Femoral head and neck excision as definitive or interim salvage for uncontrolled infection or non-reconstructable hip | advanced
Surgical Imaging
The trap: Leaving residual femoral neck or calcar (resection too proximal) creates a painful bony prominence that impinges on the acetabulum or soft tissues and prevents later reconstruction.
The fix: Resect the femoral head and neck flush with the intertrochanteric line (or 1 cm distal to the lesser trochanter in selected cases). Confirm under direct vision and with image intensifier that no residual neck remains. This level maximises bone stock for potential future conversion while removing all infected or necrotic bone.
Location: The sciatic nerve lies immediately posterior to the quadratus femoris and is at risk during posterior capsular release and debridement of the posterior column.
Risk: Excessive medial retraction or blind dissection posterior to the femur can cause permanent foot-drop. Identify the nerve early, protect it with a vessel loop or retractor, and avoid medial dissection beyond the ischium.
Location: In the direct lateral (Hardinge) approach the gluteus medius and minimus are split or elevated from the greater trochanter.
Risk: Poor repair or excessive stripping leads to permanent abductor insufficiency and a worse Trendelenburg gait than the procedure itself would cause. Limit the proximal split to 5 cm above the trochanter and repair the abductors meticulously with transosseous sutures or anchors.
Location: The femoral neurovascular bundle lies anterior to the iliopsoas and is at risk if anterior capsular release or acetabular debridement extends too far medially.
Risk: Inadvertent injury during anterior capsulotomy or acetabular rim debridement causes catastrophic bleeding or nerve palsy. Stay lateral to the iliopsoas tendon and use a Cobb elevator to protect the bundle during anterior exposure.
Location: Without adequate post-operative traction the femur migrates proximally 4-8 cm within weeks, creating a functionally useless leg.
Risk: Early removal of traction (less than 3 weeks) or insufficient weight (less than 5 kg) leads to severe shortening, pelvic obliquity, and inability to sit or stand comfortably. Maintain 5-7 kg traction for a minimum of 3 weeks, then wean gradually.
Location: Exposed bone and muscle trauma stimulate prolific heterotopic bone formation around the resection site.
Risk: Bridging HO between the acetabulum and femur causes ankylosis and pain. Perform meticulous soft-tissue interposition (gluteus medius or vastus lateralis flap) and consider prophylactic indomethacin or radiation in high-risk patients (previous HO, extensive dissection).
G.I.R.D.L.E.S.T.O.N.E.GIRDLESTONE — Core Principles
T.R.A.C.T.I.O.N.POST-OP TRACTION — Protocol Essentials
Surgical Indications
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 painful, stiff hip where reconstruction risk outweighs benefit
Relative Indications
- Failed antibiotic cement spacer with persistent infection and 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)
- Patient who is a candidate for two-stage revision but refuses further surgery without understanding the consequences
- 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)
- Patient with unrealistic expectations about post-operative mobility
Evidence for Girdlestone Resection Arthroplasty
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 post-operative protocol.
Key Evidence
Poor Outcomes of Girdlestone Resection Arthroplasty in Injection Drug Users: A Retrospective Study
Is hip resection arthroplasty a successful definitive treatment?
A comparative analysis of microbial pathogens and survivorship between native and prosthetic hips following Girdlestone resection arthroplasty
Spacer-free but prolene mesh-supported girdlestone resection arthroplasty achieves reliable infection eradication and pain relief in high-risk patients: 5-year outcomes
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 72-year-old man with a multiply-revised total hip arthroplasty presents with a draining sinus and positive culture for Staphylococcus epidermidis. Two-stage revision is discussed but the patient has significant medical comorbidities (COPD, heart failure) and states he 'cannot face another two operations'. What is your recommendation and how do you counsel him?”
“You have performed a Girdlestone resection via the direct lateral approach on a 65-year-old woman for failed two-stage revision. At 6-week review she has a pronounced Trendelenburg gait and cannot abduct her hip against gravity. What has likely occurred and how do you manage it?”
“A 58-year-old man underwent Girdlestone resection 14 months ago for native hip tuberculosis. He has been infection-free for 12 months (normal CRP, negative aspiration) and now requests conversion to total hip arthroplasty because he finds the short leg and limp unacceptable. How do you evaluate and plan his conversion?”