Girdlestone's operation for an infected hip

The previous hip procedures described in this chapter are mostly needed by children. This one may help an adult whose hip has been partly destroyed by infection, avascular necrosis or a painful ununited femoral neck fracture (77.6). He will walk less painfully, if what is left of the head and neck of his femur is excised, so as to allow the upper end of his femur to bear on scar tissue on the under side of his ilium. A false joint will develop, his leg will be short and he will need a stick, but he will probably have very little pain. This is a difficult procedure and is for more experienced surgeons only, which is why it is in small print. If you are inexperienced: (1) The joint cavity may become infected and seal off. (2) You can injure his sciatic nerve. (3) You may have to abandon the procedure uncompleted, in which case you will feel ashamed, and he will be made worse.

Girdlestone's operation is a salvage procedure to relieve pain when an arthrodesis or, exceptionally, a prosthesis is impractical. It is inelegant and old-fashioned, and is not indicated if you can refer him for an arthrodesis or a hip prosthesis. If this is impossible, [f10]and you are fairly experienced [f09]Girdlestone's operation will be much better than nothing. There are two varieties: (1) For a previously septic or tuberculous hip infection which is now inactive. This is the method which is described below. (2) For an ununited fracture of the neck of the femur, as described in Section 77.13.

Use a posterior approach, like Ober's (7.18), except that you carry the incision further down his femur, for 25 to 40 cm. Make sure that his sciatic nerve is out of the way, and that your assistant does not grasp it with his retractor.

GIRDLESTONE'S OPERATION INDICATIONS FOR INFECTIVE CONDITIONS. A patient who is walking painfully as the result of: (1) Previous septic arthritis, which is now inactive. (2) Previous tuberculous arthritis, which is now inactive but is still painful. (3) Aseptic necrosis of the head of the femur. (4) A longstanding ununited fracture of the femoral neck. (5) An infected prosthesis.

If you cannot refer him, proceed as follows.

EQUIPMENT. An orthopaedic set (4.12). A Gigli saw. Ideally, two special retractors. Have two units of blood cross- matched.

INCISION. Follow the method in Secction 77.13 until you get to the paragraph ''Cut the neck[...]' then proceed as follows:

Incise the capsule of the patient's hip joint to expose the head and neck of his femur and the remainder of his greater trochanter. Now open up his exposed hip joint by incising its capsule widely. Ask your assistant to move the patient's leg to help you identify the head of the femur.

If the head of his femur is not necrotic, or his hip is ankylosed, end the operation here.

You will find that removing the head is easier if you excise part of the rim of his acetabulum. Curette all necrotic and infected bone from his acetabulum. Make the excision as complete as possible and leave only the raw surfaces of vascular cancellous bone. Remove the neck down to its base, and smooth it by chiselling away all sharp edges.

Sew back the edges of his incised gluteus maximus. If there is little active infection and you have suction drainage, use it. If you find the bone seriously infected, leave the wound partly open. Insert 2 or 3 rubber drains.

POSTOPERATIVELY, to prevent shortening, apply 3 to 10 kg of skeletal traction through his tibia with his hip in 20 or 30[de] of flexion for 6 weeks. This will not be necessary if his hip is already fibrotic.

CAUTION ! Try to prevent proximal displacement of his femur. This will prematurely ''seal off' the area and defeat the purpose of the operation, which is to saucerize his acetabulum and allow free drainage when there is active infection.

8 Pus in the hands and feet