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24. Piccione C, Hilgard ER, Zimbardo PG. On the degree of 29. Arrow K, Burgoyne LL, Cyna AM. Implications of nocebo in
stability of measured hypnotizability over a 25-year anaesthesia care. Anaesthesia 2022; 77: 11e20
period. J Pers Soc Psychol 1989; 56: 289e95 30. Rafi MA, Arfeen Z, Misra U. Conversion of regional to
25. Kohen DP, Kaiser P. Clinical hypnosis with children and general anaesthesia at caesarean section: increasing the
adolescentsdwhat? Why? How? Origins, applications and use of regional anaesthesia through continuous prospec-
efficacy. Children (Basel) 2014; 1: 74e98 tive audit. Int J Obstet Anesth 2010; 19: 179e82
26. Carlyle AV, Ching PC, Cyna AM. Communication during 31. Cyna AM, Tomkins D, Maddock T, et al. Brief hypnosis for
induction of paediatric anaesthesia: an observational severe needle phobia using switch-wire imagery in a 5-
study. Anaesth Intensive Care 2008; 36: 180e4 year old. Paediatr Anaesth 2007; 17: 800e4
27. Nowak H, Zech N, Asmussen S, et al. Effect of therapeutic 32. Pesce A, Palmieri M, Cofano F, et al. Standard awake surgery
suggestions during general anaesthesia on postoperative versus hypnosis aided awake surgery for the management
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28. Lang EV, Hatsiopoulou O, Koch T, et al. Can words hurt? 33. Lang E, Laser E. Patient sedation without medication: rapid
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British Journal of Anaesthesia, 130 (6): 650e654 (2023)

doi: 10.1016/j.bja.2023.03.023
Advance Access Publication Date: 26 April 2023
© 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Regional analgesia for total hip arthroplasty and Schwartz’s paradox

David W. Hewson1,2,* , Chloe E. H. Scott3,4 and Alan J. R. Macfarlane5,6
1
Department of Anaesthesia and Critical Care Medicine, Academic Unit of Injury, Recovery and Inflammation Sciences,
School of Medicine, University of Nottingham, Nottingham, UK, 2Department of Anaesthesia, Queen’s Medicine Centre,
Nottingham University Hospitals NHS Trust, Nottingham, UK, 3Edinburgh Orthopaedics, Royal Infirmary of Edinburgh,
NHS Lothian, Edinburgh, UK, 4Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK, 5Department
of Anaesthetics, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK and 6School of Medicine,
Dentistry and Nursing, University of Glasgow, Glasgow, UK

*Corresponding author. E-mail: [email protected]

This editorial accompanies: Quality of recovery after pericapsular nerve group (PENG) block for primary total hip arthroplasty under spinal
anaesthesia: a randomised controlled observer-blinded trial by Kukreja et al., Br J Anaesth 2023:130:773e779, doi:10.1016/j.bja.2023.02.017

Summary
Enhanced recovery after total hip arthroplasty aims to facilitate return to function and early hospital discharge, but the
role of novel fascial plane block techniques in such pathways is uncertain. A randomised trial by Kukreja and colleagues
describes superior quality of recovery after hip arthroplasty in patients receiving a pericapsular nerve group (PENG) block.
We discuss the trial findings in the context of ongoing uncertainty regarding best analgesic practice for this surgical
procedure.

Keywords: arthroplasty; enhanced recovery after surgery; hip replacement; PENG block; peripheral nerve block; regional
anaesthesia

Learning to choose is hard. Learning to choose well is harder. And lists for a total hip arthroplasty. However, with inpatient fa-
learning to choose well in a world of unlimited possibilities is harder cilities experiencing ongoing bed shortages, and concern that
still, perhaps too hard. planned uplifts to elective surgical capacity will be insufficient
to treat both new cases and address the COVID-19 backlog,
d Barry Schwartz, The Paradox of Choice: Why More Is Less day-case arthroplasty pathways have never been so impor-
tant. Successful Enhanced Recovery After Surgery (ERAS)
As we recover from the COVID-19 pandemic, thousands of pathways rely on the entire multidisciplinary team, but an
people in the UK remain on National Health Service waiting important anaesthetic component of hip arthroplasty ERAS is
ensuring adequate analgesia while preserving motor function
to facilitate ambulation.
DOI of original article: 10.1016/j.bja.2023.02.017.
 Editorials - 651

The innervation of the hip joint is primarily derived from hydromorphone, or both. The PENG block group reported
the lumbar plexus via the femoral, obturator, and accessory clinically significant superior Quality of Recovery-15 (QoR15)
obturator nerves. The sacral plexus provides a smaller, vari- scores and lower opioid consumption at 24 and 48 h. No pre-
able innervation via the superior and inferior gluteal nerves, viously conducted study had systematically measured quality
the nerve to quadratus femoris, and the sciatic nerve.1 Tradi- of recovery, increasingly recognised as an important patient-
tional peripheral nerve blockade techniques for hip surgery centred endpoint in perioperative clinical trials.17 Although
include lumbar plexus, infra-inguinal fascia iliaca, ‘three in neither study group received local anaesthetic infiltration, and
one’ and femoral nerve blocks. All provide a degree of anal- therefore one might argue some local anaesthetic in the form
gesia but at the expense of quadriceps muscle weakness and of a PENG block may be better than nothing, the evidence of
safe early mobilisation. In addition to often missing the benefit of local anaesthetic infiltration in total hip arthroplasty
obturator nerve, a further limitation of infra-inguinal blocks is is conflicting. It is not considered standard practice by all, nor
that some articular branches from the femoral nerve may is it routinely recommended.18,19
arise more proximally.2 Newer ultrasound-guided fascial It is a criticism of many studies of fascial plane blocks that
plane block techniques, many currently lacking in procedure- patients are deprived of multimodal analgesia, potentially
specific, high-quality evidence, are emerging at an exponential enhancing any analgesic benefit of the block,20 and so it is a
rate and the hip is not exempt. The supra-inguinal fascia further strength of this study that the PENG block still
iliaca, quadratus lumborum, lumbar erector spinae plane, and demonstrated superiority over a multimodal analgesic control
the pericapsular nerve group (PENG) blocks have all been arm. Another common criticism of some studies, that could
described relatively recently and their use in hip surgery also be levelled here, is that the novel block is not compared
subsequently studied.3e7 with a ‘gold standard’. Given the panoply of regional tech-
The PENG block was first described in 2018 after an elegant niques, local anaesthetic infiltration and enteral multimodal
cadaver study demonstrating the anatomical relationship be- options and the potential permutations, are clinicians clear,
tween the anterior hip capsule and articular branches of the however, about what constitutes the analgesic gold standard
femoral, obturator, and accessory obturator nerves.2,8 The for total hip arthroplasty ERAS programmes?
ultrasound-guided PENG block targets these articular nerve Unsurprisingly, practice varies greatly between anaesthe-
branches by injecting local anaesthetic in the plane between tists, arthroplasty units, and even between internationally-
the pubic ramus and the iliopsoas tendon. Selectively blocking ratified evidence-based guidelines. European Society of
articular nerve branches to the anterior hip capsule is an Regional Anaesthesia and Pain Therapy (ESRA) Procedure
attractive option, theoretically providing analgesia to this the Specific Postoperative Pain Management (PROSPECT) guidance
most richly innervated area of the hip joint without associated makes recommendations based primarily upon whether an
motor block. Other theoretical mechanisms of action include intervention influences postoperative pain. For total hip
spread of local anaesthetic to the iliopsoas muscle, perhaps arthroplasty, 2021 PROSPECT guidance18 recommends para-
reducing painful muscle spasm in hip fracture patients or, as cetamol and cyclo-oxygenase 2 inhibitors or non-specific non-
proposed with other fascial plane blocks, local anaesthetic steroidal agents, intravenous dexamethasone, and post-
systemic absorption.9 operative rescue opioids. Fascia iliaca block or local anaes-
Early case reports and case series using the PENG block in thetic infiltration are recommended ‘especially if there are
hip fracture surgery suggested benefit, reducing preoperative contraindications to basic analgesics and/or in patients with
pain, postoperative pain, or both while generally preserving high expected post-operative pain’ taking into consideration
quadriceps muscle strength.2,10 Small randomised controlled the adverse effects of femoral nerve, lumbar plexus, or
trials have since examined PENG blocks in total hip arthro- epidural blocks. Although meta-analysis has demonstrated
plasty, either comparing PENG block with periarticular local intrathecal morphine 100 mg to be an efficacious analgesic dose
anaesthetic infiltration,11,12 no block (although both groups in total hip arthroplasty,19 the PROSPECT authors noted con-
received wound infiltration),7 or other peripheral nerve blocks flict amongst the group because of potential side-effects and
such as the supra-inguinal fascia iliaca block.13 Two other suggested intrathecal morphine only be considered rather
studies have combined PENG block and local anaesthetic than recommended. In contrast, the 2019 ERAS Society
infiltration and compared this with local anaesthetic infiltra- consensus recommendations,21 which focus on the ability of
tion alone.14,15 The primary outcomes vary, but although most an intervention to accelerate early discharge while minimising
studies were in favour of the PENG block with either some complications, suggest ‘modern general’ or spinal anaesthesia
analgesic benefit, reduced opioid consumption, shorter time to with no intrathecal opioid, and do not recommend peripheral
ambulation, or improved quadriceps strength, there were nerve blocks or local anaesthetic infiltration as essential
various limitations. The most recent study comparing PENG components for total hip arthroplasty. The International
and local anaesthetic infiltration, where quadriceps weakness Consensus on Anaesthesia-Related Outcomes after Surgery
was the primary outcome, found no difference in motor block (ICAROS) group,22 examining morbidity and mortality end-
between groups but significantly reduced static and dynamic points, strongly recommend spinal anaesthesia for total hip
pain scores with local anaesthetic infiltration showing that the arthroplasty. They also recommend peripheral nerve blocks
PENG block is not a panacea in total hip arthroplasty.11 for total hip arthroplasty to reduce odds of cognitive
In this issue of the British Journal of Anaesthesia, Kukreja and dysfunction, respiratory failure, cardiac complications, surgi-
colleagues16 report a well-conducted observer-blinded rando- cal site infections, thromboembolism, blood transfusion, and
mised trial comparing PENG block with placebo block (skin critical care admissions, with stronger effects noted when
puncture with local anaesthetic only) in patients undergoing nerve blocks are combined with general rather than neuraxial
total hip arthroplasty using a posterior approach. Patients in anaesthesia.23 There are limitations to this latter work,
both groups received a spinal anaesthetic with hyperbaric notably that all peripheral nerve blocks are grouped as one
bupivacaine (no opioid additive), intravenous dexamethasone, intervention and that novel fascial plane techniques such as
oral paracetamol and celecoxib, and as required oxycodone, the PENG block are not included in the 2019 ICAROS analyses.
 652 - Editorials

In the face of inconsistent best-practice recommendations The value of any new technique or technology must
from groups whose focus is on different outcomes and the include an assessment of risk. The study by Kukreja and col-
burgeoning selection of perioperative interventions in total leagues16 was not powered to detect differences in ambula-
hip arthroplasty, are anaesthetists suffering Schwartz’s tion, but several studies have encountered a significant
paradox of choice, where almost ‘unlimited choice’ has proportion of patients developing motor block after a PENG
become part of the problem and not the solution? block, thought to be secondary to spread of local anaesthetic
Further difficulty lies with the fact that total hip arthro- towards the femoral nerve. Aliste and colleagues,13 comparing
plasty is not a homogenous procedure performed on a uniform PENG to the supra-inguinal fascia iliaca block, found that 45%
group of patients. In this study from Kukreja and colleagues,16 of patients receiving a PENG block had weakness of knee
as with many other regional anaesthesia studies, surgeons are extension or hip adduction at 3 h, and 25% at 6 h. Although
absent from the authorship team. This certainly does not there were no differences in secondary physiotherapy out-
invalidate the results, but many aspects of surgical technique comes between the PENG and supra-inguinal fascia iliaca
can affect early postoperative outcomes and must therefore be block groups, these outcomes were executed at 24 h by which
considered when translating trial results into practice. For point blocks might have worn off. In centres where physio-
total hip arthroplasty, different surgical approaches involve therapy needs to be completed to achieve same-day discharge,
not only different skin incisions, but different muscle releases such outcomes need to be assessed earlier. Interestingly the
that can affect early recovery.24,25 Although surgical approach same team subsequently compared PENG with local anaes-
is typically considered, other parameters such as the indica- thetic infiltration,11 and found a lower incidence of 25%
tion for total hip arthroplasty, disease severity and the im- quadriceps weakness in the PENG group at 3 h, despite using
plants used are often not. Severe disease with deformity and the same technique as before, compared with 30% in the local
stiffness requires more extensive soft tissue releases which anaesthetic infiltration group. As yet, no clinical studies have
can affect both postoperative pain and early mobilisation, as been undertaken to determine the optimal PENG injectate
can involvement of other joints. Cemented or uncemented volume to provide adequate analgesia but without spread to
implants can also be associated with different recovery tra- the femoral nerve, and it remains to be seen if the PENG block
jectories. Robotic-assisted surgery and the haptic boundaries is truly motor-sparing in same-day discharge total hip
it creates are designed to prevent unintentional soft tissue arthroplasty.
damage,26 thought to be the mechanism by which robotic Theatre utilisation and workflow efficiency, especially in the
assistance reduces early postoperative pain for total hip27 and current climate of excessive waiting lists and backlogs, must
total knee arthroplasty.28 With the various anaesthetic and also be considered. The study by Kukreja and colleagues16 was
surgical practice permutations, differing international rec- performed in the context of a separate block room typically not
ommendations, and at times a lack of input from multidisci- available in the NHS. The time taken to deliver a PENG block is
plinary colleagues in clinical trial design, it can be challenging not reported, and although likely short, could be relevant in
to know how to incorporate results from clinical trials of pe- other healthcare systems. Some concern also exists that the
ripheral nerve blocks into everyday practice for total hip application of local anaesthetic near the anterior hip capsule
arthroplasty. risks the introduction of infection. Single-shot peripheral nerve
In addition to increased research collaboration between blocks, undertaken in an aseptic fashion, are associated with
surgeons and anaesthetists, one strategy to improve research extremely low risk of infection.33 Many local anaesthetic solu-
generalisability and assist in the meta-analysis of individual tions are bacteriostatic, and although in competent hands the
trial results, is to apply evidence-based core outcome sets of aseptically inserted needle tip does not contact the hip joint,
maximal importance to patients and clinicians. The Core there is insufficient evidence at present to conclude that PENG
Outcome Measures in Perioperative and Anaesthetic Care blocks present no infection risk in total hip arthroplasty. A
(COMPAC) Standardised Endpoints in Perioperative Medicine further potential risk of injudicious needling is damage to the
(StEP) projects generated various clinical trial endpoints femoral or lateral cutaneous nerve to the thigh. A final rate-
including a domain focussed on patient comfort incorporating limiting step in any anaesthetic pathway is the ability of pro-
QoR-15, as studied by Kukreja and colleagues.16 A recently viders to undertake specific techniques. A recent Regional
published Core Outcome Measures in Effectiveness Trials Anaesthesia-UK (RA-UK) and Research and Audit Federation of
(COMET) initiative aiming to determine important endpoints Trainees (RAFT) UK survey found that a significant proportion of
in trials of regional anaesthetic techniques also identified QoR- senior trainees (ST6-7 UK training grades) did not feel confident
15 as an important endpoint,17 even though some components performing even Plan A regional nerve blocks (unpublished
of QoR-15 are influenced by factors unrelated to any regional data). This will hopefully improve with implementation of the
technique. Unlike short-term QoR-15 scores, well validated 2021 Royal College of Anaesthetists curriculum. As regional
orthopaedic-specific patient-reported outcomes measures anaesthesia enthusiasts we aspire to the competence, indeed
such as the Oxford hip and knee scores,29 the forgotten joint the excellence, of the many not the few.34 Nevertheless, if the
score,30 or the more generic EQ-5D are applied preoperatively PENG block is proved to be of benefit in specific populations,
and typically at 6 or 12 months postoperatively. Functional anaesthetists must have the skills to deliver this safely, effec-
outcomes so measured typically peak at 1 or 2 yr and it is tively, and reproducibly.
unrealistic to expect single-shot regional anaesthetic tech- Has the work of Kukreja and colleagues16 clarified or
niques to influence such measures. It is realistic, however to worsened the paradox of choice for total hip arthroplasty
examine the role of peripheral nerve blocks in patient comfort, ERAS? Many centres (including that of AJRM) are now suc-
known to affect long-term patient satisfaction,31 and pace of cessfully performing day-case total hip arthroplasty without
recovery, increasingly recognised as important to both sys- any peripheral nerve blocks or local anaesthetic infiltration,
tems and patients, using objective measures of function such but instead ‘simply’ spinal anaesthesia with no intrathecal
as the timed up-and-go (TUG) test32 and of course length of opioid plus enteral multimodal analgesia, with or without a
hospital stay or proportion of same-day discharges. short course of modified-release opioids (personal
 Editorials - 653

communication). Is a PENG, or any, block even necessary for 10. Morrison C, Brown B, Lin DY, Jaarsma R, Kroon H. Anal-
all patients undergoing total hip arthroplasty? Or does its gesia and anesthesia using the pericapsular nerve group
indication lie in a limited subset of patients undergoing total block in hip surgery and hip fracture: a scoping review.
hip arthroplasty? The PENG block has mechanistic plausibility, Reg Anesth Pain Med 2021; 46: 169e75
is straightforward to perform, and its efficacy in improving a 11. Bravo D, Aliste J, Layera S, et al. Randomized clinical trial
core patient-centred outcome compared with using multi- comparing pericapsular nerve group (PENG) block and
modal analgesia alone has now been demonstrated, with the periarticular local anesthetic infiltration for total hip
caveats above, in total hip arthroplasty. It may be too early to arthroplasty. Reg Anesth Pain Med 2023. Advance access
recommend routine adoption of PENG block in total hip published on February 16 https://doi.org/10.1136/rapm-
arthroplasty ERAS pathways, but we look forward to refining 2023-104332
our conclusions in light of further, hopefully increasingly 12. Iglesias SL, Nieto I, Lo pez P, et al. Pericapsular nerves
collaborative, studies. Only through collaboration will we block (PENG) is an effective and safe alternative for post-
improve regional anaesthesia trial design and achieve the ul- operative pain management after primary total hip
timate common goal of maximising patient experiences, out- arthroplasty: a randomized clinical trial. Rev Esp Cir Ortop
comes, and throughput. Traumatol 2022. S1888-4415(22)00352-6. https://doi.org/10.
1016/j.recot.2022.12.004. PMID: 36529424
13. Aliste J, Layera S, Bravo D, et al. Randomized comparison
Declarations of interest
between pericapsular nerve group (PENG) block and
DWH accepts fees for advising in civil, criminal and coronial suprainguinal fascia iliaca block for total hip arthroplasty.
medicolegal cases. CEHS reports consultancy for Stryker Reg Anesth Pain Med 2021; 46: 874e8
(Newbury, UK) and Smith and Nephew (Watford, UK), advisory 14. Lin D, Brown B, Morrison C, et al. The Pericapsular Nerve
board activity for Pfizer (New York, NY, USA), and payments Group (PENG) block combined with Local Infiltration
for lecturing from Depuy Synthes (Raynham, MA, USA) and Analgesia (LIA) compared to placebo and LIA in hip
Editorial Board membership of the Bone and Joint Journal. AJRM arthroplasty surgery: a multi-center double-blinded
has received consultancy fees from Intelligent Ultrasound randomized-controlled trial. BMC Anesthesiol 2022; 22: 1e9
(Cardiff, UK). Both AJRM and DWH are members of the asso- 15. Hu J, Wang Q, Hu J, Kang P, Yang J. Efficacy of ultrasound-
ciate editorial board of the British Journal of Anaesthesia. guided pericapsular nerve group (PENG) block combined
with local infiltration analgesia on postoperative pain af-
ter total hip arthroplasty: a prospective, double-blind,
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