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The pericapsular nerve group (PENG) block for hip surgery.

A narrative review
Blokada okołopanewkowej grupy nerwów (PENG) w zabiegach w obrębie stawu biodrowego.
Przegląd narracyjny

Tomasz Reysner1, Grzegorz Kowalski2, Monika Grochowicka2, Małgorzata Domagalska2

1
Department of Anesthesiology and Intensive Care, W.Dega Orthopedic and Rehabilitation Clinical Hospital, University of Medical Sciences, Poznań, Poland
2
Chair and Department of Palliative Medicine, University of Medical Sciences, Poznań, Poland

REVIEW Abstract
Introduction. Perioperative pain management associated with hip surgery is challenging. The pericapsular
Chir Narzadow Ruchu Ortop Pol,
nerve group (PENG) block is a new technique thought to provide better postoperative analgesia in addition
2023; 88(1): 17-24 to its motor-sparing effects.
Aim. This review aims to evaluate the safety and efficacy of the PENG blockade in managing postoperative
DOI: 10.31139/chnriop.2023.88.1.3 pain in patients undergoing hip surgery.
Methods. The literature was reviewed through four electronic databases: PubMed, Cochrane Library,
Level of evidence: III Google Scholar, and Embase.
Results. The initial search yielded 416 articles. Twenty-seven relevant articles were selected based
Received: 28.02.2023 on relevance, recentness, search quality, and citations. Twelve of the studies were related to patients
Accepted: 17.03.2023 undergoing total hip arthroplasty. Twelve studies were related to patients undergoing total hip surgery
Published: 31.03.2023 due to hip fracture. Finally, three studies were related to patients undergoing hip arthroscopy.
Conclusions. The PENG block provides superior analgesia and low opioid consumption in the first
postoperative period. However, current evidence is insufficient, and there is a need for high-quality
randomized, controlled trials with larger sample sizes.
Correspondence:
Malgorzata Domagalska Key words: coxarthrosis, pain management, opioids, peripheral nerve block, hip arthroscopy, hip alloplasty,
Os. Rusa 55, 61-245 Poznań, Poland hip replacement.
e-mail: [email protected]

Streszczenie
Wstęp. Leczenie bólu okołooperacyjnego związanego z operacją stawu biodrowego jest bardzo
wymagające. Blokada grupy nerwów okołopanewkowych (PENG) to nowa technika anestezji regionalnej,
która zapewnia lepszą analgezję pooperacyjną, nie upośledzając funkcji motorycznych.
Cite this article: Cel. Celem tego przeglądu jest ocena bezpieczeństwa i skuteczności blokady PENG w leczeniu bólu
Reysner T., Kowalski G, Grochowicka M, pooperacyjnego u pacjentów poddawanych operacjom stawu biodrowego.
Domagalska M: The Pericapsular Nerve Group Metody. Literatura została przejrzana za pośrednictwem czterech elektronicznych baz danych: PubMed,
(PENG) block for hip surgery. A narrative Cochrane Library, Google Scholar i Embase.
review. Chir Narzadow Ruchu Ortop Pol, Wyniki. Wstępne wyszukiwanie przyniosło 416 artykułów. Wybrano dwadzieścia siedem odpowiednich
2023; 88(1): 17-24. artykułów na podstawie trafności, aktualności, jakości wyszukiwania i cytowań. Dwanaście badań
DOI: 10.31139/chnriop.2023.88.1.3 dotyczyło pacjentów poddawanych całkowitej alloplastyce stawu biodrowego z powodu zaawansowanej
choroby zwyrodnieniowej. Dwanaście badań dotyczyło pacjentów poddawanych całkowitej operacji
stawu biodrowego z powodu złamania szyjki kości udowej. Wreszcie trzy badania dotyczyły pacjentów
poddawanych artroskopii stawu biodrowego.
Wnioski. Blokada PENG zapewnia lepszą analgezję i niskie zużycie opioidów w bezpośrednim okresie
pooperacyjnym. Jednak obecne dowody są niewystarczające i istnieje potrzeba przeprowadzenia wysokiej
jakości randomizowanych badań kontrolowanych z większymi próbami.
Słowa kluczowe: choroba zwyrodnieniowa stawów, leczenie bólu, opioidy, blokada nerwów obwodowych,
artroskopia stawu biodrowego, alloplastyka stawu biodrowego, endoprotezoplastyka stawu biodrowego.

Introduction patient’s long-term prognosis and quality of life. Persistent

pain is associated with poor outcomes, with an increased
Hip surgery is one of the most frequently performed or- risk of delirium, cognitive impairment, sleep disturbances,
thopedic surgeries today [1]. Perioperative pain associat- and anxiety [3]. In addition, pain interferes with physical
ed with hip surgeries is a significant concern that requires rehabilitation. Persistent pain slows recovery, lengthens
attention as it can lead to complications, morbidity, and hospital stays, and increases costs incredibly. It also leads
reduced overall patient satisfaction [2]. Perioperative pain to delayed recruitment with all associated complications,
adversely affects the immediate outcome of surgery and the such as thromboembolic symptoms [4].

© Polskie Towarzystwo Ortopedyczne i Traumatologiczne 17

Chir Narzadow Ruchu Ortop Pol, 2023; 88(1): 17-24

Among the postoperative complications of hip sur- inclusion, with all discordance reviewed for final inclusion
gery, the most life-threatening are deep vein thrombosis by the senior author, M.D. As a result, clinical trials and
and pulmonary embolism, which are directly related to retrospective studies were included in this review. This en-
a lack of mobility [5]. Therefore, a variety of anesthesia and tire process is depicted in Fig.1.
analgesic procedures are used in THR [6]. These include
general anesthesia (GA), patient-controlled anesthesia
(PCA), opioid spinal anesthesia, and lumbar epidural an-
esthesia [7]. Spinal canal anesthesia can also be associated
with complications such as spinal hematoma, headache,
prolonged hospitalization due to reduced mobility, and de-
layed mobilization [9]. Pain management usually includes
opioids related to various side effects, even when used by
the nerve trunk (spinal or epidural) route [10]. Region-
al nerve blocks like the lumbar plexus block, fascia iliaca
compartment block (FICB), femoral nerve block (FNB),
obturator nerve block, and sciatic nerve block are also used
as a part of multimodal analgesia in hip surgery [12]. FICB
and FNB are the current standards for local anesthesia for
hip surgery. Both regional blocks provide a femoral nerve
block that anesthetizes the femur and causes quadriceps
weakness and motor block in the lower extremity, which
delays recruitment and discharge [11].
The pericapsular nerve group (PENG) block is a re-
cently reported local anesthetic technique superior to oth-
er regional methods, especially in elderly patients, due to
its more complete anesthesia of the joint capsule and its
motor-sparing effect [13]. The pericapsular nerve group
(PENG) block was first described by Girón-Arango et al.
[20] in 2018. This block was confirmed by a cadaveric dye
study that exhibited pericapsular spread targeting only the
sensory branches of the anterior hip capsule with a mo-
tor-sparing effect. The PENG block aims at the articular
branches of the femoral nerve and obturator nerve [14].
Local anesthetic is administered below the psoas muscle
tendon, between the iliopubic eminence and the anterior
iliac spine [15]. It causes the motor-sparing effect.
Fig. 1. Flow chart of the search for published reports showing the pro-
cess of inclusion and exclusion. PENG block for hip surgery.
Methods
Results from the included articles have been summa-
The literature was reviewed through four electronic da- rized as a narrative review to identify the most critical as-
tabases: PubMed, Cochrane Library, Google Scholar, and pects of the known and unknown in this literature.
Embase. The google scholar search was restricted to the
first 200 hundred records. This search was performed in
January 2023. We evaluated studies published till the end of Results
January 2023 using the following search terms: the “PENG
block” (title), “total hip arthroplasty” (title), “hip surgery” The initial search yielded 416 articles. Twenty-seven rele-
(title), and “hip fracture” (title). The titles, abstracts, and vant articles were selected based on relevance, recentness,
full texts of published studies were screened. We included search quality, and citations. Twelve of the studies were re-
studies with the following criteria: patients with hip pa- lated to patients undergoing total hip arthroplasty. Also, 12
thologies undergoing surgical procedures for treatment, studies were related to patients undergoing total hip sur-
with the PENG block as intervention and other multimod- gery due to hip fracture. Finally, three studies were relat-
al analgesic protocols or the placebo as a comparator. In ed to patients undergoing hip arthroscopy. The results are
addition, case reports, conference abstracts, and protocols presented in several tables to facilitate the analysis of the
were excluded. T.R. and M.K. holistically assessed article collected material.

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 Tomasz Reysner et al.: The pericapsular nerve group (PENG) block for hip surgery. A narrative review

Table 1. PENG vs. placebo

Author Type of Study Participants Type of surgery Intervention Results

Pascarella [16] Single-center, 60 Total hip PENG block vs. Lower pain scores (2,5 vs. 5,5 at 12h; 3,0 vs.6,0
observer-masked, arthroplasty placebo at 24 h; 2,0 vs. 3,0 at 48h; all p<0,001)
randomized Time to first opioid (12h vs. 6h; p=0,001)
controlled trial Total opioid consumption (4,0mg vs. 8,9mg;
p<0,001)

Zhen [17] Double-blinded 70 Primary total hip PENG block with Highest VAS score (3,3 vs.5,2; p<0,01)
trial replacement LIA vs. LIA alone

Patel [18] Single-center, 89 outpatient hip PENG vs. placebo Intraoperative (6,6mg vs 7,5mg; p=0,01)
retrospective arthroscopic and postoperative (10,7mg vs 13,9mg; p=0,01)
pragmatic surgery intravenous morphine consumption
exploratory cohort VAS (5,5 vs 6,5; p=0,02)
study

Amato [19] Randomized, 68 Hip arthroscopy PENG block vs. No difference in pain scores (p=0,17)
double-blinded, placebo
placebo-controlled
trial

Chung [20] Randomized, 50 Hip surgery PENG block vs. Opioid consumption (440 vs. 611; p=0,037)
double-blinded, placebo lower pain scores (p<0,001)
placebo-controlled
trial

Martín [21] Prospective, 12 Hip surgery due PENG block vs. VNS score (p<0,001)
descriptive to pathological placebo
observational study fractures over
metastases

Remily [22] Retrospective chart 96 Total hip PENG block vs. Shorter length of stay (p<0,001)
review arthroplasty placebo Further initial postoperative distance walked
(p<0,001)
Lower pain scores (p<0,001)
Longer time to first opioid (p<0,001)

Gupta [23] Retrospective study 50 Total hip PENG block v Lower total morphine requirement (p<0,01)
arthroplasty placebo Time to discharge from hospital (22,1 vs. 31,7;
p<0,01)

Güllüpınar [24] Single-center, 39 Hip fracture PENG vs. placebo Lower NRS score at rest and movement
randomized, (p<0,001)
prospective study

Tavares [25] Retrospective study 49 Transtrochanteric PENG vs. placebo Lower reports of moderate to severe pain
fractures (p=0,003)
Ability to walk (p=0,012)

Kollmorgen Retrospective 50 Hip arthroscopy PENG vs. placebo VAS score (3,7 vs. 5,5; p=0,04)
[26] review Fentanyl usage intraoperatively (108,5 vs. 137,3;
p=0,04)
Narcotic use (34,3 vs50,29; p=0,001)
Discharge time (81,5 vs.95,8; p=0,05)

Eleven studies compared the PENG block to the placebo. Up to five studies were retrospective ones.

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Chir Narzadow Ruchu Ortop Pol, 2023; 88(1): 17-24

Table 2. PENG vs. local infiltration injection (LIA)

Author Type of Study Participants Type of surgery Intervention Results
Zheng [17] Randomized 60 Total hip PENG vs. LIA The mean difference in pain score 12 hours
controlled trial arthroplasty postoperatively was 0,6.

Hu [27] Prospective, 90 Total hip PENG with LIA Opioid consumption (5,67 vs. 13.11; p<0,001)
double-blind, arthroplasty vs. LIA alone Lower pain scores at rest and on movement (p<0,001)
randomized trial Time to first rescue analgesia (15,11 vs. 8,53; p<0,001)

Mysore [28] Retrospective study 122 Total hip PENG with LIA 2,4mg reduction in 24-hr hydromorphone
arthroplasty vs. LIA alone consumption

Three studies compared the effectiveness of the PENG block to local infiltration injection (LIA).

Table 3. PENG block vs. Femoral Nerve block (FNB)

Author Type of Study Participants Type of surgery Intervention Results
Lin [29] Single center, 60 hip fracture PENG block vs. FNB less pain (63%vs.30%, p=0,04)
double-blinded. surgery Quadriceps strength (60% intact vs.no intact, p=0,04)
randomized
comparative trial
Allard [30] Comparative 42 Total hip PENG block vs. FNB Total opioid consumption (10mg vs. 20mg; p=0,458)
observational study arthroplasty Quadriceps strength (5/5 vs. 2/5; p=0,001)
Lin [31] Single-center, 60 Hip fracture PENG block vs. FNB Block duration (6:00-32:00 vs. 4:08-30:45)
double-blinded, surgery
randomized Discharge readiness (3d vs. 4d; p=0,02)
comparative trial

Three studies compared the PENG block to the femoral nerve block; only two were prospective, randomized trials.

Table 4. PENG block vs. fascia iliaca block (FIB)

Author Type of Study Participants Type of surgery Intervention Results
Aliste [32] Double-blinded, 40 Total hip PENG block Lower incidence of quadriceps motor block at 3 hours
randomized trial arthroplasty vs. FIB (45% vs. 90%; p<0,001)
and 6 hours (25% vs. 85%; p<0,001),
better preservation of hip adduction at 3 hours (p=0,023),
decreased sensory block of the anterior, lateral, and
medial thighs at all measurement intervals (all p≤0,014)
Mosaffa [33] Randomized, 52 Hip fracture PENG block Time to first opioid (4,7 vs.2,58; p=0,007)
controlled clinical surgery vs FIB Total opioid consumption (54 vs.74; p=0,008)
trial
Choi [34] Randomized, 58 Total hip PENG block VAS scores 48h at rest (p=0,079) and during movement
controlled clinical arthroplasty vs. FIB (p=0,323)
trial Cumulative opioid consumption similar in both groups
(p=0,265)
Quadriceps strength (p=0,513)
Hua [35] Randomized, 48 hip arthroplasty PENG block VAS scores are lower in the PENG group (p<0,05)
control trial due to a femoral vs. FIB
neck fracture weakness of quadriceps (0 vs. 7 patients; p<0,05)
Fahey [36] A prospective 67 Hip fracture PENG vs FIB or No difference in the maximum pain score reduction
observational femoral nerve No difference in adverse effects
comparative cohort block (FNB) Similar opioid use
study
Kalashetty Double-blinded 90 Hip fractures PENG vs. FIB VAS scores at rest with passive leg raise (2,16 vs. 3,29;
[37] randomized control p<0,0001)
trial
Senthil [38] Double-blinded 40 Hip fracture PENG vs. FIB Better motor power (p<0,01)
randomized control Less fentanyl consumption after 24h (213 vs. 255; p<0,01)
trial
Natrajan [39] A prospective, 24 Hip fracture PENG vs. FIB Lower NRS score (p=0,001)
randomized, Time to first opioid (8,17 vs. 4,00; p=0,001)
double-blinded,
controlled study
Kong [40] A double-blinded, 50 Intertrochanteric PENG vs. FIB Lower VAS scores (p>0,001)
randomized, femur fracture Lower opioid consumption (p<0,001)
controlled trial The ratio quadriceps weakness at 6h after surgery
(0% vs. 48%; p<0,001)

Nine studies compared the PENG block to the fascia iliaca compartment block. Only one was a prospective, observational, comparative cohort
study. The remaining eight were randomized, controlled trials.

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 Tomasz Reysner et al.: The pericapsular nerve group (PENG) block for hip surgery. A narrative review

Table 5. PENG block vs. epidural analgesia

Author Type of Study Participants Type of surgery Intervention Results
Sousa [41] Retrospective, 38 Total hip PENG block Pain scores at rest (1,67 vs. 1,2; p=0,523)
observational study arthroplasty vs. epidural Pain scores at movement (3,95 vs. 3,72; p=0,777)
analgesia Number of complications (50% vs. 5%; p=0,04)

One study compared the PENG block to epidural analgesia.

Table 6. The motor-sparing effect of the PENG block

Volume of local anesthetic Type of local anesthetic for Muscle weakness
Author Intervention
for the PENG block the PENG block of the PENG block
Pascarella [16] The PENG block vs. 20mL 0,375% ropivacaine 0%
The placebo
Patel [18] The PENG block vs. 20mL 0,5% ropivacaine 0%
the placebo
Chung [20] The PENG block vs. 25 mL 0,5% ropivacaine 0%
the placebo
Martín [21] The PENG block vs. 20 mL 1,0% ropivacaine 0%
the placebo
Kollmorgen [26] The PENG vs. the 20 mL ropivacaine 0%
placebo
Hu [27] The PENG with LIA 20 mL 0,5% ropivacaine 0%
vs. LIA alone containing 1:200,000
epinephrine
Zheng [17] PENG vs. LIA 20 mL 0,5% ropivacaine 0%
Lin [29] The PENG block vs. 20 mL 0,75% ropivacaine 10% patients with the PENG block
FNB had reduced or absent quadriceps
strength
Allard [30] The PENG block vs. 20 mL 0,35% ropivacaine 0%
FNB
Choi [34] The PENG block vs. 30 mL 0,2% ropivacaine with Reduced quadriceps strength in
FIB epinephrine 1:200,000 both groups with no difference
between the groups
Senthil [38] PENG vs. FIB 30 mL 0.25% Levobupivacaine The PENG group had better motor
and 4 mg dexamethasone power after 18 h and 24 h
Kong [40] PENG vs. FIB 30 mL 0,375% ropivacaine 0%

In twelve studies, motor-weakness after the PENG block was one of the results. In addition, the PENG block was associated with quadriceps
weakness in three presented studies.

Discussion block was significantly lower than in the control group at

all time points. Moreover, the pericapsular nerve group
PENG blocks were initially developed to control pain and showed a significant reduction in opioid consumption,
analgesia in hip fracture patients [12]. better hip motion range, and shorter ambulation time. His
results suggest that the PENG block improved postoper-
PENG vs. placebo ative functional recovery following total hip arthroplasty.
The ultrasound-guided PENG block improves postopera- Also, Chung et al. [28] showed that the PENG block de-
tive pain relief in THR patients without weakening quad- creased total opioid consumption in the first 24 hours after
riceps muscle strength (Tab. 1). In addition, the PENG hip surgery without affecting quadriceps muscle strength.
block reduces pain scores at rest and movement, reducing The PENG block can reduce pain and the need for
analgesic drugs pre- and post surgery [23] and extending systemic analgesics in patients with hip fractures in the
the first time to rescue analgesia [27,28]. Research to date emergency department and orthopedic ward. In addition,
suggests that the PENG block should be the primary meth- due to the PENG block, mobility in patients with hip frac-
od of analgesia in Total Hip Arthroplasty due to its poten- tures is inevitable in situations such as personal needs, un-
tial to impact recovery pathways and contribute to cost- dressing for the physical examination, additional imaging
saving [22]. needs, and transfer to the operating table [32].
Pascarella et al. [16] evaluated that the maximum pain Martin et al. [21] concluded that the PENG block is
score of patients receiving the pericapsular nerve group an effective, safe, regional pain management technique

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Chir Narzadow Ruchu Ortop Pol, 2023; 88(1): 17-24

for patients with hip fractures due to metastatic disease. It The PENG block vs. the femoral nerve block
promotes early mobilization and placement before surgery Compared to a femoral nerve block, an ultrasound-guided
without pain exacerbation, promoting early mobility and PENG block provides better postoperative pain relief and
rehabilitation. less pronounced quadriceps weakness [40], as noted in ta-
The PENG block is a promising modality in the pain ble 4.
management strategy in all hip surgeries [34]. However, Lin et al. [29] randomized 60 patients and showed
hip arthroscopy may be an exception. Patel et al. [26] and that patients receiving the PENG block for intraoperative
Amato et al. [19] demonstrated that a preoperative PENG and postoperative analgesia experience less postoperative
block did not improve analgesia following arthroscopic hip pain (p=0.04) with better-preserved quadriceps strength
surgery. (p=0,004). Also, Allard et al. [30] observed that the PENG
block in hip fractures improved the mobility of the oper-
PENG block vs. LIA ated limb (p=0,001). However, it did not change the total
In combination with LIA, the PENG block can be consid- morphine consumption (p=0,458). In addition, Lin et al.
ered a valuable part of the multimodal analgesic manage- [31] evaluated that the PENG block lasted longer than the
ment of postoperative pain after hip replacement surgery FNB, resulting in a faster recovery and shorter time to dis-
for optimal opioid-sparing strategies and rapid recovery charge readiness.
[38,42].
Motor-sparing regional anesthesia modalities, such The PENG block vs. epidural analgesia
as local infiltration analgesia (LIA) and the PENG block, The PENG block is equivalent to epidural analgesia regard-
have become the mainstay of multimodal approaches used ing pain scores and opioid consumption (Tab. 5).
during hip surgery. As seen in table 2, the PENG block pro-
vides similar analgesia to LIA. The motor-sparing effect of the PENG block
The PENG block has become a prevalent, ultrasound-guid-
The PENG block vs the fascia iliaca block ed, regional technique as an announced motor-sparing
For primary total hip arthroplasty, the pericapsular nerve hip block. However, quadriceps weakness after the PENG
group block results in the better preservation of the mo- block was observed, is specified in table 6. The precise
tor function than the fascia iliaca block [34]. Also, as seen mechanism of femoral nerve involvement after the PENG
in table 3, the PENG block outperformed the fascia iliaca block is fought to result from local anesthetics spread via
block in providing adequate analgesia before positioning a plane between the pectineus and psoas major or intra-
patients undergoing hip surgery under spinal anesthe- muscularly [43]. To avoid quadriceps weakness after the
sia[37], which is especially important in patients undergo- PENG block, a laterally placed needle tip, away from the
ing hip surgery due to fracture [35]. undersurface of the iliopsoas tendon, and a reduction in
Aliste et al. [32] showed that the pericapsular nerve injection volume should be considered [44]. Çiftçi et al.
group block resulted in a lower incidence of quadri- [15], in their cadaveric study, showed that a high volume
ceps motor block at 3 hours (45% vs. 90%; p<0.001) and PENG block might result in motor weakness. For example,
6 hours (25% vs. 85%; p<0.001) compared with the fascia 30mL of dye resulted in a more extended spread around
iliaca block. Furthermore, the pericapsular nerve group the femoral nerve trance from the inguinal to the knee,
block also provided better preservation of hip adduction around the femoral cutaneous nerve and obturator nerve,
at 3 hours (p=0.023) as well as a decreased sensory block compared to 20ml of dye. Therefore, clinicians should be
of the anterior, lateral, and medial thighs at all measure- aware of motor weakness after performing a high-volume
ment intervals (all p≤0.014). No clinically significant in- PENG block. In addition, volumes up to 20mL do not ap-
tergroup differences were found regarding postoperative pear to cause quadriceps weakness and can be successfully
pain scores, cumulative opioid consumption at 24 and 48 used in hip surgery.
hours, ability to perform physiotherapy, opioid-related side
effects, and length of hospital stay.
Also, Natrajan et al. [39] concluded that the PENG Conclusion
block provides better postoperative analgesia and reduces
rescue analgesics requirement in 24 hours compared to the Our review shows that the PENG block can improve pain
fascia iliaca block in patients undergoing hip surgery. In control and reduce opioid use while retaining mobility and
addition, Zheng et al. [25] received that the PENG block quadriceps strength, which is especially important during
provided lower VAS scores, more extended time of the first the postoperative period and rehabilitation.
analgesic consumption, and lower total dose of morphine However, more evidence is needed to confirm the safe-
consumption compared with FICB. ty and efficacy of PENG block technology. Therefore, more
well-designed studies with larger sample sizes are required.

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 Tomasz Reysner et al.: The pericapsular nerve group (PENG) block for hip surgery. A narrative review

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Funding
This research received no external funding.

Data Availability Statement

The data presented in this study are available on request from the cor-
responding author.

Declaration of conflicting interests

The author reports no conflicts of interest in this work.

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