Girdlestone Procedure (Excision Arthroplasty)

The Girdlestone procedure (excision arthroplasty) involves resection of the femoral head and neck without replacement. Originally described by Gathorne Robert Girdlestone for tuberculosis of the hip, it is now primarily used as a salvage procedure for periprosthetic joint infection (PJI) when other options have failed or are contraindicated.

A painful or failing hip arthroplasty is not always infected. Distinguishing PJI from aseptic causes is the pivotal decision before resection — an unnecessary Girdlestone for aseptic loosening is a catastrophic error.

The topic states that "abductor function determines stability", that "excessive bone resection results in proximal migration and worse function", and that only 50-60% are ambulatory - but never explains what the surgeon controls that separates a stable, walkable pseudarthrosis from a flail, painful, non-ambulatory one. This is the high-yield "why" behind the outcome figures.

• Resection level is the single biggest surgeon-controlled variable. The femur is resected only as far distal as infection/removal demands - conserving length keeps the femoral stump abutting the ischium/ilium rather than riding high. A high resection (short stump) allows greater proximal migration, worsens the lever arm and produces a longer, more unstable limb-shortening; a more distal, length-preserving resection (consistent with clearing the infection) gives a shorter migration and a more stable articulation. The 4-6 cm shortening is the price; making it worse than necessary is avoidable.
• The abductor lever arm is what powers gait. A pseudarthrosis is stabilised dynamically, not by bone - so an intact abductor complex on a preserved greater trochanter lets the patient generate a functional (if Trendelenburg) gait, whereas a detached/non-viable trochanter or a deficient abductor mass produces a flail hip, a lurching or non-functional gait and aid-dependence or wheelchair use. Preserving the trochanter and its attachment whenever it is viable is therefore a functional imperative, not a cosmetic one.
• Soft-tissue interposition and scar create the fibrous articulation. A broad, well-vascularised soft-tissue envelope between the proximal femur and pelvis (capsule remnants, vastus/glutei, sometimes a formal muscle interposition) matures into a stable fibrous pseudarthrosis and cushions the bone-on-bone contact that causes pain; extensive dead space or a bare femoral stump against pelvis gives instability and pain.
• Host and disease factors set the ceiling. Even with perfect technique, bilateral disease, poor abductors from prior surgery, neuromuscular disease, uncontrolled pain and low functional reserve cap the achievable result - which is why the honest counselling figure is "50-60% walk, with aids".

The topic repeatedly frames the procedure as "interim" before reimplantation and contrasts "definitive" with "staged", but never describes the conversion operation itself - taking a healed excision arthroplasty back to a THA is a distinct, difficult undertaking that examiners probe, and its difficulty is exactly why definitive Girdlestone is sometimes accepted.

• When it is done, and the prerequisites. Conversion is considered once the infection is truly eradicated (normalised inflammatory markers, negative aspirate/intra-operative samples, an interval off antibiotics) in a host now fit and motivated for a major reconstruction. It is the "second stage" that a spacer was meant to facilitate - and the longer the hip has been left as a bare Girdlestone (no spacer), the harder it becomes.
• The soft tissues are the enemy. After months of a shortened, migrated hip the abductors and capsule contract and scar, the femur sits proximal, and restoring length re-tensions a chronically shortened neurovascular envelope - so conversion carries a real risk of sciatic/femoral nerve traction injury when length is regained, and full LLD correction is often not achievable in one sitting. Heterotopic bone and dense scar further obscure planes.
• Bone stock and fixation are compromised. Repeated debridements and the original resection leave deficient femoral and acetabular bone, frequently needing revision/reconstruction implants (long stems, cup-cage/augments, sometimes a proximal femoral replacement) rather than a primary THA.
• Abductor deficiency drives instability - the dominant complication. The scarred, shortened, often-deficient abductor mechanism makes the converted hip prone to dislocation, so constrained or dual-mobility bearings are frequently used; overall complication, dislocation and re-infection rates are markedly higher, and functional outcomes poorer, than a primary THA - though still usually better than a retained Girdlestone in a suitable host.

Hip PJI affects roughly 1-2% of primary and up to 4-5% of revision total hip replacements worldwide. As arthroplasty volumes rise, the absolute burden of PJI is growing, and resection arthroplasty persists as the salvage of last resort across all health systems.