Hip Int 2012 ; 22 (Suppl 8 ) : S36 - S39 DOI: 10.5301/HIP.2012.

9568

Management of Chronic Infections

Girdlestone procedure: when and why

José Cordero-Ampuero

Department of Orthopaedic Surgery, Hospital Universitario La Princesa, Medical School, Universidad Autónoma de Madrid,
Madrid - Spain

Abstract: Girdlestone is one of the options for treating an infected hip arthroplasty (along with isolated
antibiotics, debridement, and one or two-stage exchange). The choice must be based on a list of
previous considerations.
Results of girdlestone: Major differences among different series are reported in literature: from 13% to
83% of patients are satisfied with the result.
Healing of infection is attained in 80% to 100% of patients, but figures are worse in special subsets
(rheumatoid arthritis, enterococcal and methicillin-resistant infections, or when cement is retained).
Pain is reported as severe in 16% to 33% of patients, moderate in 24% to 53% and mild in 76%, while
only some authors refer to “satisfactory pain relief”. Up to 45% of geriatric patients are unable to walk
and only 29% walk independently. The literature reports Harris Hip scores from 25 to 64.
Indications for girdlestone: Absolute indications: non-ambulatory patients because of other problems
or diseases, and impossible reimplantation (2nd-stage surgery) (unacceptable anaesthetic or surgical
risk, technical difficulties, patient rejection).
Relative indications: Dementia (risk of dislocation vs. severely reduced walking ability), immunocom-
promise (up to what degree of immune impairment do we accept to take the risk?), intravenous drug
abuse (how can you prove it?)

Key words: Functional results, Girdlestone, Infected hip

Accepted: April 28, 2012

INTRODUCTION and formation of glycocalix, antibiotic resistance, co-mor-

There are several options widely reported in literature for
the treatment of an infected hip arthroplasty: only antibi-
otics, antibiotics plus debridement, resection-arthroplasty
(Girdlestone procedure), one-stage exchange or two-stage
exchange.
When deciding about the most adequate treatment for an
infected hip arthroplasty in the individual patient, major
attention should be dedicated to evaluate the “previous
considerations”: acute vs. chronic infection, bacteriology
bidity of the patient, implant stability, bone stock and tech-
nical abilities and the environment.
Before discussing resection-arthroplasty as an option, it
should be interesting to know more about published results.
RESULTS of RESECTION ARTHROPLASTY
There are a number of papers about results of the Girdle-
stone procedure. Most of them analyze one or more of the

S36 © 2012 Wichtig Editore - ISSN 1120-7000

Cordero-Ampuero
following aspects: healing of infection, residual pain, leg
length discrepancy, Trendelenburg, oxygen consumption,
need for external supports and walking limitations, global
functional limitations and patient satisfaction.
Healing of infection
Among the orthopaedic community there is a general ac-
ceptance of resection-arthroplasty as a sure and direct
method of healing infection. This is true for most patients,
but not for all of them. Published series report from 80%
or 90% of healing (1, 2) to more optimistic figures such as
90% or 100% (3, 4).
However, figures are not so good in determined clinical
subsets. Results worsen to 61% of healing in rheumatoid
arthritis patients (5), grow up to only 76% in enterococcal
infections (6), or offer 84% of healing when methicillin-re-
sistant Staphylococci are present (vs. 100% with methicil-
lin-sensitive Staphylococci) (7). Sometimes the problem is
a technical mistake: for example, residual cement is clearly
a cause for persistence of infection (8, 9).
Residual pain
It is also classical teaching in orthopaedics that Girdlestone
is a painless situation, but this is not at all true according
to literature. In some papers pain is referred as severe in
16% to 33% of patients (10), moderate in 24% (11) to 53%
(2, 10) and mild in 76% of patients (11). There are also
communications of “adequate” or “satisfactory” pain relief
in 85% to 100% of patients (but observe, not “absence of
pain”!) (1, 3, 12).
Oxygen consumption
It has been known for many years that resection-arthro-
plasty patients, when moving around, suffer an oxygen
consumption 264% greater than normal, even worse than
recorded in persons with an above-knee amputation (13).
Walking limitations
Of course, Girdlestone greatly limits walking ability (13).
The problem increases dramatically in the geriatric popula-
tion, where a significant proportion, up to 45%, are abso-
lutely unable to walk, and only 29% walk independently
with one or two crutches (11).
© 2012 Wichtig Editore - ISSN 1120-7000
Global functional limitations
Universally validated hip scales reveal severe impairment
in resection-arthroplasty patients. Published Harris Hip
Scores range from only 25 (14) to 39 (8, 15), 51 (11), 53 in
methycillin-resistant (7), 60 (1), or up to 64 (10, 16). Merle
d’Aubigné only stands at 3.5 to 6.7 points (2, 8).
Patient satisfaction
Satisfaction of patients with a Girdlestone procedure is a
completely subjective evaluation, so published figures are
also quite variable. In fact, the literature offers extremely
low percentages as only 13% (8, 15), discrete ones such
as 59% (2) to 74% (10, 12), or quite good figures such as
83% of satisfied patients (3).
GIRDLESTONE: INDICATIONS
Considering the published results, indications for resection-
arthroplasty of the hip must be strictly limited (2, 15, 17).
Usual indications in literature are non-ambulatory patients,
dementia, immunocompromise, intravenous drug-abuse
and impossible reimplantation (overcome Cierny C-type
or patient rejection). It is appropriate to discuss them in
detail.
Non-ambulatory patients
There is a general consensus about patients who are
non-ambulatory because of other problems or diseases.
Possibly this is the most clear indication for a Girdlestone
procedure. A number of situations are included here, most
of them related to neurologic comorbidities.
Dementia
Nowadays this is one of the most doubtful and discussed
indications. Classical teaching was based on the high risk
of dislocation in these patients.
Nevertheless, it is previously reported how Girdlestone
drastically reduces functional status and walking ability,
compromising social and nursing management (11). In ad-
dition, some modern technical solutions such as bipolar,
tripolar and constrained cups will help to reduce the risk
of dislocation.
S37
Girdlestone: results and indications
Immunocompromise
This is another classical indication, but has become quite
doubtful from a contemporary medical point of view. Im-
munocompromise is not a bipolar (“yes vs. no”) status, but
rather a quantitative or gradual individual characteristic.
Where do we put the point of separation between reim-
plantation and Girdlestone? HIV-infection? Organ-trans-
plant? Corticoids and/or biologic treatments for inflamma-
tory arthritis? Diabetes or obesity? Senile patients?
Possibly the best recommendation is to try reimplantation
in these patients after a well designed informed consent
and implementing an exhaustive prophylaxis protocol.
Intravenous drug abuse
Although possibly this is one of the more clear indications
for resection arthroplasty, the problem arises with diagnos-
ing this behaviour. Except in severely deteriorated patients,
how can you prove it? Most of these patients will argue
that they abandoned drugs a long-time ago, especially
when asked about intravenous administration.
Fortunately, intravenous drug abuse has been increasingly
abandoned in the last few years, so the number of poten-
tial patients at risk is lower and lower.
Impossible reimplantation
Sometimes the surgeon and patient desire reimplantation
of a total hip, but 2nd-stage surgery becomes impossible
REFERENCES
1. Bourne RB, Hunter GA, Rorabeck CH, Macnab JJ. A six-year
follow-up of infected total hip replacements managed by Gir-
dlestone’s arthroplasty. J Bone Joint Surg Br 1984; 66: 340-3.
2. Esenwein SA, Robert K, Kollig E, Ambacher T, Kutscha-
Lissberg F, Muhr G. Long-term results after resection arthro-
plasty according to Girdlestone for treatment of persisting
infections of the hip joint. Chirurg 2001; 72: 1336-43.
3. Sharma H, Kakar R. Outcome of Girdlestone’s resection ar-
throplasty following complications of proximal femoral frac-
tures. Acta Orthop Belg 2006; 72: 555-9.
4. Klima S, Zeh A, Josten C. Reimplantation of a hip prosthesis
in patients with an infected resection arthroplasty. Z Orthop
Unfall 2008; 146: 616-23.
S38 © 2012 Wichtig Editore - ISSN 1120-7000
(12, 17, 18). This situation is usually established by new
medical comorbidities, and could be named as “secondary
(after 1st stage) Cierny C-type”.
Less frequently, technical difficulties appear in medically
compromised situations. This is, for example, the case of
severe bone defects whose reconstruction requires too
long and aggressive surgery for a weak patient (10, 12).
Another cause for an impossible reimplantation is patient
rejection (10, 15). This decision is becoming less-frequent
with the years, but still accounts for an important propor-
tion of resection-arthroplasties in the hip (approximately
one-third of cases) (7, 16). Cultural, clinical, psycho-social
and/or financial reasons may influence that resolution.
This paper was presented at the joint meeting of the EHS (European
Hip Society) and EBJIS (European Bone and Joint Infection Society)
held during the 12th EFORT Congress in Copenhagen, 1-4 June 2011.
Financial support: The author states that he has not received any pub-
lic or private grant or funds in support of this study.
Conflict of interest: The author states that he has no proprietary interest.
Address for correspondence:
José Cordero Ampuero
c/ Océano Antártico 41
Tres Cantos
28760 Madrid, Spain
jcordera@telefonica.net
5. Berbari EF, Osmon DR, Duffy MC, et al. Outcome of pros-
thetic joint infection in patients with rheumatoid arthritis: the
impact of medical and surgical therapy in 200 episodes. Clin
Infect Dis 2006; 42: 216-23.
6. El Helou OC, Berbari EF, Marculescu CE, et al. Outcome
of enterococcal prosthetic joint infection: is combination
systemic therapy superior to monotherapy? Clin Infect Dis
2008; 47: 903-9.
7. Cordero-Ampuero J, Esteban J, García-Cimbrelo E. Oral An-
tibiotics Are Effective for Highly Resistant Hip Arthroplasty
Infections. Clin Orthop Relat Res 2009;467:2335-42.
8. Rittmeister M, Müller M, Starker M, Hailer NP. Functional
results following Girdlestone arthroplasty. Z Orthop Ihre
Grenzgeb 2003; 141: 665-71.
9. Buttaro M, Valentini R, Piccaluga F. Persistent infection as-
Cordero-Ampuero
sociated with residual cement after resection arthroplasty of
the hip. Acta Orthop Scand 2004; 75: 427-9.
10. Stoklas J, Rozkydal Z. Resection of head and neck of the
femoral bone according to Girdlestone. Acta Chir Orthop
Traumatol Cech 2004; 71: 147-51.
11. Manjón-Cabeza Subirat JM, Moreno Palacios JA, Mozo
Muriel AP, Cátedra Vallés E, Sancho Loras R, Ubeda
Tikkanen A. Functional outcomes after resection of hip
arthroplasty (Girdlestone technique). Rev Esp Geriatr Gerontol
2008; 43: 13-8.
12. Sharma H, De Leeuw J, Rowley DI. Girdlestone resection
arthroplasty following failed surgical procedures. Int Orthop
2005; 29: 92-5.
13. Kantor GS, Osterkamp JA, Dorr LD, Fischer D, Perry J,
Conaty JP. Resection arthroplasty following infected total
hip replacement arthroplasty. J Arthroplasty 1986; 1: 83-9.
© 2012 Wichtig Editore - ISSN 1120-7000
14. Cherney DL, Amstutz HC. Total hip replacement in the previ-
ously septic hip. J Bone Joint Surg Am 1983; 65: 1256-65.
15. Rittmeister M, Manthei L, Müller M, Hailer NP. Reimplanta-
tion of the artificial hip joint in girdlestone hips is superior
to girdlestone arthroplasty by itself. Z Orthop Ihre Grenzgeb
2004; 142: 559-63.
16. Cordero-Ampuero J, Esteban J, García-Cimbrelo E, Munuera
L, Escobar R. Low relapse with oral antibiotics plus two-stage
exchange for late arthroplasty infections in 40 patients after
2-to-9 years. Acta Orthop 2007; 78: 511-9.
17. Barrack RL, Aggarwal A, Burnett RS. Resection arthro-
plasty: when enough is enough. Orthopedics 2006; 29:
820-1.
18. Salvati EA, González Della Valle A, Masri BA, Duncan DP.
The infected total hip arthroplasty. Instr Course Lect 2003;
52: 223-45.
S39
Copyright of Hip International is the property of Wichtig Editore and its content may not be copied or emailed
to multiple sites or posted to a listserv without the copyright holder's express written permission. However,
users may print, download, or email articles for individual use.