Background and Aims Total femoral replacement (TFR) with endoprosthesis is a rare operation with few indications, primarily malignant bone tumors and requires extensive soft-tissue dissection and reconstruction of the joints.

Psoas compartment block (PCB) is a useful but controversial technique for lower limb surgery. There are often limitations due to essential antithrombotic therapy because of the risk of hematoma in this deep block, but the benefit of excellent analgesia outweighs the risk in major surgery.

Methods A 72 year old patient with recent pulmonary embolism(PE) under fondaparinux was presented for oncologic total replacement of the femur. Fondaparinux was discontinued for 48 hours preoperatively. A lumbar plexus block according to the Chayen approach was performed with 10 ml prilocaine 1% +20 ml ropivacaine 0.45% and a catheter was placed in the psoas compartment, combined with a single shot transgluteal sciatic block with 20 ml of ropivacaine 0.45% with the use of nerve stimulation technique. The duration of the surgery was 6h and was completed under general anesthesia without the use of opioids except the initial induction dose of 150γ fentanyl.

The catheter remained for 4 days postoperatively with continuous infusion of 12 ml/h ropivacaine 0.2% by elastomeric pump.

Results The surgery was uncomplicated, the patient reported no severe pain (VAS 2–3), and didn’t require rescue opioid analgesia. He could move the other leg and manage to start his physiotherapy strengthening exercises.

Conclusions CPCB appears to be a useful alternative in major oncologic orthopedic surgery especially when neuraxial techniques should be avoided.