The Girdlestone Procedure for Hip Fractures in the Elderly

The Girdlestone procedure is a salvage procedure. It refers to the removal or resection of the head and neck of the femur. During this procedure, the diseased femoral head is cut off with a bone saw and removed. Girdlestone is usually performed when the patient has a severely painful hip and a total hip replacement cannot be done due to severe infection of the hip. This procedure is also done in nonabulatory cerebropalsy patients with a painful hip dislocation or if a patient has selective tumors in the area.

This procedure may have a role in cases of displaced femoral neck fractures or in cases of failed internal fixation of femoral neck fractures in debilitated elderly patients. Let us agree that in the elderly patient, hip prosthesis either unipolar or bipolar (usually cemented), is the ideal surgical procedure for displaced femoral neck fractures, especially if the patient is debilitated and old. In an active elderly patient, a total hip replacement should be considered. Sometimes the medical condition and the age of the patient does not support or allow the use of a prosthesis in the elderly. I use the girdlestone procedure in some cases of displaced femoral neck fractures in the elderly, especially if the patient is debilitated and nonambulatory, and when the medical comorbidities are almost prohibitive for surgery. These medical conditions include: chronic renal failure (the worst), COPD, and congestive heart failure.

Even if the prosthesis could be done, the pre-injury cognitive and physical function is predictive of postoperative functional outcome after hip fracture surgery and this select group of patients will not be functional with the prosthesis. The purpose of the Girdlestone procedure is to decrease the pain and to preserve the life of the patient despite the considerable shortening of the extremity. It is an alternative to hospice or alternative care. It is the simplest and the least complex procedure for the patient. Counseling should be provided to the patient and their family.

The Girdlestone procedure can be performed anteriorly or posteriorly. The physician will not need traction post-operatively. The patient should be encouraged to move and get out of bed as soon as possible and physical therapy should be started early. The patient should remain in a step down or ICU for a few days after surgery. The patient should be admitted by the geriatric services in cooperation with the trauma services. Surgery should be done within 48 hours or as soon as the patient is optimized medically because that could decrease the mortality rate. Sometimes the optimization of the patient is not that easy.

The mortality rate is 25% at one year and 6% during hospitalization. The pre-injury mobility is the most significant determining factor for post-operative survival. In patients with femoral neck fractures, surgery done on weekends was associated with an increase in hospital mortality rate, so it is better to do this surgery one week days. If you try to do a simple procedure such as fixation of the displaced femoral neck fracture, this failure rate is about 46% with fixation techniques in the elderly. There is a growing number of people over 90 years of age who will suffer from femoral neck fractures and these patients will need decisions and appropriate care for their situation. Advanced age is associated with increased mortality and poor functional recovery, so it is necessary for physicians to approach the increased number of femoral neck fractures in the elderly and I think that Girdlestone procedure should be utilized in some select indications.

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