➢ Hip resection arthroplasty has a nearly 100-year surgical history and has been utilized for the treatment of a diverse array of diseases and conditions involving the hip, including extrapulmonary tuberculosis, septic arthritis, penetrating war-related trauma, infection following total hip arthroplasty, and degenerative osteoarthritis secondary to neuromuscular disease.
➢ The average limb shortening reported in the literature following hip resection arthroplasty is 4.27 cm.
➢ When hip resection arthroplasty was used for the treatment of an infected hip, 92% of 533 treated hips had eradication of the infection, 89% of 711 hips had much less pain or were pain-free, 90% of 721 hips were in patients who maintained walking ability, and 74% of 426 hips were in patients who reported satisfaction.
➢ When hip resection arthroplasty was used for the treatment of spastic hip disease in patients with cerebral palsy, pain was controlled in 95% of 155 patients, sitting ability was improved in 96% of 129 patients, and perineal care was improved in 96% of 102 patients.
➢ Compared with two-stage exchange arthroplasty for the treatment of infection following total hip arthroplasty in medically compromised individuals, hip resection arthroplasty may be a more cost-effective option and may have a lower risk profile in the United States health-care system.
Hip resection arthroplasty is an operative technique that can be a valuable tool for the treatment of complex hip disease. The relative rarity of the procedure makes prospective study of outcomes somewhat difficult. The purpose of this review was to gather, summarize, and analyze the entirety of cases and series published on the topic to date.
Historical Origin of Hip Resection Arthroplasty
Prior to the introduction of antibiotics in the 1940s, the treatment of extrapulmonary tuberculosis consisted of either isolation of the patient in a sanitarium or crude attempts at surgical debridement. Untreated infection led to pain, septic arthritis, chronic osteomyelitis, joint destruction, and disability. In the early 20th century, under the tutelage of Sir Robert Jones, Dr. Gathorne Robert Girdlestone developed resection arthroplasty as a treatment for chronic tuberculosis of the hip1,2. At that time, the accepted treatment for tuberculosis of the hip was joint immobilization and symptomatic management; although some alleviation of symptoms could be expected, long-term outcomes were unfavorable3,4.
Girdlestone believed that limb-preserving treatment for tuberculous hip disease required ankylosis or pseudarthrosis of the hip to provide a suitable platform for weight-bearing following the resolution of infection3,4. One operative procedure that was originally used by Girdlestone and others was extra-articular arthrodesis1,2. Unfortunately, ossification frequently failed because of the poor health of the native bone as well as the suspicion that Mycobacterium tuberculosis impaired bone formation; the exact mechanism for this suppression was unknown at that time1.
In cases of very serious infections, Girdlestone advocated for amputation as a means of excising all diseased tissue2. In one such case, involving a severely ill patient with a secondary tuberculous lesion of the hip, an amputation was to be completed in two stages. The first stage consisted of debridement and excision of the femoral head, neck, and infected synovial membrane5. The excision resulted in such a dramatic improvement in the patient’s condition that the secondary amputation was never performed. Postoperatively, the patient maintained free movement of the hip, could walk with support, and was satisfied with the outcome. As a result of these findings, Girdlestone began using this procedure in similar cases and later expanded its use to treat other conditions5.
Evolution of the Modern Technique
During World War I, Girdlestone was in charge of the orthopaedic division of a large military hospital in Oxford, United Kingdom, where he managed patients who had penetrating trauma. Reasoning that pyogenic arthritis of the hip could be effectively treated with surgical debridement, Girdlestone applied his resection arthroplasty technique to the treatment of hip wounds that had been sustained on the battlefield3. His success ultimately led to the use of the technique for the treatment of osteoarthritis of the hip, which he later presented to the Royal Society of Medicine, in 19445 (Fig. 1 and Fig. 2).
In 1926, Girdlestone detailed his arthroplasty procedure in a letter to Sir Robert Jones. A 6-in (15.2-cm) transverse incision was made at the greater trochanter with beveled excision of skin, subcutaneous tissue, fascia, muscle, and bone (Fig. 3). The femoral head and neck were removed, and skin flaps were sutured to the remaining periosteum. The wound healed by secondary intention while drainage was allowed to occur. Scar-tissue formation resulted in a pseudarthrosis, which permitted hip motion to be preserved and relieved the strain put on the lumbar spine and knees by otherwise inflexible hips4.
The Girdlestone resection arthroplasty has evolved since the introduction of antibiotics and the technological revolution of hip replacement surgery. Resection arthroplasty can be performed with use of any surgical approach to the hip, and it can be performed through the so-called internervous plane of the direct anterior approach. Careful preoperative planning with regard to the level of resection and soft-tissue management are critical. Meticulous removal of implants and cement from the site of infection is an important consideration to help minimize the risk for persistent infection.
Application of skin or skeletal traction to the affected limb can be considered postoperatively but is not mandatory and has not been consistently beneficial according to the literature6,7. If possible, the greater trochanter and abductor insertions should be retained for the possibility of delayed hip reconstruction in the future, and the superolateral aspect of the acetabulum may be resected, if prominent, to reduce osseous impingement. In all cases, the wound is now closed primarily to allow healing and to prevent unintended infection. Limb shortening is inherent to the procedure, with an average reported shortening of 4.27 cm observed in five case series8-12 published between 1989 and 2004 (Table I).
Because Girdlestone developed his procedure in the pre-antibiotic era, his technique was far more radical than the modern technique used today, making the eponym Girdlestone arthroplasty unfit to describe the modern hip resection arthroplasty procedure. While the term Girdlestone arthroplasty has become nearly universal when referring to salvage operations based on removal of the femoral head and neck, it is now more appropriately termed an excision arthroplasty or a hip resection arthroplasty13.
Modern Hip Resection Arthroplasty for Hip Disease in Adults
Hip resection arthroplasty is utilized most commonly as a salvage procedure for failed total hip arthroplasty (Fig. 4). As the popularity of hip replacements has soared, so has the number of patients needing revision operations because of loosening or infection8. While the rates of complications, especially infections, have decreased dramatically from the early days of total hip arthroplasty as a result of gradual improvements in the delivery of care, complications are still a substantial issue because of the large number of procedures being performed10. Although the failure rate is reported to be between 0.25% and 1.7% overall, hundreds of thousands of total hip arthroplasties are being performed annually in the United States alone; thus, treatment of infections following total hip arthroplasty will remain a major concern moving forward14-16. Simple debridement is an option for infection control, but it has been associated with poor infection-control outcomes and high rates of infection recurrence15.
As many patients managed with total hip arthroplasty are elderly, additional major operations to eradicate a periprosthetic joint infection and to replace the implant can be very difficult or even impossible. High rates of complications and poor outcomes may occur because of loss of bone stock, soft-tissue deficiency, chronic infection, immunodeficiency, and the poor overall condition of the host bone8,17,18. In cases in which revision or re-implantation is risky or impossible, hip resection arthroplasty offers a potential solution8,19,20. In this review, we have comprehensively assembled reports from around the world that have focused on this technique (Table II).
While hip resection arthroplasty has been touted as highly successful with regard to pain and infection control, it has been associated with mixed functional outcomes as a consequence of limb shortening caused by the removal of the femoral head and neck5, which results in a lifelong need for external support to walk21. Today, patients generally expect full mobility to be the outcome after any hip arthroplasty surgery. However, the disadvantages associated with the functional outcome of hip resection arthroplasty may be outweighed by the advantages, which include eradicating infections and eliminating pain. It is critical during management to recognize the inherent dichotomy between the surgeon’s primary goal of infection eradication and the patient’s primary goal of a painless, functional hip.
Results of Literature Review
Table II outlines the outcomes of hip resection arthroplasty for various indications, but mainly for the treatment of failed total hip arthroplasty and/or infection following total hip arthroplasty. Overall, 490 (92%) of 533 infected hips had eradication of infection and 635 (89%) of 711 hips were much less painful or were pain-free postoperatively. These results were consistent and spanned historical series published from 1948 to 2012. Functional outcomes were acceptable, with 317 (74%) of 426 patients reporting satisfaction and with 650 (90%) of 721 patients maintaining walking ability.
The vast majority (90%) of patients retained their mobility; however, nearly all patients needed some form of walking aid9. Additionally, preexisting conditions such as paraplegia or associated conditions such as obesity and severe arthritis of other lower-body joints may have contributed to poor mobility after hip resection arthroplasty, leading to bias of the reported results4,6,9,10,21-23. Overall, hip resection arthroplasty allowed most patients to retain the ability to walk and therefore maintain their independence, which has been described as “highly important” to most elderly patents9.
Two-stage exchange arthroplasty for the treatment of infection following total hip arthroplasty involves multiple operations and has a high chance of associated complications that can require additional subsequent operations and more time spent in the hospital. These factors make two-stage exchange arthroplasty an expensive option15. Fitzgerald estimated that hospitals routinely provide $50,000 of unreimbursed medical care with each two-stage exchange arthroplasty performed to treat an infection following total hip arthroplasty because of the vast range of hospital resources needed to eliminate the infections7.
Expense has become an important consideration in an era of escalating medical costs and declining reimbursements in the United States; however, financial considerations may be different elsewhere in the world because of the inherent differences across health-care systems. Fisman et al. concluded that debridement with prosthesis retention is the most monetarily reasonable treatment for elderly patients, but it may not be a cost-effective option because infection will recur in many patients (30% annually), who eventually will have to undergo additional operative procedures15. Those authors also considered antibiotic suppression to be the cheapest option, but this treatment also was associated with a high infection recurrence rate (30%), again requiring additional treatment.
The two-stage exchange arthroplasty may offer satisfactory rates of infection control and may be worth the increased cost for younger patients who are unlikely to accept a reduced functional outcome and who have a better chance of recovering. However, for the average patient with an infection following total hip arthroplasty who has a high-risk medical profile, hip resection arthroplasty may be the most reliable, safest, and most cost-effective option. Hip resection arthroplasty costs substantially less than two-stage exchange arthroplasty, making it a potentially reliable and economical option15.
Cost is also an important concern in developing countries, where medical resources are limited and pyogenic and tuberculosis infections of the hip remain common24. Many of these countries are in the Eastern hemisphere, where mobile hips are highly desirable because of the social, cultural, and religious importance of kneeling, squatting, and sitting cross-legged24. While a two-stage exchange reimplantation total hip arthroplasty theoretically would give the best function, it may be exceedingly expensive for the average patient in many developing countries. Hip resection arthroplasty offers a viable alternative. It is a simple and inexpensive operation that does not require complex management postoperatively, and it can be performed almost anywhere in the world. Tuli and Mukherjee found that twenty-seven (90%) of thirty Indian patients were able to squat and sit cross-legged after undergoing a hip resection arthroplasty, and these patients were generally very satisfied with the result24.
The subjective evaluation of the results of hip resection arthroplasty was quite varied. For example, in the study demonstrating the lowest satisfaction, patients were asked whether they were satisfied with the functional outcome, not whether they were satisfied with the operative treatment overall, indicating that the way in which subjective follow-up questions are phrased can have an important influence on patient responses16.
The low rate of patient satisfaction after resection arthroplasty may be related to a discrepancy between the actual postoperative function as reported by patients and the expected hip function that is typically achieved following a successful total hip arthroplasty8. When patients take into account the pain relief and infection control provided by hip resection arthroplasty, they may be more likely to view the outcome favorably.
Older patients tended to be more satisfied with the outcome. Patients who underwent bilateral hip resection arthroplasty tended to be unsatisfied because walking with two pseudarthroses proved to be difficult and because having two procedures increased the chances of pain and other complications postoperatively16,20,25. Accordingly, perhaps poor functional outcomes should be considered not as a complication but rather as an expected secondary consequence of the procedure. It is therefore essential for the surgeon to explain this critical distinction to patients and their families to help establish realistic expectations regarding postoperative hip function.
When it comes to treating an infection following total hip arthroplasty, single-stage exchange offers the benefit of a potentially superior functional outcome; however, it has been shown to be less effective than hip resection arthroplasty for infection control, even with the use of antibiotic-loaded bone cement22. Overall success rates have been poor, with Buchholz et al. finding that only 77% of 583 patients were still free from periprosthetic infection in the short term after a single-stage exchange arthroplasty26. Long-term results were even worse, with Röttger reporting that 50% of 745 patients had a relapse of infection within eight years27. While the results of single-stage exchange have improved because of modern antibiotic techniques, the technique may not be appropriate for all patients. Ure et al.28 reported that single-stage exchange was as successful as two-stage exchange or hip resection arthroplasty for the eradication of infection, but this was true only for a carefully selected cohort of patients (i.e., those who were not immunocompromised, had no gram-negative infections, had no antibiotic-resistant infections, and were in good general health) who were managed with meticulous operative technique and extensive postoperative antibiotics. Therefore, for the majority of patients with infection following total hip arthroplasty, one-stage exchange may be a less effective option for controlling infection29.
The more accepted option for the treatment of infection following total hip arthroplasty in the United States is the two-stage exchange arthroplasty. The first stage is a resection arthroplasty (for infection control), with or without implantation of an antibiotic-loaded cement spacer, followed by a healing period before the implantation of a new total hip prosthesis during a second procedure. This option can be highly appealing as it potentially offers a high rate of infection control following the resection arthroplasty as well as an improvement in functional outcome once the second stage is complete compared with hip resection arthroplasty alone.
Unfortunately, the contemporary success rate following two-stage exchange has been highly variable. In a recent study by Berend et al.30, a two-stage exchange led to infection control in 83% (157) of 189 hips in which an infection had developed following total hip arthroplasty. However, when both patient survival and infection control were assessed, the overall success rate decreased to 77% (157 of 205 hips) as fourteen patients (fourteen hips) in the series of 202 patients (205 hips) did not survive to undergo the planned second stage of the operation. Therefore, a two-stage protocol for the treatment of infection following total hip arthroplasty may in fact be associated with substantial mortality and a substantial failure rate resulting from both reinfection and the potential inability to perform the second stage.
The two-stage exchange arthroplasty is associated with other potential complications related to multiple operations, extensive rehabilitation, and potentially longer hospitalization for patients who often have poor medical profiles11,15. It can be a technically challenging procedure because the second-stage total hip arthroplasty is performed on a joint with soft-tissue scarring, distorted anatomy, and loss of bone stock in patients who are often in poor overall condition8,11. Consequently, in one series involving reimplantation after initial resection, 33% of forty-four patients experienced a local complication, including dislocation (prevalence, 11.4%) and persistent limp (prevalence, 39%)11. Schröder et al. found that even when the two-stage exchange arthroplasty was successful, the improvement in function after the second-stage reimplantation was not substantial compared with that for patients in whom a mature pseudarthrosis formed after hip resection arthroplasty12. After second-stage reimplantation, patients still had substantial limb-length discrepancies and similar ranges of motion; the majority (75%) of the sixteen patients still relied on walking aids for support, and more than half (63%) walked with a positive Trendelenburg gait12. Additionally, the health-care costs of providing a two-stage exchange are a major cause of concern for hospitals and surgeons alike.
There are even many cases in which patients could benefit from hip resection arthroplasty as a primary procedure. Ahlgren et al.31 found that 100% (twenty-seven) of twenty-seven patients who had had an infection after total hip arthroplasty believed that they were better off after hip resection arthroplasty than they had been before treatment of the infection, and Lowry and Brand22 found that 59% (sixteen) of twenty-seven such patients believed that they were better off after hip resection arthroplasty than they had been before treatment of the infection. Parr et al.6, Collis and Johnston32, and Golda et al.18 suggested that hip resection arthroplasty should be viewed as much more than just a salvage procedure because total hip arthroplasty is often not worth the risks or is not even technically possible in patients with the surgical risk factors mentioned earlier, whereas hip resection arthroplasty can address the problem of infection with a much lower risk of morbidity and mortality. Additionally, high-risk patients who are in poor general health may lack the requisite respiratory capacity to perform the extensive rehabilitation needed to achieve satisfactory function after total hip arthroplasty; this subgroup of patients may instead be considered as candidates for hip resection arthroplasty because of the lower functional expectations related to their poor health at baseline as the procedure may potentially require less-intense therapy6.
Hip Resection Arthroplasty in Patients with Neuromuscular Disease
Hip resection arthroplasty has shown promising results when used for the treatment of neuromuscular disease, including cerebral palsy (Fig. 5). Hip problems are very common in patients with severe spastic cerebral palsy (prevalence, 6.5% to 60%)33,34. Subluxation and dislocation result from the spasticity of adductor and hip flexion motor groups33,34. Progressive deformity of the femoral head results, making anatomic reduction impossible. The joint becomes painful and immobile because of damage to the cartilage and contracture of the soft tissues around the hip35.
Repeated dislocations in patients with cerebral palsy may cause deformation and notching of the femoral head, whereas spasticity of the hip muscles may lead to erosion of the articular cartilage of the acetabulum36,37. Hip muscle spasticity generates abnormal posture, leading to excessive local cartilage pressures between the head and the acetabulum34,37. The constant pressure prevents the articular cartilage from taking in nutrients that it needs, resulting in a common final pathway of degradation that subsequently prevents the hip from obtaining a congruous reduction37.
Once a hip is fully degenerated, it will likely prevent the patient from comfortably sitting in an upright position. Painful, incongruous, and immobile hips can cause a host of difficulties, including pain, skin breakdown due to restricted positioning, decubitus ulcers, inadequate perineal hygiene, difficulty with feeding, and difficulty with pulmonary ventilation35,36,38. Therefore, the goal of treatment is a pain-free hip with a range of motion that allows for sitting and improved perineal hygiene34.
Surgical options that previously have been used to achieve these goals while maintaining hip function have included soft-tissue releases, soft-tissue and osseous reconstruction, femoral and pelvic osteotomies, open reduction, acetabular reconstruction, or hip-resurfacing procedures34,36,39,40. While these procedures can be successful in young patients in whom the hips are not yet severely degenerated, they may not work well for older patients with damaged hips34. As the pain in degraded joints is often related to the femoral head deformity, soft-tissue procedures do not address the main cause of pain in the hips of patients with cerebral palsy33,41.
Of note, even if soft-tissue procedures are initially successful in a young patient, the continued spasticity of the hip muscles ultimately may lead to a recurrence of spastic hip dislocations, pain, and eventual incongruity of the hip with aging36,40. This point has been illustrated by the fact that many patients with cerebral palsy who have elected to have a hip resection arthroplasty have previously undergone soft-tissue surgery that did not fix the problems in the long term33,39,40,42. Total hip arthroplasty would be challenging or contraindicated in a patient who is unable to walk because of neuromuscular imbalances and hip muscle spasticity34,36,38. Additionally, total hip arthroplasty components often are not available in the extremely small sizes that would fit within a poorly developed acetabulum and an often exceedingly small proximal femoral canal.
The pain and perineal-care issues caused by hip degeneration in patients with cerebral palsy can be reliably alleviated with use of hip resection arthroplasty. The result of the procedure is a painless and mobile hip, which is required for sitting and leads to considerable improvement in the overall quality of life. We reviewed the available literature to quantify the success of the operation in terms of both pain relief and an increase in sitting tolerance as a proxy for an increase in the general quality of life for patients with cerebral palsy (Table II). Often, these patients are unable to walk at baseline, so achieving pain relief via hip resection arthroplasty can be an excellent surgical option.
Results of Literature Review
Table III shows the outcomes of hip resection arthroplasty when used for the treatment of the symptoms resulting from spastic cerebral palsy involving the hip. Pain was controlled in 147 (95%) of 155 patients. Hip resection arthroplasty was also extremely successful for improving the sitting ability of 124 (96%) of 129 patients and improving perineal care for ninety-eight (96%) of 102 patients. Patients noted these improvements during the postoperative recovery following hip resection arthroplasty36. Most patients saw improvements in their general quality of life because of the increased ease of mobility and perineal care. Importantly, the increases in sitting ability and the resulting ease of perineal care were durable35.
Hip resection arthroplasty is also a highly cost-effective, inexpensive option for patients with cerebral palsy. While soft-tissue procedures are potentially less expensive than hip resection arthroplasty, these procedures are often a short-term solution that requires further surgery. However, once patients with cerebral palsy had undergone the hip resection arthroplasty, their primary care physicians reported that they required fewer acute-care hospital visits and infirmary visits because of the improvement in their general health35. Because of less frequent reliance on supportive medical care, hip resection led to dramatically lower medical care-related costs in the long term.
While hip resection arthroplasty has been shown to be highly successful for the treatment of spastic cerebral palsy involving the hip, the most common causes of complications and poor results were proximal migration of the femoral stump and formation of heterotopic bone33,35,42. These complications were reported in association with the use of a more extensive resection procedure, similar to Girdlestone’s original technique, in which the femoral head and neck are resected along with adjacent abductor tissues35. However, with focal resection of the femoral head and neck as well as meticulous surgical technique (to minimize abductor damage that can cause the formation of heterotopic bone) and possible use of traction postoperatively, the rate of complications can be lowered33,35. While the formation of small amounts of heterotopic bone was still seen in the majority of patients, it had no negative effect on the outcome33,35,38.
In the study by Muthusamy et al., the functional outcomes of hip resection arthroplasty in patients with cerebral palsy were examined in great detail. Fifteen different functional categories relating to aspects of care were assessed; postoperatively, patients saw improvement in twelve of these categories and maintained their level of function in the other three34. Hip resection arthroplasty resulted in a sizeable improvement in many areas of the patients’ lives, and it accordingly led to an improvement in the patients’ general well-being (with more smiling, increased happiness, and better attitude) and a decrease in irritability for most patients34,42. McCarthy et al. also saw similar improvements in patients’ attitudes35. They and others even noted that many patients had increased independence, functional skills, and cognitive skills postoperatively35,42.
On the basis of the data gathered in this review, hip resection arthroplasty appears to be a reliable procedure and should be one of the evidence-based options in the arsenal of any orthopaedic surgeon who treats hip disease. Hip resection arthroplasty should be considered for patients with painful hip degeneration secondary to neuromuscular disease as well as for the primary treatment of severe hip arthritis, inflammatory disease, or acute fracture in patients who may not be suitable candidates for arthroplasty. The procedure is also a reliable and potentially cost-effective salvage operation after an infection following total hip arthroplasty for patients who may not be able to tolerate or survive a two-stage exchange12,17,30,43. Hip resection arthroplasty has a consistently high rate of success and a low rate of complications, and it can provide acceptable functional outcomes in the treatment of complex hip disease.
Source of Funding: No external grant funding was utilized in conjunction with this project.
Investigation performed at Brown University and Rhode Island Hospital, Providence, Rhode Island
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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