Comparıson Of PENG Block wıth Intra-articular And Quadratus Lumborum Block İn Primary Total Hip Arthroplasty

Overview

90 patients ASA I-III, undergoing Total hip arthroplasty (THA) under spinal anesthesia, will be randomly assigned into one of three groups, namely group A (n=30), where an PENG block, group B (N:30) where an inra-articuler, and group C (n=30) where Quadratus lumborum block will be performed preoperatively. All patients will receive a standardized postoperative analgesia regimen. NRS scores will be evaluated in static and dynamic conditions during the first 48 hours postoperatively.

Full Title of Study: “Comparıson Of PENG Block wıth Intra-articular And Quadratus Lumborum Block İn Primary Total Hip Arthroplasty: : Randomized Controlled Double Blinded Trial Trial”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Treatment
    • Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
  • Study Primary Completion Date: December 8, 2022

Detailed Description

Total hip arthroplasty (THA) is the second most common joint replacement surgery, partly due to the aging population. The primary aim of this study is to compare the analgesic efficacy of Pericapsular nerve group (PENG) block with intra-articular and Quadrotus lumborum block (QLB). Regional anesthesia (RA), such as the recently described pericapsular nerve group (PENG) block, may provide additional analgesic benefit in this situation. Pericapsular nerve group (PENG) block is a new regional anesthesia technique to provide analgesia after hip fractures and hip arthroplasty. The aim of this single-center, double-blind, randomized controlled trial is to confirm the efficacy of PENG block for postoperative recovery after primary THA. Routine multimodal analgesia will be used for postoperative analgesia

Interventions

  • Procedure: Group A
    • PENG BLOCK
  • Procedure: Group B
    • Intra-articular
  • Procedure: Group C
    • Quadratus lumborum block

Arms, Groups and Cohorts

  • Active Comparator: PENG BLOCK ( Group A)
    • A regional block will be applied while the patient is in the supine position. A curvilinear low-frequency ultrasound probe (2-5MHz) will initially be placed in a transverse plane on the AIIS and then rotate the probe approximately 45 degrees counterclockwise to align with the pubic ramus. In this view, IPE, iliopsoas muscle and tendon, femoral artery and pectineus muscle will be observed. A 22 gauge, 80 mm needle will be inserted from lateral to medial in an in-plane approach to place the psoas tendon anteriorly and posteriorly in the musculofacial plane between the pubic ramus. Following negative aspiration, a local anesthetic solution (20ml bupivacaine 0.5%) will be injected.
  • Active Comparator: Intra-articular( Group B)
    • It will be applied to the intra-articular region by the surgeon at the end of the operation. A volume of 60 ml (30 ml of 0.5% bupivacaine and 30 ml of 0.9% NaCl)
  • Active Comparator: Quadratus lumborum block ( Group C)
    • The patient will be in the lateral position. A low-frequency convex probe will be vertically attached above the iliac crest and a needle will be inserted in-plane from the posterior edge of the convex probe through the quadratus lumborum in an anteromedial direction. The needle tip will be placed between the psoas major muscle and the quadratus lumborum muscle. After negative aspiration, 30 mL of 0.5 % of bupivacaine will be injected into the fascial plane incrementally, aspirating every 5 ml.

Clinical Trial Outcome Measures

Primary Measures

  • Numerical Rating Scale (NRS) scores
    • Time Frame: 48 Hours
    • Range 0-10, 0=no pain, 10=the worse pain ever

Secondary Measures

  • Opioid consumption
    • Time Frame: 3-6-8-12-24 and 48 hours
    • Analgesic consumption
  • Static and dynamic pain
    • Time Frame: 3-6-8-12-24 and 48 hours
    • Pain intensity at rest and during active movement using a numeric rating score (NRS) 0 = no pain and 10 = worst imaginable painranged from 0 to 10
  • Presence of quadriceps motor block (defined as paralysis or paresis )
    • Time Frame: 3-6-12-24 hours after the block
    • Quadriceps motor function will be tested with the patient supine and with the hip and knee flexed at 45º and 90º, respectively. The subject will be asked to extend the knee first against gravity and then against resistance. Quadriceps strength will be graded according to a 3-point scale: normal strength = 0 point (extension against resistance); paresis = 1 point (extension against gravity but not against resistance); and paralysis = 2 points (no extension).
  • Hip adduction strength
    • Time Frame: 3-6-12-24 hours after the block
    • Hip adduction will be evaluated by comparing it to baseline strength (i.e., prior to spinal anesthesia). A blood pressure cuff, inflated at 40 mmHg, will be inserted between the knees of the patient: the latter will then be instructed to squeeze the cuff as hard as possible and to sustain the effort. We will define hip adduction scores of 0, 1 and 2 points as decreases in strength of 0-20%, 21-70% and 71-90% compared to baseline measurement, respectively
  • Presence of postoperative nausea, vomiting, pruritus, urinary retention, respiratory depression
    • Time Frame: 3-6-12-24 hours after the block
    • Presence of postoperative nausea, vomiting, pruritus, urinary retention, respiratory depressio
  • Patient satisfaction
    • Time Frame: 48 hours
    • Patients asked whether they would choose the same anaesthetic management in a future operation: Yes/No
  • Quality of Recovery (QoR-40) score
    • Time Frame: measurements are obtained at 24 hours, 48 hours, and one week
    • QoR-40, a 40-item questionnaire that provides a global score and sub-scores across five dimensions: patient support, comfort, emotions, physical independence, and pain. Each item is rated on a scale of 1-5, providing a minimum score of 40 and maximum of 200.
  • Mobilization time
    • Time Frame: 24 hour
    • Mobilization time

Participating in This Clinical Trial

Inclusion Criteria

  • Physical status according to American Society of Anesthesiologists (ASA ) I-III Exclusion Criteria:

  • Previous operation on the same hip – Hepatic or renal insufficiency – Younger than 18 years old and older than 85 – Patients undergoing general anesthesia – Allergy or intolerance to one of the study medications – BMI >40 – ASA IV – Chronic gabapentin/pregabalin use ( regular use for longer than 3 months) – Chronic opioid use ( taking opioids for longer than 3 months, or daily oral morphine equivalent of >5 mg/day one month

Gender Eligibility: All

Minimum Age: 18 Years

Maximum Age: 85 Years

Are Healthy Volunteers Accepted: Accepts Healthy Volunteers

Investigator Details

  • Lead Sponsor
    • Karaman Training and Research Hospital
  • Provider of Information About this Clinical Study
    • Sponsor

References

Adhikary SD, Short AJ, El-Boghdadly K, Abdelmalak MJ, Chin KJ. Transmuscular quadratus lumborum versus lumbar plexus block for total hip arthroplasty: A retrospective propensity score matched cohort study. J Anaesthesiol Clin Pharmacol. 2018 Jul-Sep;34(3):372-378. doi: 10.4103/joacp.JOACP_335_17.

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