ARTICLE IN PRESS

Current Orthopaedics (2005) 19, 385–392

www.elsevier.com/locate/cuor

HIP

Girdlestone resection arthroplasty of the hip:

Current perspectives
H. Sharma, C.R. Dreghorn, E.R. Gardner

Victoria Infirmary, Glasgow G42 9TY, UK

KEYWORDS Summary Modern technological advancements in revision hip arthroplasty have

Girdlestone revolutionised the treatment of failed primary total hip replacements. The decision
operation; to perform a Girdlestone operation is taken as a last resort, particularly for
Resection medically sub-optimal and functionally compromised patients, who have a high
arthroplasty; anaesthetic and operative risk at one-stage and two-stage reimplantations.
Excision Girdlestone resection arthroplasty should be considered as a salvage procedure,
arthroplasty; primarily aimed at pain relief and infection control. Such patients must be warned to
Hip expect 2–3 in of limb shortening and reliance upon a walking aid postoperatively.
& 2005 Elsevier Ltd. All rights reserved.

Introduction There are several retrospective studies published

With an increase in life expectancy, the number of
patients with primarily replaced and revised hips is
increasing dramatically. Although, revision total hip
arthroplasty has revolutionised the treatment of
failed primary total hip replacements, medically
sub-optimal and functionally compromised patients,
who have a high anaesthetic and operative risk, may
not be suitable for any further major interventions,
especially one-stage and two-stage reimplantations.
In such cases, Girdlestone resection arthroplasty
(i.e. removal of prosthesis and/or cement) is
considered to be an acceptable salvage option.
Corresponding author. Tel.:+44 141 639 3697;
fax: +44 141 201 5082.
E-mail addresses: hksharma1@aol.com (H. Sharma),
clark.dreghorn@gvic.scot.nhs.uk (C.R. Dreghorn),
eric.gardner@gvic.scot.nhs.uk (E.R. Gardner).
on long-term outcome of this salvage procedure,
mainly infected total hip arthroplasty with variably
reported results.1–10 The indication for the Girdle-
stone operation has now become a salvage proce-
dure. This article is an overview of Girdlestone
resection arthroplasty of the hip with special
regard to indications, patient selection, surgical
technique, mortality and morbidity characteristics,
outcome analysis and prognostic factors influencing
outcome.
Historical perspectives
The first report of resection arthroplasty (removal of
the head and the neck of femur) as a treatment for
septic arthritis of the hip was published by White in
1849.11 In 1928, Gathorne Robert Girdlestone

0268-0890/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cuor.2005.06.005
 ARTICLE IN PRESS
386
(1881–1950), an orthopaedic surgeon from Oxford,
described a similar procedure for the tuberculous
hip joint.11 In 1943, Girdlestone popularised it for
the treatment of late septic arthritis. Girdlestone
himself did not report any long-term functional
results.
In 1945, Batchelor recommended dividing the
femoral neck distally, flush with the lesser trochan-
ter, to achieve smooth surfaces. He observed that
irregular osseous spurs or prominences might cause
considerable pain with motion. He also advocated
performing an abduction osteotomy in conjunction
with the resection of the femoral head and neck to
improve stability.11 The modern Girdlestone proce-
dure predominantly consists of removal of the
prosthesis and/or cement following septic and
aseptic loosening of total hip arthoplasty or hemi-
prosthesis.11
Types of girdlestone resection
arthroplasty
The Girdlestone procedure can be described into
two main categories:
Primary
Performed for primary hip disorders like septic hip,
tuberculous hip, and rarely for osteoarthritis and
rheumatoid arthritis.
Figure 1 Early Girdlestone for septic total hip arthroplasty.
H. Sharma et al.
Secondary or modified
Used for failed hip replacements or failed con-
struction after hip trauma (Figs. 1 and 2).
For all practical purposes, any Girdlestone
procedure performed nowadays can be considered
as a secondary or modified Girdlestone procedure.
Why resection, why not revision?
The modern Girdlestone operation involves the
removal of the prosthesis and/or cement following
septic or aseptic loosening of a total hip prosthesis,
hemi-prosthesis or a failed osteosynthesis. It has
proved to be an effective salvage procedure, for
controlling pain and infection. With the advance-
ments in revision hip technique and technology,
Girdlestone resection arthroplasty is rarely indi-
cated as a primary procedure. It is a salvage
procedure, and it should not be considered as an
alternative to one- or two-stage reimplantations.
Indications include infective and aseptic loosen-
ing of total or hemi-arthroplasties, recurrent
dislocations and un-united operated femoral neck
fractures.
Girdlestone pseudarthrosis may also be consid-
ered as the first stage of a two-stage revision. The
decision to perform a resection arthroplasty with-
out reimplantation of a second prosthesis is based
upon multiple factors. Important considerations
include infection with multiple organisms or bac-
teria resistant to antibiotic therapy, poor quality
 ARTICLE IN PRESS
Girdlestone resection arthroplasty of the hip: Current perspectives
Figure 2 Late Girdlestone with proximal migration of
greater trochanter nearly abutting against lower ilium.
Table 1 Indications for resection.
Infection with multiple organisms or bacteria
resistant to antibiotic therapy
Poor quality local soft tissues
Unacceptable complexity of any possible
reconstruction
Refusal by the patient to have another operation
after removal of the implant
Patients with systemic disease or poor overall
health
Inadequate bone stock
Or combinations of these factors
local soft tissues, unacceptable complexity of the
reconstruction, refusal by the patient to have
another operation after removal of the implant,
and patients with systemic disease, poor overall
health, inadequate bone stock or combinations of
these factors.12,13 The problem of repeated opera-
tions, prolonged morbidity, intercurrent illnesses
and repeated invasive investigations after an
infected prosthesis leads to depression and dis-
satisfaction. Table 1 therefore summarises the
circumstances when resection may be the appro-
priate option.
387
Surgical technique of girdlestone
procedure
A standing anteroposterior radiograph of the pelvis
should be taken to plan the resection. The role of
preoperative traction is debatable. A direct lateral or
posterior approach through the previous scar should
include the excision of any sinus or scar. Iliopsoas
tenotomy and/or adductor tenotomy may be re-
quired. Femoral preparation comprises removal of
the prosthesis (with or without trochanteric osteot-
omy), removal of cement and smoothing of the
transected femoral surface. Utmost care should be
observed to prevent femoral shaft fractures intrao-
peratively. Tissue specimens should be sent for both
bacteriology and histology. Acetabular preparation
consists of the removal of the prosthesis and cement.
Primary wound closure is preferred even in infected
cases.14 Intra- and immediate postoperative blood
loss may vary from 1 to 5 l.
Radiographic classification
Grauer et al.11 described four possible levels of
proximal femoral resection:
Type I—a substantial portion (41.5 cm) of the
femoral neck remains, usually performed for
failed resurfacings,
Type II—a small portion of the femoral neck
remains (1.5 cm or less),
Type III—intertrochanteric resection,
Type IV—sub-trochanteric resection.
The obvious clinical implication of this classifica-
tion is that the more proximal the resection, the
better is the overall function, walking and activity
of the patient. Contrary to this observation, no
correlation could be found between the radiologi-
cal appearances and the quality of the result in
some studies.15,16
Overall outcome
Girdlestone arthroplasty patients cannot be as-
sessed with the usual parameters routinely applied
for hip evaluation.3 The functional outcome in
previous studies on Girdlestone arthroplasty is
illustrated in Table 2. The reported results of
Girdlestone arthroplasty are not uniform. Satisfac-
tory results have been reported by Campbell
et al.,19 Mallory,21 Ahlgren et al.,17 Grauer
et al.,11 Bohler and Salzer18 and Castellanos
 ARTICLE IN PRESS
388 H. Sharma et al.

Table 3 Favourable outcome determinants with

Girdlestone resection arthroplasty.

Sharma
et al.23

88.88%

77.77%
Old patient (Marchetti et al.,3 Bittar and Petty22

94.4%
100%
found poor results in younger patients)

18

—
Male
Unilateral16
Healed wound5
Esenwein

Non-diabetic (Rittmeister et al.27 found poor

et al.2

results in diabetics)

81.5

59.3
100
5.2
27
— Smooth inter-trochanteric line5
Summary of the functional outcome with Girdlestone resection arthroplasty of the hip in the previously published studies.

No cement left in the femoral canal1,27. Contrary

paper by Ballard et al.15
Castellanos

Less limb shortening/conservative proximal

et al.20

femoral resection11
100

Reduced level of expectation

4.1
78
83
86

83
Unfavourable preoperative condition with strong
pain or persistent infection
et al.12
Bourne

et al.,20 while poor outcomes were recorded Clegg,1

33
91
97
85

79
4

Petty and Goldsmith,5 Bittar and Petty,22 McElwaine

and Colville4 and Esenwein et al.2 In Table 3, the
favourable outcome determinants with Girdlestone
resection arthroplasty have been listed.
Clegg1

4–7.5
100
30
90
80

Mortality analysis
Mallory21

Intra- or postoperative mortality is reported to be

100
100
3.8

between 7% and 62% following Girdlestone opera-

10
90

90

tion for infected total hip replacements.20 A higher

postoperative mortality follows the Girdlestone
procedure for failed hip fractures than after
Ahlgren
et al.17

revision for failed arthroplasty.23

100
100

100
4–5
27
89

Morbidity analysis
Campbell
et al.19

Complications include infection with persistent

Good

100

discharging sinuses and fistulae, haemorrhage and

45

73

88
—

hypovolaemia, proximal femoral fracture, traction-

related problems (pin-site infection, common per-
Goldsmith5
Petty and

oneal nerve compression, joint stiffness, contrac-

tures), the effects of immobilisation (decubitus
100
5.4

ulcers, urinary infection, chest infection, disuse

21

76

15
0

osteoporosis, muscle wasting), persistent pain,

thrombo-embolism, psychological disturbances (de-
Leg length discrepancy
Need for walking aid

pression, psychosis, suicidal tendency), a Trende-

Control of infection

Patient satisfaction

lenburg gait and generalised fatigue.

No. of patients
Relief of pain

Age, sex, side and body mass index

Table 2

(in cm)

Younger patients have higher functional demands

and expectation so they are likely to be dissatisfied
 ARTICLE IN PRESS
Girdlestone resection arthroplasty of the hip: Current perspectives
with the operation. The results are reported to be
significantly poorer in women, particularly older
ones as reported by Grauer et al.11 The patients
were satisfied with the operation in unilateral cases
as a secondary operation, but it was generally
unsatisfactory as a primary procedure or when
performed bilaterally.16 Grauer et al.11 also ob-
served that body weight, height and body habitus
pose no statistically significant influence on pain,
walking or function.
Pain relief
The primary goal of the Girdlestone procedure is
pain relief. Adequate pain relief was observed in
60% (Scalvi et al.), 77% (Ballard et al.), 80% (Parr
et al.), 83% (Castellanos), 91% (Bourne et al.) and
89% (Sharma et al.).6,12,15,20,23,24
Infection control
Control of infection has been reported in 73–100%
cases postoperatively following the Girdlestone
operation.1,5,11,18 Sharma et al.23 achieved 100%
infection control in the surviving patients, similar
to Mallory21 and Ahlgren et al.17. Infection control
was achieved in the majority of the studies
Figure 3 Septic failure of revision total hip arthroplasty with recurrent dislocation is a common indication for
Girdlestone procedure.
389
(83%—Parr et al.; 86%—Castellanos; 97%—Bourne
et al.).12,20,24
Castellanos et al.20 found no correlation between
the type of organisms and the persistence of
infection, although, Kantor et al. identified worse
functional results in patients with chronic drai-
nage.10 Clegg1 advocated a complete removal of all
the cement in order to achieve an eradication of
infection. Practically, it can be quite difficult to get
rid of all cement remnants (Figs. 3–5). We agree
with the views of Petty and Goldsmith,5 Ahlgren
et al.,17 Bourne et al.12 that small amounts of
retained cement do not seem to influence wound
healing after resection arthroplasty.
Leg length discrepancy and need for
walking aids
Most of the studies reported limb shortening of
approximately 4–6 cm.2,12,20,25 The degree of short-
ening is often dependent on the amount of bone
lost from the proximal femur and the quality of the
scar tissues at the time of surgery.11 Associated
gluteus medius insufficiency magnifies the need for
walking aids. McElwaine and Colville4 noted that
calipers were found to be unacceptable in the
majority of patients. Grauer et al.11 reported a
positive correlation between shortening and level
of resection, patients with less shortening walking
 ARTICLE IN PRESS
390
Figure 4 Pre-Girdlestone radiograph showing aseptic
recurrent dislocation of total hip arthroplasty.
better, although the difference was not statistically
significant.
Electromyocinesigraphic26 examination per-
formed in Girdlestone patients in order to study
the automatic function of the muscles with patients
standing and walking confirmed that there was no
innervation of the hip abductors but high activity in
the rectus femoris during standing. The contral-
ateral abductor group and the trunk muscles were
hyperactive during standing and walking.
Overall satisfaction
Subjective satisfaction varies between 14% and
100%.5,12,18,23 in the reported series. It is hard to
attach much credibility to this overall measurement
in view of this major discrepancy in reported results.
Failed total hip replacements versus
failed hip fractures
The mortality was higher in the failed fracture
group (68%) in comparison to those with failed
arthroplasty23 (48%) (Figs. 6 and 7).
H. Sharma et al.
Figure 5 Post-Girdlestone radiograph of the same pa-
tient. Note that stable components, cement and circlage
wires could be left alone in these relatively high
anaesthetic risk patients.
Delayed reimplantation following
girdlestone arthroplasty
Rittmeister et al.27 reported greater patient satis-
faction and better function if Girdlestone hips were
converted to a hip arthroplasty rather than being
left with the excisional procedure. The incidence of
postoperative complications and revisions were
similar for both groups. Charlton et al.28 in retro-
spective study showed a high rate of dislocation
(11.4%) and persistent limp (39%) following delayed
conversion. A high dislocation rate following con-
version of the Girdlestone procedure to secondary
total hip arthroplasty relates to soft tissue con-
tracture, limb length discrepancy, deficient bone
stock and malpositioning of the components. A
constrained acetabular component should be con-
sidered to reduce the dislocation rate.
Schroder et al.29 followed two groups of patients:
32 patients had a long-standing pseudarthrosis; in
the other group of 16 patients, a total hip
replacement was reimplanted at an average of 3
years after a pseudarthrosis. The improvement in
 ARTICLE IN PRESS
Girdlestone resection arthroplasty of the hip: Current perspectives
Figure 6 Aseptic loosening of Thompson’s uncemented
hemi-arthroplasty subsequently underwent Girdlestone
procedure.
hip function after the reimplantation was marginal
and the results were comparable to a well-
functioning pseudarthrosis. Personal satisfaction
and the activities of daily living were marginally
better in the reimplantation group, (Harris hip
score 64 compared to 58 in those with a pseudar-
throsis). Brandt et al.30 stated that prosthesis
removal and delayed reimplantation arthroplasty
is an effective treatment to limit the recurrence of
Staphylococcus aureus prosthetic joint infection,
provided there is no evidence of infection at the
time of reimplantation arthroplasty.
Conclusions
Various studies have confirmed that the Girdlestone
procedure is very effective in achieving its primary
goals of infection control and pain relief for
irreversibly failed total hip joints and to salvage
failed operated hip trauma. A high mortality and
a poor functional outcome could be attributed to
a higher age group, poor general health and highly
selected group of patients, who were unfit for
reimplantation surgery. Patients who have had
391
Figure 7 While performing Girdlestone operation in the
same patient, an intraoperative femoral shaft fracture
occurred. It was successfully treated non-operatively.
resection arthroplasty following failed operated hip
trauma do considerably worse than after failed total
hip arthroplasty. There is no significant difference
between the long-term outcomes of Girdlestone
procedures performed at a District General Hospital
compared to a University Teaching Hospital.
The decision to perform a Girdlestone operation
is mostly taken as a last resort, as all the suitable
candidates are filtered off for revision surgery,
before reaching the stage of this salvage operation.
The decision between revision and resection should
not be taken lightly and it should not be considered
as an alternative to one-stage or two-stage
reimplantations. Such patients must be warned to
expect 2–3 in of limb shortening and reliance upon
a walking aid postoperatively. This operation can be
made acceptable by proper explanation to the
patient with realistic expectations.
Practice points
 The primary goals of the Girdlestone opera-
tion are pain relief with infection control. It
 ARTICLE IN PRESS
392
is a salvage procedure, and should not be
considered as an alternative to one-stage or
two-stage reimplantations
 A high mortality is observed in the literature
with such groups of patients which can be
attributed to higher age group, poor general
health and highly selected group of patients,
who are unfit for reimplantation surgery
 Patients must be warned to expect 2–3 in of
limb shortening and invariable assisted
mobility postoperatively
Research directions
 Future studies with larger number of pa-
tients utilising results from multiple centres
may reveal more meaningful results with
primary pathology diagnosis stratification
 Need for a separate questionnaire for
assessing Girdlestone patients
 To compare the long-term outcome of
patients with septic retained implants with
those treated by excisional arthroplasty
 To assess the role of Girdlestone resection
arthroplasty for MRSA (Methicillin Resistant
Staphylococcus Aureus) infected hips
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