Girdlestone procedure is excision arthroplasty of hip in which femoral head, neck, proximal part of trochanter and the acetabular rim are removed. Modern technological advancements in revision hip arthroplasty have revolutionised the treatment of failed primary total hip replacements. The decision to. Girdlestone resection arthroplasty should be considered as a salvage procedure, primarily aimed at pain relief and infection control. Such patients must be.
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Girdlestone hip arthroplasty, though described as a salvage procedure for infected hip joints, can also be considered for failed Hemiarthroplasty procedures. The functional results of such Girdlestone hip may not be satisfactory. They gurdlestone require total hip replacement to improve the quality of life, which are technically challenging.
Here we are reporting such a case ina 60 year old male patient, with review of literature. A 60 year old male patient underwent cemented bipolar hemiarthroplasty for fracture neck of femur which failed, owing to improper implantation. Subsequently he underwent Girdlestone arthroplasty which resulted in persistent painful hip. He presented to us in this situation, where we successfully converted the Girdlestone arthroplasty to a Total Hip arthroplasty.
Improper implantation in Hemiarthroplasty fails subsequently. In such cases Girdlestone arthroplasty may be arthroplqsty option to consider, though it may not give requisite relief to patient in some cases. In such situations total hip arthroplasty procedure, though technically challenging will give stable painless hip to the patient.
Hemiarthroplasty unipolar or bipolar of the hip is a commonly performed procedure in elderly patients with intracapsular displaced fractures of the neck of femur with good short-term results with regard to pain relief, return to activity, morbidity and mortality [ 123 ]. An improperly implanted bipolar prosthesis creates more problems with one of the options being a Girdlestone arthroplasty. Though good relief is achievable in some cases from Girdle stone arthroplasty, in most cases the results are not satisfactory [ artyroplasty56 ].
With the following treatment option we report this case of re implantation with total hip arthroplasty in Girdlestone hip. A 60 year old male patient presented to us in the outpatient department with complaints of limp and shortening of the right lower limb for the past one year. The patient had sustained fracture neck of femur following a fall while working one and half years back [ Figure 1 ].
He underwent cemented bipolar hemiarthroplasty for the same [ Fig 2 ].
The old post-operative x-rays showed a proud bipolar prosthesis with extravasations of cement from proximal femoral aspect. X-ray showing the fracture neck of femur which the patient had sustained one and half years back.
The patient gave history of lengthening of girdleston operated limb, which he noticed on day one.
He had continuous dull aching pain in the right hip with stiffness for a period of six months from the day of surgery.
Patient was walking with the support of a walking aid. Since, last one year he has been walking with pain, limp, shortening and instability. Patient had a Harris hip score of The recent X-ray of the hip [ Fig 4 ] showed gross proximal migration of femur with osteoporotic greater trochanter and cement mantle without any signs of loosening.
Present X-ray showed gross girdlestohe migration of femur with porotic trochanter and cement mantle. The patient was thoroughly investigated to rule out any signs of underlying infection. The hip joint aspiration under C-arm arthroplxsty was done to rule out any infective collection which turned out to be negative. Later an Girdlfstone scan of the hip was also done to rule out any possible signs of infection.
With an operative plan of removal of cement mantle and total hip arthroplasty with or without extended trochanteric girdlestonne, patient was posted for surgery. The standard posterior approach was used to expose the hip joint. The acetabulum was filled with hard fibrous tissue which was completely cleared and acetabular floor aryhroplasty prepared. Once the preparation of acetabulum was done the proximal femur was exposed without having to do the trochanteric osteotomy, the cement mantle in the proximal part of shaft was removed with some effort enblock, but the distal mantle was impacted in the shaft.
The mantle was drilled with 3. But the peripheral part was integrated very well within the canal.
The K- nail reamers of 6. The breach in the wall, which was about 6mm in diameter was identified immediately and the exposure was further extended to visualize it.
Total Hip Arthroplasty in a Girdlestone Hip following a Failed Hemiarthroplasty
The break in the cortex was used to remove the distal part of the cement mantle. Once the cement was completely removed the femoral canal was prepared. Long cemented stem was arthroplaaty to bypass the cortical breach by at least 2 cortical diameters. An undisplaced split in the trochanter was stabilized using a steel cable.
The trial prosthesis was placed and reduction was attempted. It was noted that in spite of adequate soft tissue release the reduction was not achievable, unless the vertical offset was decreased. Uncemented acetabular cup with a long cemented revision stem total hip arthroplasty was done [ Fig 5 ]. An uncemented stem could not be used as the reduction was difficult, even with the smallest trial offsets. The immediate post-operative period was uneventful and he was made to walk with support on the 3rd day.
The patient is ambulant without support, without any significant pain at present though shortening of the limb of about 2. The latest follow up was one year after surgery. The patient was able to walk independently with the help of a stick, has mild pain on walking for more than a kilometer.
The postoperative Harris hip score was Intracapsular fracture neck of femur is one of the most common fragility fractures in the elderly. Most patients are managed by replacement with either a hemiarthroplasty or a total hip arthroplasty. An improperly implanted bipolar prosthesis would create more problems to the patient, leaving the surgeon to choose one of the options being a Girdlestone arthroplasty. Converting such painful Girdlestone hip is technically challenging.
There are no reports of Reimplantation of Total hip components in a case, where a failed hemi replacement is converted to a Girdlestone hip, as in our case report. He concluded that if the surgery is done well the result is good with dramatic relief from the condition. Oheim et al in in their series of 27 cases opined Girdle stone arthroplasty is still an essential surgery though not functionally satisfactory [ arthropllasty ].
However Bitter ES, Petty W in their series of 14 patients concluded that the functional results were not good following Girdlestone and the patient often needed further procedures, like fusion or replacement depending on the age of the patients [ 4 ]. InPankaj A, Surya bhan et al in their series of 44 cases concluded that conversion of symptomatic hemiarthroplasty to total hip arthroplasty is a safe option that gives good functional results, with marginally higher rates of intra-operative complications [ 10 ].
Pradeep bhosle et al in their series of 89 cases inwhere Total hip replacement was performed for failed hemiarthroplasty concluded that THR is an excellent option in failed hemiathroplasty cases [ 11 ]. In Markus E Rittemeister et al in their series of 39 patients assessed the functional outcome of total hip replacement following Girrlestone hip arthroplasty.
They concluded that the results were unpredictable from poor to fair hip function as evaluated with standardized hip scoring systems. In 17 cases they had to do revision surgeries.
Microbiological culture, patient age, duration of Girdlestone arthroplasty and the number of preceding surgical procedures did not correlate with the functional outcome after conversion [ 12 ]. Although Girdlestone hip arthroplasty is a useful surgery, it is generally reserved for multiple failed attempts at reconstruction of arthropalsty hip, generally as a result of infection or for septic and tubercular hips.
The results of girdlestone hips vary from good to poor in the various studies published. On the other hand conversion of arthhroplasty long standing Girdlestone hip to a Total hip though is a well documented procedure in the literature, it is generally done for septic hips.
The results mentioned in the literature are not generally uniform. Each case has to be looked at individually and decision to offer a Total hip in such cases should be taken judiciously in consultation with the patient, after explaining pros and cons with a guarded prognosis. Better results with total hip arthroplasty in Girdlestone hips can be expected in cases where more bone on the proximal femur can be preserved [ 7 ]. In this case where tirdlestone proximal femur was completely girdlfstone was ideal for conversion to total hip arthroplasty.
Arthroppasty the muscle strength around the hip in such cases which are operated multiple times is difficult to assess. It is important to explain guarded prognosis of the procedure beforehand to the patient. The longevity of implants following hemiarthroplasty depends on its proper placement. Girdlestone arthroplasty may not give requisite functional relief to the patient.
Though technically challenging, total hip arthroplasty in certain cases will give yirdlestone relatively stable and painless hip, as is the observation in our case. Rathroplasty has been ambulant without pain till his last follow up of 1 year. A Long term follow up of this case may throw more information in these cases.
Hemiarthroplasty will fail if not done properly. Converting such failed arthrop,asty to Girdlestone hip arthroplasty may not be a good option. In such cases where Hemiarthroplasty has failed or subsequent Girdlestone hip arthroplasty has failed to give relief to patient, Total hip grdlestone should be considered though it is technically demanding especially after 2 failed surgeries prior to it.
National Center for Biotechnology InformationU. J Orthop Case Rep. India Find articles by VJ Purushotham. India Find articles by BT Girdlestome. Author information Copyright and License information Disclaimer. Arthropasty of Correspondence Dr V. This article has been cited by other articles in PMC. Hemiarthroplasty, Girdlestone arthroplasty, TotaIhiparthropalsty.
Introduction Hemiarthroplasty unipolar or bipolar of the hip is a commonly performed procedure in elderly patients with intracapsular displaced fractures of the neck of femur with good short-term results with regard to pain relief, return to activity, morbidity and mortality [ 123 ].
Case report A 60 year old male patient presented to us in the outpatient department with complaints of limp and shortening of the right lower limb for the past one year. Open in a separate window.
Post operative x-ray showing the proud bipolar prosthesis and extravasated cement. Discussion Intracapsular fracture neck of femur is one of the most common fragility fractures in the elderly. Conclusion The longevity of implants following hemiarthroplasty depends on its proper placement. Clinical Messege Hemiarthroplasty will fail if not done properly.
Footnotes Conflict of Interest: Nil Source of Support: Critical radiological analysis after Austin Moore hemiarthroplasty.