Girdlestone Procedure: A Comprehensive Guide to Hip Salvage Surgery

The Girdlestone procedure, formally known as the Girdlestone procedure or Girdlestone excision arthroplasty of the hip, is a specialised surgical approach used to manage complex hip problems when more conventional operations are not feasible. This article provides a thorough overview of the girdlestone procedure, including what it is, when it is considered, how it is performed, what outcomes patients can expect, and how best to navigate recovery and rehabilitation. Written in clear, patient‑friendly terms, it also explains the differences between the girdlestone procedure and other hip salvage options, with practical guidance for patients and carers alike.

What is the Girdlestone Procedure?

The girdlestone procedure is a type of hip excision arthroplasty—often described in everyday terms as a hip salvage operation. In this operation, the femoral head and neck are removed, and the hip joint is left without its ball and socket articulation. The goal is to relieve pain, eradicate infection when present, and provide a stable, tolerable limb for mobilisation. The result is a shortened limb and a new, albeit unstable in some respects, pseudoarthrosis between the remaining femur and the pelvic socket. This is a well-established option in the armamentarium of hip surgeons for specific, carefully selected cases.

Historically, the girdlestone procedure is named after Sir Gathorne Girdlestone, who described excision arthroplasty procedures that later became standard practice in certain clinical situations. Today, the girdlestone procedure remains an important consideration in the management of infected hip implants, severe hip destruction, and other challenging hip disorders where re‑replacement is not immediately possible or desirable.

Indications for the Girdlestone Procedure

The girdlestone procedure is not a first‑line treatment for most hip problems. It is typically considered in carefully chosen circumstances where alternative options are deemed unsuitable or carry unacceptable risks. Common indications include:

• Persistent or complex infection of a hip arthroplasty where a two‑stage revision is not feasible or infection control is challenging.
• Severe, end‑stage hip disease that causes uncontrollable pain and limited function, where re‑implantation is not possible due to bone loss or patient factors.
• Failed hip replacement with recurrent instability or soft tissue deficiency that makes other reconstructive options unlikely to succeed.
• Traumatic destruction of the hip joint when reconstruction is impractical or would carry excessive risk.
• Poor general health or frailty where prolonged surgery and multiple procedures carry unacceptable risk, and a shorter, reliable intervention is preferred.
• In some paediatric or adolescent cases, where growth and development considerations render other options inappropriate, though this is less common.

In every case, the decision to proceed with the girdlestone procedure depends on a comprehensive assessment by an experienced orthopaedic team, including imaging, infection screening, and an open discussion with the patient about expected outcomes, rehabilitation, and the possibility of future reconstructive options if conditions change.

How the Girdlestone Procedure Is Performed

The girdlestone procedure is a major operation that requires careful surgical planning. The exact technique may vary slightly between surgeons and by patient anatomy, but the general principles are well established. Below is a typical sequence of events you might expect in a girdlestone procedure for a hip salvage indication.

Preoperative Preparation

Before surgery, patients undergo a thorough evaluation, including:

• Imaging studies such as X‑rays and possibly MRI or CT to map bone loss and plan the resection.
• Blood tests and infection screening if infection is suspected or possible.
• Assessment of overall health, nutrition, and any medicines that could affect surgery or recovery.
• Discussion with the surgical team about anesthesia, pain management, and postoperative rehabilitation goals.

Operative Steps

During the girdlestone procedure, the surgeon performs excision of the femoral head and neck, sometimes with careful removal of surrounding diseased tissue. In cases of infection, views of the joint are shared with meticulous debridement to remove infected tissue and contaminated materials. The key goals of this stage are to reduce source of pain and infection while preserving limb length as much as possible, though some shortening is common.

After the head and neck are removed, the remaining femur may be shortened further in some situations to create a stable pseudarthrosis and to facilitate wound healing and rehabilitation. Soft tissue structures around the hip—such as the gluteal muscles and surrounding capsules—are assessed, and meticulous closure is performed to minimise wound complications. In many cases, surrounding soft tissues are rearranged or reinforced to provide as much stability as possible without a prosthetic joint.

Infection Control and Antibiotics

If infection is present, an antibiotic strategy is employed alongside surgical management. This can include targeted antibiotics based on culture results, sometimes delivered intravenously for a defined period. In some infection scenarios, an antibiotic spacer may be used in the interim to maintain limb length and soft tissue tension before definitive management. The girdlestone procedure itself may be performed as a definitive procedure or as part of a staged approach in infected hips.

Postoperative Immobilisation and Support

After surgery, the hip is typically immobilised for a short period to protect tissues and support healing. Depending on the surgeon’s protocol and the patient’s condition, this may involve a brief period of limited movement, followed by early mobilisation with crutches or a walking frame. Rehabilitation is tailored to the individual, with a focus on pain control, preservation of knee and ankle motion, and gradual return to weight bearing as advised by the surgical team.

Variants and Adaptations of the Girdlestone Procedure

While the classic girdlestone procedure involves excision of the femoral head and neck, several adaptations have evolved to improve outcomes in specific situations. Understanding these variants can help patients and families discuss options with their surgeon more confidently.

Girdlestone Excision Arthroplasty vs. Girdlestone with Spacer

In the context of infection, surgeons may employ an antibiotic spacer during a two‑stage approach. The first stage involves removing the prosthesis and inserting an antibiotic‑loaded spacer to deliver high concentrations of antibiotics locally while preserving limb length and soft tissue tension. Once infection is controlled, reimplantation may be considered. If reimplantation is not feasible, a girdlestone procedure may be performed as the definitive treatment.

Modified Girdlestone with Muscle Flaps

Some cases require reinforcement of soft tissues to provide greater stability and reduce wound complications. In these scenarios, muscle flaps or local tissue rearrangements may be used to cover exposed bone, improve vascularity, and support wound healing. These modifications can enhance comfort and function after the girdlestone procedure, especially in patients with poor soft tissue coverage.

Two‑Stage Approaches in Complex Infections

For certain infections, a two‑stage strategy may be employed. The first stage removes the infected prosthesis and performs thorough debridement, with an interim spacer. The second stage, after a period of infection control, may or may not include reimplantation, depending on how the patient’s condition evolves. In some circumstances, the girdlestone procedure remains the ultimate salvage option if reimplantation is not suitable.

Outcomes and Expectations with the Girdlestone Procedure

Outcomes after the girdlestone procedure vary depending on the original problem, patient health, age, bone stock, infection status, and rehabilitation. Several general trends are observed in patients who undergo a girdlestone procedure for hip salvage:

• Pain relief is often reported as a major benefit. Many patients experience a significant reduction in hip pain, enabling more comfortable daily activities and easier weight bearing with assistive devices.
• Mobility can improve or stabilise, but a fully normal range of motion is not expected. Most individuals adopt a gait pattern that uses assistive devices such as a stick, crutch, or walker, and gait symmetry may be limited by abductor weakness and limb length discrepancy.
• Limb shortening is common and may range from a few centimetres to several centimetres, depending on surgical technique and patient anatomy. This can affect balance and posture but does not preclude independent living in many cases.
• Activity levels after a girdlestone procedure are highly individual. Some patients resume day‑to‑day activities with adaptations, while others require ongoing assistance or limited walking with aids.
• Infection control outcomes depend on the presence of infection and the success of antibiotic therapy. In treated infections, careful monitoring reduces the risk of recurrence, but vigilance remains important.

It is important to discuss realistic expectations with the surgical team before undergoing the girdlestone procedure. The aim is to achieve a stable, pain‑free and functional limb where possible, accepting that the hip will no longer function as a normal hip joint.

Recovery and Rehabilitation After the Girdlestone Procedure

Recovery and rehabilitation after the girdlestone procedure are critical to achieving the best possible outcome. A structured plan, guided by the orthopaedic team and physiotherapists, helps patients regain safety, mobility and confidence.

During the initial days after surgery, pain management, wound care, and prevention of complications such as blood clots are priorities. Gentle, assisted movement often begins early to reduce stiffness, with a focus on ankle pumps and quadriceps activation to maintain circulation and leg strength. The patient typically uses crutches or a walking frame for stability and to distribute weight gradually as advised by the surgeon.

Rehabilitation milestones

• Weeks 1–4: Controlled weight bearing as permitted; ongoing pain control; progressive range‑of‑motion exercises for the knee and ankle; gradual strengthening work for the hip abductors and thigh muscles.
• Months 2–3: Increase in walking distance with aids; balance and proprioception training; continued hip and thigh strengthening; attention to gait training and posture.
• Months 3–6: Independent mobility may be achieved with support devices; consideration of home adaptations or phased activity goals; ongoing monitoring for complications or infection.

Recovery timelines are individual. Some patients regain substantial independence within a few months, while others may require longer rehabilitative support. Regular follow‑up appointments enable clinicians to monitor wound healing, pain levels, limb function and any signs of complications.

Potential Complications of the Girdlestone Procedure

As with any major surgery, the girdlestone procedure carries potential risks and complications. Being aware of these can help patients and carers recognise problems early and seek timely medical advice. Common complications include:

• Limb shortening and resultant gait imbalance, which may necessitate the use of walking aids or orthotics.
• Persistent pain or discomfort in the hip region, especially with activity or after prolonged standing.
• Instability or microinstability at the site of resection, occasionally requiring additional stabilisation or supportive devices.
• Infection or wound complications, particularly in the context of prior infection or compromised soft tissue envelopes.
• Soft tissue weakness or abductor dysfunction, contributing to a limp or reduced range of motion.
• Need for further surgery if pain persists, if infection recurs, or if future reconstructive options become feasible.

Early discussion with the surgical team about warning signs — such as increasing redness, swelling, fever, escalating pain, wound drainage — can lead to prompt assessment and intervention if problems arise.

Girdlestone Procedure vs. Alternative Treatments

Choosing between a girdlestone procedure and alternative treatments depends on multiple factors, including the underlying diagnosis, the patient’s health, bone quality, bone stock, infection status, and rehabilitation expectations. Key alternatives include:

• Total hip arthroplasty (THA) revision or reimplantation, if infection is controlled and bone stock is adequate and patient factors allow.
• Hemiarthroplasty or partial hip replacement, in select cases where only one component is necessary or where soft tissue balance is favourable.
• Antibiotic spacer with staged revision for infection control while maintaining limb length and soft tissue tension.
• Palliative options for pain relief and comfort in patients with limited life expectancy or those whose functional goals are modest.

Discussing these options with an experienced orthopaedic team is essential. Each approach has its own risk profile, recovery path, and likely functional outcome, and the girdlestone procedure is one tool among many in the effort to restore comfort and mobility where other options are impractical.

Practical Considerations for Patients and Families

Facing the girdlestone procedure involves practical planning and realistic expectations. Here are some important considerations to discuss with your healthcare team:

• Recovery needs: time off work or normal activities, assistance at home, and the potential need for rehabilitation services.
• Weight bearing and activity limits: how and when you can bear weight on the operated leg, and what activities to avoid during healing.
• Assistive devices: crutches, a walking frame, or a stick, and guidance on safe ambulation and transfers.
• Pain management: plan for analgesia to manage postoperative pain effectively while minimising side effects.
• Wound care and infection prevention: signs of infection to monitor and when to seek medical help.
• Nutritional and lifestyle considerations: nutrition, smoking cessation, and comorbid conditions that may affect healing.

Being actively involved in decision‑making and maintaining open communication with the care team can help patients navigate the girdlestone journey more confidently and minimise stress for carers and family members.

Frequently Asked Questions About the Girdlestone Procedure

Here are answers to common questions that patients and families often raise:

Is the girdlestone procedure painful?

Pain is a common concern. While pain is present around the time of surgery, the aim is to achieve meaningful pain relief once the procedure has healed. Pain management strategies, including medications and regional anaesthesia options, are discussed with the anaesthetist before surgery.

Will I be able to walk after a girdlestone procedure?

Many patients can walk with aids after recovery, though the gait is usually asymmetrical, and leg length discrepancy may persist. The level of mobility depends on factors such as muscle strength, nerve function, infection status, and adherence to rehabilitation.

How long does recovery take?

Recovery timelines vary widely. Some people regain comfortable function within a few months, while others may require longer‑term rehabilitation. Regular follow‑ups with the surgical team help tailor expectations and rehabilitation plans.

Can the girdlestone procedure be reversed?

In some cases, future reconstructive options may become feasible if conditions improve, including re‑implantation or alternative reconstruction. However, reversal is not always possible, and expectations should reflect what is realistically achievable given the clinical context.

What are the long‑term considerations after the girdlestone procedure?

Long‑term considerations include ongoing leg length discrepancy, potential changes in gait, risk of recurrent infection in some cases, and the possibility of further surgical interventions if functional goals change or new problems arise.

Bottom Line: Understanding the Girdlestone Procedure

The girdlestone procedure stands as a valuable, well‑established option for hip salvage in carefully selected patients. While it is not a cure for all hip problems, it offers reliable pain relief and an opportunity to regain functional independence for many individuals where conventional reconstructions are not suitable. By understanding the indications, the surgical process, expected outcomes, and rehabilitation pathway, patients and families can make informed decisions in partnership with their orthopaedic team.

Key Takeaways

• The girdlestone procedure is a hip excision arthroplasty used mainly for infection control and complex hip destruction when other options are unsuitable.
• Outcomes often include significant pain relief and improved comfort with a limb that is shortened and functionally limited compared with a native hip.
• Recovery requires a structured rehabilitation programme, with gradual weight bearing, muscle strengthening and gait training.
• Options such as antibiotic spacers, staged revisions, or alternative reconstructions may be discussed depending on infection status and bone stock.

For anyone facing the girdlestone procedure, engaging with a multidisciplinary team, seeking a second opinion if needed, and planning ahead with practical supports can help ensure that the journey focuses on comfort, safety, and the best possible quality of life.