The number of patients with osteoarthritis of large joints in the Russian Federation may reach 4 million, with the demand for knee arthroplasty estimated at approximately 300,000 procedures annually. Improved osteoarthritis diagnostics, increased life expectancy, and advancements in prosthetic technologies have driven the rise in knee arthroplasties. However, unresolved challenges related to anesthetic management for such surgeries underscore the importance of effective pain management during total knee arthroplasty (TKA) from both scientific and practical perspectives. Anesthetic techniques for TKA have evolved significantly over time. Advances in medical knowledge and technology have led to the development and refinement of various anesthetic approaches aimed at improving patient outcomes. Historically, general and infiltration anesthesia, along with neuraxial blocks, were used. The introduction of ultrasound-guided (US-guided) techniques has expanded the use of peripheral nerve blocks. Current practices include multimodal general anesthesia, spinal anesthesia, and, less commonly, epidural anesthesia. US-guided techniques encompass obturator nerve block, anterior-medial and posterior-lateral capsule blocks, periarticular infiltration, “four-in-one” block, and selective genicular nerve blocks, among others. Future directions in anesthetic management for TKA include evaluating the clinical efficacy of radiofrequency catheter ablation and cryoablation. Additionally, addressing the significant challenge of rebound pain by identifying its causes and developing effective treatment strategies is essential. The global increase in TKA volumes presents a challenge for anesthesiologists and surgeons, emphasizing the need to further advance regional anesthesia techniques to improve recovery quality following surgery.