Surgeon-performed pericapsular nerve group (PENG) block for total hip arthroplasty using the direct anterior approach: a cadaveric study

Reg Anesth Pain Med. 2022 Jun;47(6):359-363. doi: 10.1136/rapm-2022-103482. Epub 2022 Mar 14.


Background: During total hip arthroplasty (THA) using the direct anterior approach, orthopaedic surgeons can identify all anatomical landmarks required for pericapsular nerve group (PENG) blocks and carry out the latter under direct vision. This cadaveric study investigated the success of surgeon-performed PENG block. Success was defined as dye staining of the articular branches of the femoral and accessory obturator nerves.

Methods: 11 cadavers (18 hip specimens) were included in the current study. To simulate THA in live patients, an orthopaedic surgeon inserted trial prostheses using the direct anterior approach. Subsequently, a block needle was advanced until contact with the bone (between the anterior inferior iliac spine and iliopubic eminence). 20 mL of 0.1% methylene blue was injected. Cadavers were then dissected to document the presence and dye staining of the femoral, lateral femoral cutaneous, obturator and accessory obturator nerves as well as the articular branches of the femoral, obturator and accessory obturator nerves.

Results: Methylene blue stained the articular branches of the femoral nerve and the articular branches of the accessory obturator nerve (when present) in all hip specimens. Therefore, surgical PENG block achieved a 100% success rate. Dye stained the femoral and obturator nerve in one (5.6%) and two (11.1%) hip specimens, respectively. No dye staining was observed over the accessory obturator nerve in the pelvis nor the lateral femoral cutaneous nerve.

Conclusion: Surgeon-performed PENG block during direct anterior THA reliably targets the articular branches of the femoral and accessory obturator nerves. Future trials are required to compare surgeon-performed PENG block with anaesthesiologist-performed, ultrasound-guided PENG block, and surgeon-performed periarticular local anaesthetic infiltration.

Keywords: lower extremity; nerve block; pain, postoperative.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Arthroplasty, Replacement, Hip*
  • Cadaver
  • Femoral Nerve / anatomy & histology
  • Humans
  • Methylene Blue
  • Obturator Nerve / anatomy & histology
  • Surgeons*


  • Methylene Blue