Is Head and Neck Resection of the Femur (Girdlestone's Procedure) Still Relevant? Indications and Results About 24 Cases

Poor Outcomes of Girdlestone Resection Arthroplasty in Injection Drug Users: A Retrospective Study

This retrospective cohort study aims to investigate the clinical outcomes of Girdlestone resection arthroplasty (GRA) in injection drug users with septic hip arthritis. Patients who underwent primary GRA for septic hip arthritis secondary to injection drug use at two academic trauma centers from 2015 to 2023 were retrospectively reviewed. Patient demographics, surgical details, and follow-up outcomes, including patient-reported outcome measures, were collected and analyzed. The cohort included 15 patients, with a mean age of 44 ± 11 years and a mean follow-up period of 25 ± 20 months. Among the 15 patients, overall mortality was 27%, and only 4 patients underwent total hip arthroplasty (THA) following GRA. Infection resolution rates were significantly higher in patients who received an antibiotic spacer (75% vs. 0%, p = 0.048). GRA in injection drug users is associated with high mortality and low conversion rates to THA. The use of an antibiotic spacer during GRA significantly improves infection resolution rates. Larger studies are required to determine the optimal management strategies for this patient population.

Total Hip Arthroplasty Following the Girdlestone Procedure in a Sickle Cell Disease Patient

Sickle cell disease often leads to avascular necrosis (AVN) of the hip joint, resulting in joint pain and restricted range of motion. In cases where traditional treatments like total hip arthroplasty or core decompression may not suffice, the Girdlestone procedure, involving the resection of the femoral head, is considered. This case study centers on a 19-year-old male nursing student with sickle cell disease who underwent a Girdlestone procedure at 16 years of age, seeking relief from hip pain and limited mobility. However, the procedure led to leg length discrepancy and reduced hip function. Subsequent total hip arthroplasty successfully converted the prior procedure into a stable joint, improving the patient's range of motion and eliminating pain. The comprehensive surgical approach, including soft tissue releases and postoperative rehabilitation, significantly enhanced the patient's quality of life, emphasizing the importance of total hip arthroplasty as a superior intervention post-Girdlestone procedure.

Girdlestone resection arthroplasty for femoral neck fractures has poorer outcomes than hemiarthroplasty in frail patients with increased risk for arthroplasty-related complications: a retrospective case study of 21 patients

BACKGROUND AND PURPOSE

Hemiarthroplasty (HA) is the usual treatment for displaced femoral neck fractures (FNF) in elderly patients. Patients may be unsuitable for HA due to secondary conditions such as systemic infections or severe neurological conditions, which is why Girdlestone resection arthroplasty (GRA) may be an option. We aimed to determine (1) patient survival in matched patient groups treated with either GRA or HA and (2) functional outcomes.

PATIENTS AND METHODS

21 patients treated with GRA for FNF in a German university hospital were retrospectively reviewed (2015-2019). After matching for age and comorbidities, a control group of 42 HA patients was established. Patient survival was determined by a Kaplan-Meier analysis. The mean follow-up (FU) was 1.5 (0-4.4) years. Function at FU was documented using the modified Harris Hip Score (mHHS) and the National Hip Fracture Database (NHFD) mobility score.

RESULTS

The 1-month-mortality was 19% in the GRA group and 12% in the HA group; the 1-year mortality was 71% and 49%, respectively (P = 0.01). The mHHS at FU was lower in the GRA group than in the HA group (22 [range 0-50] vs. 46 [11-80]). 82% of patients in the GRA group were bedridden post-surgery as opposed to 19% in the HA group.

CONCLUSION

Patients with HA after FNF had higher survival and better functional outcomes when compared with GRA in matched patient groups. Considering this, GRA for FNF should be selected restrictively.

Review of the Pathogenesis, Diagnosis, and Management of Osteoradionecrosis of the Femoral Head

Osteoradionecrosis (ORN) of the femoral head is an important issue for orthopedists and radiologists in clinical practice. With the rapid development of technological advances in radiation therapy and the improvement in cancer survival rates, the incidence of ORN is rising, and there is an unmet need for basic and clinical research. The pathogenesis of ORN is complex, and includes vascular injury, mesenchymal stem cell injury, bone loss, reactive oxygen species, radiation-induced fibrosis, and cell senescence. The diagnosis of ORN is challenging and requires multiple considerations, including exposure to ionizing radiation, clinical manifestations, and findings on physical examination and imaging. Differential diagnosis is essential, as clinical symptoms of ORN of the femoral head can resemble many other hip conditions. Hyperbaric oxygen therapy, total hip arthroplasty, and Girdlestone resection arthroplasty are effective treatments, each with their own advantages and disadvantages. The literature on ORN of the femoral head is incomplete and there is no criterion standard or clear consensus on management. Clinicians should gain a better and more comprehensive understanding on this disease to facilitate its early and better prevention, diagnosis, and treatment. This article aims to review the pathogenesis, diagnosis, and management of osteoradionecrosis of the femoral head.

Increasing trend toward joint-preserving procedures for hip osteonecrosis in the United States from 2010 to 2019

INTRODUCTION

The incidence of osteonecrosis of the femoral head is estimated at about 10 to 20,000 patients annually, and, when left untreated, 80% or more of cases progress to femoral head collapse. A series of joint-preserving procedures have been developed to prevent/delay the need for hip arthroplasty. The aim of this study was to provide a five-year update: (1) evaluating temporal trends of arthroplasty vs. joint-preservation techniques such as core decompression, bone grafting, osteotomies, and arthroscopy; (2) determining proportions of procedures in patients aged less than vs. over 50 years; and (3) quantifying rates of specific operative techniques.

METHODS

A total of 10,334 patients diagnosed with osteonecrosis of the femoral head and having received hip surgery were identified from a nationwide database between 1 January 2010 and 31 December 2019, by using the International Classification of Disease, the Ninth/Tenth revision (ICD-9/10) codes. The percentage of patients managed by each operative procedure was calculated annually. To identify trends, patients were grouped by age under/over 50 years and divided into a joint-preserving and a non-joint-preserving (arthroplasty) group. Chi-squared tests were performed to compare the total number of procedures per year.

RESULTS

Rates of arthroplasty far exceeded those for joint-preserving procedures. However, from 2015 to 2019, significantly more joint-preserving procedures were performed than in 2010 to 2014 (4.3% vs. 3.0%, P < 0.001). Significantly more joint-preserving procedures were performed in patients aged < 50 years relative to those ≥ 50 years (7.56% vs. 1.86%, P < 0.001). Overall, total hip arthroplasty was the most common procedure (9,814; 94.97%) relative to core decompression (331; 3.20%), hemiarthroplasty/resurfacing (102; 0.99%), bone grafting (48; 0.46%), and osteotomy (5; 0.05%).

CONCLUSION

Management of patients who have osteonecrosis of the femoral head continues to be predominantly arthroplasty procedures, specifically, total hip arthroplasty. Our findings suggest a small, but significant trend toward increased joint-preserving procedures, especially in patients under 50 years. In particular, the proportion of patients receiving core decompression has increased significantly from 2015 to 2019 relative to prior years.

Analysis of perioperative outcomes in hip resection arthroplasty

BACKGROUND

Hip resection arthroplasty (HRA) is a salvage surgical technique for the management of complex hip conditions wherein arthroplasty may be contraindicated. The purpose of this study was to review modern-day indications for HRA and compare outcomes between patients undergoing HRA and revision total hip arthroplasty (RTHA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients undergoing HRA or RTHA between 2012 and 2017. Patient demographics, risk factors, and perioperative complications were analyzed. Multivariate regression was used to determine predictors of early postoperative complications. Propensity score matching (PSM) was performed to compare relative risks (RR) of complications in HRA compared to RTHA.

RESULTS

290 patients underwent HRA between 2012 and 2017. Infection was the most common indication for HRA (39.8%), followed by femoral neck fracture or malunion/nonunion (26%) and prosthetic instability (12.2%). Increased body mass index (BMI) (p = 0.012) and chronic obstructive pulmonary disease (COPD) (p = 0.007) were associated with increased risk of complication in HRA. There were no significant differences in short-term complication risks between RTHA and HRA.

CONCLUSIONS

HRA was associated with short-term complication rates comparable to RTHA. These findings may help in surgical decision-making and appropriate indications in the present day.

LEVEL OF EVIDENCE

III.

Hip resection arthroplasty for acute femoral neck fractures in the non-ambulator

Objectives:

Hemiarthroplasty (HA) is the current standard of care for displaced femoral neck fractures (FNFs) in non-ambulators. Despite excellent outcomes, arthroplasty-specific risks remain, including dislocation, implant failure, periprosthetic fracture and infection, and fat embolization syndrome. To eliminate the possibility of these complications, should non-ambulatory patients with acute, native hip FNFs be treated with simple hip resection arthroplasty (HRA) instead of HA?

Design:

Retrospective case series.

Setting:

Large, urban level-1 trauma center.

Patients/Participants:

Five non-ambulatory patients (6 hips) with acute, native hip FNF underwent femoral head and neck resection. Also, the most recent 10 FNFs treated with HA were also identified for comparison purposes.

Intervention:

HRA was performed via a Smith-Peterson approach with an oscillating saw or osteotome to complete the fracture or perform a fresh neck cut.

Main Outcome Measurements:

Outcomes included postoperative vs preoperative VAS pain scores and narcotics usage, and return to baseline functional status (sit up in bed or a chair postoperatively). Procedure time for HRA was compared with the 10 most recent patients with FNF treated with HA.

Results:

HRA resulted in decreased postoperative vs preoperative VAS pain scores (7.7 vs 3.3, P = .002), and decreased operative times (59.2 minutes for HRA, 111.8 minutes for HA, P < .001). All HRA patients had immediate return of baseline function.

Conclusion:

HRA offers shorter operative times when compared with HA, decreased postoperative VAS pain scores, and immediate return to functional baseline status without possibility of arthroplasty-specific complications. HRA may be an acceptable treatment option for FNFs in the non-ambulator.

Level of evidence: IV

Socioeconomic Status Is Associated With the Risk of Girdlestone Resection Arthroplasty After Periprosthetic Infection of the Hip

INTRODUCTION

Girdlestone resection arthroplasty (GRA) is a radical but sometimes necessary treatment of periprosthetic joint infection (PJI) of the hip. The purpose of this of this study was to identify the independent risk factors for GRA after PJI of the hip.

METHODS

This is a retrospective, cross-sectional analysis of the National (Nationwide) Inpatient Sample from 2010 to 2014. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) was used to identify 27,404 patients with PJI of the hip, including 889 patients who underwent GRA (ICD-9-CM 80.05). A multivariate model was created to examine the association between GRA and patient characteristics such as age, sex, race, primary payer, median household income, and location and teaching status of the hospital where the procedure was performed. Furthermore, the model controlled for patient comorbidities, including diabetes, anemias, hypertension, congestive heart failure, chronic pulmonary disease, peripheral vascular disease, and drug abuse.

RESULTS

The strongest independent risk factor for GRA was Medicare insurance (odds ratio [OR], 1.859, 95% confidence interval [CI], 1.500 to 2.304). Medicaid insurance was also associated with GRA (OR, 1.662, CI, 1.243 to 2.223). Compared with the wealthiest quartile for household income, patients in the poorest quartile (OR, 1.299, CI, 1.046 to 1.614) and second poorest quartile (OR, 1.269, CI, 1.027 to 1.567) were significantly more likely to have a GRA. Furthermore, patients older than 80 years old were at a higher risk of GRA than all other age groups (P < 0.05). No statistical differences were seen regarding patient race or sex.

CONCLUSIONS

This study demonstrates that poorer patients, patients with government health insurance plans, and elderly patients are each at independently heightened risk of undergoing a GRA for the treatment of PJI of the hip.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Functional outcomes of an adult with osteogenesis imperfecta after rehabilitation post bilateral Girdlestone procedure

This is a case of a 54-year-old woman managed as a case of osteogenesis imperfecta type 1 who sustained a left subtrochanteric fracture and eventual ankylosis of both hips after surgery and immobilisation. These injuries rendered her bedridden, maximally assisted in transitions and transfers, and unable to be positioned past 30° of backrest elevation. The patient underwent a bilateral Girdlestone procedure and had tailored progressive postoperative rehabilitation in both the inpatient and outpatient settings. The patient also continued to receive bisphosphonates during her preoperative and postoperative period, to improve bone stock and aid in relieving pain. Through the efforts of a team of physiatrists, geneticists and orthopaedic surgeons, the patient was able to achieve pain-free sitting, independent transitions and short-distance ambulation, which have allowed her to care for herself more effectively and return to her work and activities of daily living.

A Devasting Course of an Iliopsoas Muscle Abscess Subsequently Leading to Septic Shock, Septic Hip Arthritis, and Extended Gluteal Soft Tissue Necroses in an Elderly Immunocompromised Patient with Multiple Carcinomas: A Case Report and Brief Review of Literature

BACKGROUND

A devasting course of Iliopsoas Muscle (IPM) abscess remains a challenging therapeutic problem.

METHODS

A 69-year-old polymorbid male had a history of multiple carcinomas and presented with advanced stage of septic shock due to a right IPM abscess which communicated with the right hip joint and subsequently led to septic hip arthritis accompanied with post-infectious right gluteal deep soft tissue necroses. Management of surgical treatment included abscess revision, coverage with the use of Long Head Biceps Femoris Muscle (LHBFM) 180° turnover flap, and creating a Girdlestone resection-arthroplasty.

RESULTS

After a duration of patient's hospitalization of six months that included the necessity of artificial respiration over two months accompanied with in summary 18 required surgical procedures, the patient could be recovered successfully regarding his polymorbidity and his low-demand claims in activities of daily living with his Girdlestone resection-arthroplasty.

CONCLUSION

Recovery of immunocompromised patients with those life-threatening situations can only be achieved by an interdisciplinary management. The LHBFM 180° turnover flap can be useful for filling off post-infectious deep soft tissue cavities communicating with the hip joint. The definitive Girdlestone resection-arthroplasty for treatment of septic hip arthritis is the method of choice for mobilization of elderly polymorbid patients with low demand claims in their activities of daily living.