Girdlestone Resection Arthroplasty

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Original Editor - Kirsten Coutts

Top Contributors - Kirsten Coutts and Lucinda hampton  

History

This surgical procedure was first described by an English Orthopaedic surgeon, Gathorne Robert Girdlestone in 1928. The procedure has been known by his name ever since. It was first used for chronic septic arthritis of the hip, mostly arising from Tuberculosis. As there was not yet good access to antibiotics and arthroplasty, this procedure was used to resect the femoral head, to relieve the pain and source of infection.

The method and techniques used have evolved over time.

Also referred to as : Hip resection arthroplasty, Girdlestone excision arthroplasty of Hip, Girdlestone procedure and Femoral head ostectomy.

Description of procedure and Indications

The first documented surgery of this kind, in 1928, involved radical excision of the femoral head and neck to drain the tuberculous hip. A transverse incision of 5-6 inches (12-15cm) long with its centre near the greater trochanter is made, which exposes the gluteal muscles and fascia. All deep tissues, including greater trochanter and the gluteal muscles are removed. A transfer wedge is removed to allow the surgeon access to the joint and surrounding area. All decayed bone and septic debris is removed. The cavity is packed with gauze wicks and rubber drains to ensure drainage and control secondary granulation. The skin flaps are drawn back and stitched into the periosteum to prevent sinus-track from forming, to reduce the pain of dressings and allowing covering of the raw areas with excessive granulation.The subcutaneous and muscle tissues are largely covered, decreasing the granulating surface. Lastly, a spica splintage was fitted for the patient. The 3 main goals of this surgery was to remove dead and devitalised tissues, flatten down dead spaces, and allow drainage so the wound would heal from the bottom.

The surgery described above is mostly no longer used thanks to modern medicine, lower tuberculosis prevalence and better infection control measures. It is however still used as a salvage procedure in many cases such as :

• Patients where mobility is poor - such as non-ambulatory cerebral palsy patients who often have persistent pain and chronic hip dislocation and subluxation . This allows pain relief, improvement of sitting balance and better perineal care.
• Patients where bone or soft tissue coverage is not strong enough to insert a new prosthesis
• Patients with severe comorbidities who are unfit for surgery
• Patients where infection cannot be controlled
• Patients with cognitive impairments such as Dementia, who may not follow hip advice and precautions post THA.
• Recurrent hip dislocations
• Patients with hip fractures in developing countries who do not have access to THA and modern surgical techniques

Total hip arthroplasty(THA) gained success in the 1960s when it was developed by Sir John Charnley. Since then it has evolved and is now one of the fastest growing orthopaedic procedures worldwide.

One of the main causes for hip arthroplasty failure leading to Girdlestone resection arthroplasty (GRA) , is prosthetic joint infection (PJI). PJI after THA is an increasing and severe complication. The main concern of a THA is infection. In these cases, the hip prosthesis is removed without replacement. An incision is made though the fascia lata and gluteal muscles, the joint capsule is released and the femoral stem is removed. The bone marrow is cleaned and flushed and the wound is closed with a drain inserted. Various approaches are used by different surgeons, under spinal or general anaesthesia. The posterolateral approach is most commonly used because of the nearly circumferential exposure of the acetabulum and the ability to displace the femoral component. This leaves only a crude articulation between femur and acetabulum. The proximal femur migrates 5-10cm cranially, and finds support at the abductor muscles. It also exorotates due to the shape of the pelvis. The patient is left with a leg length discrepancy (LLD).

The second option available is to use GRA as part of a two-stage revision arthroplasty, whereby a new prosthesis is fitted. This is less viable in many cases, due to many patients with GRA being older and having multiple comorbidities. The average age of GRA is 72 years.

Indications

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Clinical Presentation

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Diagnostic Tests

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Pre-Op

Functional outcome and quality of life after GRA is often impaired due to limb shortening, pain, hip instability and an inevitable need for a walking aid

Post-Op

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Resources

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