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Abbreviations: ASA, American Society of Anesthesiologist; AGIRG, Autonomy Gerontology Iso-Ressources Group; IQR, InterQuartile Range; VAS, Visual Analog Scale. a = values are given as median 95% CI or percentages. b = p-value compares Femoral block group versus PENG block group. c = Fisher test was used to compare qualitative variable, t-test for quantitative variable.
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Background
Regional analgesia is worth performing in the multimodal postoperative management of hip fracture (HF) because it reduces hospital morbidity and mortality. The aim of this study is to compare the efficacy and side effects of the recently described “Pericapsular Nerve Group (PENG) Block” with those of the femoral block, which is considere...
Citations
... An observational cohort study compared the data of 42 patients who received either PENG or FNB and reported that there was no significant difference in mean postoperative VAS and opioid consumption for 24-48 hours [32]. Another randomized, double-blinded study compared the duration of PENG and FNB based on the ability of patients to recall their sensory and motor recovery, and hence only data from 24 patients (13 in FNB, 11 in PENG) could be analyzed and found, with PENG lasting for 22.5 hours compared to FNB, which lasted for 15.35 hours [33]. ...
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.
... Quadriceps muscle strength is essential for basic activities like walking and standing from a seated position. 27 By preserving this strength, PENGB may reduce the duration of hospital stays and improve overall recovery times, thereby enhancing patient outcomes and reducing healthcare costs. The significant reduction in quadriceps muscle weakness aligns with PENGB's mechanism of action, which provides targeted analgesia without extensive motor blockade. ...
Hip fracture surgeries are challenging, with postoperative pain management being a critical component of patient care. This systematic review and meta‐analysis aimed to compare the effectiveness of Pericapsular nerve group block (PENGB) and fascia iliac compartment block (FICB) in postoperative wound pain management for patients undergoing hip fracture surgery. The study followed the PRISMA guidelines and was structured around the PICO framework. Comprehensive searches were conducted across PubMed, Embase, Web of Science, and the Cochrane Library. Inclusion criteria were limited to RCTs comparing the effectiveness of PENGB and FICB in adult patients undergoing hip fracture surgery. Key outcomes included pain control effectiveness, safety, and complication incidence. The quality of studies was assessed using the Cochrane Collaboration's risk of bias tool. Statistical heterogeneity was evaluated using I ² statistics, and meta‐analysis effect values were calculated using random‐effects or fixed‐effect models, depending on the degree of heterogeneity. The search identified 1095 articles, with 5 studies meeting inclusion criteria. The meta‐analysis revealed that PENGB and FICB were comparable in managing postoperative pain and opioid consumption. However, PENGB significantly reduced the incidence of quadriceps muscle weakness (RR = 0.12, p < 0.05) and did not increase the risk of PONV (RR = 1.36, p = 0.51), suggesting its advantage in maintaining motor function without adding to PONV complications. No significant publication bias was detected. PENGB is comparable to FICB in pain and opioid consumption management after hip fracture surgeries. Its significant benefit lies in reducing the incidence of quadriceps muscle weakness, facilitating better postoperative mobility. Additionally, PENGB does not increase the risk of postoperative nausea and vomiting, underlining its suitability for comprehensive postoperative care in hip fracture patients.
... Given its selective targeting of sensory nerves, the PENG block preserves motor function. Previous studies consistently demonstrated signi cantly less motor blockade in patients who received PENG block compared to those who received an FNB or FICB [9,10]. Moreover, a recent randomized controlled trial reported that PENG block reduces preoperative dynamic pain score [11], providing additional support for its application in preoperative mobilization. ...
Background
Despite surgery intervention for femoral neck fractures is recommended within 48 hours of admission, achieving timely surgery presents challenges for patients with severe comorbidities, or in resource-limited settings. Preoperative rehabilitation (prehabilitation) reduces bedridden time, enhances mobility, and improves postoperative outcomes for patients scheduled for hip arthroplasty due to femoral neck fractures. However, prehabilitation is hindered by insufficient pain control. The pericapsular nerve group (PENG) block provides effective analgesia while preserving motor function. We designed a study to assess the efficacy of PENG block in facilitating prehabilitation for patients with femoral neck fractures who are scheduled for hip arthroplasty.
Methods
This prospective randomized placebo-controlled double-blinded trial aims to enroll 100 patients with Garden 3 or 4 femoral neck fractures who are scheduled for hip arthroplasty. Participants will be randomly assigned to receive a PENG block with 0.375% ropivacaine (PENG group) or with normal saline (placebo group) before the initial prehabilitation session. The prehabilitation program comprises five items: Bed-sitting, Edge-sitting, Stand-up, Maintaining-standing, and Wheelchair-transfer, performed with the assistance of a single physical therapist. The primary outcome is the percentage of patients completing the entire prehabilitation program. Secondary outcomes during the initial prehabilitation session are the achievement of each program item and the Numerical Rating Scale (NRS) pain score. Other secondary outcomes include intraoperative bleeding amounts, thromboembolic events during postoperative day 0 to 7, postoperative 3-day cumulative Cumulated Ambulation Score (CAS), and discharge destination. The postoperative outcomes will be compared between subgroups of patients undergoing surgery within 48 hours of admission and those undergoing surgery more than 48 hours of admission.
Discussion
This is the first study aiming to assess the efficacy of PENG block in prehabilitation for patients with femoral neck fractures who are scheduled for hip arthroplasty. PENG block could be beneficial, especially for patients facing delayed surgery, providing a potential treatment option during the waiting period.
Trial registration
jRCT1031220294
... In addition, quadriceps strength was found to be better protected in the PENG block group [21]. The authors of a study comparing PENG and femoral blocks in femur fracture surgery concluded that PENG block provided no analgesic advantage [22]. ...
Previous studies have demonstrated the effectiveness of the pericapsular nerve group (PENG) block and suprainguinal fascia ilica compartment block (SIFCB) in providing postoperative pain relief. This retrospective study aimed to compare the analgesic contribution and quality of recovery of SIFCB added to PENG block for hip surgery in elderly patients. This retrospective study analyzed data from patients over the age of 65 who underwent hip surgery between January 2023 and September 2023. The patients included were all American Society of Anesthesiologists (ASA) 2-3, and received a standard perioperative and postoperative analgesia regime. According to the regional anesthesia method applied to the patients, they were grouped as PENG and PENG+SIFCB. The study was conducted on 38 patients. Of these, 20 were in the PENG group, while 18 were in the PENG+SIFCB group. The study evaluated the 48-hour oral opioid consumption and quality of recovery on postoperative day 1 and month 1 in both groups. The results indicated that the average oral opioid consumption was similar in both groups, with the PENG group consuming an average of 26.5 (IQR: 20-30) and the PENG+SIFCB group consuming an average of 20 (IQR: 10-28), respectively (p=0.100). Furthermore, there was no significant difference between the two groups in terms of quality of recovery on postoperative day 1 and month 1 (p=0.271, p=0.936, respectively). The study found that combining SIFCB with PENG block provides similar benefits compared to PENG block alone for postoperative opioid consumption and quality of recovery in multimodal analgesia planning.
... The description of the hip pericapsular nerve group (PENG) block technique using ultrasound (US) occurred in 2018. PENG block has been widely studied for pain management, [1][2][3][4][5][6][7][8][9][10][11][12][13] mainly in the perioperative period of hip surgeries, with promising results. [2][3][4][5][6][7][8][9][10][11][12] This technique can also be used in patients with femoral neck fractures admitted to the emergency care unit who present with significant associated pain 1,3-8, [11][12][13] or even in subjects with degenerative diseases who cannot undergo an immediate surgical procedure. ...
... PENG block has been widely studied for pain management, [1][2][3][4][5][6][7][8][9][10][11][12][13] mainly in the perioperative period of hip surgeries, with promising results. [2][3][4][5][6][7][8][9][10][11][12] This technique can also be used in patients with femoral neck fractures admitted to the emergency care unit who present with significant associated pain 1,3-8, [11][12][13] or even in subjects with degenerative diseases who cannot undergo an immediate surgical procedure. 14 Jaramillo et al. 14 showed that PENG neuroablation in patients with chronic hip pain can drastically reduce the use of opioid analgesics for a long time and improve their quality of life. ...
... PENG block has been widely studied for pain management, [1][2][3][4][5][6][7][8][9][10][11][12][13] mainly in the perioperative period of hip surgeries, with promising results. [2][3][4][5][6][7][8][9][10][11][12] This technique can also be used in patients with femoral neck fractures admitted to the emergency care unit who present with significant associated pain 1,3-8, [11][12][13] or even in subjects with degenerative diseases who cannot undergo an immediate surgical procedure. 14 Jaramillo et al. 14 showed that PENG neuroablation in patients with chronic hip pain can drastically reduce the use of opioid analgesics for a long time and improve their quality of life. ...
Resumo
Objetivo Descrever e avaliar a acurácia da técnica do bloqueio PENG realizado sem auxílio de ultrassonografia.
Método Série de 40 infiltrações em pacientes com dor no quadril, em acompanhamento ambulatorial no grupo de cirurgia do quadril ou admitidos no pronto atendimento de um hospital na cidade de São Paulo. Utilizada a técnica de bloqueio nervoso pericapsular do quadril (PENG) guiado por estruturas anatômicas palpáveis da pelve e sem auxílio de ultrassonografia no posicionamento da agulha, usando o aparelho apenas para conferência da localização correta após punção não guiada.
Resultados Nos 40 quadris infiltrados em 35 pacientes com idade média de 59,2 anos, obtivemos um índice de acerto de 85%. Dos casos mal posicionados 71,4% ocorreram nas primeiras 13 aplicações e 28,6% nas 27 aplicações subsequentes. Em todos os pacientes o feixe neurovascular estava situado no terço medial da marcação realizada à caneta e mesmo nos casos em que houve falha da localização da agulha havia distância segura ao feixe neurovascular. Obtivemos apenas 1 caso de efeito adverso, onde ocorreu apraxia do nervo femoral com melhora espontânea em 2 dias.
Conclusão O bloqueio PENG não guiado é uma técnica viável e pode ser realizada por um médico que já possui conhecimento na aplicação, em serviços onde não haja disponibilidade do aparelho de ultrassonografia.
... [12,[14][15][16] Although limited studies have been conducted comparing the efficacy of the PENG block with that of FNB for perioperative pain management in hip fractures, a specific study on the effects of the PENG block on spinal anesthesia position pain management is not available in the literature. [17,18] Therefore, this study aimed to compare the analgesic efficacy of the PENG block with that of FNB in managing the pain due to lateral decubitus positioning for spinal anesthesia during hip fracture surgery in geriatric patients. The secondary objective of our study was to compare the effects of the PENG blocks with those of FNB on the quality of the patient's position for spinal anesthesia and the number of spinal anesthesia interventions. ...
... [11,19,20] However, the effect of FNB on motor nerves can cause loss of strength in the quadriceps muscle and adversely affect the ambulation, rehabilitation, and discharge processes, especially in geriatric patients. [18] In addition, FNB does not act on all of the nerves that provide sensory innervation to the hip joint. [21] This has led to the introduction of alternative regional techniques. ...
... [12] The previous studies have shown that the PENG block anesthetizes the nerves that innervate the hip joint to provide effective analgesia by acting only on the joint branches and does not delay early ambulation by not causing a motor block. [16,18] In addition, it can be administered with a single injection in the supine position without having to place the patient in a position that causes pain. [10,12] Furthermore, the PENG block mostly targets the sensory nerves in the anterior capsule, thereby contributing to effective physical therapy and early discharge. ...
... Some case series and randomised control studies suggest PENG block as an effective alternative for femur fracture pain relief. [5,6] The literature is scarce to compare the immediate analgesic effect of ultrasonography (USG)-guided PENG block and FNB for positional pain during spinal anaesthesia. So, we aimed to compare the analgesic effect of USG-guided PENG block and FNB during positioning before spinal anaesthesia in patients undergoing surgery for proximal femur fractures. ...
... The median pain score was 2 (1-2) vs. 3 (2-4) at 6 h and 3 (2-3.75) vs. 5 (4)(5) at 8 h in the PENG and FNB groups, respectively. D-Yin Lin compared PENG and FNB for short-term analgesia. ...
... They observed pain score at 4 h was significantly lower with the PENG block group than with FNB. [14] Contrary to this, Allard et al. [5] did a cohort study to compare the analgesic effect of PENG block vs. Femoral block and 48 h morphine consumption. They did not find a difference in morphine consumption till 48 h postoperatively. ...
Background and Aims
Femoral nerve block is a widely used analgesia technique for positioning before spinal anaesthesia for proximal femur fracture surgeries. Pericapsular nerve group (PENG) block is a newer technique with motor-sparing characteristics. We compared the analgesic efficacy of these blocks for patient positioning for spinal anaesthesia.
Methods
In this study, 60 patients were randomised to either the PENG group ( n = 30) or the femoral group ( n = 30). After performing the block, the pain was assessed every 10 min using a visual analogue scale (VAS) score for 30 min. The primary objective was the median [interquartile range (IQR)] reduction in pain (dynamic VAS with 15-degree passive limb elevation) at 30 min. Secondary objectives were ease of spinal position score (EOSP), angle obtained during positioning, duration of postoperative analgesia and quadriceps weakness.
Results
The demographics were comparable in both groups. After 30 min, the median (IQR) VAS was 6 (5–7) in the PENG group and 5 (5–6) in the femoral group ( P = 0.004). Secondary outcomes such as EOSP score and angle obtained by patients were comparable. In the postoperative period, patients had significantly lower pain in the PENG group compared to the femoral group. The duration of analgesia was prolonged with PENG block. Quadriceps weakness was significantly low with PENG block ( P < 0.001).
Conclusion
PENG block provides better analgesia than a femoral block before spinal anaesthesia for proximal femur fracture surgery. The postoperative duration of analgesia was also longer.
... The pericapsular nerve group (PENG) block is an ultrasound-guided approach first described by Giron-Arango et al. [10]. The PENG block targets the articular branches of the obturator nerve, the accessory obturator nerve, and the femoral nerve, providing sensory innervation to the anterior capsule of the hip [7,11,12]. It has been used successfully in multimodal pain management for hip fractures [12,13] and for pain management after total hip arthroplasty [14]. ...
... The PENG block targets the articular branches of the obturator nerve, the accessory obturator nerve, and the femoral nerve, providing sensory innervation to the anterior capsule of the hip [7,11,12]. It has been used successfully in multimodal pain management for hip fractures [12,13] and for pain management after total hip arthroplasty [14]. It has been shown that the PENG block can protect the body, speeding up the first ambulance and recovery. ...
... The PENG block is a relatively novel ultrasound-guided regional anesthesia technique designed to block the branches of the femoral, obturator, and obturator accessory nerves innervating the anterior capsule of the hip joint [10,14]. Currently, the PENG block is used for pain management in various hip surgeries, including fractures and hip replacements [11][12][13][14]17]. However, most recent evidence is limited to trials with small group sizes [11,14] and case reports [19][20][21][22]. ...
Background:
The immediate postoperative period after total hip arthroplasty can be associated with significant pain. Therefore, this study aimed to evaluate the effect of pericapsular nerve block on pain management and functional recovery after total hip arthroplasty.
Methods:
This prospective, randomized, double-blinded, placebo-controlled trial was conducted on 489 adult patients scheduled for total hip arthroplasty, ASA 1-2, operated under spinal analgesia. Participants were assigned to receive either a pericapsular nerve group (PENG) block with 20 mL of 0.5% ropivacaine or a sham block.
Results:
The primary outcome measure was the postoperative NRS score in motion. The secondary outcomes were cumulative opioid consumption, the time to the first opioid, and functional recovery. Demographic characteristics were similar in both groups. Intraoperative pain scores were significantly lower in patients who received the PENG block than in the control group (p < 0.0001). Also, the time to the first opioid was considerably longer in the PENG group (p < 0.0001). Additionally, 24% of PENG patients did not require opioids (p < 0.0001).
Conclusions:
The pericapsular nerve group showed significantly decreased opioid consumption and improved functional recovery. Pericapsular nerve group block improved pain management and postoperative functional recovery following total hip arthroplasty.
... This requires not only minimizing postoperative pain during activity but also maximizing the retention of mobility. The pericapsular nerve group (PENG) block, which has been successfully employed for analgesia in patients with hip fracture and surgery, and has been shown to facilitate early postoperative mobilization [15][16][17][18]. However, some recent studies have reported quadriceps motor block following PENG block [19][20][21]. ...
Background
Iliopsoas plane block (IPB) is a novel analgesic technique for hip surgery that retains quadriceps strength. However, evidence from randomized controlled trial is remains unavailable. We hypothesized that IPB, as a motor-sparing analgesic technique, could match the femoral nerve block (FNB) in pain management and morphine consumption, providing an advantage for earlier functional training in patients underwent hip arthroplasty.
Methods
We recruited ninety patients with femoral neck fracture, femoral head necrosis or hip osteoarthritis who were scheduled for unilateral primary hip arthroplasty were recruited and received either IPB or FNB. Primary outcome was the pain score during hip flexion at 4 h after surgery. Secondary outcomes included quadriceps strength and pain scores upon arrival at post anesthesia care unit (PACU) and at 2, 4, 6, 24, 48 h after surgery, the first time out of bed, total opioids consumption, patient satisfaction, and complications.
Results
There was no significant difference in terms of pain score during hip flexion at 4 h after surgery between the IPB group and FNB group. The quadriceps strength of patients receiving IPB was superior to those receiving FNB upon arrival at PACU and at 2, 4, 6 and 24 h after surgery. The IPB group showed a shorter first time out of bed compared to the FNB group. However, there were no significant differences in terms of pain scores within 48 h after surgery, total opioids consumption, patient satisfaction and complications between the two groups.
Conclusion
IPB was not superior to FNB in terms of postoperative analgesia for hip arthroplasty. However, IPB could serve as an effective motor-sparing analgesic technique for hip arthroplasty, which would facilitate early recovery and rehabilitation. This makes IPB worth considering as an alternative to FNB.
Trial registration
The trial was registered prior to patient enrollment at the Chinese Clinical Trial Registry (ChiCTR2200055493; registration date: January 10, 2022; enrollment date: January 18, 2022; https://www.chictr.org.cn/searchprojEN.html).
... Aliste at al. [18], Hua et al. [19], and Mostaffa et al. [20] have reported that PENG block was more effective than the iliac fascia block. Allard et al. [21] and Lin et al. [22] have found that PENG block was more effective than femoral nerve block in the management of hip fractures' pain. Fascia iliaca compartment block and femoral nerve block have moderate analgesic effect as these blocks spare the obturator nerve. ...
... Furthermore, this study lacked the necessary statistical power to distinguish between the two groups in terms of either opiate usage or patient-reported outcome measures. Also, Allard et al. [21] found that PENG block was not associated with a significant change in postoperative morphine consumption compared to femoral block in the management of hip fractures. Allard et al. used 20 ml of ropivacaine at 3.5 mg/ml without any adjuvants, which could have prolonged the duration of postoperative analgesia. ...
Background
This study aimed to assess the safety and efficacy of analgesia with pericapsular nerve group (PENG) block as an adjuvant to morphine infusion for the management of preoperative pain in patients with proximal femur fractures.
Methods
This single-blinded, parallel-group, randomized trial enrolled 36 adult patients with proximal femur fractures who were prepared for surgery. The patients were randomly allocated to two groups. In the PENG group, 18 patients received a US-guided PENG block as an adjuvant to patient-controlled morphine analgesia (PCA), while in the PCA group, 18 patients received PCA only. The primary outcome was the total morphine consumption in 24 hours before the surgery. The secondary outcomes included the visual analogue scale (VAS), need for rescue analgesia, total sleep hours, incidence of respiratory depression, hemodynamic stability, and incidence of nausea and vomiting during the first 24 hours post-procedure.
Results
The PENG block significantly decreased the total dose of morphine, VAS score at one-hour post-procedure, need for rescue analgesia, incidence of respiratory depression and nausea but increased the sleeping hours. Vomiting was comparable in the two groups (p = 0.121). Significantly higher mean arterial pressures from 8 to 20 hours after the block as well as heart rates immediately after the block were observed in the PENG group compared to the PCA group.
Conclusion
In patients with proximal femur fractures, preoperative PENG block can be used as an adjuvant to morphine infusion for controlling the pain and the total dose of morphine usage.
