Case Report Journal of Orthopaedic Case Reports 2015 April - June: 5(2):Page 47-49

Total Hip Arthroplasty in a Girdlestone Hip following

a Failed Hemiarthroplasty
Purushotham VJ1, Ranganath BT1
What to Learn from this Article?
Total hip arthroplasty is a good option for failed Hemirthroplasty cases though it is technically demanding. Girdlestone
arthroplasty may not be considered in such situation.

Abstract

Introduction: 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
may require total hip replacement to improve the quality of life, which are technically challenging. Here we are reporting such a
case in a 60 year old male patient, with review of literature.
Case Report: 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.
Conclusion: Improper implantation in Hemiarthroplasty fails subsequently. In such cases Girdlestone arthroplasty may be an
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.
Keywords: Hemiarthroplasty; Girdlestone arthroplasty; Totalhip arthropalsty.

Introduction with total hip arthroplasty in Girdlestone hip.

Hemiarthroplasty (unipolar or bipolar) of the hip is a commonly
performed procedure in elderly patients with intracapsular displaced Case report
fractures of the neck of femur with good short-term results with A 60 year old male patient presented to us in the outpatient department
regard to pain relief, return to activity, morbidity and mortality [1,2,3]. with complaints of limp and shortening of the right lower limb for the
An improperly implanted bipolar prosthesis creates more problems past one year. The patient had sustained fracture neck of femur
with one of the options being a Girdlestone arthroplasty. Though following a fall while working one and half years back [Figure 1].He
good relief is achievable in some cases from Girdle stone arthroplasty, underwent cemented bipolar hemiarthroplasty for the same [Fig 2].The
in most cases the results are not satisfactory [4,5,6]. With the old post-operative x-rays showed a proud bipolar prosthesis with
following treatment option we report this case of re implantation extravasations of cement from proximal femoral aspect.

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Website: Dr. Purushotham VJ Dr. Ranganath BT

www.jocr.co.in

DOI: 1
2250-0685.272 Assistant Professor, Department of Orthopaedics, ESICMC PGIMSR, Rajajinagar, Bangalore. India.

Address of Correspondence
Dr V.J.Purushotham
Associate Professor & HOD Orthopaedic Department, ESIC medical college, Rajajinagar Bangalore 560010.
Email:- [email protected]

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Figure 1: X-ray Figure 2: Post

showing the fracture operative x-ray
neck of femur which showing the proud Figure 3: X-ray of Figure 4: Present X-ray showed gross
Figure 5: X-ray of Re implanted
the patient had bipolar prosthesis G i r d l e s t o n e proximal migration of femur with
total hip arthroplasty
sustained one and a n d e x t r a v a s a t e d arthroplasty porotic trochanter and cement mantle
half years back cement

The patient gave history of lengthening of the operated limb, which he noted that in spite of adequate soft tissue release the reduction was not
noticed on day one. He had continuous dull aching pain in the right hip achievable, unless the vertical offset was decreased. Hence a decision of
with stiffness for a period of six months from the day of surgery. Patient placing the stem deeper in the shaft, accepting the shortening was
was walking with the support of a walking aid. As the pain & limp taken & executed. Uncemented acetabular cup with a long cemented
persisted, he was advised removal of bipolar prosthesis. Patient revision stem total hip arthroplasty was done [Fig 5]. An uncemented
underwent the procedure of removal of improperly placed implant & stem could not be used as the reduction was difficult, even with the
Girdlestone arthroplasty [Fig 3]. Since, last one year he has been smallest trial offsets.
walking with pain, limp, shortening and instability. Patient had a The immediate post-operative period was uneventful and he was
Harris hip score of 26. The recent X-ray of the hip [Fig 4] showed made to walk with support on the 3rd day. The patient is ambulant
gross proximal migration of femur with osteoporotic greater without support, without any significant pain at present though
trochanter and cement mantle without any signs of loosening. shortening of the limb of about 2.5cms is present, which is
The patient was thoroughly investigated to rule out any signs of compensated by a heel raise. The latest follow up was one year after
underlying infection. The markers of infection; CRP was negative and surgery. The patient was able to walk independently with the help of a
ESR was around 25mm at the end of one hour. The hip joint aspiration stick, has mild pain on walking for more than a kilometer. The
under C-arm guidance was done to rule out any infective collection postoperative Harris hip score was 64.
which turned out to be negative. Later an MRI scan of the hip was also
done to rule out any possible signs of infection. Discussion
As the patient's intention was to have a painless joint with stability, he Intracapsular fracture neck of femur is one of the most common
was advised total hip arthroplasty. With an operative plan of removal fragility fractures in the elderly. Most patients are managed by
of cement mantle and total hip arthroplasty with or without extended replacement with either a hemiarthroplasty or a total hip arthroplasty.
trochanteric osteotomy, patient was posted for surgery. The standard An improperly implanted bipolar prosthesis would create more
posterior approach was used to expose the hip joint. The acetabulum problems to the patient, leaving the surgeon to choose one of the
was filled with hard fibrous tissue which was completely cleared and options being a Girdlestone arthroplasty. Converting such painful
acetabular floor was prepared. Once the preparation of acetabulum Girdlestone hip is technically challenging.
was done the proximal femur was exposed without having to do We reviewed the literature pertaining to results of Girdlestone
the trochanteric osteotomy, the cement mantle in the proximal part arthroplasty & total hip replacement in failed Girdlestone hips. There
of shaft was removed with some effort enblock, but the distal are no reports of Reimplantation of Total hip components in a case,
mantle was impacted in the shaft. The mantle was drilled with where a failed hemi replacement is converted to a Girdlestone hip, as in
3.2mm drill bit, to remove it in piece meal. But the peripheral part our case report.
was integrated very well within the canal. The K- nail reamers of Girdlestone in both his articles in 1928 & 1942, has described radical
6.0mm, 7.0mm and 8.0mm were used to gradually remove the excision of hips in tuberculosis & pyogenic infections [8]. He
mantle, in the attempt the antero-lateral wall of the femur was emphasized that the surgery involving excision of head, neck, greater
breached. The breach in the wall, which was about 6mm in trochanter & all musculatures is only for severe infections of hip joints.
diameter was identified immediately and the exposure was further He concluded that if the surgery is done well the result is good with
extended to visualize it. The break in the cortex was used to remove dramatic relief from the condition. In 1989 R T Muller, KF Schalgel5
the distal part of the cement mantle. Once the cement was endorsed this in their study where results of Girdlestone arthroplasty
completely removed the femoral canal was prepared. Long were good to satisfactory. Oheim et al in 2011 in their series of 27
cemented stem was planned to bypass the cortical breach by at cases opined Girdle stone arthroplasty is still an essential surgery
least 2 cortical diameters. An undisplaced split in the trochanter though not functionally satisfactory [9].
was stabilized using a steel cable. However Bitter ES, Petty W in their series of 14 patients concluded that
48 The trial prosthesis was placed and reduction was attempted. It was the functional results were not good following Girdlestone and the

Journal of Orthopaedic Case Reports | Volume 5 | Issue 2 | April - June 2015 | Page 47-49
Purushotham VJ et al www.jocr.co.in

patient often needed further procedures, like fusion or literature are not generally uniform.. Each case has to be looked at
replacement depending on the age of the patients [4]. individually and decision to offer a Total hip in such cases should be taken
In 2008, Pankaj A, Surya bhan et al in their series of 44 cases judiciously in consultation with the patient, after explaining pros and cons
concluded that conversion of symptomatic hemiarthroplasty to with a guarded prognosis.
total hip arthroplasty is a safe option that gives good functional Better results with total hip arthroplasty in Girdlestone hips can be
results, with marginally higher rates of intra-operative expected in cases where more bone on the proximal femur can be
complications [10]. preserved [7]. In this case where the proximal femur was completely intact
Pradeep bhosle et al in their series of 89 cases in 2012, where Total was ideal for conversion to total hip arthroplasty. However the muscle
hip replacement was performed for failed hemiarthroplasty strength around the hip in such cases which are operated multiple times is
concluded that T H R is an excellent option in failed difficult to assess. It is important to explain guarded prognosis of the
hemiathroplasty cases [11]. procedure beforehand to the patient.
In 2004 Markus E Rittemeister et al in their series of 39 patients
assessed the functional outcome of total hip replacement following Conclusion
Girdlestone hip arthroplasty. They concluded that the results were The longevity of implants following hemiarthroplasty depends on its
unpredictable from poor to fair hip function as evaluated with proper placement. Girdlestone arthroplasty may not give requisite
standardized hip scoring systems. In 17 cases they had to do functional relief to the patient. Though technically challenging, total hip
revision surgeries. Microbiological culture, patient age, duration of arthroplasty in certain cases will give a relatively stable and painless hip, as
Girdlestone arthroplasty and the number of preceding surgical is the observation in our case. Patient has been ambulant without pain till
procedures did not correlate with the functional outcome after his last follow up of 1 year. A Long term follow up of this case may throw
conversion [12]. more information in these cases.
Although Girdlestone hip arthroplasty is a useful surgery, it is
generally reserved for multiple failed attempts at reconstruction of
the hip, generally as a result of infection or for septic and tubercular Clinical Messege
hips. The results of girdlestone hips vary from good to poor in the
various studies published. Though girdlestone arthroplasty was a Hemiarthroplasty will fail if not done properly. Converting
common surgery previously, the number of surgeries in the such failed cases to Girdlestone hip arthroplasty may not be a
present date have decreased probably owing to the refusal from good option. In such cases where Hemiarthroplasty has failed
patients to accept an excision of the hip, improved surgical or subsequent Girdlestone hip arthroplasty has failed to give
outcomes following revision hip reconstruction and decreased relief to patient, Total hip arthroplasty should be considered
incidence of septic /tubercular hips. though it is technically demanding especially after 2 failed
On the other hand conversion of a long standing Girdlestone hip to surgeries prior to it.
a Total hip though is a well documented procedure in the literature,
it is generally done for septic hips. The results mentioned in the

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How to Cite this Article

Conflict of Interest: Nil
Purushotham VJ, Ranganath BT. Total Hip Arthroplasty in a Girdlestone Hip following a Failed Hemiarthroplasty.
Source of Support: None
Journal of Orthopaedic Case Reports 2015 April-June;5(2): 47-49

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Journal of Orthopaedic Case Reports | Volume 5 | Issue 2 | April - June 2015 | Page 47-49