PENG Block + LIA For Endoprosthesis Surgery With Anterior Approach

NCT ID: NCT07239817

Last Updated: 2025-12-10

Basic Information

• Recruitment Status: RECRUITING
• Clinical Phase: NA
• Total Enrollment: 100 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2025-12-01
• Study Completion Date: 2026-04-30

Brief Summary

The goal of this clinical trial is to learn if a new local anesthesia technique can control pain as well as the standard spinal anesthesia for adults having hip endoprosthesis surgery. The main questions it aims to answer are:

• Is the new local anesthesia technique as effective as standard spinal anesthesia in managing pain during the first two days after surgery?
• Does the new technique allow participants to move their leg sooner after the operation?

Researchers will compare the new local anesthesia technique (numbing medicine injected directly around the hip joint) to standard spinal anesthesia (a numbing injection in the back) to see if the new technique works just as well for pain control while possibly causing fewer side effects like nausea.

Participants who join this study will be randomly placed into one of two groups.

One group will receive the standard spinal anesthesia before their surgery.

The other group will receive the new local anesthesia technique before their surgery.

After the operation, researchers will track the amount of extra pain medicine each participant uses and will check their ability to move their hip, knee, and foot.

Detailed Description

Study Rationale Standard anesthetic techniques for hip fracture surgery in the target population, which often includes fragile and elderly individuals, present distinct challenges. Both neuraxial (spinal) and general anesthesia can have a significant hemodynamic impact. Furthermore, traditional regional anesthetic techniques like lumbar plexus or femoral nerve blocks, while providing effective analgesia, often result in significant motor and sensory blockade of the lower limb, which can impede early mobilization and rehabilitation.

This study investigates a motor-sparing anesthetic approach. The intervention is based on pericapsular nerve group blocks (A-PENG and PONG), anterior and posterior, which target only the sensory articular branches innervating the hip capsule. This technique, combined with local infiltration analgesia (LIA), aims to provide comprehensive surgical anesthesia and post-operative analgesia without affecting motor function, thereby facilitating immediate post-operative mobilization.

Anesthetic Intervention Details (PENG 360° Arm) Participants randomized to the investigational arm will receive a combination of three injections prior to surgical incision. A convex ultrasound probe will be used for A-PENG and PONG.

• Anterior A-PENG Block: An injection of 20 mL of "plain" anesthetic solution is administered into the fascial plane between the iliopsoas muscle and the hip joint capsule. This solution consists of 10 mL of 0.75% ropivacaine, 10 mL of 2% mepivacaine with 1:200,000 epinephrine, and 2 mg of dexamethasone.
• Local Infiltration Analgesia (LIA): An injection of 20 mL of "diluted" anesthetic solution is used to infiltrate the planned incision line and subcutaneous tissue. This solution consists of 5 mL of 0.75% ropivacaine, 5 mL of 2% mepivacaine with 1:200,000 epinephrine, 1 mg of dexamethasone, and 10 mL of normal saline.
• Posterior PONG Block: With the participant in the lateral decubitus position, an injection of 10 mL of "plain" anesthetic solution is administered into the fascial plane deep to the quadratus femoris muscle. This solution consists of 5 mL of 0.75% ropivacaine, 5 mL of 2% mepivacaine with 1:200,000 epinephrine, and 1 mg of dexamethasone.

During surgery, participants in this arm will receive supplemental oxygen and sedation with propofol, with the depth of anesthesia monitored using a Bispectral Index (BIS) monitor.

Post-operative Pain Management Protocol To ensure a standardized approach to analgesia for all participants in both study arms, a uniform post-operative pain management protocol will be implemented. Unless contraindicated, all participants will receive a fixed-dose regimen of intravenous paracetamol (1000 mg) and ketorolac (30 mg) every 8 hours.

In addition, all participants will be provided with an intravenous patient-controlled analgesia (PCA) pump delivering morphine. The PCA pump will be set to deliver on-demand rescue boluses of 2 mg of morphine with no continuous background infusion. The maximum daily dose will be limited to 10 mg for participants over 65 years of age and 20 mg for those 65 or younger.

Data Management and Randomization Participant data will be collected and managed using an electronic Case Report Form (CRF) built with Google Forms and stored in a secure cloud database (Google Sheets). All data will be pseudonymized using a unique alphanumeric identifier assigned at the time of enrollment to ensure participant confidentiality.

Randomization will be performed using a dedicated Google Form configured to provide response options in a random order. The investigator will select the first option presented to assign the participant to either the "case" or "control" group19.

Statistical Analysis Plan Descriptive statistics (mean, median, standard deviation, min/max) will be used to summarize the collected data. The primary endpoint (cumulative number of PCA rescue doses at 48 hours) will be analyzed using a Poisson distribution model.

For other outcomes, a Chi-square test will be used for categorical variables (e.g., need for conversion to general anesthesia), while a t-test (or a non-parametric equivalent) will be used for continuous variables (e.g., NRS pain scores in the recovery room). Analysis of covariance and multiple linear regression may also be conducted to evaluate the role of demographic and clinical characteristics on study outcomes.

Conditions

Hip Fractures; Arthroplasty, Replacement, Hip; Pain, Postoperative; Anesthesia and Analgesia; Nerve Block; Local Anesthesia Infiltration

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: SINGLE

Study Groups

PENG 360°

Participants assigned to this arm will receive a motor-sparing anesthetic technique. This consists of three ultrasound-guided injections performed before surgery: an anterior Pericapsular Nerve Group (PENG) block, a Local Infiltration Analgesia (LIA) of the incision line, and a posterior PENG (PONG) block.

Group Type: EXPERIMENTAL

Pericapsular Nerve Group Blocks with Local Infiltration Analgesia

Intervention Type: PROCEDURE

An ultrasound-guided, motor-sparing regional anesthesia procedure. It involves three distinct injections: 1) An anterior Pericapsular Nerve Group (A-PENG) block targeting the sensory articular branches of the femoral and obturator nerves. 2) A Local Infiltration Analgesia (LIA) of the surgical incision line. 3) A posterior PENG (PONG) block targeting sensory branches from the sciatic plexus. The local anesthetic mixture consists of ropivacaine, mepivacaine with epinephrine, and dexamethasone in specific volumes for each injection site.

Spinal

Participants assigned to this arm will receive standard spinal anesthesia. The procedure will be performed according to the center's standard practice and guidelines, with the choice of local anesthetic and dosage at the discretion of the anesthesiologist

Group Type: ACTIVE_COMPARATOR

spinal anesthesia

Intervention Type: PROCEDURE

Standard neuraxial anesthesia technique involving the injection of a local anesthetic into the subarachnoid space. The procedure is performed according to the institution's standard clinical practice. The choice of the specific local anesthetic agent, dose, and technique will be at the discretion of the attending anesthesiologist, based on the participant's clinical characteristics.

Interventions

Pericapsular Nerve Group Blocks with Local Infiltration Analgesia

An ultrasound-guided, motor-sparing regional anesthesia procedure. It involves three distinct injections: 1) An anterior Pericapsular Nerve Group (A-PENG) block targeting the sensory articular branches of the femoral and obturator nerves. 2) A Local Infiltration Analgesia (LIA) of the surgical incision line. 3) A posterior PENG (PONG) block targeting sensory branches from the sciatic plexus. The local anesthetic mixture consists of ropivacaine, mepivacaine with epinephrine, and dexamethasone in specific volumes for each injection site.

Intervention Type: PROCEDURE

spinal anesthesia

Standard neuraxial anesthesia technique involving the injection of a local anesthetic into the subarachnoid space. The procedure is performed according to the institution's standard clinical practice. The choice of the specific local anesthetic agent, dose, and technique will be at the discretion of the attending anesthesiologist, based on the participant's clinical characteristics.

Intervention Type: PROCEDURE

Other Intervention Names

PENG 360°; A-PENG +PONG +LIA; Spinal Block; Subarachnoid Block

Eligibility Criteria

Inclusion Criteria

• Provision of signed and dated informed consent form.
• Scheduled for hip endoprosthesis surgery for femoral fracture with an anterior approach.
• Age 18 years or older.
• Willing and able to comply with the study protocol.

Exclusion Criteria

• Failure to provide informed consent.
• Age less than 18 years.
• Known allergy to local anesthetics or other medications used in the protocol.
• Presence of infection at the planned injection site.
• Pre-existing hip prosthesis or prior major surgery on the same hip (e.g., revision surgery).
• ASA physical status class > IV.
• Administration of intraoperative opiates or conversion to general anesthesia.

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

ASST Gaetano Pini-CTO

OTHER

Sponsor Role: lead

Responsible Party

Romualdo Del Buono

Principal Investigator

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Romualdo Del Buono, MD

Role: PRINCIPAL_INVESTIGATOR

Unit of Anesthesia, Intensive Care and Pain Management, ASST Gaetano Pini, Milan, Italy;

Locations

Gaetano Pini-CTO

Milan, , Italy

Site Status: RECRUITING

Countries

Italy

Central Contacts

Romualdo Del Buono, MD

Role: CONTACT

romualdo.delbuono@asst-pini-cto.it

+39 02 5829 6592

Facility Contacts

Romualdo Del Buono, MD

Role: primary

romualdo.delbuono@asst-pini-cto.it

+39 02 5829 6592

References

Del Buono R, Pascarella G, Costa F, Barbara E. Ultrasound-guided local infiltration analgesia for hip surgery: myth or reality? Minerva Anestesiol. 2019 Nov;85(11):1242-1243. doi: 10.23736/S0375-9393.19.13701-7. Epub 2019 May 21. No abstract available.

Reference Type: BACKGROUND

PMID: 31124626 (View on PubMed)

Del Buono R, Padua E, Pascarella G, Costa F, Tognu A, Terranova G, Greco F, Fajardo Perez M, Barbara E. Pericapsular nerve group block: an overview. Minerva Anestesiol. 2021 Apr;87(4):458-466. doi: 10.23736/S0375-9393.20.14798-9. Epub 2021 Jan 12.

Reference Type: BACKGROUND

PMID: 33432791 (View on PubMed)

Del Buono R, Pascarella G, Padua E, Costa F, Tognu A, Terranova G, Greco F, Fajardo Perez M, Barbara E. PENG block: from standard to unconventional approaches. Minerva Anestesiol. 2021 Oct;87(10):1157-1158. doi: 10.23736/S0375-9393.21.15847-X. Epub 2021 Jul 14. No abstract available.

Reference Type: BACKGROUND

PMID: 34263587 (View on PubMed)

Del Buono R, Padua E, Pascarella G, Costa F, Tognu A, Terranova G, Greco F, Fajardo Perez M, Barbara E. Reply to: Tips for pericapsular nerve group (PENG) neurolytic blocks. Minerva Anestesiol. 2021 Oct;87(10):1151-1152. doi: 10.23736/S0375-9393.21.16019-5. Epub 2021 Aug 2. No abstract available.

Reference Type: BACKGROUND

PMID: 34337929 (View on PubMed)

Del Buono R, Padua E, Pascarella G, Costa F, Tognu A, Terranova G, Greco F, Fajardo Perez M, Barbara E. Pericapsular hip radiofrequency: future approaches to treat hip chronic pain. Minerva Anestesiol. 2021 Dec;87(12):1393-1394. doi: 10.23736/S0375-9393.21.16081-X. Epub 2021 Sep 16. No abstract available.

Reference Type: BACKGROUND

PMID: 34527412 (View on PubMed)

Del Buono R, Tognu A. Hip replacement using pericapsular nerve blocks in a high-risk patient. Minerva Anestesiol. 2024 Nov;90(11):1052-1054. doi: 10.23736/S0375-9393.24.18242-9. Epub 2024 Jul 9. No abstract available.

Reference Type: BACKGROUND

PMID: 38980297 (View on PubMed)

Giron-Arango L, Peng PWH, Chin KJ, Brull R, Perlas A. Pericapsular Nerve Group (PENG) Block for Hip Fracture. Reg Anesth Pain Med. 2018 Nov;43(8):859-863. doi: 10.1097/AAP.0000000000000847.

Reference Type: BACKGROUND

PMID: 30063657 (View on PubMed)

Other Identifiers

PeBILIA 5680-25.06.2025

Identifier Type: -

Identifier Source: org_study_id