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Letter to the editor
Could the combination of PENG block and LIA be a useful analgesic strategy in the treatment of postoperative pain for hip replacement surgery?
  1. Pierfrancesco Fusco1,
  2. Stefano Di Carlo2,
  3. Giuseppe Paladini3,
  4. Paolo Scimia4,
  5. Eugenio Di Martino2,
  6. Franco Marinangeli5 and
  7. Emiliano Petrucci6
  1. 1 Department of Anesthesia and Intensive Care Unit, San Salvatore Academic Hospital of L’Aquila, L’Aquila, Italy
  2. 2 Department of Medical, Oral and Biotechnological Sciences, University of Chieti, Chieti, Italy
  3. 3 Department of Anesthesia and Intensive Care Unit, F Del Ponte Hospital, ASST Sette Laghi, Varese, Italy
  4. 4 Department of Anesthesia and Perioperative Medicine, ASST of Cremona, Cremona, Italy
  5. 5 Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy
  6. 6 Department of Anesthesia and Intensive Care Unit, SS Filippo and Nicola Hospital of Avezzano, L’Aquila, Italy
  1. Correspondence to Dr Stefano Di Carlo, Department of Anesthesia and Intensive Care Unit, University of Chieti, Chieti CAP 67100, Italy; stefanodik87{at}

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Dear Editor,

We found the pericapsular nerve group (PENG) block, first described by Giron-Arango et al, extremely interesting.1 Based on these speculations, we performed this analgesic technique in four patients undergoing hip replacement surgery. All patients, next of kin, or legal guardians approved reporting the cases. The standards for basic anesthetic monitoring were applied in each patient. The analgesic procedure was performed using a low-frequency convex probe (3–5 MHz) and a 21 G, 100 mm, echogenic needle was inserted in the fascial plane between the psoas tendon and the pubic branches posteriorly. Then, 20 mL of a solution containing 75 mg of isobaric levobupivacaine 0.375% and dexamethasone 4 mg was injected. Subarachnoid block was performed by injecting 12 mg of 0.5% isobaric levobupivacaine at L3-L4 level. Before closing the surgical wound, a 20 mL solution containing 75 mg of levobupivacaine 0.375%, 30 mg of ketorolac trometamina and 0.1 mg of epinephrine (local infiltration analgesia (LIA)) was injected by the surgeon, in the fascial and subcutaneous tissues of the surgical wound.2 At the end of surgery, patients were discharged to the postanesthesia care unit (PACU) and then they went to the ward, in accordance with PACU policy. Acetaminophen 3000 mg/day was systematically administered after surgery. Postoperative pain at rest (PR) and pain with movement (PM) were recorded at 8, 12 and 24 hours after surgery using numeric rating scale for pain. By passive mobilization of the hip joint and knee, PM was assessed, whereas PR was evaluated in the sitting or lying position on the bed. Postoperative PR was two controls and postoperative PM was four controls during the first 24 hours after surgery, and the patients reported better performance with lower perceived pain and they were very satisfied. No side effects and no toxicity of local anesthetics (LA) were noted. No supplemental opioids or non-steroidal anti‐inflammatory drugs were required.

The regional analgesic techniques represent a gold standard for hip replacement, allowing one to reduce the consumption of analgesic drugs.3

We believe that the new PENG block is a promising analgesic technique also for hip replacement surgery, but it is not possible to exactly predict the spread of the analgesic solution. The point of injection is located in the musculofascial plane between the psoas tendon anteriorly and the pubic ramus posteriorly.1

We hypothesize that the LA could spread following the ilioinfratrochanteric muscular bundle, in a deeper position, under the iliopsoas tendon. This bundle arises from the interspinous incisure and on the anterior inferior iliac spine, and it inserts without any tendon onto the anterior surface of the lesser trochanter of the femur and in the infratrochanteric area.4 So, the LA could reach the subpectineal plane where the articular branches of obturator nerve can be found,5 by spreading throughout this ‘lacuna musculorum’.

This is a possible explanation for the analgesic efficacy of the PENG block, also for hip replacement surgery. We believe that the combination of this analgesic procedure and LIA could be considered a useful part of a multimodal analgesic treatment for postoperative pain after the hip replacement surgery, for the best opioid-sparing strategy and fast-track recovery. Clinical studies are needed to support our observations.



  • Contributors All authors contributed equally to the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.