Background/Objectives: Total knee arthroplasty (TKA) is associated with severe postoperative pain that can impair early mobilization and prolong recovery. While adductor canal block combined with iPACK is commonly recommended, this strategy may provide incomplete articular coverage and occasionally compromise quadriceps function. Genicular nerve block (GNB) selectively targets the sensory innervation of the knee, and when combined with iPACK may achieve near-complete joint analgesia while preserving motor function. This case series aimed to evaluate the magnitude and duration of analgesia and functional recovery provided by a four-nerve GNB combined with iPACK. Methods: Five patients undergoing unilateral TKA under spinal anesthesia received ultrasound-guided blocks of the superolateral, superomedial, inferomedial genicular nerves and the nerve to vastus intermedius, together with an iPACK block. Ropivacaine combined with dexamethasone and dexmedetomidine was used. The primary outcome (pain intensity) [Numeric Rating Scale, NRS] and secondary outcomes (time to first rescue analgesia, opioid consumption, range of motion, and complications) were recorded up to 72 h postoperatively within a standardized multimodal analgesic protocol. Results: Pain scores at rest and on movement remained consistently below 3/10 in all patients. Three patients required no rescue analgesia, while two required a single dose at 36–40 h. Knee range of motion exceeded 90° in all cases, and early mobilization was achieved without quadriceps weakness. No neurological or systemic adverse events occurred. Conclusions: Four-nerve genicular block combined with iPACK, enhanced with perineural adjuncts, provided prolonged, opioid-sparing analgesia with preserved motor function after TKA. This joint-selective, motor-sparing strategy warrants further evaluation in randomized trials.

Background: Frail patients undergoing hip and knee revision surgery represent a major anesthetic challenge because of advanced age and multiple comorbidities. Continuous spinal anesthesia (CSA) with titrated low-dose levobupivacaine may offer a potentially useful alternative to general anesthesia or single-shot spinal anesthesia in this high-risk population. Methods: A retrospective review was conducted of ASA II-III patients who underwent complex hip and knee revision surgeries between February and October 2024 under CSA. The technique was performed using a 25-gauge spinal catheter with incremental boluses of 0.25% levobupivacaine (2.5 mg). Hemodynamic parameters, including mean arterial pressure (MAP), stroke volume index (SVI), and cardiac index (CI), were continuously monitored using the EV1000 hemodynamic monitoring system. Postoperative complications were recorded. Results: 37 high-risk patients were included in the study. Catheter placement was successful in all patients, with no conversions to general anesthesia. MAP decreased by a mean of 14.6% after boluses (p < 0.05); 9 patients (24.3%) experienced reductions ≥ 20%, but all remained >65 mmHg and responded to fluid therapy. CI and SVI decreased by 10.1% and 10.5%, respectively (p < 0.05), without clinical instability. No major complications (neurological injury, infection, post-dural puncture headache) were observed. Conclusions: In this retrospective single-center experience, CSA with titrated low-dose levobupivacaine was feasible and associated with stable hemodynamic profiles and a low rate of complications in frail patients undergoing complex lower-limb revision surgery. However, given the absence of a control group and the limited sample size, these findings should be interpreted cautiously. Further prospective comparative studies are needed to better define the role of CSA in high-risk orthopedic patients.