Pericapsular Hip Block Guided by Ultrasonography in Elderly People with Hip Fracture in the Emergency Sector: Clinical Trial

Fontes, Gustavo Martins; Perez, Marcelo Vaz; Miashiro, Edson Hidenori; Sousa Neto, Antonio Isidoro de; Grigio, Thiago Ramos; Rodrigues, Luiz Henrique Silveira

doi:10.1055/s-0044-1785494

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Original Article • Rev bras ortop 59 (2) • 2024 • https://doi.org/10.1055/s-0044-1785494 copy

Pericapsular Hip Block Guided by Ultrasonography in Elderly People with Hip Fracture in the Emergency Sector: Clinical Trial

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives

This study evaluated pain intensity in elderly subjects with hip fractures admitted to the emergency sector and undergoing preoperative pericapsular nerve group (PENG) block. Additionally, the degree of tolerable hip flexion was assessed.

Methods

A prospective, randomized, and controlled clinical trial with parallel groups. The control group consisted of elderly subjects with hip fractures undergoing standardized intravenous systemic analgesia. The intervention group consisted of elderly patients with hip fractures undergoing PENG block and standardized systemic analgesia. The groups were evaluated at rest and during movement using the Pain Assessment in Advanced Dementia (PAINAD) scale. We determined pain intensity and reduction, in addition to the degree of tolerable flexion of the fractured hip. All patient assessments occurred before the medication or block administration and at 45 minutes, 12, 24, and 36 hours postmedication or block.

Results

Preoperatively and 24 hours after PENG block, elderly subjects with hip fracture showed a significant reduction in pain at rest or movement compared to control patients (p< 0.05), with 60% of patients assessed at rest demonstrating desirable pain reduction (≥50%) and only 13.3% of the control group achieving the desired pain reduction. During movement, after undergoing PENG block, 40% of subjects demonstrated the desired pain reduction and no patient from the control group. The intervention group also showed a significant improvement in the tolerable hip flexion group (p< 0.05).

Conclusion

Preoperative PENG block in elderly subjects with hip fractures admitted to the emergency sector provided a significant reduction in pain compared with the control group.

Keywords
analgesia; anesthesia, conduction; nerve block; pain; hip fractures; ultrasonography

Statistical power (1-β)	p₁ = 0,05 and p₂ = 0,50
	n	n per group	+5%
	n	n per group	n	n per group
0.80	30	15	32	16

Characteristic		Control	Intervention	Total	p-value
		n = 15	n = 15	n = 30
		n (%)	n (%)	n (%)
Gender					0.999^a a Fisher exact test.
	Female	12 (80.0)	12 (80.0)	24 (80.0)
	Male	3 (20.0)	3 (20.0)	6 (20.0)
Age (years)					0.618^c c Mann-Whitney test.
	Mean (SD)	79.5 (11.3)	80.9 (9.7)	80.2 (10.4)
	Median (min-max)	77 (65–98)	82 (65–98)	79.5 (65–98)
Fracture classification					0.705^b b Pearson chi-square test.
	Transtrochanteric (extracapsular) fractures	9 (60.0)	10 (66.7)	19 (63.3)
	Femoral neck (intracapsular) fractures	6 (40.0)	5 (33.3)	11 (36.7)

Characteristic			Control	Intervention	p-value^a a Mann-Whitney test.
			n = 15	n = 15
			n (%)	n (%)
Rest
	Hospitalization	Mean (SD)	2.0 (1.3)	1.7 (1.6)	0.464
		Median (Q₁-Q₃)	2 (1–3)	1 (1–3)
	45 minutes	Mean (SD)	1.7 (1.2)	0.5 (0.8)	0.001
		Median (Q₁-Q₃)	1 (1–2)	0 (0–1)
	12 hours	Mean (SD)	1.9 (1.4)	0.3 (0.8)	<0.001
		Median (Q₁-Q₃)	2 (1–3)	0 (0–0)
	24 hours	Mean (SD)	2.0 (1.5)	0.3 (0.8)	0.001
		Median (Q₁-Q₃)	2 (1–3)	0 (0–0)
	36 hours	Mean (SD)	2.0 (1.5)	0.9 (1.2)	0.046
		Median (Q₁-Q₃)	2 (1–3)	1 (0–1)
Movement
	Hospitalization	Mean (SD)	6.2 (1.5)	7.3 (1.5)	0.051
		Median (Q₁-Q₃)	6 (5–8)	8 (6–8)
	45 minutes	Mean (SD)	6.1 (1.2)	3.6 (2.1)	0.001
		Median (Q₁-Q₃)	6 (5–7)	3 (2–5)
	12 hours	Mean (SD)	6.5 (1.2)	3.1 (2.0)	<0.001
		Median (Q₁-Q₃)	6 (5–7)	3 (2–4)
	24 hours	Mean (SD)	6.5 (1.2)	3.8 (1.6)	<0.001
		Median (Q₁-Q₃)	6 (6–7)	4 (2–5)
	36 hours	Mean (SD)	6.3 (1.3)	4.3 (1.1)	0.001
		Median (Q₁-Q₃)	6 (5–7)	4 (4–5)

Comparison				Control	Intervention	p-value^a a Mann-Whitney test.
Rest	Hospitalization	45 minutes	Mean (SD)	-0.27 (0.80)	-1.20 (1.32)	0.044
			Median (Q₁-Q₃)	0 (-1; 0)	-1 (-2; 0)
		12 hours	Mean (SD)	-0.07 (1.16)	-1.47 (1.36)	0.008
			Median (Q₁-Q₃)	0 (-1; 1)	-1 (-2; 0)
		24 hours	Mean (SD)	0 (1.00)	-1.40 (1.35)	0.004
			Median (Q₁-Q₃)	0 (-1; 1)	-1 (-2; 0)
		36 hours	Mean (SD)	0 (1.60)	-0.80 (1.37)	0.117
			Median (Q₁-Q₃)	0 (-1; 1)	0 (0; 1)
*Movement*	Hospitalization	45 minutes	Mean (SD)	-0.13 (0.74)	-3.73 (1.79)	<0.001
			Median (Q₁-Q₃)	0 (0; 0)	-4 (-4; -2)
		12 hours	Mean (SD)	0.27 (0.96)	-4.27 (2.19)	<0.001
			Median (Q₁-Q₃)	0 (0; 1)	-4 (-5; -3)
		24 hours	Mean (SD)	0.33 (1.23)	-3.53 (1.85)	<0.001
			Median (Q₁-Q₃)	1 (0; 1)	-4 (-4; -2)
		36 hours	Mean (SD)	0.07 (1.53)	-3.00 (1.41)	<0.001
			Median (Q₁-Q₃)	0 (-1; 1)	-3 (-4; -2)

	Hospitalization	PAINAD	Control	Intervention	p-value^a a Fisher exact test.
Rest	45 min	<50%	13 (86.7)	8 (53.3)	0.109
		≥50%	2 (13.3)	7 (46.7)
	12 h	<50%	12 (80.0)	5 (33.3)	0.025
		≥50%	3 (20.0)	10 (66.7)
	24 h	<50%	13 (86.7)	6 (40.0)	0.021
		≥50%	2 (13.3)	9 (60.0)
	36 h	<50%	12 (80.0)	10 (66.7)	0.682
		≥50%	3 (20.0)	5 (33.3)
Movement	45 min	<50%	15 (100)	9 (60.0)	0.017
		≥50%	0	6 (40.0)
	12 h	<50%	15 (100)	6 (40.0)	0.001
		≥50%	0	9 (60.0)
	24 h	<50%	15 (100)	9 (60.0)	0.017
		≥50%	0	6 (40.0)
	36 h	<50%	15 (100)	12 (80.0)	0.224
		≥50%	0	3 (20.0)

Characteristic			Control	Intervention	p -value
			n = 15	n = 15
			n (%)	n (%)
Hospitalization
	Tolerable hip flexion measured in degrees	Mean (SD) Median (Q₁-Q₃)	20.7 (8.8) 20 (15-20)	13.9 (10.5) 10 (8–15)	0.022^a a Mann-Whitney test.
	Flexion degree	0–15	5 (33.3)	12 (80.0)	0.010^c c Pearson chi-square test.
		16–45	10 (66.7)	3 (20.0)
45 minutes
	Tolerable hip flexion measured in degrees	Mean (SD)	20.3 (8.5)	47.0 (14.6)	<0.001^a a Mann-Whitney test.
	Tolerable hip flexion measured in degrees	Median (Q₁-Q₃)	20 (15–25)	45 (40–60)
	Flexion degree	0–15	5 (33.3)	0	0.002^c c Pearson chi-square test.
		16–45	10 (66.7)	8 (53.3)
		46–60	0	6 (40.0)
		>60	0	1 (6.7)
12 hours
	Tolerable hip flexion measured in degrees	Mean (SD)	19.0 (10.2)	49.7 (10.1)	<0.001^a a Mann-Whitney test.
	Tolerable hip flexion measured in degrees	Median (Q₁-Q₃)	20 (10–30)	50 (45–60)
	Flexion degree	0–15	7 (46.7)	0	<0.001^a a Mann-Whitney test.
		16–45	8 (53.3)	5 (33.3)
		46–60	0	10 (66.7)
24 hours
	Tolerable hip flexion measured in degrees	Mean (SD)	18.7 (9.3)	42.7 (10.5)	<0.001^a a Mann-Whitney test.
	Tolerable hip flexion measured in degrees	Median (Q₁-Q₃)	20 (10–25)	45 (40–50)
	Flexion degree	0–15	7 (46.7)	0	0.002^b b Fisher exact test.
		16–45	8 (53.3)	11 (73.3)
		46–60	0	4 (26.7)
36 hours
	Tolerable hip flexion measured in degrees	Mean (SD)	19.2 (8.2)	43.3 (11.3)	<0.001^a a Mann-Whitney test.
	Tolerable hip flexion measured in degrees	Median (Q₁-Q₃)	15 (15–25)	45 (40–50)
	Flexion degree	0–15	8 (53.3)	1 (6.7)	0.011^b b Fisher exact test.
		16–45	7 (46.7)	10 (66.7)
		46–60	0	3 (20.0)
		>60	0	1 (6.7)

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E-mail: rbo@sbot.org.br

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[1] Address for correspondence Gustavo Martins Fontes, MD, Departamento de Ortopedia e Traumatologia, Hospital Municipal Dr. Alípio Corrêa Netto (HMACN), Rua Canário 644, apto 91, Moema, São Paulo, SP, Brazil (e-mail: gm_fontes@uol.com.br).