerve blocks, including fascia iliaca block, femoral block (FB), and some interfascial plane blocks such as quadratus lumborum block (QLB), have also been suggested to decrease postoperative pain and opioid use. Lumbar plexus block/psoas compartment block is a technically difficult deep block that requires greater skill and hence can be time consuming. The lumbar paravertebral region is highly vascular and non-compressible. Hence, patients on anti-coagulation are at high risk for bleeding complications. There is also high risk of unintentional neuraxial block or inadvertent intravascular injection with local anaesthetic systemic toxicity. Some nerve branches responsible for hip joint innervation may not be blocked by QLB, which should be taken into consideration while using these blocks for hip fracture. High-volume suprainguinal fascia iliaca block and traditional fascia iliaca block have also been reported to be associated with a significant incidence of muscle weakness and to predispose the patient to fall. The anterior hip capsule is innervated by the obturator nerve (ON), accessory obturator nerve (AON), and femoral nerve (FN) as reported by previous anatomic studies. The anterior capsule is the most richly innervated section of the joint, suggesting these nerves should be the main targets for hip analgesia. Femoral block (FB) does not block the AON or the articular branches of the ON. Also, femoral nerve block accompanied by decreasing the strength of quadriceps muscles. Pericapsular nerve group (PENG) block was described in 2018 and reported that it was successfully used for postoperative pain management in hip surgery. The PENG block is a technique that involves deposition of local anaesthetic in the musculofascial plane between the psoas muscle and the superior pubic ramus for the blockade of the articular branches of the FN, ON and AON that provide sensory innervation to the anterior hip capsule.

Official Title
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Pericapsular Nerve Group (PENG) Block Versus Femoral Never Block for Perioperative Pain Management in Patients With Hip Fracture: A Prospective Randomized Study.

Conditions
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Pain

Intervention / Treatment
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* Procedure: PENG block
* Procedure: FN block


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients with a hip fracture. Aged 50 years and older. Exclusion Criteria: Consent refusal. Allergy to local anaesthetics. Infection of the puncture site. Dementia or cognitive impairment.

Ages Eligible for Study
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Minimum Age: 50 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: PENG block group<br>using ultrasound-guided technique, a total of 20ml of 0.25 % bupivacaine will be injected after negative aspiration. | Procedure: PENG block<br>* Using ultrasound-guided technique, a total of 20ml of 0.25 % bupivacaine will be injected after negative aspiration.<br>|
| Active Comparator: FN block group<br>using ultrasound-guided technique, after negative aspiration, 20 mL of 0.25 % bupivacaine will be administered. | Procedure: FN block<br>* Using ultrasound-guided technique, after negative aspiration, 20 mL of 0.25 % bupivacaine will be administered.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Quadriceps muscle strength in recovery. | Quadriceps muscle strength will be assessed using Oxford muscle strength grading with grouped scores of intact (5/5), reduced (1-4/5) and absent (0/5). Muscle Grading Scores: 0 No detectable muscle contraction (visible or palpation) Detectable contraction (visible or palpation), but no movement achieved Limb movement achieved, but unable to move against gravity Limb movement against resistance of gravity Limb movement against gravity and external resistance Normal strength | 24 hours of the procedure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Visual analogue scale | before and 30 minutes after the block both at rest and during dynamic hip movement. 0 means no pain 10 means the worst pain | 24 hours of the procedure. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Femoral nerve, Pericapsular nerve group, Pain, Hip fracture