Hip Resection Arthroplasty via the Direct Anterior Approach

Murillo Adrados

Lee E. Rubin

Introduction

Hip resection arthroplasty (HRA), historically referred to as the Girdlestone procedure, is a rare surgery.¹ The removal of the native hip joint, or terminal explantation of a hip prosthesis, is typically a salvage procedure that aims to produce a purposeful pseudarthrosis. The lack of direct skeletal continuity restricts the patient’s weight-bearing ability postoperatively and may impact the patient’s ability for prolonged independent ambulation. Although the operation remains rarely used, HRA should have a place in the armamentarium of every hip surgeon. It is a valuable operation in a variety of clinical situations in which implantation of arthroplasty components is unwise and an arthrodesis is either physiologically impossible or clinically undesirable. Although it is likely to be used sparingly by the modern orthopaedic surgeon, there are specific situations, as we describe in this chapter, that call for the procedure. The direct anterior approach (DAA) is particularly well suited for HRA.

History of the Eponym

A discussion of HRA would not be complete without mentioning Dr. Gathorne Robert Girdlestone. His often-quoted article describing his namesake operation appeared in The Lancet in 1942, but his first description of a proximal femur resection was published in 1928 along with other surgical techniques of treating hip tuberculosis infections.²

Girdlestone’s technique evolved during his time in charge of the orthopaedic division of a large military hospital in Oxford, UK, where he managed patients who had penetrating trauma from World War I. Born at a time before antibiotics, Girdlestone’s procedure involved resection of the abductors and their trochanteric attachment, debridement of the infected hip joint, open packing with gauze and wick drains, prolonged inpatient hospitalization for dressing changes, and spica cast application (Figure 29.1).³ The intention was to stage the surgery to allow a hip arthrodesis in a clean bed of tissue, but patients did not wish to, or need to, proceed with arthrodesis after enduring the initial injury, radical debridement, and prolonged hospitalization with painful deep dressing changes.

FIGURE 29.1 Diagrams from Girdlestone’s Lancet article depicting his procedure in 1943.

A wedge of soft tissue and bone, including skin, fascia, muscle, and bone, is removed en bloc. A, Coronal transection view. B, Lateral view of the would that is created after the en bloc resection. C, The patient is then immobilized with a cast, and the wound is packed to allow for continued drainage and secondary healing.

(Reproduced with permission from Girdlestone GR. Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. Lancet. 1943;241:419-421.)

The original Girdlestone procedure bears little resemblance to any contemporary operation now commonly performed. It was a product of the times predating antibiotic therapy in the shadow of the horrific ballistic injuries inflicted during the first world war. The operation was large and quite morbid, resulting in a protracted recovery that required full granulation of the resected wedge volume before the patient was allowed to mobilize. Thus, the modern practice of removing the femoral head and neck, preserving the trochanter and abductors, and closing the surgical wound primarily is more precisely referred to as hip resection arthroplasty. Despite this, the eponym “Girdlestone procedure” remains frequently used in colloquial lexicon and is recognized worldwide. In this chapter, we refer to both the procedure and the resulting pseudarthrosis as HRA.

Indications

The indication of HRA for a native joint afflicted with severe hip disease is for the avoidance of hardware implantation and related complications. By avoiding hardware, the surgeon thus avoids the infectious burden of implants, fatigue, and cut through. By avoiding prosthetic arthroplasty, the surgeon also avoids possible implant dislocations. The main complication of HRA is the intended consequence of creating a pseudarthrosis. Patients end up with a soft tissue articulation, which, although allowing for range of motion, does not optimize weight bearing. Ambulatory patients will typically require a walking device after HRA, but this is not a concern for patients who are nonambulatory at baseline.

Resection of the hip is expected to result in shortening of the leg. This has two components: the acute shortening from the loss of neck height and a continuous shortening observed from progressive contracture of periarticular soft tissues. The musculature that crosses the hip will result in dynamic proximal migration of the femur, which is no longer securely anchored to the pelvis. This process can potentially result in the physical abutment of the proximal femur to the acetabulum, creating incongruous and painful articulation. The continuous shortening can also lead to the more commonly seen proximal migration of the femur toward the iliac wing drawn by the strong pull of the abductors.

In the vast majority of cases, HRA is used as a salvage procedure to manage cases of recalcitrant prosthetic joint infection after multiple debridements, component exchanges, or antibiotic spacers have failed to eradicate an infection. It is also used when the more standard reconstructive technique is bound to result in too high a risk for complications and reoperation. It does provide significantly less morbidity than hip disarticulation, allowing more balance while seated, and acts as a limb salvage operation to retain a functional, weight-bearing limb. The resultant limited weight-bearing capacity of the leg, progressive shortening, and potential for secondary femoroacetabular impingement are the expected consequences.

Infection

The majority of published studies on HRA describe surgeries performed for infection, frequently as a salvage procedure after failed treatment with one- or two-stage revisions. Thus, our largest repository of information regarding the results of this operation is when it is used as a salvage operation after total hip infection. Chronic infections that cannot be eradicated by two-stage revision may ultimately end up restricting reimplantation of components. Some of the literature also refers to the first stage of two-stage revision for infection as HRA.⁴ Nowadays, the development of modern antibiotic spacers has made a true, definitive HRA less common. Instead of simply removing the infected components, the insertion of antibiotic spacers allows for the preservation of skeletal weight bearing and leg length. Different types of spacers even allow for smooth articulation between the femur and the acetabulum.

Failed Total Hip Replacement

Chronic prosthetic dislocations and large femoral defects may ultimately also result in a surgeon recommending HRA to their patient.⁵ The avoidance of further dislocations or several repeat procedures may lead the patient to opt for a more definitive surgery, avoiding ongoing need for hospitalizations and unexpected trips to the operating room.

Tumor

The proximal femur and acetabulum are frequent sites of bony metastasis and primary bone tumors. HRA can be considered for the treatment of these lesions, especially when the patient’s physiology or local pathology severely restricts their chances for a successful reconstruction. For example, resection arthroplasty severely cuts down the infectious risk of a megaprosthesis, which in some series can be as high as 50%. Many tumor resections of the
proximal femur match the original Girdlestone procedure in their scope and morbidity, sometimes requiring large soft tissue and acetabular resections concomitant with the proximal femur resection. Some hip resection procedures can be undertaken as palliative surgeries with minimal physiologic impact and without the need or expense related to complex endoprosthetic implant components.

Fracture

Depending on a patient’s comorbidities and level of ambulation, a proximal femoral resection can be considered as definitive treatment of some femoral neck and intertrochanteric fractures. This approach allows for a much shorter hospitalization, lower physiologic surgical demand, and predictable pain control without the potential complications of osteosynthesis or prosthetic replacement. The option for HRA in such cases also may be indicated when exceptionally poor bone quality of the acetabular walls or proximal femur is encountered or when the patient may be at extraordinary risk of dislocation from baseline contractures or other disorders that severely limit their functional capacity.

Spasticity, Deformity, and Cerebral Palsy

Chronic hip dislocation is a well-described problem in several childhood spastic diseases in nonambulatory children, with cerebral palsy (CP) being the most common. Pain associated with these dislocations is not universal but may exceed 50%.⁶ The stiff hip and rigid soft tissues can also limit perineal hygiene for nonambulatory children. Proximal femoral resection is a reasonable option for some of these cases, with similar satisfaction as reconstructive techniques.⁷ HRAs performed in these cases differ from those for adult indications and also in technique. The Castle and McCarthy techniques tend to involve a greater part of the proximal femur, often involving the greater and lesser trochanter to further control the muscular forces causing shortening of the extremity. Recently, pediatric surgeons have modified their proximal femoral resection techniques in non-ambulatory pediatric patients with CP who have painful coxofemoral spastic dislocation or subluxation. This updated procedure involves resection-interposition of the proximal femur, with preservation of the greater trochanter and capsulodesis to prevent “ascension” or promixal femoral migration following the procedure.⁸

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