Girdlestone resection arthroplasty following failed surgical procedures

Modular endoprosthetic replacement for failed internal fixation of the proximal femur following trauma

PURPOSE

Although originally designed for reconstruction after primary malignant bone tumour resection, modular endoprosthetic replacement (EPR) can be used in salvage surgery for complex periprosthetic fracture and failed internal fixation. The purpose of this study was to assess the functional outcome following EPR for failed internal fixation of the proximal femur.

METHODS

We assessed clinical and functional outcomes of using a modular tumour endoprosthesis to reconstruct the proximal femur following failed internal fixation in eight consecutive patients between 2001 and 2008.

RESULTS

There were four men and four women, with a mean age of 67.5 (range 50-79) years and a mean follow-up of 16.5 (6-36) months. All patients had failed internal fixation for traumatic proximal femoral fractures--four 31.A2.3, two 31.A3.1, two 31.A3.3 using the Arbeitsgemeinshaft für Osteosynthesefragen (AO) fracture classification. Mean time from the first attempted internal fixation to definitive EPR was 34 (6-102) months, and the median number of previous surgical procedures was two (1-11). Histology revealed infection (two cases), uninfected nonunion (five cases) and plasmocytoma (one case). The EPR was carried out as a one-stage procedure in six cases and a two-stage procedure in two cases. Mean postoperative Harris Hip Score was 71.4 (range 64-85). There were no surgical complications. One patient died as a result of systemic complications of myeloma several years following EPR.

CONCLUSIONS

EPR is an effective salvage procedure for failed fixation of traumatic proximal femoral fractures. Immediate weightbearing and a good functional outcome can be expected in this difficult group of patients.

Girdlestones excision arthroplasty: current update

Girdlestones procedure has become a salvage operation reserved for patients with significant co-morbidities. Recent literature addresses this infrequently used intervention inadequately. This observational study aims to update current literature and review the modern role of this intervention in orthopaedic practice. Twenty-four records were obtained from which patient demographics, indications and co-morbidities were investigated. Seventeen patients completed an abridged Harris Hip Scoring questionnaire and commented on satisfaction. The average age was 78 years and patients had multiple co-morbidities. Dementia was the most frequent condition but several patients suffered from cardiovascular and respiratory disease. The most common operative indication was persistent prosthetic infection with Staphylococcus aureus, the most common pathogen. Overall mortality was 41% but all surviving patients had complete resolution of infection and 65% had adequate pain control. No patients mobilised without aids although 29% of patients were able to manage stairs and 29% were able to mobilise outdoors. Only 29% were unsatisfied with the outcome. This study demonstrates that Girdlestones candidates are an ageing high-risk group and shows that the Girdlestones procedure can, in select cases, provide good functional outcomes. However such intervention comes at the expense of high mortality and should therefore only be used as a last resort.

[Functional outcomes after resection of hip arthroplasty (Girdlestone technique)]

INTRODUCTION

the complications of hip arthroplasty in elderly patients can lead to resection of the prosthesis and cement, also known as the Girdlestone technique. This kind of surgery causes serious dysmetria and alters gait dynamics, thus affecting the patient's functional ability. The aim of this study was to describe the functional outcome, 1 year after surgery, in a group of patients that underwent surgery with this technique.

MATERIAL AND METHODS

we performed a descriptive study of 48 patients aged more than 65 years old who underwent surgery with the Girdlestone technique from 1999 to 2005. Twenty-one patients completed the study. Functional outcome and pain were measured with the Harris scale, and gait with the Functional Ambulatory Classification (FAC) scale 1 year after surgery.

RESULTS

the mean age was 79.71 years. The most frequent causes of exeresis were periprosthetic infection in 42% and recurrent hip dislocation in 36%. Of the 21 patients assessed 1 year after the intervention, 42.8% were unable to walk and needed a wheelchair and only 28.5% were able to walk with the aid of one or two crutches. Pain was moderate in 23.8% of the patients and was mild in the remainder. The mean score on the Harris scale was 51 out of 100 points.

CONCLUSIONS

failure of hip arthroplasty requiring Girdlestone resection is very damaging to functional outcome in elderly patients.

Managing femoral head osteonecrosis in patients with sickle cell disease

With an increasing number of people immigrating between different countries, sickle cell disease (SCD) is spreading all over the world. Due to improved health care, the life span of SCD patients has increased and many of them live to adulthood and middle-age. Osteonecrosis of the femoral head is one of the most common musculo-skeletal problems in SCD patients. Once osteonecrosis starts in the femoral head, it can progress from early to late stages in just a few years. Managing osteonecrosis of the femoral head in young-adults is a challenging problem and, in many situations, it requires major surgical procedures. In the early stages of the disease it is advisable to treat it by femoral head preserving procedures. In advanced stages, hip replacement arthroplasty (HPA) is indicated. In SCD patients, the incidence of operative complications and failure rates are higher than that for osteonecrosis due to other causes. Understanding the problems of SCD patients; appropriate diagnosis, prognosis, implications of the procedure performed and taking the necessary precautions, can reduce the complications and delay the failure of surgical procedures.

Analysis of clinical data in patients with Girdlestone arthroplasty: a new score

Girdlestone's arthroplasty is an uncommon surgical procedure; it is performed in patiens with recurrent infection of the hip, polymicrobic sepsis or after multiple revisions. The number of hip replacements all over the world is always increasing, so the total number of prosthesis infections also continues to rise, although the relative incidence is lower than in the past. For this reason Girdlestone's arthroplasty must be a well-known procedure to hip surgeons. Clinical assessment of such patients cannot be performed with common hip ratings (e.g. Harris Hip Score) since hip instability, low range of motion, limb shortening and severe muscle loss are common. The patient's independence in daily living activity and freedom from pain should be the surgeon's main goals. We propose a specific clinical score for the outcome of the procedure, which is not to be found in the current literature as far as the authors are aware. The score can be useful for comparative clinical trials, for legal medicine purposes, etc. To illustrate it, we present 20 cases of Girdlestone's arthroplasty out of 265 hip revisions performed in our hospital. The outcome of the procedure in our patients was clinically good in eight cases, intermediate in ten cases, and bad in two cases. We believe the performing of such an intervention is justified when indicated by clinical signs, as we analyse them in our work. Our clinical score has been shown to be adequate to assess the clinical presentation of such patients.

Avaliação da função e qualidade de vida em pacientes submetidos a artroplastia de ressecção tipo Girdlestone

OBJETIVOS: Avaliar a função e a qualidade de vida dos pacientes pós-artroplastia de Girdlestone e comparar os resultados entre os grupos Girdlestone unilateral e o grupo com prótese total de quadril contralateral. MÉTODOS: estudo transversal no qual foram avaliados 9 pacientes com Girdlestone unilateral e 3 com Girdlestone em um quadril e prótese total no quadril contralateral. A avaliação constitui-se em aplicar o questionário genérico de qualidade de vida SF-36 e um questionário funcional específico para o quadril, Harris Hip Score (HHS). A comparação dos grupos foi realizada usando-se o teste t- Student e o teste de Fisher. RESULTADOS: Os pacientes do grupo Girdlestone unilateral apresentaram maior quantidade de domínios do SF-36 classificados como elevados, embora 77,8% destes tenham obtido resultados ruins no HHS. Todos os pacientes apresentaram o teste de Trendelenburg positivo e discrepância de membros, o que levou à marcha claudicante em 11 dos 12 pacientes avaliados. Destes, apenas 6 submeteram-se a fisioterapia pós-operatória. CONCLUSÃO: A qualidade de vida e a função pós-operatória de Girdlestone, na população brasileira, ainda necessita ser mais pesquisada, pois estes resultados são indicações do comportamento das variáveis de estudo e não podem ser consideradas encerradas.