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Osteoarthritis is among the most prevalent degenerative musculoskeletal disorders worldwide, with its clinical and epidemiological patterns varying by anatomical location, diagnostic criteria, and population characteristics. Gonarthrosis, or knee osteoarthritis, has a global estimated prevalence of 23% in adults over the age of 40, according to a recent meta-analysis, equating to approximately 654 million individuals. 1 The condition is more frequent in women and its prevalence increases with both age and body mass index. Similarly, hip osteoarthritis shows an overall prevalence of 8.6% in adults, though regional disparities are evident: prevalence is highest in Europe (12.6%) and lowest in Africa (1.2%). Among individuals aged 60 years and older, the prevalence of symptomatic hip osteoarthritis is approximately 6.2%. Like gonarthrosis, its incidence rises with age, although no significant sex differences have been observed at the global level.2 Low back pain also represents a leading global cause of disability, with an estimated point prevalence of 12% among adults and a lifetime prevalence approaching 40%. Spinal osteoarthritis, often underlying chronic back pain, shows highly variable prevalence rates depending on the population studied, the diagnostic methods used, and the spinal segment evaluated. For example, U.S. Medicare data report a prevalence of diagnosed degenerative spinal disease of 27.3% in older adults; however, this figure is likely underestimated due to asymptomatic cases that remain undiagnosed.3 In the advanced stages of osteoarthritis, surgical intervention often becomes necessary to restore function and relieve pain. Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are considered the gold standard treatments for end-stage joint degeneration, offering substantial improvements in joint mobility and quality of life. Likewise, in the context of spinal pathology, most of which arises as a consequence of aging and is initially addressed with conservative management, surgery may be indicated when symptoms persist or worsen. This is particularly true in cases involving radicular pain unresponsive to medical therapy. Spinal fusion (arthrodesis) is a commonly employed surgical technique in such scenarios, involving the permanent union of adjacent vertebrae through osteogenesis to eliminate pathological motion and stabilize the affected segment. Effective postoperative pain management following major orthopedic surgery remains a significant clinical challenge, as it has a direct and measurable impact on surgical outcomes, functional recovery, and overall patient satisfaction. Despite advances in perioperative care, procedures such as total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal fusion (SF) are still commonly associated with intense postoperative pain and substantial perioperative blood loss. These factors can delay mobilization, prolong hospital stays, and increase the risk of complications, thus underscoring the need for refined, evidence-based strategies. Estimates of intraoperative blood loss in these major orthopedic procedures vary widely, with reported volumes ranging from approximately 726 to 1,768 mL.4 This variability reflects not only differences in surgical technique and patient physiology but also the influence of modifiable perioperative factors. Although the surgeon’s expertise remains a critical determinant of intraoperative outcomes, additional risk factors—such as patient age, comorbidities, anticoagulant use, and procedural complexity—can significantly influence the magnitude of blood loss. Consequently, a variety of intraoperative strategies have been proposed to reduce bleeding, including optimized patient positioning, acute normovolemic hemodilution, and controlled hypotension. While effective, these techniques require careful application, particularly in patients with cardiovascular or systemic comorbidities, where physiological reserves may be limited and the margin for hemodynamic compromise is narrow. In parallel, the approach to postoperative analgesia has evolved substantially over recent decades. Historically reliant on opioids as the mainstay of treatment, contemporary pain management strategies have shifted toward multimodal analgesia. This model integrates multiple pharmacological and regional techniques with the aim of enhancing analgesic efficacy while minimizing opioid-related adverse effects such as nausea, constipation, respiratory depression, and the potential for dependency. The multimodal approach typically includes agents such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), COX-2 selective inhibitors, gabapentinoids, and corticosteroids. When combined with motor-sparing regional nerve blocks, tailored to the surgical site and the individual patient, these regimens offer improved pain control, facilitate early rehabilitation, and support enhanced recovery protocols. Together, these evolving strategies in bleeding control and analgesia reflect a broader paradigm shift toward precision perioperative care, where individualized risk assessment and patient-centered planning form the foundation of improved surgical outcomes. In 1987, Dr. Jeffrey Klein first described tumescent anesthesia as a technique involving the infiltration of large volumes of a diluted solution containing lidocaine and epinephrine.5 Its main advantages include effective anesthesia and a marked reduction in perioperative bleeding, thereby facilitating surgical dissection and improving the overall surgical field. Building on this technique, in 2010, Dr. Donald Lalonde introduced the use of tumescent anesthesia in orthopedic hand surgery under the acronym WALANT (Wide Awake Local Anesthesia No Tourniquet). WALANT eliminates the need for a tourniquet, thereby avoiding the discomfort it causes during limb surgeries. Due to its advantages in outpatient settings and its cost-effectiveness, WALANT has gained increasing popularity.6 Importantly, the risks associated with systemic local anesthetic toxicity (LAST) and vasoconstrictor-induced ischemia have proven to be minimal. Effective postoperative pain control is a key determinant of patient satisfaction in both joint replacement and spinal fusion procedures. Poorly managed postoperative pain may evolve into chronic pain, making its aggressive treatment essential. One widely adopted technique is local infiltration analgesia (LIA), which involves the periarticular injection, by the surgeon during the procedure, of a combination of local anesthetics, epinephrine, and anti-inflammatory analgesics. This simple yet effective approach significantly contributes to early pain relief and enhanced recovery. To date, however, there is no definitive evidence favoring a specific infiltration method, drug combination, or dosage in the use of LIA. Systematic reviews and meta-analysis support LIA for postoperative pain management in TKA.7 However, there is little evidence to support using this technique in hip replacement and spine fusion, either intraoperatively or with a postoperative wound infusion catheter technique, if multimodal oral non-opioid analgesia is given. The use of LIA has retrospectively been shown to be associated with decreased perioperative blood loss in TKA.8 Nonetheless, not many randomised controlled trials have examined the effect of preoperative LIA on blood loss. Preoperative LIA seems to decrease perioperative blood loss by 39% during TKA surgery compared to its administration at the end of the surgery, while providing non-inferior postoperative pain relief.8 This occurrence is likely a result of the limited exposure time of epinephrine to a surgical field that has already undergone dissection when the administration takes place towards the conclusion of the surgery. Such a scenario might potentially result in a weakened vasoconstrictor impact of epinephrine, leading to a reduction in its overall effectiveness. Consequently, initiating the procedure at the commencement of the surgery could enhance haemostatic outcomes. In the case of hip surgery, there are no studies to date that demonstrate changes in blood loss when LIA is employed. In this context, the periarticular vasoconstrictor infiltration (PVI) technique has recently been defined.9 10 PVI involves an ultrasound injection of diluted local anaesthetic with epinephrine into deep periarticular planes at the vascular capsular entry. This aims to achieve a chemical tourniquet and reduce perioperative bleeding adding good quality postoperative analgesia. The vascular supply to a joint typically runs in close anatomical association with the nerves responsible for its innervation. This relationship enables the concurrent achievement of two key therapeutic objectives when anesthetic and vasoconstrictive agents are administered in the periarticular region: regional analgesia and localized vasoconstriction. Analgesia results from the blockade of afferent nerve fibers, while vasoconstriction reduces intraoperative bleeding and enhances surgical field visibility. PVI is an ultrasound-guided technique that should be performed after the primary anaesthesia procedure (spinal or general anaesthesia, as appropriate). The mixture solution consists of a preparation of 200 ml levobupivacaine 0.125% or ropivacaine 0,2% with 1 mg of epinephrine (1:200,000). For those patients with an unstable heart condition, solutions with up to 1:1,000,000 epinephrine have shown to provide effective haemostasis.References Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: a review. Jama. 2021;325(6):568–578. Doi:10.1001/jama.2020.22171.Fan Z, Yan L, Liu H, et al. The prevalence of hip osteoarthritis: a systematic review and meta-analysis. Arthritis Research & Therapy 2023;25(1):51. doi:10.1186/s13075-023-03033-7.Silva-Díaz M, Blanco FJ, Quevedo Vila V, et al. Prevalence of symptomatic axial osteoarthritis phenotypes in spain and associated socio-demographic, anthropometric, and lifestyle variables. Rheumatology International 2022;42(6):1085–1096. doi:10.1007/s00296-021-05038-4.Donovan RL, Lostis E, Jones I, Whitehouse MR. Estimation of blood volume and blood loss in primary total hip and knee replacement: an analysis of formulae for perioperative calculations and their ability to predict length of stay and blood transfusion requirements. J Orthop. 2021 Mar 12;24:227–232. doi: 10.1016/j.jor.2021.03.004. eCollection 2021 Mar-Apr.Klein. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4:263–267. https://doi.org/10.1177/074880688700400403.Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin. 2014 Feb;30(1):1–6. doi: 10.1016/j.hcl.2013.08.015. Epub 2013 Nov 9.Andersen LO, Kehlet H. Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review. Br J Anaesth. 2014 Sep;113(3):360–74. doi: 10.1093/bja/aeu155. Epub 2014 Jun 17.Lapidus O, Baekkevold M, Rotzius P, Lapidus LJ, Eriksson K. Preoperative administration of local infiltration anaesthesia decreases perioperative blood loss during total knee arthroplasty - a randomised controlled trial. J Exp Orthop. 2022 Dec 12;9(1):118. doi: 10.1186/s40634-022-00552-1.Roqués Escolar V, Oliver-Forner P, Fajardo Pérez M. Periarticular vasoconstrictor infiltration: a novel technique for chemical vasoconstriction in major orthopaedic surgery. Br J Anaesth. 2022 Oct;129(4):e97-e100. doi: 10.1016/j.bja.2022.07.003. Epub 2022 Aug 13.Roqués-Escolar V, Molina-Garrigós P. 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