Hip fractures are a common and disabling injury caused by osteoporosis of the joints, and they have a significant socioeconomic impact. Any movement at the hip joint, whether during the transfer to the hospital or during a radiological procedure followed by OT, causes excruciating pain. Multiple comorbidities increase the need for regional analgesia and anaesthesia in elderly people(1). The most popular anaesthetic technique for treating these fractures is spinal anaesthesia(2). Severe fracture-related pain makes it difficult to position oneself optimally for these operations, which makes it difficult to access the subarachnoid area(3). Along with increasing opioid use, inadequate postoperative analgesia might limit limb movement, postponing healing. In this group, effective perioperative analgesia that lessens the need for opioids and their side effects is crucial(3). Lower extremity peripheral nerve blocks, such as 3-in-1 Femoral Nerve block, Fascia Iliaca block (FIB), and Femoral Nerve (FN) block, are common analgesic options primarily because they reduce need for opioids and thus opioid-related side effects and sedatives(4). The research indicates that while the articular branches of the femoral nerve are blocked by both femoral nerve block and fascia Iliaca block, the articular branches of obturator nerve and the Accessory obturator nerve are not reliably blocked, and the analgesia resulting from these anterior blocks is only moderate(5). According to earlier anatomic studies, the anterior hip capsule is innervated by articular branches of the Femoral nerve, Obturator nerve, and Accessory Obturator nerve(6). This suggests that hip analgesia should primarily target these sensory branches, which can be blocked by Peri-capsular nerve group (PENG) block(5)(7). Regional analgesic techniques such as Pericapsular nerve group [PENG] block and Supra-inguinal Fascia Iliaca [SIFI] block have been found to be effective in providing good pain relief in patients with hip fractures(8). Since PENG block could block the accessory obturator nerve additionally, it might have greater analgesic effect compared to SIFI block theoretically. However interventional comparative studies between them are still lacking. The aim of this study is to compare the analgesic efficacy of PENG block and SIFI block and assess their efficacy in optimal patient positioning for spinal anesthesia Objectives of the study Primary objectives: 1]Efficacy of Each block: We will assess the mean pain score using NRS pain scale before and 15 mins after applying the assigned block. NRS-Numerical rating scale 0-No pain, 10-the worst imaginable pain. 2]Ease of spinal positioning [EOSP]in each block: The EOSP will be assessed on the scale of 0-3 0 unable to position 1 Patient had abnormal posturing due to pain and requiring support for positioning 2 Mild discomfort but does not require support for positioning. 3 Optimal condition, where the patient is able to position himself Secondary Objectives: A] Post-operative pain score: Resting and dynamic pain using NRS pain scale at postoperative times of 4,8,12 and 24hrs. B] Post-operative analgesic drug consumption: Postoperative analgesia was provided with IV paracetamol 1 gm every 8 h. The rescue analgesia was provided with 50 mg tramadol on demand or when NRS was >5. Time frame for postop period- 4,8,12 and 24hrs. C] Patient Satisfaction: Assessed using a questionnaire at the time of discharge Study Design: A prospective observational study Study Population: Patients of age group 18 to 60 years of either gender scheduled for hip surgery Sample Size: 60 Study Duration: Over a period of 8 months (March 2024 – October 2024) Place Of Study: King George Hospital, Andhra Medical College, Visakhapatnam Inclusion Criteria: ● ASA 1 & 2 Patients. ● Age: 18 to 60 years ● Surgery: Elective ● Who have given valid informed consent. Exclusion Criteria: ● Patient not willing for block ● Any bleeding disorder and patient on anticoagulants. ● Neurological and musculoskeletal disease. ● Local infection at the injection site. ● Allergy to local anaesthetic ● Significant history of drug/alcohol abuse ARMS AND INTERVENTIONS GROUP P: PENG BLOCK group Pericapsular nerve group (PENG) block to be given 15 mins prior to spinal anesthesia before surgery Procedure: USG guided PENG block with 20ml of LA mixture (10 ml 0.5% Bupivacaine+10 ml 2%Lignocaine with 5mcg/ml Adrenaline). GROUP S: SIFI BLOCK group Supra-inguinal Fascia Iliaca compartment block to be given 15mins prior to spinal anesthesia before surgery Procedure: USG guided SIFI block with 20ml of LA mixture (10 ml 0.5% Bupivacaine +10 ml 2% Lignocaine with 5mcg/ml Adrenaline). PERICAPSULAR NERVE GROUP BLOCK A low-frequency (2-5 MHz) curvilinear transducer was positioned horizontally over the anterio r inferior iliac spine (AIIS). The pubic ramus, ilio-pubic eminence, and femoral artery were identified by sliding over the probe inferiorly. Then the probe was rotated clockwise or counter-clockwise approximately 45 degrees to align with the pubic ramus(9). Using the in-plane technique, the 22G, 10 cm long, echogenic needle was introduced by keeping the direction lateral to medial in the musculofascial plane between the psoas tendon and the pubic ramus. The accurate position of the needle was confirmed by hydro dissection and spread under the ilio-psoas muscle. Then 20 cc of the drug was injected Figure 1: Ultrasound image of PENG block. The lateromedial approach of PENG block. The white arrow shows the direction of the needle in the plane between the psoas tendon and periosteum and between the anterior inferior iliac spine and ilio-pubic eminence or iliopsoas notch. (FA: Femoral artery, PENG: Pericapsular Nerve Group) SUPRA-INGUINAL FASCIA ILIACA BLOCK A high-frequency linear transducer (8-14 MHz) probe was kept longitudinally over the inguinal crease to locate the anterior superior iliac spine, and then to glide medially. The “bow-tie sign” formed by the internal oblique and the sartorius muscle, the iliopsoas muscle and fascia iliaca were identified. A 22G, 10cm long, echogenic needle was inserted 1 cm above the inguinal ligament. With the in-plane technique, the tip of the needle is positioned underneath the fascia iliaca, lateral to the femoral artery, and confirmed with the separation of the iliacus muscle by hydro dissection. Then the needle was advanced cranially while continuing with the hydro dissection. The injection was accomplished once the spread of local anaesthetic was observed in the cephalic direction from where the iliacus muscle passes under the abdominal muscles. A total of 20 cc drug was injected(10). Figure 2: Ultrasound image of SIFI block. The appearance of the "BOW-TIE" sign formed by the sartorius and internal oblique muscles. The white arrow shows the direction of the needle to pierce the fascia iliaca. (SIFI: Supra-inguinal Fascia Iliaca)

• All 60 patients satisfying the inclusion criteria after thorough Pre-anesthetic checkup were investigated for pre-operative biochemical tests (Renal Function Test & Liver Function Test, Random Blood Sugar), Haemogram (Haemoglobin %, Total Count, Differential Count, Platelet count), Chest X-ray & - 12 lead ECG. • Patients were randomly allocated into two groups, Group A and Group B, using slips in the box technique Group P: 30 members received PENG block Group S: 30 members received SIFI block • Standard monitors- Pulse oximetry for oxygen saturation (SpO2), Non- invasive blood pressure monitoring (NIBP), Electrocardiogram (ECG) were attached and baseline pulse rate, blood pressure, oxygen saturation were recorded. • An intravenous line was placed before procedure with 18G cannula and crystalloid infusion started. • Oxygen at the rate of 4 l/min was administered through face mask. • Vital parameters were recorded throughout the procedure. • Before the commencement of the procedure, patients were explained about the method of sensory and motor assessments. • Ultrasound machine with linear probe and curvilinear probe was used to inject the drug. The drug used was Bupivacaine 0.5% (10 cc), 2% Lignocaine + Adrenaline (10 cc) and other materials used were 10 cm long echogenic needles, two 20 ml syringes, 2 stainless steel bowls on each for Povidone Iodine and Spirit, sterile gauze pieces and one sterile centre hole towel. • Spinal anaesthesia was performed at L4-L5 using 0.5% hyperbaric bupivacaine 3 ml and 25 mcg of fentanyl added as adjuvant. ETHICS Study was conducted after • Obtaining consent for interview and examination. • Obtaining consent for being a part of the Study Procedure. • Confidentiality of the patient was maintained. • The academic purpose behind the study was explained to the patient and then enrolled. STATISTICAL ANAALYSIS • Appropriate Statistical tests were applied to compare the groups for efficacy. • Data Entry was done in Microsoft excel spreadsheet and data analysis was done by Statistical Package for Social Sciences (SPSS). • Categorical data was expressed as Proportions and quantitative data as mean and standard deviations. • A p-value of < 0.05 was considered statistically significant.

Demographic profile of the study groups Parameters Group(N=60) Mean SD SE Coefficient of Variation Age P (PENG) 28 4.11 0.752 0.147 S (SIFI) 26.43 3.98 0.727 0.151 BMI P (PENG) 26.02 2.96 0.541 0.114 S (SIFI) 24.61 2.93 0.535 0.119 Group Sex Chi square P value Male Female P (PENG) 15 15 1.086 0.297 S (SIFI) 19 11 Comparison Of NRS Between 2 Groups Variable Group Mean SD Before intervention P (PENG) S (SIFI) 5.90 6.02 1.400 1.430 Just before positioning P (PENG) S (SIFI) 2.80 3.30 1.064 1.485 While positioning P (PENG) S (SIFI) 1.80 2.20 0.809 0.934 EOSP Score in each group Group Mean SD P (PENG) 2.2 0.38 S (SIFI) 2.05 0.45 Postoperative Pain scores Mean NRS Pain Score Group P (PENG) Group S (SIFI) Rest Mean SD Mean SD At 4 hrs 8 hrs 12 hrs 24 hrs 0 1 2 3 0.28 0.31 0.26 0.35 0 1 2 2 0.16 0.23 0.22 0.29 Movement Mean SD Mean SD At 4 hrs 8 hrs 12 hrs 24 hrs 1 2 4 4 0.33 0.34 0.29 0.36 1 1 2 3 0.18 0.25 0.28 0.37 Patient Satisfaction Group Satisfied Dissatisfied Chi square P value P (PENG) 28 2 0.218 0.64 S (SIFI) 27 3

Demographic profile of the study groups The mean age of the patients in P group (PENG) was 28 with SD of 4.11 years. And mean age in the S group (SIFI) was 26.43 with SD of 3.98 years. The mean age in both groups was same and was not statistically significant (p-value > 0.05). The mean BMI of the patients in P group (PENG) was 26.02 with SD of 2.96 years and mean BMI in the S group (SIFI) was 24.61 with SD of 2.93 years and was not statistically significant (p- value > 0.05). Regarding sexes, Among P group (PENG), there were 15 males and 15 females and in S group (SIFI), there were 19 males and 11 females and was not statistically significant (p-value > 0.05). Comparison of pain score using NRS between both groups Before intervention, mean pain score was 5.90 with SD of 1.40 among Group P (PENG) and was 6.02 with SD of 1.43 among Group S (SIFI). Just before positioning, mean pain score was 2.80 with SD of 1.06 among Group P (PENG) and was 3.3 with SD of 1.485 among Group S (SIFI). While positioning, mean pain score was 1.80 with SD of 0.809 among Group P (PENG) and was 2.2 with SD of 0.93 among Group S (SIFI). EOSP Score in both groups Mean Score for Ease of spinal positioning was 2.2 with SD of 0.38 among Group P (PENG) and was 2.05 with SD of 0.45 among Group S (SIFI). Post-operative comparison of NRS at various time periods Mean pain scores were comparable and similar in between both the groups at different time points post-operatively Post-operative Analgesia Time for First analgesic request and total doses for pain relief in the first 24-hour period were similar between the groups. Patient Satisfaction Assessed by questionnaire at the time of discharge, Among Group P (PENG), 28 patients were satisfied and 2 were dissatisfied and in Group S (SIFI), 27 were satisfied and 3 were dissatisfied and was not statistically significant (p-value > 0.05). In 2018, Girón-Arango L et al., performed PENG block on 5 patients having hip fracture. Study showed that there was reduced pain scores without quadriceps weakness in all patients(11). In 2018, Ueshima et al., documented their successful clinical experience using the PENG technique in four patients for perioperative pain management in hip replacement surgery(11). Both groups showed minimal adverse events, with no block-related complications, comparable to results by Shariat et al (12).

The newer technique PENG block’s analgesic efficacy to facilitate sitting position in hip joint fracture for spinal anaesthesia was equally effective to supra- inguinal Fascia Iliaca block. Despite promising findings, further research is needed to support a patient-centered approach in block selection to optimize outcomes.

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