A Preliminary Analysis of a Modified Anterior Approach to Hip Pericapsular Neurolysis for Inoperable Hip Fracture Using the IDEAL Framework

Abstract

Introduction: With an increasingly ageing population, there is a growing impact of fragility hip fracture on the healthcare system and on society as a whole. Oral and injectable analgesics are often insufficient whilst traction and regional blocks do not allow patients to be discharged easily. While the conventional approach of ultrasound-guided anterior hip pericapsular neurolysis can help a lot of inoperable hip fracture patients to relieve their fracture pain and facilitate subsequent nursing care, enormous technical challenges are encountered in some cases. In this retrospective case study, we evaluated the overall pain and functional outcomes of our modified approach of anterior hip pericapsular neurolysis for inoperable hip fractures using the IDEAL framework. Method: This retrospective case series studied patients with acute inoperable hip fracture who received the modified approach of anterior hip pericapsular neurolysis from January 2018 to June 2019 according to the IDEAL recommendations. The modified approach consisted of pericapsular nerve group (PENG) injection, iliopsoas plane infiltration, and the sagittal approach of obturator nerve articular branches (ONAB) injection. Subsequent alcohol neurolysis would be performed in the same setting if there were positive diagnostic blocks. Assessments were carried out on post-intervention day 5. The primary outcome was pain intensity during hip flexion at 80 degrees in the recumbent position and during gentle hip internal and external rotation using an appropriate pain scoring tool. The secondary outcomes were the range of tolerable hip flexion and occurrence of any lower limb neurological deficit because of the procedure. Interim outcomes were also briefly evaluated. Results: Among the 74 patients who were reviewed in the study period, the median dynamic pain at hip flexion 80° (p < 0.001) and on gentle hip external and internal rotation (p < 0.001) was significantly reduced from a composite score of 3 (severe pain) to 1 (mild pain) on post-intervention day 5 after the modified approach of hip neurolysis. This translated to 72% of patients achieving satisfactory pain control, which was defined as a composite pain score of ≤1 on hip flexion at 80°. Functionally, the mean range of tolerable hip flexion significantly improved from 39.7° at baseline to 74° on post-intervention day 5 (p < 0.001). Transient and reversible hypotension was seen in about 10% of the patients. No other major procedural adverse event was noted. Interim follow-up at 4–6 months post-intervention revealed that more than 95% of patients continued to have satisfactory dynamic pain control (i.e., composite pain score ≤ 1). According to the IDEAL classification, this study could be ranked as stage 2a (development). Conclusions: Our findings suggested that anterior hip pericapsular neurolysis using a modified approach could offer consistent and satisfactory analgesic and functional benefits to a majority of patients with inoperable hip fractures during the interim of the fracture healing process, and it was potentially safer than the conventional approach. This technique might have achieved its readiness to proceed to the next stage of research according to the IDEAL framework.

Genicular nerve and fracture site chemical neurolysis for distal femoral fracture: a case report

“…Phenol neurolysis involves denervation of target nerves via protein denaturation, thereby leading to separation of the myelin sheath from the axon and axonal edema. Several studies have emerged on the use of phenol and alcohol CN for proximal hip fracture pain using the PENG (pericapsular nerve group) block 11 12. Fractures involving the distal femur are beyond the innervation coverage of the PENG block.…”

Parameters of Iliopsoas Plane Immediately Caudal to the Indirect Tendon of Rectus Femoris in Axial Plane Measured on Magnetic Resonance Images in an Adult Eastern Asian Population

“…The lateral-to-medial in-plane approach of the anterior hip pericapsular infiltration firstly described by Sasaki et al [4] allows visualization of all the relevant structures during IP injection. However, the needle tip was advanced all the way through until it was buried deep to the IT [4,5] as in the pericapsular nerve group block [8], which may cause accidental iliopectineal bursal injection [6]. For a "true" ultrasound-guided IP injection in the transverse scan, we propose that the needle tip be left inside the hyperechoic layer between the iliopsoas complex and capsular ligaments of hip (i.e., IP, see Figure 2) within 10 mm lateral to IT.…”

“…Since the MR images give far better structural contrast than ultrasound images and are generally not subject to operator-related variations, anatomic landmarks that can be reliably identified on both MR and ultrasound images are needed to translate the findings on MR images into ultrasound-guided techniques. To locate the level where IPB [1,3] and anterior hip pericapsular neurolysis [4,5] are performed in the transverse section on the ultrasound, we found the indirect (reflected) tendon of RF to be a very useful anatomic landmark. From the level where the RF indirect tendon is identifiable in an MR axial plane (Figure 1a), when going caudally, the RF indirect tendon can be seen joining its direct (straight) tendon to merge into the RF conjoined tendon (Figure 1b).…”

“…With advances in knowledge on the iliopsoas plane (IP) [1] and its neural contents [2], ultrasound-guided analgesic interventions for hip performed at the level of capsular ligaments of hip, such as iliopsoas plane block (IPB) [3] and the anterior approach to hip pericapsular neurolysis [4,5], have recently been developed. However, little is known about the IP parameters and their interindividual variations.…”

COVID-19 hip fracture outcomes: The role of Ct values and D-dimer levels?

“…Anaesthetically unfit patients were treated conservatively, where a hip spica brace was given while mobilisation exercise was still encouraged with maintenance limb physiotherapy and sitting [ 18 , 19 ]. Neurolysis, if not contraindicated, was performed by the pain team for better pain control in these patients [ [20] , [21] , [22] ].…”