Girdlestone Procedure for Femoral Neck Fractures in the Elderly

Girdlestone Procedure for Femoral Neck Fractures in the Elderly

Girdlestone procedure is a salvage procedure. It means removal or resection of the neck of the femur. The diseased femoral head is cut off with a bone saw. It means removal or resection of the head and neck of the femur. The affected femoral head is removed as you can see in this picture. Girdlestone is usually done in the following situations: patient has a severely painful hip and a total hip replacement cannot be done such as in cases of severe infection of the hip or in a nonabulatory cerebropalsy patient with a painful hip dislocation. It can also be done in selective tumors of this area. girdThe procedure is referred to as a “salvage” procedure. It is the lesser of two evils or it is the final alternative procedure. 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’s agree that in the elderly patient, hip prosthesis either unipolar or bipolar and 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, 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. Comorbidities include chronic renal failure, COPD, and congestive heart failure. Even if the prosthesis could be done, the pre-injury cognitive and physical function is predictive of post-operative 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. grdIt is the simplest and the least complex procedure for the patient. Counseling to the patient and the patient’s family should be done. The Girdlestone procedure can be done anteriorly or posteriorly. You do not need traction post-operatively. You should get the patient out of bed immediately, and you should do physical therapy early. You will keep the patient 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 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 on week days. If you try to do a simple procedure such as fixation of the displaced femoral neck fracture, the 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 we need to think of new ways to approach the increased number of femoral neck fractures in the elderly, and I think that Girdlestone procuedre should be utilized in some select indications.

Osteonecrosis of the Hip

Osteonecrosis or Avascular Necrosis of the hip is death of a segment of bone in the femoral head due to disruption of the blood supply. The etiology of this condition is not fully understood. There are several risk factors associated with osteonecrosis of the hip. The condition occurs bilaterally in about 80% of patients. It is important for the physician to check both hips, even if one is asymptomatic. An early diagnosis is important because during the early stages of osteonecrosis, a femoral head preserving procedure can be done. In the late stages of osteonecrosis, the femoral head collapses and cannot be saved. The femoral head may need to be replaced. Obtain AP and Frog Leg Lateral views of the hip. The Frog Leg Lateral view will show the crescent sign.

An MRI is the imaging of choice, especially when the patient has persistent hip pain, the radiographs are negative, and the diagnosis of osteonecrosis is suspected.

osteonoThe Ficat Classification is a commonly used system to stage osteonecrosis of the hip. Stage I classifications will have a normal appearing x-ray and an MRI will detect the lesion; changes in the marrow. Stage II classifications are identified by sclerosis and cyst formation. Characteristics of the Stage III classifications are a subchondral fracture and the appearance of a crescent sign and flattening of the femoral head. Stage IV classifications will show advanced lesions with arthritis, osteophyte formation, and a loss of the joint space.

stages

Treatment

For early stages of osteonecrosis of the hip, initial trial of nonsurgical treatment is usually done. Surgery may be needed if nonsurgical methods are not successful. Nonoperative treatment typically consists of bisphosphonates.

femoral head collapsedThese drugs may be used before the femoral head collapses and are still in the experimental stages. In regards to traditional surgical treatment, when the lesion is small a head preserving procedure can be done. For stages I & II, a core decompression is used. The surgeon can make a single large hole or multiple small holes in the femoral head. It decompresses the head and stimulates a healing response. The lesion is done anteriorly and superiorly.

bonegraft222If the surgeon chooses to perform a core decompression with bone graft, they will debride the necrotic area and insert the bone graft into the open space. Vascularized Fibular Grafts are done in younger patients. Complications include: donor site pain and leg dysfunction as well as tibial stress fractures on the side the graft was taken. Stages III and IV will require a total hip arthroplasty (cementless cup and stem) or total hip resurfacing; however, resurfacing is not commonly used. A total hip replacement is considered to be the traditional procedure for advanced stages of osteonecrosis of the hip. Total hip resurfacing is considered to be controversial because the patient will need adequate bone stock to support the femoral component. The result is not as good when compared with a patient with osteoarthritis.totalhip