Girdlestone Resection (Excision) Arthroplasty of the Hip

What the operation is. A Girdlestone resection (excision) arthroplasty removes the femoral head and neck and debrides the acetabulum, leaving a flail, shortened but pain-controlled hip. It is a salvage operation: it trades a painful, infected or non-reconstructable joint for pain relief and infection control at the price of a permanent functional deficit. It is used either as definitive treatment or as an interim measure before later conversion. Absolute indications

• Uncontrolled or recurrent periprosthetic joint infection (PJI) after failed debridement, antibiotics, and implant retention (DAIR) or one-stage revision
• Multiply-revised total hip arthroplasty with non-reconstructable bone loss (Paprosky IIIB or IV acetabulum, severe femoral deficiency)
• Native hip infection (septic arthritis, tuberculous hip) with destroyed femoral head and acetabulum in a medically frail patient
• Non-ambulatory or household-ambulatory patient with a painful, stiff hip where reconstruction risk outweighs benefit Relative indications
• Failed antibiotic cement spacer with persistent infection and a patient unwilling or unfit for further staged reconstruction
• Massive heterotopic ossification causing ankylosis and pain after previous surgery
• Pathological fracture of the femoral neck or acetabulum in a patient with limited life expectancy
• Patient preference for definitive single-stage salvage after full counselling about functional trade-offs Contraindications
• Absolute: active systemic infection or sepsis (stabilise medically first); a patient who is a candidate for two-stage revision but refuses further surgery without understanding the consequences; a high-demand ambulatory patient who has not exhausted reconstructive options
• Relative: adequate bone stock and soft tissues for conversion to THA or hip fusion (consider these first); a patient with unrealistic expectations about post-operative mobility Patient selection is everything. The ideal candidate is a low-demand, non-ambulatory or household-ambulator patient with uncontrolled infection who cannot tolerate further reconstruction. Ambulatory patients must be counselled in detail about the permanent functional deficit — they will not walk normally again — before this option is chosen. Approach selection. Two approaches are used, each with a distinct rationale:
• Posterior (Moore-Southern) — preferred for infection cases requiring extensive posterior column and ischial debridement, and gives excellent exposure of the sciatic nerve.
• Direct lateral (Hardinge) — preferred when abductor preservation is prioritised and anterior acetabular access is adequate; it preserves the posterior capsule but risks abductor detachment. Consent points. Permanent leg shortening (3-6 cm), a Trendelenburg gait requiring a walking aid, risk of sciatic or femoral nerve injury (1-3%), heterotopic ossification (15-30%), infection persistence (10-20%), and the possibility of later conversion to THA (30-50%).

The goal is to expose the hip, remove the femoral head and neck flush with the intertrochanteric line, thoroughly debride the acetabulum, interpose healthy soft tissue, and apply traction in theatre — all while protecting the sciatic nerve, the femoral neurovascular bundle and the abductor mechanism. The exposure is laid out as the first steps of the sequence below (and in depth on the posterior (Moore-Southern) approach and direct lateral (Hardinge) approach pages).

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Rehabilitation | Phase | Timing | Mobilisation & traction | Therapy focus | |-------|--------|-------------------------|---------------| | 1 | Day 0-21 | 5-7 kg longitudinal skeletal traction; hip in slight abduction, neutral rotation; wheelchair only, no weight-bearing | Ankle pumps and quadriceps sets hourly; DVT prophylaxis (LMWH or DOAC) for 6 weeks | | 2 | Weeks 3-6 | Reduce traction by 1 kg per week; transition to abduction pillow or skin traction | Gentle passive hip ROM (flexion less than 70 degrees, abduction 20 degrees); continue wheelchair | | 3 | Weeks 6-12 | Traction removed; progress to partial weight-bearing with crutches or walker | Abductor strengthening and gait training; assess conversion candidacy at 3 months | | 4 | Long-term | Most patients need a walking aid permanently; shoe lift 2-4 cm | Annual clinical and radiographic review for HO and proximal migration | Infection surveillance continues throughout: daily wound inspection, CRP on days 3, 7, 14 and 21, and culture-directed intravenous antibiotics for 6 weeks if a spacer is present or infection is confirmed.

Conversion to total hip arthroplasty Conversion is possible in 30-50% of patients who regain bone stock and abductor function. The prerequisites and plan: - Selection: resolution of infection (normal CRP, negative aspiration); adequate bone stock (Paprosky I-II acetabulum, sufficient femoral length); recoverable abductor function (gluteus medius strength 4/5 or better); a motivated patient who understands staged soft-tissue procedures may be required.

• Pre-operative lengthening: if shortening exceeds 4 cm, gradual soft-tissue lengthening with traction or an external fixator for 4-6 weeks before THA.
• Technical considerations: acetabular reconstruction often needs augments or structural graft; femoral reconstruction may need a modular or cemented stem with distal fixation; a dual-mobility or constrained liner is recommended because of abductor insufficiency.
• Staged approach: first stage soft-tissue release and length restoration; second stage definitive THA 3-6 months later.
• Outcomes: Harris Hip Score improvement of 30-40 points in selected series; infection recurrence 5-10%; dislocation rate 10-15% despite constraint; overall satisfaction 70-80% when patient selection is appropriate. Complications

Historical context and modern role. Girdlestone originally described the procedure in 1943 for tuberculous hip disease. In the modern era it serves as both a definitive salvage and an interim measure before later conversion. Contemporary series report pain relief in 70-85% of patients, but functional outcomes are modest and highly dependent on patient selection and adherence to the post-operative traction protocol. Bony anatomy and resection landmarks. The femoral head and neck are excised to the intertrochanteric line, which runs from the greater trochanter anteriorly to the lesser trochanter medially. Resection proximal to this line leaves a residual neck that impinges and blocks later reconstruction; in selected cases of massive proximal femoral bone loss, resection 1 cm distal to the lesser trochanter may be required. The acetabulum is debrided of all cartilage, infected membrane and necrotic bone, while the transverse acetabular ligament and posterior wall are preserved as landmarks for potential future cup placement. Soft-tissue envelope and interposition options. Several structures can be interposed between the resected femur and acetabulum: the posterior capsule and short external rotators elevated as a flap; the gluteus medius detached from the greater trochanter and sutured into the acetabulum or over the femoral stump; the vastus lateralis reflected proximally as a muscle flap in lateral approaches; and the tensor fascia lata for additional lateral coverage. Interposition reduces direct bone-on-bone contact, decreases heterotopic ossification and cushions weight-bearing attempts. Neurovascular structures at risk.

• Sciatic nerve (posterior approach): exits the greater sciatic notch and lies on the posterior surface of the quadratus femoris and adductor magnus; identified and protected during posterior capsular release and ischial debridement.
• Femoral nerve and vessels (anterior): lie anterior to the iliopsoas tendon; anterior capsular release must stay lateral to the iliopsoas to avoid injury.
• Superior gluteal nerve (lateral approach): enters the gluteus medius 5 cm proximal to the greater trochanter; the lateral split must not extend more than 5 cm proximally to avoid denervation. Abductor mechanism. The gluteus medius and minimus insert on the greater trochanter. In the lateral approach they are split or elevated; in the posterior approach they remain attached. Post-operative abductor function determines whether the patient can achieve a stable gait or will require permanent walking aids. Key evidence. Contemporary retrospective series confirm hip resection arthroplasty as a viable definitive salvage with reliable infection eradication and pain relief but a substantial functional deficit, with low conversion rates requiring careful patient selection. Comparative work shows differential microbial profiles and survivorship between native septic arthritis and prosthetic joint infection cases, and long-term series of mesh-supported Girdlestone demonstrate durable infection eradication and pain relief at 5 years in high-risk patients.