Novel Nerve Block Combination Decreases Opioid Use, Enables Earlier PACU Discharge Times After Hip Arthroscopy
A retrospective cohort study conducted at Hospital for Special Surgery (HSS) demonstrated that combining a pericapsular nerve group (PENG) block with a lateral femoral cutaneous nerve (LFCN) block significantly reduced opioid use and enabled earlier post-anesthesia care unit (PACU) discharge after ambulatory hip arthroscopy, compared with the current anesthetic standard of care, a femoral nerve block or fascia iliaca block. These findings were presented at the 6th World Congress on Regional Anaesthesia & Pain Medicine in Paris, France, September 2023.1
“Usually for hip arthroscopy, the anesthesiologist performs a type of neuraxial block; in this case, a femoral nerve block or fascia iliaca block,” said Lisa Reisinger, MD, a research fellow at HSS and one of the authors of the study. “With these blocks, there is an adverse effect of quadriceps weakness leading to elevated fall risk and prolonged hospital stay.”
“PENG and LFCN are both motor-sparing blocks, but neither provide adequate pain relief for hip arthroscopy on their own,” Dr. Reisinger explained. “The purpose of this study was to evaluate whether these nerve blocks performed at the same time would lead to adequate analgesia with opioid-sparing effects and earlier discharge. While these are two commonly used techniques, it is not yet common to use them together for hip arthroscopy.”
Twenty-six patients who received only the PENG block and 86 patients who received both the PENG and LFCN blocks were matched to a control group of 112 patients who received only a neuraxial block using propensity score matching (1:1) and a caliper of 0.2, to match patients by American Society of Anesthesiologists classification, gender, and age.
The primary examined outcome was average opioid consumption in the PACU. Secondary outcomes included maximum numerical rating scale (NRS) pain score, intravenous (IV) rescue analgesia, and PACU readiness for discharge times.
The combination of a PENG block and LFCN block showed a significant reduction in average opioid consumption (more than 40% less) and earlier PACU discharge times (more than 1.7 hours earlier) compared with neuraxial alone.
There were also significantly lower severe pain scores in the PENG/LFCN group than the neuraxial alone group, which was demonstrated with the PENG/LFCN group using significantly less IV rescue analgesia and having lower maximum NRS pain scores. The PENG block alone did not demonstrate a significant pain relief benefit compared with the control group, although it did decrease the amount of time to discharge.
These results demonstrate that using both the PENG and LFCN nerve blocks may provide the best pain relief, reduce opioid use, and reduce discharge times compared with PENG block alone or neuraxial analgesia alone.
“Patients are looking for alternatives to minimize narcotic use after surgery,” said David Kim, MD, an anesthesiologist at HSS and lead author of the study. “This study offers an opioid-sparing alternative for ambulatory hip arthroscopy.”
“The next stage of research should be focusing on whether PENG/LFCN combination provides any longer-term outcome benefits to our patients, such as functional outcomes, post-discharge opioid consumption, etc.,” said Jiabin Liu, MD, an anesthesiologist and one of the authors of the study.
“Most blocks have a duration of 24 to 48 hours,” Dr. Kim added. “The next focus should be on methods for lengthening the duration beyond that.”
1. Lisa Reisinger, MD, Genewoo Hong, MD, JD, Edward Lin, MD, Sang Jo Kim, MD, Jonathan Beathe, MD, Douglas Wetmore, MD, Jiabin Liu, MD, David H Kim, MD. “Pericapsular nerve group block combined with a lateral femoral cutaneous nerve block decreases opioid consumption after hip arthroscopy: a retrospective cohort study.” Presented at: 6th World Congress on Regional Anaesthesia & Pain Medicine, September 6-9, 2023, Paris, France.
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 14th consecutive year), No. 2 in rheumatology by U.S. News & World Report (2023-2024), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2023-2024). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a third consecutive year (2023). Founded in 1863, the Hospital has the lowest readmission rates in the nation for orthopedics, and among the lowest infection and complication rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. In addition, more than 200 HSS clinical investigators are working to improve patient outcomes through better ways to prevent, diagnosis, and treat orthopedic, rheumatic and musculoskeletal diseases. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 165 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.