Proximal femur surgeries are frequently associated with significant perioperative pain, particularly in patients with femoral fractures, in whom movement and positioning for neuraxial anaesthesia may be extremely uncomfortable. Effective preoperative analgesia is therefore important not only for patient comfort but also for facilitating appropriate positioning for spinal anaesthesia and improving the overall perioperative experience [1,2]. Inadequate pain control may contribute to delayed mobilisation, increased physiological stress, and postoperative morbidity [3].

 

Regional anaesthesia techniques have traditionally included femoral nerve block and fascia iliaca compartment block for providing analgesia in patients undergoing proximal femur and hip surgeries. However, these techniques may provide incomplete analgesia because the sensory innervation of the hip joint is complex, and femoral nerve blockade may also produce quadriceps motor weakness [1,4,5]. The pericapsular nerve group (PENG) block was introduced as a relatively novel ultrasound-guided regional anaesthetic technique targeting the articular branches of the femoral, obturator, and accessory obturator nerves supplying the anterior hip capsule [2]. Its motor-sparing characteristics have generated considerable interest in patients undergoing hip and proximal femur surgery.

 

The PENG block has been reported to provide effective analgesia while potentially preserving motor function, making it attractive for both perioperative pain management and facilitating early mobilisation [2,4]. Subsequent clinical studies have demonstrated its usefulness in hip fracture and arthroplasty patients, although the analgesic efficacy of the technique may depend on the local anaesthetic used, volume administered, and addition of appropriate adjuvants [6-8].

 

Ropivacaine is commonly used for peripheral nerve blocks because of its long duration of action and favourable safety profile. However, the duration of analgesia produced by local anaesthetic alone may be insufficient for prolonged postoperative pain control. Consequently, various adjuvant drugs have been investigated to enhance the duration and quality of regional analgesia. Dexamethasone has been widely studied as a perineural adjuvant and may prolong the duration of analgesia when combined with local anaesthetics [9]. Fentanyl, an opioid analgesic, has also been used as an adjuvant to regional anaesthetic techniques with the objective of improving analgesic efficacy [10].

 

In patients undergoing proximal femur surgery, an effective regional block has an additional advantage because it may reduce pain during the transition from the supine to sitting position required for spinal anaesthesia. Previous studies have demonstrated the usefulness of regional blocks for facilitating positioning of patients with femoral fractures for neuraxial anaesthesia [4,5]. Therefore, comparison of different adjuvants in PENG block is clinically relevant, particularly when both immediate positioning comfort and postoperative analgesia are considered.

 

The present study was undertaken to compare 0.2% ropivacaine combined with dexamethasone versus 0.2% ropivacaine combined with fentanyl in ultrasound-guided PENG block for patients undergoing proximal femur surgery. The primary objective was to compare the analgesic efficacy of the two adjuvant combinations, while the secondary objectives were to evaluate patient comfort during positioning for spinal anaesthesia and to assess haemodynamic changes and potential adverse effects.

 

This prospective, randomized, double-blind comparative study was conducted after obtaining approval from the Institutional Ethics Committee and appropriate trial registration. A total of 60 patients aged 18–65 years, belonging to ASA physical status I or II, and scheduled for elective proximal femur surgery under subarachnoid block were included after obtaining written informed consent. Patients with central or peripheral neuropathies, bleeding disorders, allergy to any study drug, infection at the proposed block site, psychiatric disorders affecting pain assessment, BMI >30 kg/m², or pregnancy were excluded. The patients were randomly allocated into two groups of 30 patients each. Group PD received an ultrasound-guided PENG block using 15 mL of 0.2% ropivacaine with dexamethasone 4 mg, whereas Group PF received 15 mL of 0.2% ropivacaine with fentanyl 50 µg. Preoperative assessment included demographic characteristics, clinical examination, ASA physical status, and routine investigations. Patients were familiarized with the Visual Analog Scale (VAS), ranging from 0 for no pain to 10 for the worst imaginable pain. The PENG block was performed under strict aseptic precautions using a low-frequency curvilinear ultrasound probe. The probe was positioned over the anterior inferior iliac spine and rotated approximately 45° counter-clockwise to identify the superior pubic ramus. The ilio-pubic eminence, iliopsoas muscle, psoas tendon, and femoral neurovascular structures were identified. A 22-gauge needle was advanced using an in-plane technique, with the needle tip positioned between the psoas tendon anteriorly and the pubic ramus posteriorly. After negative aspiration, the assigned study solution was injected into the identified fascial plane. Pain was assessed before the block and again 10 minutes after administration of the PENG block. Patients were subsequently positioned for spinal anaesthesia. Comfort during positioning was evaluated using a four-point patient satisfaction scale, ranging from 0, representing unsatisfactory comfort, to 3, representing optimal comfort. Patients who failed to achieve adequate analgesia and required rescue medication for positioning were considered block failures. Subarachnoid anaesthesia was subsequently administered using a conventional midline approach at the L3–L4 interspace with a 26-gauge Quincke needle. After confirmation of intrathecal placement, 3 mL of 0.5% hyperbaric bupivacaine was administered. Heart rate, blood pressure, oxygen saturation, and ECG were monitored throughout the perioperative period. Hypotension was managed according to the study protocol, while bradycardia was treated with intravenous atropine when required. Postoperative pain was assessed using the VAS at regular intervals, initially every 30 minutes for the first 2 hours, followed by two-hourly assessments for the subsequent 8 hours and then four-hourly assessments for the next 24 hours. The duration of effective analgesia was defined as the time from administration of the PENG block to the first requirement for rescue analgesia or a VAS score greater than 3. Intravenous diclofenac 75 mg was used as the initial rescue analgesic, while intravenous tramadol 1 mg/kg was administered when additional analgesia was required. Patients were monitored throughout the postoperative period for adverse effects and other complications. The study initially enrolled 60 patients, with 30 patients allocated to each group. Quantitative variables were expressed as mean ± standard deviation, while categorical variables were expressed as frequencies and proportions. Statistical analysis was performed using appropriate comparative tests, including the unpaired t-test and chi-square test. A p value <0.05 was considered statistically significant. Postoperative assessments were performed by an anaesthesiologist who was blinded to the group allocation.