Background and Aims Hemophilia A is an X-linked recessive bleeding disorder characterized by FVIII deficiency. Development of FVIII-alloantibodies is the major complication of hemophilia treatment, occurring in about 30% of these patients.

We report the perioperative management of a 30-year-old male patient with known history of severe Hemophilia A (FVIII <1%) and FVIII inhibitors proposed for elective TKA.

Methods Multidisciplinary optimization involved Orthopedics, Imuno-hemotherapy and Anesthesiology departments. Factor VII was initiated pre-induction and continued every 2h for 48h. General anesthesia was performed. Tranexamic acid was administered as a bolus (1g) followed by an infusion (1,5mg/kg/h), until the end of the surgery and adequate hemostasis was confirmed. A tourniquet was inflated. Before anesthetic emergence, a single-shot US-guided adductor canal block was performed using 25 ml of 0,2% ropivacaine and 1mcg/kg dexmedetomidine. Additionally, acetaminophen 1g, parecoxib 40mg, tramadol 100mg and ketamine 20mg were administered. Surgery was uneventful and estimated blood loss was 400 mL. Approximately 24h post-operatively he developed intense pain (8/10) refractory to intravenous analgesics. A continuous adductor canal block was performed with substantial pain relief (0/10), maintained at D3 post-operatively.

Results No major hemorrhagic complications were reported. Adequate analgesia allowed for early physical rehabilitation.

Conclusions Perioperative management of hemophilic patients is challenging due to the high bleeding risk requiring a multidisciplinary approach. Continuous adductor canal block, as part of a multimodal analgesic strategy, provided a safe and effective motor-sparing analgesic technique which enables faster recovery and enhanced patient outcomes.