https://orcid.org/0009-0003-5217-6067
Figures
Abstract
Background
While the pericapsular nerve group (PENG) block has become increasingly popular for managing pain after hip surgery, its efficacy remains controversial.
Methods
We systematically searched Pubmed, Web of Science, Embase, and the Cochrane Library for randomized controlled trials to assess current evidence about the efficacy of the PENG block. Patients who received PENG block were compared to those who received sham/no block in terms of opioid consumption and pain within 24h after surgery, time to first opioid requirement, functional recovery, risk of nausea and vomiting, and patient dissatisfaction. The quality of evidence was assessed using the "Grading of Recommendations Assessment, Development and Evaluation" (GRADE) system.
Results
We meta-analyzed six trials involving 416 patients who received preoperative PENG block and 415 who received sham/no block. Patients did not receive any other type of multimodal analgesia. Within 24 h after hip surgery, PENG block significantly reduced postoperative opioid consumption (MD = -12.03, 95% CI: -21.47 to -2.59, P < 0.01, I2 = 97%), particularly in subpopulations undergoing hip replacement, hip fracture, or who had spinal anesthesia, and it significantly decreased dynamic pain scores, but not static scores, without increasing risk of nausea or vomiting or patient dissatisfaction. Individual studies suggested that the PENG block can prolong the time to the first opioid requirement and can improve functional recovery. Most meta-analyses provided evidence of moderate quality according to the GRADE system.
Conclusions
The available evidence indicates that preoperative PENG block can significantly decrease opioid consumption and pain early after hip surgery, and it may also promote early functional rehabilitation. However, the limited number of included studies and sample size make it difficult to draw firm conclusions. The decision on whether to apply the PENG block should take into account the patient’s age and the type of surgery and anesthesia.
Citation: Hu X, Chenyang D, Xu B, Lao Y, Sheng H, Zhang S, et al. (2024) Pericapsular nerve group block reduces opioid use and pain after hip surgery: A systematic review and meta-analysis of randomized controlled trials. PLoS ONE 19(11): e0310008. https://doi.org/10.1371/journal.pone.0310008
Editor: Robert Jeenchen Chen, Stanford University School of Medicine, UNITED STATES OF AMERICA
Received: December 15, 2023; Accepted: August 22, 2024; Published: November 8, 2024
Copyright: © 2024 Hu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: 95%CI, 95% confidence intervals; GRADE, Grading of Recommendations Assessment, Development and Evaluation; MD, Mean difference; PENG, Pericapsular nerve group; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; QoR-15, Quality of Recovery-15 score; RCTs, Randomized controlled trials; RR, Risk ratio
1. Introduction
Hip fractures are a significant public health concern globally and are expected to occur in 6.3 million people annually by 2050 as populations age [1]. They have sometimes been called the "last fracture of life" because they are associated with numerous complications as well as rates of disability and mortality [2–4], which place a significant healthcare burden on society and the economy [5–7].
Most patients experience pain after hip surgery, leading them to limit their activities [8], which can compromise functional recovery [9] and can shorten years of healthy living [10]. One way to reduce such pain is by giving patients opioids perioperatively, which are effective analgesics but increase the risk of nausea and vomiting [11], respiratory depression [12], cognitive impairment [13], and even mortality [14]. The application of multimodal analgesia has been shown to decrease the amounts of opioids required for pain management [15]. In recent years, a pericapsular nerve group (PENG) block has emerged as a promising approach for selectively blocking the articular branches of the femoral, obturator, and accessory obturator nerves, while preserving motor function [16].
Some randomized controlled trials (RCTs) have demonstrated the effectiveness of the PENG block in diminishing opioid consumption, an important outcome in pain management, while also maintaining the functionality of the quadriceps muscles, critical for patient mobility [17, 18]. However, other research has indicated no significant difference in analgesic efficacy or opioid consumption when comparing the PENG block to placebo interventions [19, 20]. One problem is that studies have varied in whether they compared patients who received PENG block to patients who received fascia iliaca compartment block, femoral nerve block, or peri-articular injection of local anesthetic [21–23].
To clarify the current evidence on the efficacy of the PENG block, we meta-analyzed only RCTs that compared patients who received this block to patients who received sham/no block without any other type of multimodal analgesia.
2. Methods
This study was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (S1 Appendix) and registered on PROSPERO (CRD42023483095).
2.1 Search strategy
Pubmed, Embase, Web of Science, and Cochrane Library were searched through August 30, 2023, using combinations of the terms “Hip surgery”, “pericapsular nerve group or PENG”, and “placebo or no block” (S2 Appendix). The reference lists of review articles were also searched manually. No language restrictions were imposed during study selection. Two investigators (XHH and DHCY) conducted their searches independently, and then discrepancies were resolved by a third investigator (YLH).
2.2 Inclusion criteria
To be included, studies had to have a randomized controlled design involving patients at least 18 years old who underwent hip surgery, during which they received a PENG block or sham/no block for analgesia. Studies had to report one or more of the following outcomes: pain scores, opioid consumption, nausea and vomiting, patient dissatisfaction, and functional recovery. Studies were excluded if patients received combinations of PENG block with other interventions.
2.3 Data extraction
Two investigators (XHH and DHCY) independently extracted on 23 August 2023 the following information from included studies using a predefined form: investigator, year, country, patient demographics, type of surgery, anesthetic and dose, block timing (pre- or peri-operative), and outcomes. Intravenous morphine or fentanyl equivalents were converted to oral morphine equivalents as described [24]. If studies reported outcomes in the "post-anesthesia care unit", we defined that as within 1 h after surgery. For missing data, the corresponding author was contacted by e-mail. If there is a disagreement, another author (YLH) will assist in resolving it.
2.4 Outcomes evaluation
The primary outcomes of this study were to compare opioid consumption, and static and dynamic pain scores between the PENG group and the sham/no block group over the 24 h post-operatively. Secondary outcomes were time to the first opioid requirement, functional recovery, risk of nausea and vomiting events, and patient satisfaction.
2.5 Quality of evidence
The risk of bias in included studies was assessed using the Cochrane tool "Risk of Bias 2". The quality of evidence from our meta-analyses was assessed using the "Grading of recommendations assessment, development and evaluation" (GRADE) system [25]. Then discrepancies were resolved by a third investigator.
2.6 Statistical analysis
Data were analyzed statistically using R 4.3.1, and meta-analyses were performed using the meta package in R. Continuous variables were meta-analyzed in terms of the mean difference (MD) using the "Metacont" function, while binary variables were meta-analyzed in terms of the risk ratio (RR) using the "Metabin" function. Effect sizes were reported together with a 95% confidence interval (95%CI). All meta-analyses involved a random-effects model because of the substantial variation across studies. Results that could not be analyzed quantitatively were described qualitatively (HFS and SLZ). All data extracted for quantitative analysis are presented in S3 Appendix. Discrepancies were resolved by discussion with a third researcher (YLH).
Heterogeneity in a meta-analysis was considered significant if I2 > 50%. We assessed the robustness of meta-analyses by repeating them after deleting each study one at a time. We did not assess the included studies for risk of publication bias because there were fewer than 10 [26].
3. Results
3.1 Search results
We initially retrieved 339 potentially relevant publications from four electronic databases and supplementary resources. After the meticulous removal of duplicates, this number was reduced to 267. Following a stringent screening process that eliminated experimental registries, conference abstracts, review articles, and non-peer-reviewed documents such as letters and errata,105 publications were left for further evaluation. Upon reviewing the titles and abstracts, 90 publications were excluded, and after a thorough full-text review, an additional nine were deemed ineligible for inclusion (S4 Appendix). Fig 1 illustrates the literature screening process. In the end, six RCTs were included in the systematic review and meta-analysis (Table 1), involving 416 patients who received PENG block and 415 who received either sham PENG block or, in one study [19], no block at all. Two trials were conducted in the United States [19, 20], and one each in South Korea [27], Poland [17], Germany [28], and Singapore [29]. Types of surgery were total hip arthroplasty [17, 19], hip arthroscopy [20, 28], and hip fracture surgery [27, 29]. The two studies involving hip arthroscopy involved patients no older than 58 years. The type of anesthesia was general [20, 27, 28] or spinal [17, 19, 29]. Two studies were published in 2022 and four in 2023.
3.2 Risk of bias
We assessed four of the six RCTs as having a low risk of bias, one as having an unclear risk of bias because we were unable to access the study protocol [28], and one as having a high risk of bias because we identified deviations from the original protocol and risk of selective reporting [20] (Fig 2).
A. Summary of risk of bias; B. Percentage of risk of bias.
3.3 The primary outcomes of meta-analysis
We focused on opioid consumption and pain within 24 h postoperatively because in most patients undergoing hip surgery, acute severe pain disappears within 4–6 h [30].
3.3.1 Opioid consumption within 24 h after surgery.
All six of the included RCTs examined opioid consumption within 24 h after surgery. PENG block was associated with significantly lower consumption (MD = -12.03, 95%CI: -21.47 to -2.59, P < 0.01, I2 = 97%; Fig 3). Furthermore, sensitivity analyses showed no significant differences in the pooled results after excluding Domagalska et al. [17] (MD = -10.56, 95%CI: -21.84 to 0.71, P = 0.07, I2 = 81%; Fig 1 of S5 Appendix).
To investigate the source of heterogeneity, we conducted further subgroup analyses based on the population, anesthesia, age, and intervention in the control group (Fig 4). Subgroup analysis based on the population showed that PENG block was able to significantly reduce opioid consumption in hip fracture surgery (MD = -18.89, 95%CI: -31.91 to -5.88, P = 0.28, I2 = 14%) and total hip arthroplasty (MD = -18.35, 95%CI: -19.88 to -16.82, P = 0.58, I2 = 0%) populations with reduced heterogeneity in all groups (all I2 < 50%). Subgroup results based on anesthesia indicated that PENG block led to a significant reduction in opioid consumption among those who received spinal anesthesia (MD = -18.3, 95%CI: -19.81 to -16.79, P = 0.78, I2 = 0%), though there remained high heterogeneity within the general anesthesia group (I2 = 57%). Furthermore, a subgroup analysis based on age demonstrated increased benefits with PENG block for individuals aged above 58 years (MD = -18.34, 95%CI: -19.85 to -16.83, P = 0.69, I2 = 0%), and reduced heterogeneity was observed in both groups (all I2 = 0%). In contrast to the low heterogeneity observed in these analyses, subgroup analyses of control patients who received sham PENG block exhibited high levels of heterogeneity.
3.3.2 Static pain scores.
Five studies [17, 19, 20, 28, 29] reported static scores based on a visual analog scale within 24 h of surgery (Fig 2 of S5 Appendix). Within these five studies, three studies [19, 28, 29] involving 232 patients reported pain scores at 1 h after surgery, which did not differ significantly between the two groups (MD = -0.39, 95%CI: -0.86 to 0.08, P = 0.55, I2 = 0%). Two studies [28, 29] involving 111 patients reported scores at 3 h after surgery, but we could not meta-analyze them because one study [29] reported a score of 0 in the PENG group. Neither study reported a significant difference between the groups. Two studies [19, 28] involving 180 patients reported scores at 6 h after surgery, with no significant differences between the groups (MD = -0.27, 95%CI: -0.80 to 0.26, P = 0.87, I2 = 0%). Finally, four studies [17, 19, 20, 29] involving 685 patients found no significant difference between the two groups at 24 h after surgery (MD = -0.80, 95%CI: -2.29 to 0.70, P < 0.01, I2 = 95%), which proved robust to sensitivity analysis (Fig 3 of S5 Appendix).
3.3.3 Dynamic pain scores.
Four studies [20, 27–29] reported dynamic scores based on a visual analog scale at several time points within 24 h after surgery (Fig 5). Two trials [27, 29] involving 104 patients reported that PENG block was associated with significantly lower scores at 30 min (MD = -3.24, 95%CI: -3.91 to -2.57, P = 0.99, I2 = 0%). The same two studies reported, for a total of 93 patients, that PENG block was associated with significantly lower scores at 3–6 h (MD = -2.53, 95%CI: -3.18 to -1.87, P = 0.93, I2 = 0%). Similar results were reported for scores at 12 h (MD = -0.62, 95%CI: -1.10 to -0.14, P = 0.93, I2 = 0%) in two studies [27, 28] involving 118 patients, for scores at 18 h (MD = -0.78, 95%CI: -1.24 to -0.31, P = 0.53, I2 = 0%) in two studies [27, 28] involving 118 patients, and for scores at 24 h (MD = -0.79, 95%CI: -1.14 to -0.44, P = 0.61, I2 = 0%) in four studies [20, 27–29] involving 215 patients. Notably, all I2-related P values were greater than 0.05, indicating low heterogeneity among the pooled studies.
3.4 Secondary outcomes
3.4.1 Time to the first opioid requirement.
Two studies involving 526 patients reported time to first opioid requirement, but in different ways that could not be meta-analyzed. One study [27] reported that all patients in the control group required opioids within 12 h after surgery, compared to only 32% of patients who received PENG block. The other study [17] reported that PENG block was associated with a significantly longer time to first opioid requirement (9.5 ± 5.5 vs. 4.5 ± 1.6 h).
3.4.2 Functional recovery.
Three studies [17, 19, 27] involving 638 patients reported that PENG block was associated with better functional recovery based on different metrics that could not be meta-analyzed. One study [27] found no significant difference in quadricep strength between the two groups at 6–24 h after surgery. Another study [17] reported that significantly higher proportions of PENG patients were able to actively elevate the operated limb at 6 h after surgery (53 vs. 11%) and walk at 10 h postoperatively (100 vs. 46%). The third study [19] associated PENG block with a significantly higher quality of recovery based on the QoR-15 survey [31] at 24–48 h after surgery, although mean walking distance did not differ significantly between the groups on days 1 and 2 after surgery.
3.4.3 Nausea and vomiting.
Meta-analysis of three studies [20, 27, 28] involving 184 patients indicated no significant difference between the two groups in the incidence of nausea or vomiting at 24 h after surgery (RR = 0.53, 95%CI: 0.20 to 1.38, P = 0.73, I2 = 0%; Fig 4A of S5 Appendix). Similar results were obtained for incidence at 48 h from the meta-analysis of two studies [19, 20] involving 174 patients (RR = 0.97, 95%CI: 0.59 to 1.58, P = 0.49, I2 = 0%; Fig 4B of S5 Appendix).
3.4.4 Patient dissatisfaction.
Meta-analysis of data from two studies [20, 27] involving 116 people associated PENG block with significantly lower risk of unsatisfactory events (RR = 0.22, 95%CI: 0.08 to 0.61, P = 0.70, I2 = 0%; Fig 5 of S5 Appendix).
3.5 Quality of meta-analytical evidence
The quality of evidence for the various outcomes that we analyzed was classified according to the GRADE system as very low for static pain scores at 24 h; moderate for static pain scores at other time points; moderate for dynamic pain scores at all time points; low for opioid consumption within 24 h, reflecting substantial heterogeneity in the meta-analyses and risk of bias in one study [20]; high for nausea and vomiting; and moderate for patient dissatisfaction (Table 2).
4. Discussion
Although several meta-analyses [32–35] have examined the differences between PENG and other analgesic techniques in pain relief and postoperative recovery after hip surgery, there is still a lack of a relevant meta-analysis comparing PENG directly with sham/no block. Another meta-analysis of five randomized controlled trials [36] concluded that the PENG block provided better pain control than sham/no block. Still, this analysis may be less reliable as it pooled data from patients who received local anesthetic infiltration. This meta-analysis, including the most recent studies comparing PENG block against sham or no block, provides strong evidence that preoperative PENG block effectively reduces dynamic pain, although not necessarily static pain, soon after different types of hip surgery. The PENG block may also prolong the time before opioids are first needed after surgery and it may improve early functional recovery, but further studies are required to verify these possibilities. Most of our meta-analyses provide evidence of only moderate quality and some provide evidence of very low quality, highlighting the need for more rigorous assessments of the efficacy of the PENG block. Nevertheless, the evidence already available supports the PENG block as an effective tool in protocols designed to enhance recovery after surgery [37].
While the PENG block reduced opioid consumption across the various types of hip surgery in the included RCTs, it did not reduce consumption in the subgroup of patients who underwent hip arthroscopy. This procedure is less invasive and therefore intrinsically less likely to cause substantial pain, so any effect of the PENG block may be less noticeable. This may also explain why we failed to observe the efficacy of the PENG block in patients younger than 58 years old: both studies in that subgroup analysis involved hip arthroscopy [20, 28]. Subgroup analysis also showed that the PENG block reduced opioid consumption in patients receiving spinal, but not general, anesthesia. This may reflect that pain within 24 h after hip surgery is usually greater in patients who received spinal anesthesia than in those who received general anesthesia [38], which may translate to greater perceived efficacy of the PENG block. While opioid consumption within 24 hours of hip surgery was statistically significant, clinicians should carefully consider this when making clinical decisions given the included studies and small sample sizes.
Our failure to observe the benefit of the PENG block on static pain scores may reflect low static pain in the patient populations, such that the analgesic efficacy of the PENG block was less perceptible. A similar lack of benefit in static, but not dynamic, pain has been observed in individual studies [18, 39]. Even if our meta-analysis of included studies showed no benefit of PENG block on static pain, the data from individual studies consistently showed some positive effects. It is worth noting that while dynamic pain scores showed differences between the PENG and control groups at 12, 18, and 24 hours postoperatively, these differences were minimal, being less than one point. Such minor variations are unlikely to represent a clinically significant difference in the assessment of pain.
Two studies in our review reported that the PENG block prolonged the time to the first opioid requirement, but we could not meta-analyze these data because of differences in the way outcomes were reported. Other studies suggest that this effect of PENG block may be amplified by combining it with local infiltration anesthesia [18, 40], which should be explored in future work.
Two studies in our review reported that PENG block significantly improved functional recovery, while a third study failed to detect benefit. Such failure may reflect diffusion of local anesthetic into the femoral nerve [41]. Future work should examine this possibility and explore under what conditions the PENG block can enhance recovery. Also, nausea and vomiting events should be considered with caution due to the small number of included studies and sample sizes.
It should be noted that this study is subject to certain limitations. Firstly, the study included only six eligible RCTs, and the results were rated as moderate- or low-quality evidence using the GRADE Level of Evidence score. Therefore, the findings should be interpreted with caution. It would be beneficial to conduct higher-quality RCTs in the future to support the conclusions drawn from this study. Secondly, although subgroup analyses were conducted based on the type of surgery, anesthesia, age, and type of control intervention, the effects on pain may still be a source of high heterogeneity due to the inclusion of participants with a wide age range [42] and from different ethnic backgrounds [43]. It is recommended that future studies should endeavor to control the effect of confounders on outcomes as much as possible. Thirdly, before pooling the target endpoints, we attempted to standardize the same endpoint across studies to the greatest extent possible. However, given the subjective nature of pain, the different routes of opioid administration, and other factors, there may still be discrepancies in the same endpoint after standardization across studies. Fourthly, for outcomes such as time to first opioid requirement and functional recovery, different studies inconsistently presented them. Consequently, this study only provided a qualitative description. At last, our investigation did not delve into additional adverse effects of opioid utilization, encompassing sedation and delirium, nor did it scrutinize complications pertaining to the PENG block, such as vascular puncture and infection, owing to their infrequent documentation in the preliminary studies. Consequently, it is imperative for future endeavors, encompassing larger sample sizes, to strive towards a more comprehensive assessment of the safety profile associated with the PENG block.
5. Conclusion
The evidence available from RCTs suggests that PENG block significantly reduces opioid consumption and pain soon after hip surgery and may also improve early functional recovery. However, the limited number of included studies and sample size make it difficult to draw firm conclusions. Future studies are needed to support this study’s results and clarify the efficacy of PENG block according to patient age, surgery, and anesthesia, which clinicians may need to consider when choosing multimodal analgesia.
Supporting information
S4 Appendix. List of excluded studies with reasons and included studies.
https://doi.org/10.1371/journal.pone.0310008.s004
(DOCX)
S5 Appendix. Forest plots those were not included in the manuscript.
https://doi.org/10.1371/journal.pone.0310008.s005
(DOCX)
References
- 1. Cooper C, Campion G, Melton LJ. Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992;2(6):285–289. pmid:1421796
- 2. Cao H, Yu J, Chang Y, Li Y, Zhou B. Construction and validation of a risk prediction model for delayed discharge in elderly patients with hip fracture. BMC Musculoskelet Disord. 2023;24(1):66. pmid:36694160
- 3. Sing CW, Lin TC, Bartholomew S, Bell JS, Bennett C, Beyene K, et al. Global Epidemiology of Hip Fractures: Secular Trends in Incidence Rate, Post-Fracture Treatment, and All-Cause Mortality. J Bone Miner Res. 2023;38(8):1064–1075. pmid:37118993
- 4. Katsoulis M, Benetou V, Karapetyan T, Feskanich D, Grodstein F, Pettersson-Kymmer U, et al. Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project. J Intern Med. 2017;281(3):300–310. pmid:28093824
- 5. Baji P, Patel R, Judge A, Johansen A, Griffin J, Chesser T, et al. Organisational factors associated with hospital costs and patient mortality in the 365 days following hip fracture in England and Wales (REDUCE): a record-linkage cohort study. Lancet Healthy Longev. 2023;4(8):e386–e398. pmid:37442154
- 6. Guay J, Kopp S. Peripheral nerve blocks for hip fractures in adults. Cochrane Database Syst Rev. 2020;11(11):CD001159. pmid:33238043
- 7. O’Connor MI, Switzer JA. AAOS Clinical Practice Guideline Summary: Management of Hip Fractures in Older Adults. J Am Acad Orthop Surg. 2022;30(20):e1291–e6. pmid:36200817
- 8. Liu Y, Xiao S, Yang H, Lv X, Hou A, Ma Y, et al. Postoperative pain-related outcomes and perioperative pain management in China: a population-based study. Lancet Reg Health West Pac. 2023;39:100822. pmid:37927993
- 9. Sheehan KJ, Goubar A, Almilaji O, Martin FC, Potter C, Jones GD, et al. Discharge after hip fracture surgery by mobilisation timing: secondary analysis of the UK National Hip Fracture Database. Age Ageing. 2021;50(2):415–422. pmid:33098414
- 10. Papadimitriou N, Tsilidis KK, Orfanos P, Benetou V, Ntzani EE, Soerjomataram I, et al. Burden of hip fracture using disability-adjusted life-years: a pooled analysis of prospective cohorts in the CHANCES consortium. Lancet Public Health. 2017;2(5):e239–e46. pmid:29253489
- 11. Ukai T, Ebihara G, Watanabe M. Opioid administration via epidural catheter is a risk factor for postoperative nausea and vomiting in total hip arthroplasty: A retrospective study. J Orthop Sci. 2018;23(6):973–976. pmid:30431008
- 12. Yoshida K, Noji Y, Ebana H, Imaizumi T, Obara S, Murakawa M. Respiratory depression after intraoperative opioid-containing periarticular multimodal drug injection for total hip and total knee arthroplasty. J Clin Anesth. 2019;54:147–148. pmid:30551011
- 13. Awada HN, Luna IE, Kehlet H, Wede HR, Hoevsgaard SJ, Aasvang EK. Postoperative cognitive dysfunction is rare after fast-track hip- and knee arthroplasty—But potentially related to opioid use. J Clin Anesth. 2019;57:80–86. pmid:30927698
- 14. Ball CG. Surgeons as advocates for opioid control. Can J Surg. 2019;62(4):220–221. pmid:31348625
- 15. Wick EC, Grant MC, Wu CL. Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017;152(7):691–697. pmid:28564673
- 16. Girón-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):859–863. pmid:30063657
- 17. Domagalska M, Ciftci B, Reysner T, Kolasiński J, Wieczorowska-Tobis K, Kowalski G. Pain Management and Functional Recovery after Pericapsular Nerve Group (PENG) Block for Total Hip Arthroplasty: A Prospective, Randomized, Double-Blinded Clinical Trial. J Clin Med. 2023;12(15):4931. pmid:37568331
- 18. Pascarella G, Costa F, Del Buono R, Pulitanò R, Strumia A, Piliego C, 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):1492–1498. pmid:34196965
- 19. Kukreja P, Uppal V, Kofskey AM, Feinstein J, Northern T, Davis C, et al. Quality of recovery after pericapsular nerve group (PENG) block for primary total hip arthroplasty under spinal anaesthesia: a randomised controlled observer-blinded trial. Br J Anaesth. 2023;130(6):773–779. pmid:36964012
- 20. Amato PE, Coleman JR, Dobrzanski TP, Elmer DA, Gwathmey FW, Slee AE, et al. Pericapsular nerve group (PENG) block for hip arthroscopy: a randomized, double-blinded, placebo-controlled trial. Reg Anesth Pain Med. 2022: rapm-2022-103907. pmid:35998937
- 21. Farag A, Hendi NI, Diab RA. Does pericapsular nerve group block have limited analgesia at the initial post-operative period? Systematic review and meta-analysis. J Anesth. 2023;37(1):138–153. pmid:36342537
- 22. Kim E, Shin WC, Lee SM, Choi MJ, Moon NH. Efficacy of Pericapsular Nerve Group Block for Pain Reduction and Opioid Consumption after Total Hip Arthroplasty: A Meta-Analysis of Randomized Controlled Trials. Hip Pelvis. 2023;35(2):63–72. pmid:37323546
- 23. Huda AU, Ghafoor H. The Use of Pericapsular Nerve Group (PENG) Block in Hip Surgeries Is Associated With a Reduction in Opioid Consumption, Less Motor Block, and Better Patient Satisfaction: A Meta-Analysis. Cureus. 2022;14(9):e28872. pmid:36105907
- 24. Nielsen S, Degenhardt L, Hoban B, Gisev N. A synthesis of oral morphine equivalents (OME) for opioid utilisation studies. Pharmacoepidemiol Drug Saf. 2016;25(6):733–737. pmid:26693665
- 25. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–926. pmid:18436948
- 26.
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al. Cochrane Handbook for Systematic Reviews of Interventions. 2nd Edition. Chichester (UK): John Wiley & Sons. 2019.
- 27. Chung CJ, Eom DW, Lee TY, Park SY. Reduced Opioid Consumption with Pericapsular Nerve Group Block for Hip Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial. Pain Res Manag. 2022;2022:6022380. pmid:36569462
- 28. Eppel B, Schneider MM, Gebhardt S, Balcarek P, Sobau C, Wawer Matos J, et al. Pericapsular Nerve Group Block Leads to Small but Consistent Reductions in Pain Between 18 and 24 Hours’ Postoperatively in Hip Arthroscopy for Femoroacetabular Impingement Surgery: A Prospective, Randomized Controlled Clinical Trial. Arthroscopy. 2024;40(2):373–380. pmid:37355181
- 29. Lin X, Liu CW, Goh QY, Sim EY, Chan SKT, Lim ZW, 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):535–539. pmid:37055189
- 30. Panzenbeck P, von Keudell A, Joshi GP, Xu CX, Vlassakov K, Schreiber KL, et al. Procedure-specific acute pain trajectory after elective total hip arthroplasty: systematic review and data synthesis. Br J Anaesth. 2021;127(1):110–132. pmid:34147158
- 31. Chazapis M, Walker EM, Rooms MA, Kamming D, Moonesinghe SR. Measuring quality of recovery-15 after day case surgery. Br J Anaesth. 2016;116(2):241–248. pmid:26787793
- 32. Amin SR, Ahmed F. Comparison between pericapsular nerve group block and fascia iliaca compartment block for perioperative pain control in hip surgeries: A meta-analysis from randomized controlled trials. Egypt J Anaesth. 2023;39(1):185–196.
- 33. Li C, Liu Z, Chen M, Song C, Ma X, Zhou X. Comparison of pericapsular nerve group block and fascia iliaca compartment block for analgesia following hip fracture surgery: a meta-analysis. Chinese J Anesth. 2023;43(1):56–61.
- 34. Mou Z, Xiang L, Ni Y. Comparative effectiveness of pericapsular nerve group block versus fascia iliac compartment block on postoperative wound pain management in patients undergoing hip fracture surgery: A systematic review and meta-analysis. Int Wound J. 2024;21(2):e14637. pmid:38332471
- 35. Prakash J, Rochwerg B, Saran K, Yadav AK, Bhattacharya PK, Kumar A, et al. Comparison of analgesic effects of pericapsular nerve group block and fascia iliaca compartment block during hip arthroplasty: A systematic review and meta-analysis of randomised controlled trials. Indian J Anaesth. 2023;67(11): 962–972. pmid:38213682
- 36. She C, Liu H. The efficacy of pericapsular nerve group block for reducing pain and opioid consumption after total hip arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res. 2024;19(1):229. pmid:38584259
- 37. Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthop. 2020;91(1):3–19.
- 38. Neuman MD, Feng R, Ellenberg SS, Sieber F, Sessler DI, Magaziner J, et al. Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery: A Randomized Clinical Trial. Ann Intern Med. 2022;175(7):952–960. pmid:35696684
- 39. Zheng J, Pan D, Zheng B, Ruan X. Preoperative pericapsular nerve group (PENG) block for total hip arthroplasty: a randomized, placebo-controlled trial. Reg Anesth Pain Med. 2022;47(3):155–160. pmid:34873023
- 40. Hu J, Wang Q, Hu J, Kang P, Yang J. Efficacy of Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined With Local Infiltration Analgesia on Postoperative Pain After Total Hip Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial. J Arthroplasty. 2023;38(6):1096–1103. pmid:36529195
- 41. Bravo D, Aliste J, Layera S, Fernández D, Erpel H, Aguilera G, et al. Randomized clinical trial comparing pericapsular nerve group (PENG) block and periarticular local anesthetic infiltration for total hip arthroplasty. Reg Anesth Pain Med. 2023;48(10):489–494. pmid:36797036
- 42. González-Roldán AM, Terrasa JL, Sitges C, van der Meulen M, Anton F, Montoya P. Age-Related Changes in Pain Perception Are Associated With Altered Functional Connectivity During Resting State. Front Aging Neurosci. 2020;12:116. pmid:32457594
- 43. Meints SM, Cortes A, Morais CA, Edwards RR. Racial and ethnic differences in the experience and treatment of noncancer pain. Pain Manag. 2019;9(3):317–334. pmid:31140916