Quality of recovery after pericapsular nerve group (PENG) block for primary total hip arthroplasty under spinal anaesthesia: a randomised controlled observer-blinded trial.

BACKGROUND: The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that has been proposed as an effective motor-sparing block for total hip arthroplasty. Recent randomised studies show conflicting results regarding the analgesic efficacy of the PENG block for total hip arthroplasty. METHODS: We conducted a randomised controlled observer-blinded single-centre superiority trial comparing the efficacy of the PENG block with no block for patients undergoing primary total hip arthroplasty under spinal anaesthesia. All subjects received multimodal analgesia consisting of paracetamol and celecoxib. The primary outcome was quality of recovery (QoR) at 24 h as measured by the QoR-15 questionnaire. RESULTS: A total of 112 participants (56 in each group) were included in the analysis. The median (inter-quartile range [IQR]) 24-h QoR-15 scores were higher in subjects who received a PENG block (132 [116-138]) compared with subjects who did not (103 [97-112]) with a median difference of 26 (95% confidence interval, 18-31; P<0.001). Similarly, QoR-15 at 48 h was higher in the PENG group, and opioid use at 24 and 48 h postoperatively was significantly lower in the PENG group. However, we did not find significant differences in pain score, distance to ambulation, or anti-emetic use at any time point. We did not observe any PENG block-related complications. CONCLUSION: Adding a PENG block to a multimodal analgesia regimen that includes paracetamol and celecoxib improves the quality of recovery and reduces opioid requirements for patients undergoing primary total hip arthroplasty under spinal anaesthesia. CLINICAL TRIAL REGISTRATION: NCT04591353.

Comparison of Genicular Nerve Block in Combination With Adductor Canal Block in Both Primary and Revision Total Knee Arthroplasty: A Retrospective Case Series.

The management of pain in patients undergoing total knee arthroplasty (TKA) for chronic knee osteoarthritis (OA) has remained a challenge for the anesthesiologist regarding regional anesthesia as no single regional technique is adequate with regard to balancing effective analgesia with minimal muscle weakness. Severe postoperative pain following TKA has been shown to negatively impact patient outcomes and mortality. The genicular nerve block has recently been demonstrated to provide effective analgesia to the anterior and posterior knee capsule in recent studies. In this retrospective case series, we compare the efficacy of combined genicular nerve block (GNB) and adductor canal block (ACB) to only ACB in both primary and revision TKA patients. This combined novel approach for TKA patients can be utilized to improve patient pain scores and early ambulation, limiting the use of opioids and early discharge.

A Retrospective Case Series of Pericapsular Nerve Group (PENG) Block for Primary Versus Revision Total Hip Arthroplasty Analgesia.

The innervation of the hip joint is complex and it is challenging to provide effective analgesia after hip surgery utilizing any single regional anesthesia technique. The pericapsular nerve group (PENG) block is an interfascial plane block aiming to block articular branches supplied by femoral, obturator, and accessory obturator nerves. In this case series, we compare the efficacy of the PENG block to provide analgesia in primary and revision total hip arthroplasty (THA). The ultrasound-guided PENG block technique is described and post-operative pain scores and opioid requirements are reported. The PENG block was successfully used in primary THA as a solo block, and it may be used in combination with other regional blocks for any hip surgery. The PENG block is an easy regional technique to perform in the supine position with motor-sparing benefits.

Pericapsular Nerve Group (PENG) Block in Combination With the Quadratus Lumborum Block Analgesia for Revision Total Hip Arthroplasty: A Retrospective Case Series.

Orthopedic procedures involving the hip have remained challenging for regional anesthesia given the complex innervation, painful nature contributing to difficulty positioning, and a desire to maintain mobility to hasten postoperative recovery. The revision total hip arthroplasty (THA) poses a greater challenge for an effective regional analgesia due to complex surgical approach, scarring from previous surgery and limited patient mobility. The quadratus lumborum (QL) block has demonstrated to provide effective analgesia for primary hip surgery in recent studies. The pericapsular nerve group (PENG) block has also shown to provide analgesia in patients with hip fractures. There is no standard of care regional anesthesia technique for hip surgeries, and the regional practice varies widely among anesthesia providers. This retrospective case series studied the effect of combining the QL with PENG block on the revision THA analgesia.

Post-Surgical Inflammatory Neuropathy: An Underappreciated but Critical and Treatable Cause of Postoperative Neuropathy.

The diagnosis and management of postoperative nerve injury can be a challenging and frustrating proposition for the patient, surgeon, and anesthesia provider. Unfortunately, in many cases, the true etiology is never elucidated and the injury is ascribed to positioning or a nerve block with "expectant management" being the order of the day, which can result in persistent disability for the patient. However, there is a rare subset of disorders affecting the nervous system that can masquerade as a peripheral nerve injury that warrants further investigation of risk factors and co-morbidities when other common causes of nerve injury are ruled out. We describe a patient with rheumatoid arthritis that underwent revision hip arthroplasty and presented almost immediately in the postoperative period with what was initially diagnosed as femoral nerve palsy. Further diagnostic workup later revealed that she had suffered from postoperative inflammatory neuropathy resulting in lumbosacral plexus injury and not a discrete nerve injury. Had the true cause been identified early enough, treatment with corticosteroids could have been initiated in an attempt to mitigate and perhaps reverse the progress of the neuropathy. We present this cautionary tale to remind practitioners to continue to be vigilant and consider more esoteric and unconventional diagnoses in the workup of perioperative neuropathies.

Multigenerational Challenges and the Future of Graduate Medical Education.

BACKGROUND: Demographics are changing on a global scale. In the United States, an aging population continues to work, either by preference or because of insufficient resources to retire. Of even greater importance, a younger generation, referred to as the Millennial Generation, will soon predominate in the workforce and even now accounts for nearly 100% of resident physicians. By the year 2020, there will be 5 generations in the workplace. METHODS: This paper defines and details the characteristics of the 5 generations and examines how the vision, attitudes, values, and expectations of the most recent generations will reshape the workforce and graduate medical education. RESULTS: The need for change is imminent to educate the next generation of physicians. Among the changes necessary to adapt to the multigenerational challenges ahead are adopting mobile devices as preferred communication tools; using social networking sites to recruit residents; adding games, simulations, and interactive videos to the curriculum to engage students; breaking down departmental silos and forming learning teams that come from different specialties; developing benchmarks and milestones to measure progress; extending the social learning ecosystem beyond the resident years; embracing diversity as the norm for both practice and learning; and providing both coaching and mentoring. CONCLUSION: For decades, resident physicians have shown commitment, tenacity, and selflessness while shouldering the dual responsibility of patient care and the pursuit of their own education and skills development. Resident engagement has been shown to drive change in undergraduate medical education and in the learning and performance of their teachers. The latter is evidence of reverse mentoring that will be a major factor for improvement in this digital age. We have only to embrace this opportunity to the benefit of our patients, our learners, and ourselves.