PENG vs FIC Nerve Blocks for Hip Fracture Pain

Overseen By Antonios Likourezos, MPH

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Antonios Likourezos

Must not be taking: Opioids

Disqualifiers: Multi-system trauma, Pregnancy, Intoxication, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 2

Duration: 1 day

80 Participants Needed

Trial Summary

What is the purpose of this trial?

Ultrasound-guided nerve blocks are an important tool for treating pain due to orthopedic injury in the ED. They provide long lasting, opioid-sparing pain relief that is generally safe and well-tolerated by patients1. Elderly patients with hip fractures commonly present to the ED, and their injury can be painful. Commonly used opioid pain regimens can have deleterious side effects, especially in elderly patients, like somnolence, delirium, hypotension and respiratory depression. The fascia iliaca compartment (FIC) block has become a familiar technique to emergency physicians as a pain control treatment for hip fractures. The pericapsular nerve group (PENG) block has recently been proposed as a novel method to treat pain due to hip, acetabular and pelvic fracture by targeting the terminal sensory articular nerve branches of the femoral nerve (FN), obturator nerve (ON), and accessory obturator nerve (AON). At this time there has been no study comparing the efficacy of the two nerve blocks, PENG and FIC. This aim of this study is to compare the efficacy of the PENG block (20mL of Bupivacaine 0.50%) to that of the FIC block (40mL of Bupivacaine 0.25%) for patients with hip fractures in the ED. Our hypothesis is that PENG will demonstrate analgesia that is non-inferior to FIC. Subjective pain scores on a scale of 0 to 10 will be assessed before and after the block. All subjects will receive 4mg of morphine after consent and prior to the block.

Do I need to stop my current medications to join the trial?

The trial does not specify if you need to stop taking your current medications, but it does exclude patients who are on long-term systemic opioid analgesia.

What data supports the effectiveness of the PENG and FIC nerve block treatments for hip fracture pain?

Research shows that both the PENG block and the FIC block are used to manage pain after hip surgeries. The PENG block may help with faster recovery after surgery, and it is considered a good alternative for pain management in hip fractures. ^{1 2 3 4 5}

Is the PENG or FIC nerve block safe for humans?

The research articles focus on comparing the effectiveness of PENG and FIC nerve blocks for pain control in hip surgeries, but they do not provide specific safety data. Generally, both techniques are used in clinical settings, suggesting they are considered safe, but specific safety outcomes are not detailed in these studies. ^{1 2 3 4 6}

How does the PENG block treatment differ from other treatments for hip fracture pain?

The PENG block is a novel treatment for hip fracture pain that may offer better pain relief and faster recovery compared to the more commonly used FIC block. It is a motor-sparing technique, which means it helps manage pain without significantly affecting muscle movement, potentially aiding in quicker rehabilitation. ^{1 2 4 5 6}

Research Team

Lawrence Haines, MD

Principal Investigator

Maimonides Medical Center

Eligibility Criteria

This trial is for adults over 18 with an isolated hip fracture and a pain score of 5 or more. It's not for those with multiple injuries, communication issues about pain, pregnancy, under 18 years old, intoxication, abnormal vital signs, long-term opioid use or allergy to certain local anesthetics.

Inclusion Criteria

I have a hip fracture near the top of my thigh bone.

My pain level is 5 or higher on a scale of 0 to 10 before getting a nerve block.

I am over 18 and need emergency medical care.

Exclusion Criteria

Allergy to amide local anesthetics

I cannot express how much pain I am in.

I am on long-term pain medication.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

1-2 weeks

Treatment

Participants receive either a PENG block or a FIC block for pain management in the ED

1 day

1 visit (in-person)

Immediate Follow-up

Participants' pain scores and motor function are assessed at 30 and 60 minutes post nerve block

1 day

1 visit (in-person)

Follow-up

Participants are monitored for any adverse events and rescue medication usage after the nerve block

1-2 weeks

Treatment Details

Interventions

• FIC Proceedure
• PENG Proceedure

Trial Overview The study compares two types of nerve blocks in emergency department patients with hip fractures: PENG block using Bupivacaine (0.50%) and FIC block using Bupivacaine (0.25%). The goal is to see if PENG provides similar or better pain relief than FIC without opioids.

Participant Groups

Group I: PENG Block Active Control 1 Intervention

Pericapsular Nerve Group (PENG) Block (20mL of Bupivacaine 0.50%)

Group II: Fascia Iliaca Compartment Active Control 1 Intervention

Fascial Iliaca block (FIC) (40mL of Bupivacaine 0.25%) for patients with hip fractures in the ED

FIC Proceedure is already approved in United States, European Union, Canada for the following indications:

Approved in United States as Fascia Iliaca Compartment Block for:

• Pain management for hip fractures
• Pain management for orthopedic injuries

Approved in European Union as Fascia Iliaca Compartment Block for:

• Pain management for hip fractures
• Pain management for orthopedic injuries

Approved in Canada as Fascia Iliaca Compartment Block for:

• Pain management for hip fractures
• Pain management for orthopedic injuries

Who Is Running the Clinical Trial?

Antonios Likourezos

Lead Sponsor

Trials

41

Recruited

8,600+

Findings from Research

In a review of six randomized controlled trials involving 258 patients, the pericapsular nerve group block (PENG) was found to significantly reduce opioid consumption compared to the fascia iliaca compartment block (FICB) after hip surgeries, suggesting better pain management with PENG.

However, there was no significant difference in pain scores at 6, 12, or 24 hours post-surgery between the two groups, indicating that while PENG may reduce the need for opioids, it does not necessarily lead to lower pain levels compared to FICB.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Efficacy of pericapsular nerve group block vs. fascia iliaca compartment block for Hip surgeries: A systematic review and meta-analysis. Ying, H., Chen, L., Yin, D., et al.[2023]

In a study of 59 elderly patients undergoing hip fracture surgery, adding a pericapsular nerve group (PENG) block to a fascia iliaca compartment block (FICB) did not significantly improve pain relief or recovery outcomes compared to FICB alone.

Both groups experienced similar pain scores and recovery times, but the combined FICB + PENG block took significantly longer to perform, indicating that the additional procedure may not be worth the extra time if it does not enhance patient outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The Analgesic effect of adding ultrasound-guided pericapsular nerve group block to suprainguinal fascia iliaca compartment block for hip fracture surgery: A prospective randomized controlled trial. Nuthep, L., Klanarong, S., Tangwiwat, S.[2023]

In a study of 384 patients undergoing hip surgery, the Pericapsular Nerve Group (PENG) block was found to significantly reduce static pain scores at 12 hours post-surgery and decrease opioid consumption in the first 24 hours compared to the Fascia Iliaca compartment (FI) block.

However, there were no significant differences in pain scores at 6 or 24 hours post-surgery or in the time to first analgesic rescue between the two techniques, indicating that while PENG may offer some immediate benefits, further research is needed to fully understand its advantages over FI block.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Pericapsular Nerve Group (PENG) block versus fascia iliaca compartment (FI) block for hip surgery: a systematic review and meta-analysis of randomized controlled trials. Andrade, PP., Lombardi, RA., Marques, IR., et al.[2023]

The pericapsular nerve group (PENG) block significantly reduced pain scores and delayed the need for analgesics compared to the fascia iliaca compartment block (FICB) in patients with hip fractures, based on a randomized controlled trial involving 52 participants.

Patients receiving the PENG block consumed significantly less morphine in the first 24 hours post-surgery compared to those receiving the FICB, indicating that PENG may provide superior analgesia for hip fracture pain.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Comparison of pericapsular nerve group (PENG) block with fascia iliaca compartment block (FICB) for pain control in hip fractures: A double-blind prospective randomized controlled clinical trial. Mosaffa, F., Taheri, M., Manafi Rasi, A., et al.[2022]

In a study involving 40 patients undergoing hip fracture surgeries, the pericapsular nerve group (PENG) block provided better postoperative pain relief as indicated by lower Visual Analog Pain scores compared to the fascia iliaca compartment block (FICB).

While both blocks showed similar durations of analgesia, the PENG block resulted in less motor impairment of the quadriceps femoris muscle, suggesting it offers effective sensory blockade with better preservation of motor function.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Comparison of Pericapsular Nerve Group Block versus Fascia Iliaca Compartment Block as Postoperative Pain Management in Hip Fracture Surgeries. Senthil, KS., Kumar, P., Ramakrishnan, L.[2022]

In a study involving 60 elderly patients with traumatic proximal femoral fractures, the Pericapsular Nerve Group (PENG) block did not show superior pain relief compared to the Fascia Iliaca block (FIB), with both achieving similar rates of analgesic success (53.3% for PENG vs 53.6% for FIB).

The study indicates that PENG block may not be a more effective option for pain management in this patient population, suggesting that FIB remains a viable alternative for treating hip trauma pain in the emergency room.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Analgesic efficacy of Pericapsular Nerve Group (PENG) block compared with Fascia Iliaca Block (FIB) in the elderly patient with fracture of the proximal femur in the emergency room. A randomised controlled trial. Marrone, F., Graziano, G., Paventi, S., et al.[2023]

References

1. Switzerland pubmed.ncbi.nlm.nih.gov

Efficacy of pericapsular nerve group block vs. fascia iliaca compartment block for Hip surgeries: A systematic review and meta-analysis. [2023]

2. United States pubmed.ncbi.nlm.nih.gov

The Analgesic effect of adding ultrasound-guided pericapsular nerve group block to suprainguinal fascia iliaca compartment block for hip fracture surgery: A prospective randomized controlled trial. [2023]

3. Brazil pubmed.ncbi.nlm.nih.gov

Pericapsular Nerve Group (PENG) block versus fascia iliaca compartment (FI) block for hip surgery: a systematic review and meta-analysis of randomized controlled trials. [2023]

4. France pubmed.ncbi.nlm.nih.gov

Comparison of pericapsular nerve group (PENG) block with fascia iliaca compartment block (FICB) for pain control in hip fractures: A double-blind prospective randomized controlled clinical trial. [2022]

5. India pubmed.ncbi.nlm.nih.gov

Comparison of Pericapsular Nerve Group Block versus Fascia Iliaca Compartment Block as Postoperative Pain Management in Hip Fracture Surgeries. [2022]

6. Spain pubmed.ncbi.nlm.nih.gov

Analgesic efficacy of Pericapsular Nerve Group (PENG) block compared with Fascia Iliaca Block (FIB) in the elderly patient with fracture of the proximal femur in the emergency room. A randomised controlled trial. [2023]