Among orthopedic injuries in the elderly population, proximal femur fractures—encompassing femoral neck and intertrochanteric varieties—rank among the most frequently encountered conditions.[1] The associated pain can be quite severe and is frequently amplified during the positioning procedures necessary for administering spinal anaesthesia. When patients must assume the lateral decubitus or sitting position required for neuraxial blockade, they often experience substantial discomfort, which can lead to psychological distress, inadequate body positioning, and various complications during spinal anaesthesia insertion.[2] Conventional pain management strategies employed before positioning typically involve intravenous opioid medications and NSAIDs. However, these approaches often produce unwanted side effects—including respiratory depression, sedation, blood pressure reduction, and nausea—which are particularly concerning in elderly patients who frequently have multiple underlying medical conditions.[3] Consequently, regional anaesthesia methods have emerged as promising alternatives for delivering analgesia to this vulnerable patient group. In recent years, the fascia iliaca compartment block and femoral nerve block have become widely used for managing hip fracture pain.[4] Yet these conventional techniques do carry a notable drawback: they can cause weakness in the quadriceps muscles, which may increase the likelihood of falls during the postoperative recovery period. The PENG block, which was first introduced by Girón-Arango and colleagues in 2018, represents a novel interfascial plane block that specifically targets the sensory nerve branches of the femoral nerve, obturator nerve, and accessory obturator nerve—the branches responsible for providing sensation to the anterior hip joint capsule.[5] What makes the PENG block particularly attractive is that it delivers effective pain relief while simultaneously preserving motor function, since it works selectively on the sensory innervation of the hip joint itself.[6] Although initial descriptions of this technique emphasized ultrasound-guided administration, researchers have subsequently developed landmark-based approaches that make this block more practical in settings where ultrasound equipment may not be readily accessible. We undertook this investigation with the hypothesis that landmark-guided PENG block would substantially reduce positioning-related pain compared to standard pain management approaches in patients with proximal femur fractures requiring spinal anaesthesia

Study Design and Setting This prospective, randomized controlled investigation was performed at a tertiary care medical center during an 18-month period. The study protocol received approval from the Institutional Ethics Committee (IEC APPROVAL NO. 91/2024 dated 23/09/2024). All study participants or their legal representatives provided written informed consent prior to enrollment. Patient Selection Inclusion Criteria ● Age between 18 and 80 years ● Either male or female ● ASA physical status classification of I, II, or III ● Confirmed diagnosis of proximal femur fractures (femoral neck or intertrochanteric types) requiring surgical repair under spinal anaesthesia ● Baseline NRS pain score of at least 6 or greater at rest Exclusion Criteria ● Patient declining study participation ● Known allergic reactions to local anaesthetic medications ● Underlying coagulation disorders or current anticoagulant medication use ● Active infection or significant skin lesions at the proposed block site ● Existing neurological deficits affecting the lower extremities ● Multiple trauma injuries (polytrauma) ● Psychiatric conditions that could interfere with accurate pain assessment ● Body mass index exceeding 35 kg/m² ● Pathological fractures Sample Size Calculation Drawing from a pilot investigation and existing literature, we anticipated a mean difference of 3 points in NRS pain scores during positioning procedures, with a standard deviation of 2 points. Using statistical parameters of 90% power and an alpha error of 0.05, we calculated the required sample size at 25 patients per group. To account for potential patient attrition, we enrolled 30 patients in each group, resulting in a total of 60 participants. Randomization and Blinding We randomly distributed patients into two groups using computer-generated randomization sequences placed in sealed, opaque envelopes: ● Group P (PENG group, n=30): These patients received landmark-guided PENG block ● Group C (Control group, n=30): These patients received standard care without regional block Anesthetic Protocol Preoperative Assessment Every patient underwent comprehensive preanaesthetic evaluation that included detailed history taking, physical examination, and appropriate laboratory investigations. We established baseline pain measurements using the Numeric Rating Scale (NRS), which ranges from 0 to 10, where 0 represents complete pain absence and 10 represents the worst imaginable pain. Study Intervention Group P (PENG Block Group): We positioned patients supine with the affected limb in a neutral position. Following strict aseptic technique, we performed the landmark-guided PENG block as follows: Landmark Identification 1. We identified and marked the anterior superior iliac spine (ASIS) 2. We located and marked the pubic tubercle 3. We drew an imaginary line connecting these two landmarks (representing the inguinal ligament) 4. We determined the injection point at the junction where the medial two-thirds meets the lateral one-third of this line 5. We identified the precise needle insertion site 6. Block Technique 7. Following local infiltration using 2 ml of 2% lignocaine, we inserted a 22G, 80 mm nerve block needle perpendicular to the skin surface 8. We gradually advanced the needle until it made contact with either the anterior inferior iliac spine or the iliopubic eminence 9. We then carefully withdrew the needle approximately 1-2 millimeters 10. After confirming negative aspiration, we slowly injected 20 ml of 0.25% bupivacaine in divided increments with repeated aspiration checks Group C (Control Group): Control group patients received the standard pain management approach used in our institution. This consisted of intravenous paracetamol administered at 1 gram over 15 minutes. If their NRS pain score remained above 6, we provided rescue analgesia using intravenous fentanyl boluses of 25 micrograms, up to a maximum dose of 2 micrograms per kilogram of body weight. Spinal Anaesthesia We waited 30 minutes following the intervention before proceeding with patient positioning for spinal anaesthesia. Patients were then carefully positioned in the lateral decubitus position with the fractured hip side kept non-dependent. We applied standard perioperative monitoring including continuous electrocardiography (ECG), non-invasive blood pressure measurement (NIBP), and pulse oximetry (SpO₂). Spinal anaesthesia was administered at the L3-L4 or L4-L5 interspace using a 25G Quincke's spinal needle, injecting 3 ml of 0.5% hyperbaric bupivacaine. Outcome Measures Primary Outcome We assessed pain during the positioning procedure using the Numeric Rating Scale (0-10) at the moment of positioning for spinal anaesthesia. Secondary Outcomes 1. Quality of positioning: Graded as: a. Optimal: patient maintained position without difficulty b. Suboptimal: patient maintained position with some difficulty c. Poor: Patient unable to maintain adequate positioning 2. Time taken for positioning: Duration required to achieve adequate positioning, measured from initiation of positioning maneuvers to achievement of suitable position for spinal insertion (expressed in seconds) 3. The number of needle insertion attempts needed to achieve successful spinal puncture 4. Patient satisfaction score: Assessed on a 5-point Likert scale 1 (very dissatisfied ) to 5( very satisfied ) 5. Anaesthesiologist satisfaction score: Assessed on a 5-point Likert scale 6. Hemodynamic variables including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) recorded at multiple time points: baseline, during positioning, immediately following spinal injection, and at 5, 10, and 15 minutes post-spinal administration 7. Any adverse events, including block-related complications (such as vascular puncture, local anaesthetic toxicity, or nerve injury) and positioning-related complications 8. Number of patients requiring additional pain relief medication before positioning Statistical Analysis Data were analyzed using SPSS software version 25.0 (IBM Corp., Armonk, NY, USA). Normality of distribution was assessed using the Shapiro-Wilk test. Continuous variables with normal distribution were expressed as mean ± standard deviation and compared using independent t-test. Non-normally distributed continuous variables were expressed as median (interquartile range) and compared using Mann-Whitney U test. Categorical variables were expressed as numbers and percentages and compared using Chi-square test or Fisher's exact test as appropriate. A p-value <0.05 was considered statistically significant.

Patient enrollment and completion: Initially, we screened 68 patients for study eligibility. Of these, 60 patients met our inclusion criteria and were randomly assigned to the two treatment groups with 30 participants each. Importantly, all 60 enrolled patients completed the study protocol without any withdrawals or protocol deviations. Demographic and Clinical Characteristics The two groups showed similar demographic profiles and baseline clinical features (as shown in Table 1). Notably, there were no statistically meaningful differences between the groups in age distribution, gender proportions, body mass index, ASA physical status classification, fracture type, or baseline pain severity measures. Table 1: Demographic and Clinical Parameter Group P (n=30) Group C (n=30) P value Age (years) 64.3 ± 10.2 66.1 ± 9.8 0.487 Gender (M/F) 13/17 15/15 0.605 Weight (kg) 58.4 ± 8.6 60.2 ± 9.1 0.433 BMI (kg/m²) 23.8 ± 3.2 24.3 ± 3.6 0.568 ASA PS (I/II/III) 8/16/6 7/17/6 0.912 Type of fracture 0.799 -Femoral neck 18 (60%) 17 (56.7%) -Intertrochanteric 12 (40%) 13 (43.3%) Baseline NRS score 8.1 ± 0.9 8.3 ± 0.8 0.367 Data presented as mean ± SD or numbers (percentage); BMI: Body Mass Index; ASA PS: American Society of Anesthesiologists Physical Status; NRS: Numeric Rating Scale Primary Outcome Pain During Positioning A statistically and clinically significant difference emerged in pain scores between the two groups during positioning (refer to Table 2). Specifically, patients in Group P experienced substantially lower mean NRS pain scores compared to Group C (mean of 2.4 ± 0.8 versus 7.2 ± 1.1, with p<0.001). This difference represents a clinically meaningful reduction in pain perception. Table 2: Primary Outcome - Pain Scores Parameter Group P (n=30) Group C (n=30) P value NRS at positioning 2.4 ± 0.8 7.2 ± 1.1 <0.001* Reduction from baseline 5.7 ± 1.1 1.1 ± 0.6 <0.001* *Data presented as mean ± SD; NRS: Numeric Rating Scale; Statistically significant Secondary Outcomes Quality of Positioning The PENG block group achieved significantly superior positioning quality when compared to the control group (p<0.001). Within Group P, 26 patients (representing 86.7%) successfully achieved optimal positioning, whereas in Group C, only 10 patients (33.3%) achieved this optimal state. The distribution of positioning quality across categories demonstrated this substantial difference between groups. Table 3: Quality of Positioning Parameter Group P (n=30) Group C (n=30) P value Optimal 26 (86.7%) 10 (33.3%) <0.001* Suboptimal 4 (13.3%) 14 (46.7%) Poor 0 (0%) 6 (20%) *Data presented as numbers (percentage); Statistically significant Time for Positioning and Spinal Attempts Group P patients required substantially less time to achieve appropriate positioning compared to Group C patients (38.2 ± 8.4 seconds versus 78.6 ± 15.3 seconds, p<0.001). Similarly, the number of attempts needed for successful spinal anaesthesia placement was notably lower in the PENG block group (Table 4 presents these details). Specifically, 27 patients (90%) in Group P achieved successful spinal placement on their first attempt, compared to only 15 patients (50%) in the control group. Table 4: Positioning Time and Spinal Attempts Parameter Group P (n=30) Group C (n=30) P value Time for positioning (seconds) 38.2 ± 8.4 78.6 ± 15.3 <0.001* Number of spinal attempts <0.001* - Single attempt 27 (90%) 15 (50%) - Two attempts 3 (10%) 12 (40%) - Three attempts 0 (0%) 3 (10%) *Data presented as mean ± SD or numbers (percentage); Statistically significant Satisfaction Scores Both patient satisfaction ratings and anesthesiologist satisfaction scores were substantially higher in Group P relative to Group C (p<0.001). Patient satisfaction averaged 4.6 ± 0.5 in the PENG group versus 2.3 ± 0.8 in the control group. Anesthesiologist satisfaction similarly favored the PENG group at 4.7 ± 0.5 compared to 2.5 ± 0.7 in controls. Table 5: Satisfaction Scores Satisfaction Score (1-5) | Group P (n=30) Group C (n=30) P value Patient satisfaction 4.6 ± 0.5 2.3 ± 0.8 <0.001* Anaesthesiologist satisfaction 4.7 ± 0.5 2.5 ± 0.7 <0.001* *Data presented as mean ± SD; Statistically significant Rescue Analgesia Only a small number of PENG block patients needed rescue analgesia before positioning (2 patients, or 6.7%), whereas in the control group, a substantial majority required additional pain relief (18 patients, or 60%; p<0.001). Hemodynamic Parameters Baseline hemodynamic measurements were comparable between groups. However, during the positioning phase, control group patients demonstrated noteworthy increases in heart rate and blood pressure measurements, presumably reflecting their physiological stress response to severe pain. These increases were significantly less pronounced in PENG block recipients. Following successful spinal anaesthesia administration, hemodynamic parameters normalized in both groups. Table 6: Hemodynamic Parameters Parameter Group Baseline During Positioning After Spinal 5 min 10 min 15 min Heart Rate (bpm) P 78±10 82±9 80±8 76±9 74±8 73±7 C 80±11 98±12* 82±10 78±9 75±8 74±8 SBP (mmHg) P 138±14 142±12 128±11 124±10 122±9 120±10 C 140±15 164±16 130±12 126±11 123±10 121±9 DBP (mmHg) P 82±8 85±7 76±7 74±6 72±6 71±6 C 84±9 96±10 78±8 75±7 73±6 72±6 MAP (mmHg) P 101±9 104±8 93±8 91±7 89±7 87±7 C 103±10 119±11 95±9 92±8 90±7 88±7 *Data presented as mean ± SD; SBP: Systolic Blood Pressure; DBP: Diastolic Blood Pressure; MAP: Mean Arterial Pressure; p<0.05 compared to Group P at same time point Complications No serious complications—including local anaesthetic toxicity, vascular injury, or neurological damage—occurred in either group. The complication profile was excellent, with minor adverse events being uncommon. In the PENG group, one patient developed a small hematoma at the injection site that resolved spontaneously. The control group experienced a higher incidence of nausea (20% versus 3.3%), likely attributable to increased opioid use for rescue pain management. Table 7: Complications Parameter Group P (n=30) Group C (n=30) P value Nausea 1 (3.3%) 6 (20%) 0.046* Vomiting 0 (0%) 3 (10%) 0.076 Hypotension 2 (6.7%) 3 (10%) 0.999 Bradycardia 0 (0%) 0 (0%) - Hematoma at block site 1 (3.3%) 0 (0%) 0.999 *Data presented as numbers (percentage); Statistically significant

Our prospective, randomized controlled investigation provides compelling evidence that landmark-guided PENG block effectively reduces pain during patient positioning for spinal anaesthesia in individuals with proximal femur fractures. We observed both statistically significant and clinically meaningful reductions in pain scores during positioning (NRS 2.4 compared to 7.2, p<0.001), substantial improvements in positioning quality (86.7% achieving optimal positioning versus 33.3%), and notably higher patient and anesthesiologist satisfaction levels in comparison with standard management. Hip fractures remain a substantial public health concern, affecting the elderly particularly severely. With an estimated 1.5 million fractures occurring annually worldwide, these injuries carry significant implications for patient morbidity and mortality.[7] Managing pain in these patients presents genuine challenges, primarily because the fracture pain itself is intense and patients must cooperate during positioning maneuvers necessary for neuraxial blockade administration. When pain control during positioning is inadequate, patients experience considerable distress, involuntary movement during spinal needle insertion occurs, and the likelihood of serious complications—including dural puncture, nerve injury, or block failure—increases substantially.[8] The PENG block methodology targets specific nerve branches responsible for hip joint sensation, specifically the articular divisions of the femoral, obturator, and accessory obturator nerves that innervate the anterior hip capsule.[5] This represents an important distinction from conventional blocks: unlike the femoral nerve block or fascia iliaca block, which affect broader nerve distributions, the PENG block provides targeted sensory anesthesia of the hip joint itself while preserving muscle function. This occurs because the local anesthetic is deposited in the tissue plane between the psoas tendon and pubic bone, distant from the primary motor nerve branches.[9] Previous PENG block research has predominantly employed ultrasound guidance, which provides excellent visualization of relevant anatomy and local anesthetic distribution patterns.[10,11] However, ultrasound availability varies considerably, particularly in resource-constrained settings or remote geographical areas. The landmark-guided methodology we employed in this study provides a practical alternative that maintains efficacy while remaining accessible in diverse healthcare environments. Our landmark-based approach utilized easily palpable anatomical features (ASIS and pubic tubercle) for identifying the injection site—a strategy analogous to established landmark techniques for fascia iliaca blocks.[12] The success rates and clinical outcomes we achieved proved comparable to reported ultrasound-guided studies, with 86.7% of patients achieving optimal positioning and substantial pain reduction. This comparison suggests that landmark-guided PENG block, when properly performed with solid anatomical knowledge, can serve as a reliable alternative when ultrasound equipment is unavailable. The mean pain score we observed during positioning in our PENG block cohort (2.4) aligns closely with findings from comparable investigations. Lin and associates, studying ultrasound-guided PENG block administration, reported a mean pain score of 2.1.[13] Similarly, Pascarella's research team found that PENG block delivered superior pain relief compared to the more traditional fascia iliaca block in hip fracture patients undergoing positioning procedures.[14] Our observation regarding positioning quality—86.7% achieving optimal positioning in the PENG group versus 33.3% in controls—carries important implications for both the technical ease and safety profile of spinal anaesthesia. Suboptimal positioning can create significant difficulties during spinal needle insertion, necessitate more attempts, increase procedure failure rates, and elevate the risk of complications such as traumatic (bloody) spinal taps, post-dural puncture headache development, or neurological injury.[15] Our finding that 90% of PENG block patients required only a single successful spinal placement attempt (compared to 50% in controls) demonstrates the tangible clinical advantage that improved positioning provides. Positioning time—substantially shorter in the PENG group at 38.2 seconds versus 78.6 seconds—reflects not only superior pain control but also translates to important practical benefits. Reduced positioning duration decreases operating room time requirements and may lower the risk of pressure-related skin injury in elderly patients with fragile integument. The notably superior patient satisfaction in the PENG group (4.6 versus 2.3 on our 5-point scale) represents an important patient-centered outcome. Elderly individuals experiencing hip fractures frequently contend with significant psychological anxiety regarding their injury and impending surgery. Effective pain management during positioning can meaningfully attenuate this psychological distress and improve the overall quality of their perioperative experience.[16] Anesthesiologist satisfaction also favored the PENG group, presumably because performing spinal anaesthesia becomes considerably easier when working with a pain-controlled, cooperative patient in an ideal anatomical position. From a hemodynamic perspective, our PENG block recipients maintained better blood pressure and heart rate stability during positioning. Control group participants demonstrated substantial increases in heart rate (reaching 98 versus 82 bpm) and systolic pressure (reaching 164 versus 142 mmHg), reflecting their profound pain-induced sympathetic nervous system activation. For elderly patients harboring cardiovascular disease, such dramatic hemodynamic fluctuations carry real risks of triggering myocardial ischemia, dangerous arrhythmias, or cerebrovascular incidents.[17] Our observation that most PENG block patients (93.3%) avoided requiring rescue analgesia bears significant implications. Systemic opioids—the typical choice for supplemental pain control—carry troublesome risks in older populations, including respiratory depression, altered mental status and confusion, nausea and vomiting, plus constipation. Our findings align perfectly with contemporary multimodal pain management strategies and enhanced recovery after surgery (ERAS) protocols that emphasize opioid reduction.[18] The complication profile in our study was remarkably favorable. No major adverse events developed, and even minor complications proved uncommon. One patient experienced minor bruising at the injection site that resolved spontaneously—entirely consistent with the inherent safety of interfascial plane blocks, which naturally avoid major blood vessels and nerves.[19] The higher nausea rate in control patients (20% versus 3.3%) reflects the increased opioid requirements in that group. While our study contributes valuable evidence, certain limitations merit acknowledgment. First, complete blinding of participants was impossible given the intervention's nature, potentially introducing bias in subjective outcome measures such as satisfaction ratings. However, the anesthesiologist performing spinal anaesthesia and documenting primary outcomes remained blinded to group assignment. Second, we did not compare landmark-guided PENG administration with ultrasound-guided techniques—a comparison that would illuminate whether both approaches yield equivalent results. Third, our single-center design with a modest sample size may limit applicability to broader populations. Fourth, we collected no long-term outcome data regarding postoperative pain, functional recovery, or development of chronic pain—all clinically relevant endpoints. The local anesthetic dose we used (20 ml of 0.25% bupivacaine) reflected prior research and our institutional experience.[20] Future investigations into optimal dosing could potentially minimize local anesthetic volumes while preserving clinical effectiveness. Our decision to allow 30 minutes between block administration and positioning reflected the pharmacological onset profile of bupivacaine. We selected bupivacaine based on its favorable safety characteristics relative to other long-acting agents, featuring lower risks of cardiac and neurological toxicity.[21] Our investigation adds meaningfully to the accumulating evidence base supporting PENG block use for hip fracture analgesia. Importantly, we demonstrated that effective landmark-guided administration can be accomplished when ultrasound remains unavailable—particularly valuable in low-resource settings, emergency departments, and situations where ultrasound expertise is limited. Achieving this requires proper training in landmark recognition and meticulous technique. Looking ahead, future investigations should compare landmark versus ultrasound-guided approaches, investigate optimal local anesthetic dosing, evaluate the block's utility for postoperative pain management, compare it directly with other regional techniques including fascia iliaca and femoral nerve blocks, and assess its impact on long-term functional recovery and chronic pain prevention. Our findings support incorporating PENG block into standard multimodal analgesia protocols for hip fracture patients, consistent with guidelines from the American Society of Regional Anesthesia and Pain Medicine (ASRA) recommending regional techniques to diminish opioid requirements and enhance outcomes.[22] The PENG block's combination of motor-sparing properties with excellent analgesia makes it an ideal choice for this clinical scenario.

Landmark-guided PENG block represents a highly efficacious, safe, and practically applicable technique for delivering analgesia during the positioning phase of spinal anaesthesia in proximal femur fracture patients. This approach meaningfully reduces pain, substantially improves positioning quality, shortens positioning duration, decreases the necessity for rescue pain medications, and elevates both patient and anesthesiologist satisfaction—all while avoiding muscle weakness complications. Because the technique requires only straightforward anatomical landmarks for successful performance, it becomes accessible even in settings lacking ultrasound resources. We recommend incorporating landmark-guided PENG block into standard practice protocols for hip fracture patients requiring neuraxial anaesthesia.

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