Periarticular Vasoconstrictor Infiltration in a Tourniquet-Free Total Knee Arthroplasty: A Case Report of Effective Blood Loss Control in High-Thrombotic-Risk Patient

Abstract Effective perioperative pain control is essential in Total Knee Arthroplasty (TKA) to support early mobilization and enhance recovery, particularly within Enhanced Recovery After Surgery (ERAS) protocols. The use of a thigh tourniquet, although common, is increasingly questioned due to its association with postoperative pain and thromboembolic risk, especially in patients with a history of Deep Vein Thrombosis (DVT). Periarticular Vasoconstrictor Infiltration (PVI) is a recently described technique aimed at achieving localized hemostasis through epinephrine-based infiltration. This case report illustrates the clinical utility of ultrasound-guided PVI as part of a multimodal, tourniquet-free strategy in high-risk patient. A 66-year-old female with severe right knee osteoarthritis and a history of right lower limb DVT underwent primary TKA under spinal anesthesia. Due to the patient’s elevated thrombotic risk—defined by a high Caprini score—a tailored regional anesthesia protocol was adopted, combining multi-target PVI with a proximal adductor canal block and spinal anesthesia. The PVI solution included ropivacaine, dexmedetomidine, and epinephrine. No tourniquet was inflated during the procedure. The surgical field remained bloodless throughout the 72-minute procedure. Intraoperative blood loss was less than 200 mL, and no transfusion was required. Postoperative analgesia was effective, opioid use was minimized, and the patient mobilized the same evening without complications. No clinical or ultrasound signs of early postoperative thrombotic events were observed. This case demonstrates the feasibility and clinical benefit of integrating ultrasound-guided PVI into a multimodal, tourniquet-free anesthetic strategy for TKA in high-thrombotic-risk patients. The approach provided effective analgesia and hemostasis, aligned with ERAS principles, and may represent a valuable alternative for personalized perioperative care in orthopedic surgery.