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Girdlestone procedure

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Girdlestone procedure - April 12, 2001 11:58:00 AM   
Audrey Macdonald


Posts: 8
Joined: January 16, 2001
From: Winnipeg, Manitoba, Canada
Status: offline
Does anyone have any experience with Girdlestone procedure in cerebral palsy? I don't have any specific information about the patient, as the question comes from a colleague. She's been unable to find much info on her own, so has asked for help in locating info re the PT management. I haven't found anything on Medline or CINAHL. Thanks.
Post #: 1
Re: Girdlestone procedure - April 12, 2001 8:53:00 PM   
Andrew M. Ball, MS, PT


Posts: 500
Joined: October 9, 1999
From: Chapel Hill, NC, USA
Status: offline
Michael L. Richardson, M.D. of the University of Washington School of Medicine, describes the Girdlestone procedure as follows:

"The development of prosthetic joints is a Good Thing. The alternatives include chronic, debilitating joint pain, loss of mobility and function, and even life in a wheelchair. Surgery has provided other possibilities. To paraphrase the Old Testament: "If thine joint offends thee, cast it out!" This might be the Biblical rationale for an archaic procedure called the Girdlestone procedure, in which the articular surface of an end stage, painful joint is resected. The resulting articulation can be surprisingly pain-free. Nowadays, about the only time one sees this appearance is after removal of an infected joint prosthesis or occasionally in the treatment of claw-toe deformities."

Upon searching for references for your purpose was kinda tricky. Next time, remove all limits and use the following search string:

Girdlestone and "cerebral palsy"

You will generate 3 relevant references:

Wicart P, Barthas J, Guillaumat M. Replacement arthroplasty of paralytic hip. Apropos of 18 cases. Rev Chir Orthop Reparatrice Appar Mot 1999 Oct;85(6):581-90. [Article in French]

PURPOSE: Frequency of hip impairment, with sub-luxation or dislocation, during evolution of neuromuscular diseases depends on intensity and spreading of palsy. At the end of growth or at the beginning of adult life, secondary arthritis can induce pain and lack of mobility. The importance of the chondropathy and irreducible lack of congruence may doom to failure a conservative articular or periarticular surgery. Total hip arthroplasty is an alternative, but the risks of dislocation, ectopic ossifications and infection make often refute this indication. We report our experience of total arthroplasty for paralytic hip, about 18 cases. MATERIALS AND METHODS: We reviewed retrospectively 14 consecutive patients with neuromuscular disease, who had 18 total arthroplasties of paralytic hips. The origin of neuromuscular disease was cerebral for 7 patients (6 cerebral palsy: 4 spastic or athetosic tetraplegias, 1 spastic diplegia, 1 hemiplegia; 1 head trauma), 6 medullar disorders (1 Friedreich disease, 2 acute anterior poliomyelitis, 1 vascular injury, 1 malformative spine with sacral agenesis and 1 cervical spine trauma) and 1 muscular affection (Steinert disease). Mean age of the patient was 40 year old (19 to 64). Mean follow up was 5 years. Intensity and diffusion of weakness were variables, compatible with gait with or without help for 11 patients, and for 3 patients with sitting posture and transfer. The coxopathy, with pain stiffness and vicious attitudes, induced the loss of gait or sitting posture and transfer. The goal of the arthroplasty was the restitution of the initial function. 11 hip had previous surgery, with infection in 2 cases. Arthritis was secondary to hip palsy in 14 cases (4 dislocations, 6 subdislocations, 3 complications of surgery of paralytic hip dislocation in childhood, 1 nervous arthropathy), and independent of palsy in 4 cases (1 femoral head avascular necrosis ans 3 primary arthritis). The prosthesis were LFA Charnley Kerboull in all cases except 1. We used transtrochanteric approach. RESULTS: Mean follow-up is 5.6 years. Functional initial goal has been obtain in all cases. Ectopic ossifications occurred in 3 cases, without functional consequence. One acetabular loosening occurred after 13 years and has been reoperated on. There was no polyethylene wear. We noticed 1 mechanical and 2 chemical femoral loosening. Prosthetic dislocation occurred in 4 cases, always during the 4 post-operative months, without recurrence after this critical period. There were no infection. DISCUSSION: If gait is possible, there is no satisfactory alternative to total hip arthroplasty. In absence of gait, total hip arthroplasty gives also the best functional results. Girdlestone procedure is not indicated because it will induce the loss of transfer and side effects as ascension of proximal femur with recurrence of adduction bringing out pain and sometimes scabs. CONCLUSION: Total arthroplasty of paralytic hip induced restitution of initial function for all patients and an acceptable rate of complication after strict selection of patients and indications, specific operative technique and rehabilitation for each patient. This results encourage us to carry on with this therapeutic orientation.

Baxter MP, D'Astous JL. Proximal femoral resection-interposition arthroplasty: salvage hip surgery for the severely disabled child with cerebral palsy. J Pediatr Orthop 1986 Nov-Dec;6(6):681-5.

The treatment of spastic hip dislocation by proximal femoral resection-interposition arthroplasty (PFRIA) has not been popular because of previous unfavorable experience with Girdlestone-type resections. Since 1979, four severely disabled patients with cerebral palsy having five painful, spastic hip dislocations have undergone PFRIA at the Children's Hospital of Eastern Ontario (Ottawa, Ontario, Canada) by the technique described by Castle and Schneider. The preliminary follow-up shows no significant loss of motion, no bony ankylosis or impingement, no myositis ossificans, and no recurrence of pain. A comfortable sitting status was achieved within 3-6 weeks postoperatively. For a carefully selected group of severely disabled, spastic, nonambulatory patients with painful hip dislocation, we recommend this procedure over more complicated reconstructive procedures or arthrodesis.

Shanahan MD, Douglas DL, Sharrard WJ, Duckworth T, Betts R. The long-term results of the surgical management of paralytic pes cavus by soft tissue release and tendon transfer. Z Kinderchir 1985 Dec;40 Suppl 1:37-41.

Twenty-six patients with paralytic pes cavus were managed by early soft tissue correction and tendon transfer. Eighteen had spina bifida, 6 had peroneal muscular atrophy and two had cerebral palsy. The most frequent operations were flexor hallucis longus tenodesis, Girdlestone's flexor to extensor tendon transfer and plantar release. The indications for these procedures are discussed and the results presented, with particular reference to static and dynamic foot pressure studies performed at review. Follow-up averaged 5.2 years. Toe correction was found to be successful in most cases but plantar release failed in 55% of feet, with many progressing to fusion. Many failed feet had presented at an earlier age and it was felt that the initial procedures had delayed the need for bony correction thus minimising growth disturbance.

Andrew M. Ball, MS, MBA, PT

(in reply to Audrey Macdonald)
Post #: 2
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