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. This procedure continued to be used widely for hip infections and also for complex fractures following gunshot wounds.

The method and techniques used for this surgery 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 eg asthma and Chronic Obstructive Pulmonary disease
• 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/hip prostheses
• Patients with femoral head osteonecrosis -when there is a high surgical and anaesthetic risk factor
• Patients with hip fractures in low-resource developing countries who do not have access to THA and modern surgical techniques. A study done by Stephane et al in 2020, looked at 3 cases of destroyed proximal femurs from gunshot wounds, in a conflict zone in DR Congo. It concluded that GRA was an effective treatment option and showed good functional results. It restored the patients indepence, and was deemed a safe, reliable and low-complication surgical procedure.
• Patients with poor post-operative prognosis

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. 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.

Clinical Presentation

As there are many different indications for this surgery, this will depend on each case. One can expect:

1. Hip pain and possible instability
2. Hip infection
3. Reduced mobility and reliance on walking aids
4. Reduced ability to complete activities of daily living
   

Diagnostic Tests

X-rays and Magnetic Resonance imaging (MRI) are used to assess the injury and to plan the surgery. Surgeons will also do blood work to check for infection markers, clotting factors and the general health of the patient prior to surgery.

Pre-Op

Pre-Op advice from a Physiotherapist will be very important, ideally starting to establish the therapeutic relationship. It will be important to explain what the patient can expect after surgery and when the Physiotherapist will see the patient post-operatively and begin to mobilise. Explanation of possible reduced weight bearing status and management of pain prior to this will keep the patient informed and know what to expect after surgery.

Post-Op

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Resources

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