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Background and Aims Hemophilia is associated with spontaneous bleeding in muscle tissues and joints. Repeated hemarthrosis results in progressive joint cartilage damage, leading to hemophilic arthropathy. Joint pain remains a problem for many patients, necessitating orthopedic interventions. Perioperative pain management is challenging: NSAIDs are unsuitable for their impact on platelet activity; opioids are often ineffective for movement-related pain and can lead to significant side effects. RA presents an option for effective pain management, but its safety remains unclear. We report the perioperative management of 4 hemophilic patients undergoing elective TKA, performing peripheral nerve block in a safe manner.

Methods 4 patients (age 41±12) underwent TKA; they all had severe hemophilia (3 type A, 1 type B). Tranexamic acid(1g) was administered via iv infusion 1 hour prior to surgery. FVIII/FVII was administered pre-induction and continued every 12h for 48h. After infusion, a single-shot US-guided femoral and sciatic nerve block was performed (levobupivacaine 0,375% 20ml + 20 ml respectively). General anesthesia was carried out; acetaminophen 1g, methadone 0,5 mg/kg and dexamethasone 4mg were administered. Postoperative opioid-sparing analgesia was successfully maintained with low-dose oral opioids(oxycodone/naloxone 5mg bid) for 48h, and acetaminophen.

Results No major hemorrhagic complications occurred. No muscle and soft tissue bleeding after RA were reported. Adequate pain management enabled early physical rehabilitation.

Conclusions The perioperative use of regional nerve blocks proved to be safe and effective for opioid-sparing analgesia in hemophilia patients undergoing TKA, enabling early physical rehabilitation. Our findings suggest that with appropriate clotting factor replacement, RA can be a viable option in this patient population.