Q. I’m 35, in my 15th year as a T8 paraplegic, and I’ve been having severe spasticity in my right leg for at least six months. It feels as if my sitting posture has become crooked. A set of X-rays show that my hip is chronically dislocated. My doctor recommended I see an orthopedist about getting a Girdlestone procedure, where they cut the ball and neck off my thigh bone. I’m confused and a bit scared. If I do a Girdlestone procedure, how much of the femur do they take off? If I have it done, will my hip be stable? Will I be able to use my standing frame?
A. You raise important questions, James. The procedure is named for British surgeon Gathorne Girdlestone, who first performed it as a lifesaving measure in 1928 to remove hips that had become diseased by tuberculosis. It evolved into a last-ditch operation to combat a variety of severe complications of the hip, from non-healing fractures, to chronic dislocations and non-healing infections. A typical Girdlestone involves removing the ball and neck of the femur. However, various conditions may require removal of more femoral bone.
Girdlestone procedures are relatively rare among the general population today, thanks to antibiotics and artificial hips. But the procedure is still employed as a last-resort effort to salvage failed artificial hips and treat bone infections.
For Girdlestone information specific to spinal cord injury, I turned to Kathleen Dunn, a retired clinical nurse specialist and rehab case manager. She says the procedure is done to treat a variety of SCI-related conditions that may include recurrent or chronic osteomyelitis, heterotopic ossification that severely restricts movement of the hip, a dislocated hip that cannot be repositioned, or a non-healing hip fracture.
Finding a surgeon with Girdlestone experience can be a challenge. Dunn suggests getting opinions from at least two orthopedic surgeons experienced in spinal cord injury and Girdlestone procedures before proceeding. To find a qualified surgeon, try contacting major SCI centers that are part of a larger hospital system with both plastic and orthopedic surgeons, and/or check with major university teaching hospitals.
Different Conditions Call for Different Procedures
Different conditions dictate how a Girdlestone should be performed and how much bone will need to be removed, says Dr. Douglas Garland, a retired orthopedic surgeon and former director of neurotrauma at Rancho Los Amigos Rehab Center. “Ideally, if you are going to do a Girdlestone, you want to keep your trochanter [top of the femur] intact. The bone is surrounded by a huge muscle that is intrinsically attached to the pelvis. The muscle provides a cushion for the trochanter as it butts up against the wing of the ilium [pelvis] and gives the leg stability when sitting in a wheelchair,” he says.
Garland says the easiest Girdlestone to perform is for a non-healing hip fracture. “Just take out the broken ball from the socket and resect the femur neck,” he says.
Ask your orthopedist if a prosthetic is an option, he adds, since there have been major advances in prosthetic hips for people with SCI, and fewer Girdlestones are being done for acute, non-healing fractures (see resources).
If a Girdlestone is needed for a dislocated hip, it usually requires removing the same amount of bone as surgery for a non-healing hip fracture does, says Garland. He adds that in many cases with a dislocated hip, it is best to take it slow and see what happens, because doing a Girdlestone in a hip that has dislocated because of spasticity will likely make things worse. You will still have the spasticity, but now the spasticity will pull the end of the femur up into the wing of the ilium. By waiting, the body will over time often create its own Girdlestone as the ball of the femur, which is soft, rubs against the ilium and gets absorbed by the body. This is an option if the dislocation isn’t causing complications like pressure, skin issues or pain. He adds that kids with cerebral palsy frequently develop dislocated hips, but don’t undergo Girdlestone procedures. They leave them in place and do fine.
In cases of osteomyelitis, the surgeon needs to remove bone from the femur past the point of infection, says Garland. Dunn adds that because osteomyelitis is generally caused by a pressure ulcer, Girdlestone surgery is done in conjunction with a flap. Some plastic surgeons do the entire procedure themselves, and others work with an orthopedic surgeon to make sure incisions are done to spare soft tissues for the flap.
If the Girdlestone is being done for heterotopic ossification — a condition where bone forms in soft tissue — it is important to find an orthopedist who has a lot of experience in managing HO, says Garland. As in Girdlestone surgery for osteomyelitis, femur bone is removed past the area of HO. For both osteomyelitis and HO, the surgeon must transfer the largest quadriceps muscle, called the vastus lateralis, and wrap it around the end of the femur to give the hip some stability. In the case of HO, the muscle wrap also helps prevent recurrence of HO.
A properly done Girdlestone should result in a stable hip when sitting in a chair. The femur will be an inch or two shorter, depending on how much bone needs to be resected. Unfortunately, a Girdlestone will not support standing in a standing frame or standing chair.
“Following the surgery, it is important to get a post-op seating eval because it is common for a Girdlestone to cause the pelvis to tilt to one side. This will put more pressure on the ischium on the Girdlestone side,” says Dunn. “This is why a seating specialist should also be part of your team when undergoing this procedure — it is common to need specialized or custom wheelchair seating after surgery.”
A Personal Example
I am a T10 para and I had a Girdlestone done on my right leg in 2000. Following surgery for a broken hip, four stabilization screws eventually pulled apart. The Girdlestone left the top of my femur intact — it was major surgery, yet by the following day, I was able to transfer into my chair gingerly and go home, where I was able to perform my own care. I had a big incision and an extremely swollen leg for weeks. It took about a week before I felt up to being in my chair all day, and several weeks for my incision to heal enough to get the staples out and be able to bathe. Two and a half months later, I was back to my normal activities, including off-road handcycling and swimming.
My right femur is about 1-2 inches shorter than the other, barely noticeable. My right leg feels as solid as my left when I’m in my chair. The leg has full range of motion and hasn’t caused a problem, except when doing activities that put a lot of push-pull motion on the hip — for me, that means paddling a kayak. If I decide to pursue sea kayaking, I will add a quick release belt to hold my hips.
Although the Girdlestone has served me well, these days I would likely be a candidate for an artificial hip, which wasn’t an option for people with SCI until the last few years.
• “Para/Medic: Heterotopic Ossification,” newmobility.com/2018/06/heterotopic-ossification
• “Para/Medic: Fracture Risk and Treatment Options with SCI,” newmobility.com/2016/04/fracture-risk-treatment-options-sci