Acute Pyogenic Arthritis of the Hip: An Operation Giving Free Access and Effective Drainage
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Gathorne Robert Girdlestone was born in 1881, the son of the Rev. R.B. Girdlestone, Honorary Canon of Christ Church, Oxford . His early education was at Charterhouse, then he read medicine at New College, Oxford. Girdlestone received his subsequent medical training at St. Thomas’ Hospital, London, completing his house appointment there. He subsequently went to Oswestry, where he was influenced by Sir Robert Jones. During WW I he returned to Oxford to assume charge of a military hospital that eventually had over 400 beds. The Wingfield Convalescent Home, an “old fashioned institution,”  was located in Headington, then a village near Oxford, and Girdlestone’s initial military hospital consisted largely of open air huts on the Wingfield grounds. Girdlestone continued to work there and at the Radcliffe Infirmary after the war. These huts were, through the benefaction of Sir William Morris (the founder of Morris Motors and later elevated to Lord Nuffield), replaced with modern buildings beginning in 1930 with a bequest of £70,000 . These new buildings, initially named the Wingfield-Morris Orthopaedic Hospital, were opened by the Prince of Wales in 1933. As a result of his work and stature and perhaps his relationship with Lord Nuffield, Girdlestone was appointed in 1937 the first British Professor of Orthopaedic Surgery. (Oxford Medical School eventually received £2,000,000 from Lord Nuffield .) The Wingfield-Morris Orthopaedic Hospital became part of the National Health Service in 1948, then was renamed the Nuffield Orthopaedic Centre in 1950, the year of Girdlestone’s death. It is fair to say that Girdlestone was among the primary and most influential individuals creating a specialty of orthopaedic surgery in the first half of the 20th century.
Girdlestone wrote at least two articles describing excision arthroplasty of the hip. The first, from 1928, described a radical excision for draining tuberculous hips  and the second (reprinted here), from 1942, a related and perhaps at times even more radical operation for pyogenic infections . Girdlestone emphasized these radical operations were intended only for severe infections, and readers are reminded these were both published in the preantibiotic era, when radical surgery was often required to save a patient’s life. In the first article, he also emphasized the principle of “removal of diseased and devitalized tissues, flattening down of dead spaces, and leaving drainage so complete and lasting as will allow the wound to heal from the bottom” . He excised the greater trochanter and all involved muscles, suturing skin edges deep into the wound so as to achieve effective drainage. When necessary, he also “flattened” the edges of the acetabulum. In the second article he suggested less radical operations were often ineffective in pyogenic infections owing to the “miniature rabbit-warren of sinuses and cavities” . The techniques were fundamentally similar to those he had earlier described for tuberculosis. He used a wide transverse incision (Fig. 2) to access the hip, excising all lateral musculature along with the trochanter and the lateral margin of the acetabulum (Fig. 1). In the presence of infection in the intermuscular planes, he avoided suturing the skin deeply, and rather packed the wound with Vaseline gauze and rubber drains (Fig. 4). The postoperative care included splinting either on a frame (if good nursing care was available) or spica casting with a large window. Readers familiar with operations for infected total hip arthroplasties will immediately recognize current procedures are far less radical than those typically used in Girdlestone’s time. Rarely would an infected arthroplasty be treated with such radical excision of bone and muscle, open packing, and secondary healing. For that reason, I suggest the name Girdlestone not be used for contemporary operations except as they apply to what he described: excision arthroplasty more accurately describes current procedures.
Girdlestone GR. Arthrodesis and other operations for tuberculosis of the hip. In: Milford H, ed. The Robert Jones Birthday Volume. London, UK: Oxford University Press; 1928:347–374.
Girdlestone GR. Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. Lancet. 1943;241:419–421.
In Memorium: Gathorne Robert Girdlestone. J Bone Joint Surg Br. 1951;33:130–133.
Nuffield Orthopaedic Centre National Health Service Web site. Available at: http://www.noc.nhs.uk/. Accessed October 4, 2007.
KeywordsGreat Trochanter Radical Drainage Pyogenic Infection Effective Drainage Excision Arthroplasty
Severe persistent sepsis in or round the hip has been one of the bugbears of surgery; once the infection has seeped out of the joint, sinuses burrow among the tendons round the neck of the femur and the small trochanter, or having penetrated the acetabulum produce an intrapelvic abscess. The difficulty has been first of all to provide free drainage for these deep-seated lesions, then—still more difficult—to maintain that freedom continuously over the period which is required for internal healing. It is no longer now a matter of drainage of the hip-joint but of a much larger infected area which often represents a miniature rabbit-warren of sinuses and cavities.
In and after the last war I found none of the standard drainage operations satisfactory. The presence of the sciatic nerve so hampers the posterior approach that drainage can only be free for a few days, while it is futile to attempt to establish drainage of the hip by an anterior approach. The older methods do not give the surgeon a good view of the acetabulum; but their gravest fault is that it is impossible to maintain free drainage for more than a very short time. Furthermore, the posterior approach produces a discharging wound in a most awkward position.
In 1921, as a result of profound dissatisfaction with these cases, many of which resulted from gunshot wounds of the war, I worked out a method which has proved effective and reliable ever since. I have described it briefly elsewhere with special reference to secondarily infected tuberculosis1; but the method is little known and surgeons who have seen it in use believe that if it were widely known it would prove of great value in the surgery of infected wounds involving the hip.
Acute pyogenic arthritis of the hip is rare in times of peace. An early haematogenous infection of the joint, especially if the organism is a streptococcus rather than the Staphylococcus pyogenes aureus, will often subside if the joint is immobilised and aspirated every day (under anaesthesia). My colleagues and I have had a number of such cases in which immobilisation on a frame and daily aspiration (for 3 or 4 days) has led to recovery with full movement. If, however, the illness is severe and high fever persists in spite of this treatment radical drainage is quickly indicated. This outcome is to be expected where the infective organism is the Staph. pyogenes aureus, and in particular where there is infection associated with devascularisation of bone within the joint: this may be the result of an infective embolus leading to infarction and septic necrosis, or of the shattering effect of a gunshot wound. Whether in war or in peace, the illness is severe, painful and dangerous; its course may prove long, exhausting and bitterly disappointing; its victim greatly needs effective succour.
Principles of the Method
By the technique to be described something approaching saucerisation of the joint is achieved; and the advantage of the method lies not only in the full exposure it can give to the acetabulum after excision of the head, but in the access it affords for the adequate drainage of a still deeper intrapelvic abscess via ilium or acetabular floor.
The operation is called for in acute pyogenic infection of the hip—haematogenous, from compound fracture, or from gunshot wound—in which the fever has not given way to more conservative measures, such as immobilisation, daily aspiration, and chemotherapy by sulphanilamides or penicillin Such a condition is dangerous and demands radical drainage. Cases can be divided into two groups. In the first, group A, the hip-joint is not yet ankylosed; the cavity may be distended with pus, or suppuration may be almost absent with symptoms just as severe and threatening as if it was considerable. In others infective materia may already have leaked out to spread further sepsis between the muscular planes. In order to ensure effective drainage the excision of the head and neck, with erasion and saucerisation of the acetabulum, is almost always indicated as the final part of the operation. Occasionally it is better to stop after the wide exsection of capsule and synovia in the hope that it will suffice. I am still diffident of laying down the indications for this less radical procedure, but it is clearly contra-indicated wherever there is evidence of partial or complete necrosis of the head. Group B contains those cases in which ankylosis has already developed, and in which pus has escaped from the joint and burrowed into the intermuscular planes in various directions. Deep-seated sepsis round the hip is very resistant to moderate surgical measures. Abscesses are opened with but temporary relief; there is surface healing; sinuses become established; from time to time these tend to close; the pus is bottled up; there is persistent sepsis, with recurrent flares. It is a miserable prospect.
In the cases seen at a late stage with one or more sinuses it is generally wise to obtain all possible evidence as to the ramifications of the tracks, and the situation of any deep-seated abscesses, by iodised oil injection followed immediately by stereoscopic radiography. These injections are carried out on the X-ray table; and the iodised oil is injected slowly without, much pressure. Sometimes the nozzle of the syringe is applied to the opening of the sinus, at other times a small rubber catheter is inserted to carry the oil in as deeply as possible.
The new method of drainage differs from the older ones in three ways: the approach is lateral; the incisions are at right angles to the muscle and fascial planes; and a large mass of muscular tissue is exsected. In most cases the approach is external only, with a wide exsection of the abductors and the great trochanter; but an additional mesial approach is sometimes indicated with a similar wide exsection of the adductors. The main nerves and arteries in front and the sciatic nerve behind are in no way disturbed or endangered. The considerable loss of abductors and adductors is of no consequence if the hip is ultimately ankylosed; and of little consequence if pseudarthrosis is established, since active weight-bearing abduction is in any circumstances impracticable, and adduction useless. Thus the great virtue of saucerisation of this deep-seated joint is achieved by the sacrifice of muscles which are no longer valuable.
Position and splintage
After the excision of the deep tissues, I used to draw the upper flap of skin fairly far down into the wound by a continuous catgut suture, and often the lower flap too. The sutured skin-flaps thus cover the freshly cut muscular surfaces. I found this point in technique very valuable in this and similar drainage operations as it reduced the pain of dressings, and covered the more superficial raw areas from which granulations grew excessively. When however there has been infection of the intermuscular planes, the skin flaps should not be sutured deep to the deep fascia; and nowadays the use of vaseline or paraffin wax and the infrequency of dressings have made this step less often worth while.
The hip is ankylosed. with two striking advantages—the obliteration of the joint cavity and the stabilisation of the limb. It is therefore most undesirable to dig out the head. But there may well be sinus tracks ramifying round the neck and the small trochanter. In such cases, after the lateral drainage down to, but not through, the neck, it may be necessary to carry out a similar additional exsection of muscular tissue on the inner side. Portions of the pectineus and of the adductor longus and brevis are then exsected on the inner side as well as of all three glutei on the outer. When this double drainage has been performed, the skin in front remains intact over the tensor fasciae femoris, sartorius, and rectus, with the lateral cutaneous and anterior crural nerves, and the superficial and deep femoral arteries, veins and lymphatics, and the skin behind covers the posterior part of the gluteus maximus together with the hamstrings, the adductor magnus, and the sciatic nerve. As ankylosis exists, splintage is unnecessary.
The operation causes some loss of blood but only for a very short time, and one of its great virtues is that the surgeon can see and catch the bleeding points; any oozing from the vascular can cellous bone of the ilium ceases with a temporary gauze pressure followed by the much gentler pack. Some of these patients are exhausted by pain and toxaemia; these have been transfused during the operation. Of late years I have used the continuous drip method in almost all cases; the rapidity of intake of blood can be matched to the loss during the operation, and after the patient’s return to his ward a much slower drip is kept up for 6 or 12 hours.
The success of this operation and the comfort of the patient depend on good splintage, nursing and dressing. The double hip frame is best, but only if the nurses thoroughly understand the care of a patient on a frame; a big plaster spica, with ample window and bridge (Fig. 1) comes next, and the suspension and traction of the limb on a Hodgen (or Thomas) is reserved for patients to whom neither of the former methods is applicable.
After the removal of the head and most of the neck, upward displacement of the femur in relation to the innominate must not be permitted, for such a movement would close the opening, spoil the saucerisation, and bottle-neck the acetabulum. The position is maintained by fixed traction on the frame, by suspensory traction on the Hodgen, or by a well-fitting long plaster spica with the knee in flexion, and a good hold on both ischial tuberosities.
If the operation is well done the relief from illness and distress is dramatic. If the subsequent treatment is good most of the cases will heal soundly in a few months. The great gaping wound becomes a narrow scar.
The Robert Jones Birthday Volume, Arthrodesis and other operations for Tuberculosis of the Hip, London, 1928, p. 347; also Tuberculosis of Bone and Joint, London, 1940.