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Objectives and questions: Multimodal analgesia is a cornerstone of enhanced recovery pathways in total hip arthroplasty (THA). Recent evidence, including large network meta-analyses, suggests superior outcomes when local infiltration analgesia (LIA) is combined with a percutaneous pericapsular nerve group (PENG) block performed by anesthesiologists. However, the additional time required for preoperative regional anesthesia may prolong induction and operating room turnover. This study evaluated a pragmatic alternative: a surgeon-performed, open, anatomically oriented PENG-equivalent infiltration combined with LIA, performed intraoperatively.

Material and methods: In this retrospective comparative study, 200 consecutive patients undergoing primary THA via a direct anterior approach were analyzed. One hundred patients received a regional anesthesia regimen consisting of a femoral nerve block combined with a lateral femoral cutaneous nerve block, both performed by the anesthesia team (FNB+LFCN group). The remaining 100 patients were treated with intraoperative local infiltration analgesia combined with a surgeon-performed open PENG-equivalent infiltration targetingthe anterior acetabular rim, toward the anatomical interval between the iliopsoas tendon and the iliopubic eminence (oPENG+LIA group). Primary outcomes included anesthesia induction time and postoperative opioid consumption expressed as morphine milligram equivalents (MME). Secondary outcomes comprised postoperative pain intensity (NRS), motor function during mobilization, and complication rates. Groups were comparable with regard to demographic characteristics and comorbidity profile.

Results: The oPENG+LIA group demonstrated a significantly shorter anesthesia induction time compared with the FNB+LFCN group (mean reduction: 14.01 min, p<0.001), while surgical time did not differ between groups. Opioid consumption was significantly lower in the oPENG+LIA group within the first 24 postoperative hours (MME, mean reduction: 9.39 mg, p=0.046); however, cumulative opioid use at 48 hours was comparable. Pain scores were significantly lower at 12 hours postoperatively in the oPENG+LIA group, both, at rest and during activity (NRS,p=0.030, p=0.029), with no differences thereafter. No clinically relevant differences in motor function during early mobilization were observed. Complication rates were low and did not differ between groups.

Discussion and conclusions: A surgeon-performed, open PENG-equivalent infiltration combined with LIA is a safe and effective component of multimodal analgesia in primary THA. This approach significantly reduces anesthesia induction time while improving early postoperative pain control and reducing early opioid requirements, without compromising motor function or increasing complications. The technique represents a time-efficient, interdisciplinary adaptation of established analgesic concepts within enhanced recovery pathways.