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By John F. Sarwark (ed.)

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Hip or Knee Replacement Surgery In the past, patients undergoing hip or knee replacement surgery received regional anesthesia. The rare but devastating risk of epidural hematoma with common current anticoagulation regimens now outweighs the potential benefits of regional anesthesia (improved postoperative analgesia and cognitive function in the elderly). Postoperative spinal opioids, given as a “single shot” technique without placement of an epidural E S S E N T I A L S O F M U S C U L O S K E L E TA L C A R E ■ © 2 0 1 0 A M E R I C A N A C A D E M Y O F O R T H O PA E D I C S U R G E O N S 29 SECTION 1 GENERAL ORTHOPAEDICS ANESTHESIA FOR ORTHOPAEDIC SURGERY catheter, may be appropriate, although effective monitoring by a dedicated pain management team and properly trained nursing staff is mandatory.

Even young adults with this level of amputation find use of a prosthesis very challenging because of the high energy requirements and the need to control three joints (hip, knee, and ankle). Many individuals with amputations at this level therefore prefer walking with crutches rather than using a prosthesis. Principles of Prosthetic Fitting The soft-tissue envelope over the end of the amputation site is the interface, or cushion, between the bone of the residual limb and the prosthetic socket (Figure 3).

Weight bearing is accomplished directly through the end of the residual limb in knee disarticulations (A) and Syme ankle disarticulations (B). amputations. Indirect load transfer is required in transfemoral amputations. This is accomplished with either a standard quadrilateral socket (A) or an adducted, narrow, medial-lateral socket (B). The transtibial amputation socket (C) transfers weight indirectly with the knee flexed approximately 10°. SECTION 1 GENERAL ORTHOPAEDICS AMPUTATIONS OF THE LOWER EXTREMITY direct force at the end.

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