Girdlestone procedure is excision arthroplasty of the hip in which femoral head, neck, proximal part of the trochanter and the acetabular rim are removed. The procedure was described for chronic deep-seated infections of the hip joint.
After the surgery patient is put on skeletal traction followed by gradual mobilization.
Girdlestone procedure also goes by name of excision arthroplasty of the hip, femoral head ostectomy or Girdlestone resection arthroplasty is an excision arthroplasty of the hip.
Xray Pelvis Showing Hip After Girdlestone Excision Arthroplasty
Girdlestone procedure inevitably results in limb shortening.
The procedure was developed by British surgeon Gathorne Girdlestone as a lifesaving measure to remove disease and devitalized tuberculous hips in the pre-antibiotic era. The year was 1943.
Indications for Girdlestone Procedure
Indications of Girdlestone procedure are
- Painful stiff hip after tuberculosis of hip
- Peri-prosthetic infection
- Aseptic loosening of hip
- Recurrent dislocation of the hip
- Failed internal fixation of femoral neck fractures
Details of Girdlestone Procedure
Intraoperative Details
- In regional or general anesthesia, pt in supine or lateral position, as preferred by surgeon and approach.
- Hip is exposed through the anterolateral or anterior incision.
- After hip is exposed, the capsule is incised and an attempt is made to dislocate the hip joint anteriorly but this is difficult in some cases, especially when there is ankylosis.
- Where dislocation is not possible femoral neck is cut at the base and removal is done piecemeal
- In cases where dislocation could be achieved, the resection of the neck is done after the dislocation.
- The line of the bone section was kept parallel to and a little proximal to the intertrochanteric line.
- In cases of infection, other diseased tissues are removed as well. Any sharp projecting bone is cut and blunted.
- The wound is closed over a suction drain.
Postoperative Details
The patient is put on skeletal traction in 30 to 50 degrees of abduction. The traction is kept for 3 months. The patient is encouraged to sit soon after the operation, and repetitive active assisted movements of the hip and knee are started during the first week.
Active physiotherapy and exercises in traction help patients to develop good muscle power, the maximal range of hip movements.
After traction, the patient is encouraged to bear weight and use hip for squatting and sitting cross-legged.
The weight is borne using a weight-relieving caliper and crutches which is continued for 6-9 months. After that, walking with a walking stick is started.
Traction and bracing during walking keeps cut the upper end of the femur and the outer surface of acetabulum apart from one another. This allows an adequate layer of fibrous tissue is more likely to form over both. This thereby providing more ideal surfaces for a pseudarthrosis.
Outcome of Girdlestone Procedure
Shortening of the limb is inevitable with Girdlestone procedure. The mean loss of length by this technique is 1.5 cm. For optimum results regimen of postoperative care is essential.
Some degree of shortening and instability are virtually unavoidable.
Overall, Girdlestone arthroplasty provides an unstable pain-free hip.
The walking and standing tolerance vary from patient to patient. Some degree of telescoping of the limb and a tendency toward external rotation are not uncommon. At times the degree of function is good.
Excision arthroplasty may rarely leave behind a very unstable hip joint. This generally happens where the disease has healed with minimal fibrosis and scarring of the capsule and soft tissues.
Such patients may require hip stabilization procedures may be done 3 to 6 months after the Girdlestone operation.
The acceptance of Girdlestone procedure is more in people who are accustomed to floor level activities like squatting and sitting cross-legged.
Girdlestone procedure is mostly done for the tubercular hip. But there is an increasing trend towards performing replacement surgery in these patients.
Replacement surgery is more acceptable procedure across the races as it provides stable, pain-free hip, with functions close to the original hip.
As the drugs become more effective and revision arthroplasty yielding better results, in cases of infected prosthesis antimicrobial, definitive excision arthroplasty has become a salvage operation.
It is generally reserved for those with significant co-morbidities or in cases where the revisions have repeatedly failed.
The trend of Girdlestone procedure is declining but it remains a valuable surgery in select cases.
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tarun rathi says
July 6, 2017 at 11:05 amGreat work
Dr Arun Pal Singh says
July 9, 2017 at 10:31 amThank you.
Dr. K. M. Ojha says
September 28, 2017 at 4:17 pmGood effort. Keep it up ! ????
Dr Arun Pal Singh says
October 9, 2017 at 3:48 pmThank you Dr KM Ojha.
John Peel says
October 22, 2017 at 8:44 pmI just Had a Girdlestone Procedure a week ago and They didn’t put me on skeletal Traction, IS this going to create a problem? Will I be able to walk normally or will I still have a bad limp with pain
Dr Arun Pal Singh says
October 26, 2017 at 1:11 pmJohn Peel,
We do follow Girdlestone procedure with skeletal traction. That is how procedure has been described and done at all the centers I did attend. Whether there is some recent evidence to the contrary, I am not aware. Still I would look up and let you know in due course.
Meanwhile, you can have a discussion with your treating doctor.
Addendum:
I checked and found studies reporting that they found no difference in functional outcomes or limb shortening between the patients who underwent skeletal traction for 3 weeks and those who had early mobilization without skeletal traction.
I hope that helps
Ishaq Khan says
November 13, 2017 at 12:22 pmHello Dr my father had a gridle stone arthroplasty one month back Doctors initially advised him to THR but there was some failed K NAIL which they couldn’t removed now my dad has been kept under traction from past one month with 3 Kg. Could you please confirm as how much time it will take to walk with a suitable crutch support and without support.
Awaiting for your response
Dr Arun Pal Singh says
December 12, 2017 at 11:57 amIshaq Khan,
Hem may take anytime between 3-4 months to walk with support. Gradually he might leave the support though that is not advised.
Take care.
Sam Price says
October 10, 2018 at 10:22 pmMy friend underwent a left hip Girdlestone aratroplasty with tendon releases in July 2018.
He was not placed on a skeletal traction nor sent to rehab instead he was discharged 4 days later to come to his residential home.
On October 5, 2018 he had a right hip fracture. He did not fall or sustained any injuries..
Please can you help me understand how this could happen??
Dr Arun Pal Singh says
October 16, 2018 at 11:54 amIt is impossible to imagine what causes injury in case a clearcut history of trauma is present.
Was he walking?
If so then forces that act on hip could result in the fracture especially when the hip is weak. If the hip is weak even an action like standing from a sitting position may result in a break and further forces cause further injury.
A sudden twist or jerk during walk may also be responsible.
A discussion with the doctor who is seeing him might help you further.
Take care.
Patricia says
October 25, 2018 at 9:42 amDear Dr. Singh
My uncle had a girdlestone procedure in May 2017 because of two failed ortho procedures to repair a fractured femur. .Due to his age(88) he is basically bedridden, however today I noted that the affected thigh is much larger than the normal leg and he experienced pain when I moved the leg. He is diabetic but I was wondering that after one year five months the healing process would have been over.His temperature is normal so I do not think he has an infection and the thigh feels normal to touch – no redness or hotness.
Any suggestions or ideas as to what could be happening? Intend to ask his doctor if an ultrasound or x-ray would help to clarify.
Thanks in advance.
Dr Arun Pal Singh says
October 25, 2018 at 11:45 amA swelling should be examined and investigated. In old age and immunocompromised states such as diabetes, it is not always necessary to have systemic symptoms like fever etc. Moreover, not all local infections have identifiable systemic features.
I am not saying it is an infection. I am just pointing that the premise on which you assured yourself that infection is absent may not entirely hold.
Please get him examined and investigated.
Take care.
Rena says
January 8, 2019 at 11:35 pmmy son recently had this girdle stone procedure done and the incision is not healing. It continues to bleed, Is this normal? It has been 16 days.
Dr Arun Pal Singh says
January 9, 2019 at 12:50 amRena,
Generally, there seems an issue with wound healing. It is not a normal occurrence.
Please discuss with the treating doctor.
Take care.
Brittany Gilman says
January 19, 2019 at 3:09 pmi had a girdlestone procedure done two years ago i was wondering how possible it is to get a hip replacement so i can walk normal again now that i am allhealed up and walk without any support but i limp
Dr Arun Pal Singh says
January 22, 2019 at 2:47 pmTechnically, it is possible but if Girdlestone was done for infection, there is always a chance of recurrence of infection which could jeopardize the results.
Please consult a replacement surgeon near you to get an individual assessment.
A replacement after infection was big NO till recently. However, people are doing it with successful short term results but it is important to gauge what happens in long term before the procedure is widely accepted.
So do enquire if your surgeon is comfortable with such surgeries.
Liz says
April 8, 2019 at 11:33 pmMy mom is 87 years old. She had hip replacement surgery 24 years ago. In Dec and Jan her hip dislocated 4 times. She went in for revision surgery and that completely failed. Doctor scheduled four hours for complete pelvic replacement and then changed his mind, performed girdlestone procedure instead – said bones too brittle. She’s absolutely miserable. She was in rehab for a month. Her wound is still draining. They put a 3 inch lift on her shoe. She still doesn’t put full weight on the left and now everything else hurts because she’s compensating. Do you think it’s worth getting a second opinion? She’s healthy besides hip issue. Are there options if her bones are really that bad?
Dr Arun Pal Singh says
April 10, 2019 at 11:43 amLiz,
You can always take a second opinion. A doctor in person would be able to guide you better and probably help you objectively understand the reasons behind the decision for Girdlestone.
Girdlestone does alter the Gait mechanism [forces that act during walking] and other parts, as you said, are brought in for compensations.
A replacement, on the other hand, provides better biomechanics.
If her bone are too fragile, there are options of augmentation. But if that could be applied to a particular individual has to be decided by the treating doctor.
Meanwhile, to ease her movement, a wheelchair can be considered for occasional use. That would also help to reduce pain and associated anxiety for making better treatment decisions.
All the best.