Rapid recovery after total hip arthroplasty: direct anterior approach combined with PENG block and lateral cutaneous femoral nerve block

Introduction The "gold" standard for the treatment of late stages of coxarthrosis is total hip arthroplasty. Direct anterior approach (DAA) refers to minimally invasive surgical interventions in orthopaedics. Extended anesthetic measures in combination with low-traumatic surgical techniques may reduce postoperative pain and accelerate patient's recovery.

The purpose of the study was to compare the recovery times of patients after hip arthroplasty using DAA in  combination with PENG block, lateral cutaneous femoral nerve (LCFN) block and without extended anesthetic measures.

Materials and methods A prospective randomized comparative clinical study was performed, which involved 62  patients divided into two groups: the study one (n = 29) and the control one (n = 33). In  both groups, arthroplasty was performed using DAA. Patients of the study group underwent PENG block and  LCFN block. The patients in the control group did not receive extended anesthesia. The evaluation criteria were pain assessment using the visual analogue scale (VAS), administration of painkillers, patient’s mobility and the length of hospital stay.

Results The VAS score for pain in the study group were lower than in the control group after 6 hours — 3.7 (3.4; 4.1) and 4.3 (4.2; 4.8); 24 hours after surgery — 3.5 (3.3; 3.6) and 4.1 (3.9; 4.5) (p < 0.001). After 48 hours, the indices were comparable: 3.5 (3.1; 4.1) and 3.7 (3.6; 3.9) (p = 0.19). The rate of requests for pain relief in the first 24 hours was lower in the study group than in the control group: 2 (1; 2) and 3 (2; 3) cases (p = 0.003). The results of the manual muscle test after 6 hours and 24 hours were comparable (p > 0.05). The time interval between the end of the operation and the first walking on crutches was shorter in the study group — 3.1 hours (2.9; 3.4) and 3.98 hours (3.8; 4.2) (p < 0.001). The length of hospital stay was shorter in the study group: 1.5 (1.2; 2) and 2.5 (2; 3) days (p < 0.001).

Discussion Lower postoperative pain allows faster activation of patients, thus improving the results of the early rehabilitation period.

Conclusion The use of PENG block and LCFN block in arthroplasty with the use of DAA has clinical effectiveness in the first 24 hours, and helps to accelerate the postoperative recovery of patients.

1. Fan Z, Yan L, Liu H, et al. The prevalence of hip osteoarthritis: a systematic review and meta-analysis. Arthritis Res Ther. 2023;25(1):51. doi: 10.1186/s13075-023-03033-7

2. Vidović T, Ewald CY. Longevity-promoting pathways and transcription factors respond to and control extracellular matrix dynamics during aging and disease. Front Aging. 2022;3:935220. doi: 10.3389/fragi.2022.935220

3. Giorgino R, Albano D, Fusco S, et al. Knee Osteoarthritis: Epidemiology, Pathogenesis, and Mesenchymal Stem Cells: What Else Is New? An Update. Int J Mol Sci. 2023;24(7):6405. doi: 10.3390/ijms24076405

4. Nelson A. Epidemiology of hip osteoarthritis: the Johnston County Osteoarthritis Project. HSS J. 2023;19(4):413-417. doi: 10.1177/15563316231192372

5. Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am. 2018;100(17):1455-1460. doi: 10.2106/jbjs.17.01617

6. Sheth D, Cafri G, Inacio MC, et al. Anterior and anterolateral approaches for THA are associated with lower dislocation risk without higher revision risk. Clin Orthop Relat Res. 2015;473(11):3401-3408. doi: 10.1007/s11999-015-4230-0

7. Rodriguez JA, Deshmukh AJ, Rathod PA, et al. Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach? Clin Orthop Relat Res. 2014;472(2):455-463. doi: 10.1007/s11999-013-3231-0

8. Taunton MJ, Mason JB, Odum SM, et al. Direct anterior total hip arthroplasty yields more rapid voluntary cessation of all walking aids: a prospective, randomized clinical trial. J Arthroplasty. 2014;29(9 Suppl):169-172. doi: 10.1016/j.arth.2014.03.051

9. Pascarella G, Costa F, Del Buono R, et al. Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial. Anaesthesia. 2021;76(11):1492-1498. doi: 10.1111/anae.15536

10. Baker DW. History of the joint commission's pain standards: lessons for today's prescription opioid epidemic. JAMA. 2017;317:1117-1118. doi: 10.1001/jama.2017.0935

11. El Moheb M, Mokhtari A, Han K, et al. Pain or no pain, we will give you opioids: relationship between number of opioid pills prescribed and severity of pain after operation in US vs non-US patients. J Am Coll Surg. 2020;231:639-648. doi: 10.1016/j.jamcollsurg.2020.08.771

12. Scala VA, Lee LSK, Atkinson RE. Implementing regional nerve blocks in hip fracture programs: a review of regional nerve blocks, protocols in the literature, and the current protocol at the Queen's Medical Center in Honolulu, HI. Hawaii J Health Soc Welf. 2019;78(11 Suppl 2):11-15.

13. Del Buono R, Padua E, Pascarella G, et al. Pericapsular Nerve Group (PENG) block: an overview. Minerva Anestesiol. 2021;87(4):458-466. doi: 10.23736/s0375-9393.20.14798-9

14. Girón-Arango L, Peng PWH, Chin KJ, et al. Pericapsular nerve group (PENG) block for hip fracture. Reg Anesth Pain Med. 2018;43(8):859-863. doi: 10.1097/aap.0000000000000847

15. Hua H, Xu Y, Jiang M, et al. Evaluation of pericapsular nerve group (PENG) block for analgesic effect in elderly patients with femoral neck fracture undergoing hip arthroplasty. J Healthc Eng. 2022;2022:1-7. doi: 10.1155/2022/7452716

16. Choi YS, Park KK, Lee B, et al. Pericapsular nerve group (PENG) block versus supra-inguinal fascia Iliaca compartment block for total hip arthroplasty: a randomized clinical trial. J Pers Med. 2022;12(3):408. doi: 10.3390/jpm12030408

17. Zheng J, Du L, Chen G, et al. Efficacy of pericapsular nerve group (PENG) block on perioperative pain management in elderly patients undergoing hip surgical procedures: a protocol for a systematic review with meta-analysis and trial sequential analysis. BMJ Open. 2023;13(1):e065304. doi: 10.1136/bmjopen-2022-065304

18. Orozco S, Muñoz D, Jaramillo S, Herrera AM. Pericapsular Nerve Group (PENG) block for perioperative pain control in hip arthroscopy. J Clin Anesth. 2020;59:3-4. doi: 10.1016/j.jclinane.2019.04.037

19. Kukreja P, Avila A, Northern T, et al. A Retrospective Case Series of Pericapsular Nerve Group (PENG) Block for Primary Versus Revision Total Hip Arthroplasty Analgesia. Cureus. 2020;12(5):e8200. doi: 10.7759/cureus.8200

20. Berlioz BE, Bojaxhi E. PENG Regional Block. 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publ.; 2024.

21. da Costa AO, Izolani GV, Monteiro de Souza IF, Martins Santiago BV. Continuous pericapsular nerve group (PENG) block through an elastomeric infusion system, associated with the lateral cutaneous nerve block of the thigh for total hip arthroplasty. BMJ Case Rep. 2022;15(3):e246833. doi: 10.1136/bcr-2021-246833

22. Eremin IK, Daniliyants AA, Zagorodniy NV. Comparative evaluation of the clinical efffcacy and safety of surgical approaches in total hip arthroplasty. Genij Ortopedii. 2023;29(4):438-448. doi: 10.18019/1028- 4427-2023-29-4-438-448

23. Kukreja P, Uppal V, Kofskey AM, et al. Quality of recovery after pericapsular nerve group (PENG) block for primary total hip arthroplasty under spinal anaesthesia: a randomised controlled observer-blinded trial. Br J Anaesth. 2023;130(6):773-779. doi: 10.1016/j.bja.2023.02.017

24. Pagano T, Scarpato F, Chicone G, et al. Analgesic evaluation of ultrasound-guided Pericapsular Nerve Group (PENG) block for emergency hip surgery in fragile patients: a case series. Arthroplasty. 2019;1(1):18. doi: 10.1186/s42836-019-0018-0

25. Aliste J, Layera S, Bravo D, et al. Randomized comparison between pericapsular nerve group (PENG) block and suprainguinal fascia iliaca block for total hip arthroplasty. Reg Anesth Pain Med. 2021;46(10):874-878. doi: 10.1136/rapm-2021-102997

26. Valoriani J, Conti D, Gianesello L, Pavoni V. Combined pericapsular nerve group and lateral femoral cutaneous nerve blocks for hip fracture in a polytraumatized patient-A case report. Saudi J Anaesth. 2022;16(2):211-213. doi: 10.4103/sja.sja_625_21

27. Hu J, Wang Q, Hu J, et al. Efficacy of Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined With Local Infiltration Analgesia on Postoperative Pain After Total Hip Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial. J Arthroplasty. 2023;38(6):1096-1103. doi: 10.1016/j.arth.2022.12.023

28. Zheng J, Pan D, Zheng B, Ruan X. Preoperative pericapsular nerve group (PENG) block for total hip arthroplasty: a randomized, placebo-controlled trial. Reg Anesth Pain Med. 2022;47(3):155-160. doi: 10.1136/rapm-2021-103228

29. Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.Acta Orthop. 2020;91(1):3-19. doi: 10.1080/17453674.2019.1683790

30. Liang L, Zhang C, Dai W, He K. Comparison between pericapsular nerve group (PENG) block with lateral femoral cutaneous nerve block and supra-inguinal fascia iliaca compartment block (S-FICB) for total hip arthroplasty: a randomized controlled trial. J Anesth. 2023;37(4):503-510. doi: 10.1007/s00540-023-03192-6