Hip Fractures
Conditions
Keywords
Hip Fracture, Pericapsular Nerve Group Block, Femoral Nerve Block, Regional Anesthesia, Spinal Anesthesia, Hemodynamic Stability
Brief summary
Hip fractures are common in older adults and are often associated with severe pain, making it difficult for patients to sit for spinal anesthesia before surgery. Peripheral nerve blocks may improve pain control and facilitate patient positioning, but it remains uncertain whether the Pericapsular Nerve Group (PENG) block provides advantages over the traditional femoral nerve block during the spinal anesthesia procedure.
Detailed description
Hip fractures are among the most common injuries in older adults and are associated with substantial morbidity, mortality, and healthcare utilization. Spinal anesthesia is frequently used for surgical repair of proximal femur fractures because of its favorable safety profile in elderly patients. However, severe pain caused by the fracture often makes positioning for spinal anesthesia difficult, resulting in patient discomfort, prolonged procedure time, multiple needle insertion attempts, and increased procedural complexity. Peripheral nerve blocks are increasingly used before spinal anesthesia to improve analgesia and facilitate patient positioning. The femoral nerve block (FNB) has long been established as an effective regional anesthesia technique for patients with hip fractures. More recently, the ultrasound-guided Pericapsular Nerve Group (PENG) block has been introduced as a motor-sparing technique targeting the articular branches of the femoral, obturator, and accessory obturator nerves that innervate the anterior hip capsule. Previous studies have demonstrated that the PENG block provides effective analgesia during positioning for spinal anesthesia and may offer superior pain relief compared with conventional techniques. However, evidence comparing the effects of PENG block and femoral nerve block on the technical performance of spinal anesthesia and perioperative hemodynamic stability remains limited. This prospective, randomized controlled trial is designed to compare ultrasound-guided PENG block with ultrasound-guided femoral nerve block in patients undergoing surgery for proximal femur fracture under spinal anesthesia. The study will evaluate whether PENG block improves procedural conditions for spinal anesthesia compared with femoral nerve block while also assessing perioperative analgesia and hemodynamic responses. The study hypothesis is that preoperative PENG block will provide better procedural conditions for spinal anesthesia than femoral nerve block by improving patient positioning, reducing pain during positioning, facilitating spinal needle placement, decreasing the need for supplemental analgesic or sedative medication, and contributing to greater perioperative hemodynamic stability.
Interventions
Ultrasound-guided PENG block performed before spinal anesthesia using 20 mL of 0.25% bupivacaine to provide analgesia for patients undergoing surgery for proximal femur fracture.
Ultrasound-guided femoral nerve block performed before spinal anesthesia using 20 mL of 0.25% bupivacaine to provide analgesia for patients undergoing surgery for proximal femur fracture.
PROCEDURESpinal Anesthesia (bupivacaine)
Standard spinal anesthesia performed after the assigned peripheral nerve block using intrathecal hyperbaric bupivacaine according to the study protocol.
Sponsors
Taksim Egitim ve Arastirma Hastanesi
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
TRIPLE (Subject, Caregiver, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
50 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Adults aged 50 years or older. * Diagnosis of proximal femoral fracture. * Scheduled to undergo surgical repair under spinal anesthesia. * American Society of Anesthesiologists (ASA) physical status I-III. * Able to provide written informed consent.
Exclusion criteria
* Refusal to participate or inability to provide informed consent. * Coagulopathy or contraindication to spinal anesthesia or peripheral nerve block. * Local infection at the planned injection site. * Known allergy or hypersensitivity to local anesthetics. * Pre-existing neurological disease affecting lower extremity function or sensory assessment. * Cognitive impairment preventing reliable study participation or outcome assessment. * Previous lumbar spine surgery. * Polytrauma. * Body mass index (BMI) \<18 kg/m² or \>40 kg/m². * Current anticoagulant therapy that precludes neuraxial anesthesia or peripheral nerve block according to institutional practice.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Spinal Anesthesia Convenience Score (SACS) | During spinal anesthesia procedure (immediately after patient positioning and before initiation of surgery) | Spinal anesthesia convenience will be assessed using the Spinal Anesthesia Convenience Score (SACS), a composite clinical score evaluating the ease of spinal anesthesia based on anatomical landmark palpation, patient cooperation, sitting position quality, pain during passive hip flexion, and pain while maintaining the sitting position. Total scores range from 0 to 11, with higher scores indicating easier spinal anesthesia conditions. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| First-Attempt Success of Spinal Anesthesia | During the spinal anesthesia procedure. | The proportion of participants in whom successful intrathecal access is achieved on the first needle insertion attempt. |
| Number of Spinal Needle Insertion Attempts | During the spinal anesthesia procedure. | The total number of spinal needle insertion attempts required to achieve successful spinal anesthesia. |
| Duration of Spinal Anesthesia Procedure | During the spinal anesthesia procedure. | Time from the beginning of patient positioning until completion of spinal anesthesia and return to the supine position, measured in minutes. |
| Anxiety Score | Before peripheral nerve block, 30 minutes after block placement, and immediately before surgical incision (after spinal anesthesia). | Patient anxiety will be assessed using an 11-point Numeric Rating Scale (NRS) ranging from 0 (no anxiety) to 10 (maximum anxiety). Lower scores indicate less anxiety. |
| Patient Satisfaction | Postoperative Day 0 (before discharge from the post-anesthesia care unit [PACU]) | Patient satisfaction with the anesthesia process will be assessed using a Numeric Rating Scale ranging from 0 (not satisfied at all) to 10 (completely satisfied). Higher scores indicate greater satisfaction. |
| Anesthesiologist Satisfaction | Immediately after completion of spinal anesthesia. | The anesthesiologist's satisfaction with procedural conditions will be assessed using a Numeric Rating Scale ranging from 0 (not satisfied at all) to 10 (completely satisfied). Higher scores indicate greater satisfaction. |
| Perioperative Hemodynamic Parameters | Before peripheral nerve block; 1, 5, 10, 15, and 30 minutes after block placement; and 1, 5, 10, 15, and 30 minutes after spinal anesthesia. | Mean arterial blood pressure will be recorded throughout the perioperative period. |
| Incidence of Hypotension | From spinal anesthesia until 30 minutes after surgery completed. | Hypotension is defined as a mean arterial pressure below 65 mmHg. The proportion of participants experiencing hypotension will be recorded. |
| Vasopressor Requirement | From spinal anesthesia until 30 minutes after surgery completed. | Total intravenous ephedrine dose administered for the treatment of hypotension, measured in milligrams. |
| Additional Analgesic Medication Requirement | During the spinal anesthesia procedure. | Total doses of intravenous fentanyl (micrograms) administered during positioning for spinal anesthesia. |
| Additional Sedative Medication Requirement | During the spinal anesthesia procedure. | Total doses of intravenous midazolam (milligrams) administered during positioning for spinal anesthesia. |
Countries
Turkey (Türkiye)
Contacts
CONTACTCelal Kaya, MD
PRINCIPAL_INVESTIGATORCelal Kaya
Taksim Training and Research Hospital
Outcome results
None listed