What are the key considerations for an anesthesiologist managing a patient undergoing the Girdlestone procedure?

Anesthetic Management of the Girdlestone Procedure

The Girdlestone procedure is a femoral head and neck excision arthroplasty that requires anesthetic vigilance similar to cemented hip arthroplasty, with particular attention to cardiovascular stability during femoral canal instrumentation, adequate hydration, and preparation for potential fat embolism syndrome.

What is the Girdlestone Procedure

The Girdlestone procedure involves excision of the femoral head and neck, creating a pseudoarthrosis or "pendent hip." 1, 2 It is primarily performed as a salvage operation for:

• Infected hip arthroplasty (most common indication) 2
• Septic arthritis and osteomyelitis, particularly in spinal cord injury patients 1, 3
• Failed hip replacements where reimplantation is not feasible 2, 4
• Hip pathology in non-ambulatory or high-risk patients 2

The procedure typically includes thorough joint debridement, bone removal, and often muscle flap transfer (hamstring or vastus lateralis) to obliterate the pseudoarthrosis cavity. 1, 3

Critical Anesthetic Considerations

Patient Population and Risk Stratification

These patients are typically high-risk with multiple comorbidities requiring careful preoperative assessment. 2

• Elderly patients (average age 67-87 years in reported series) with significant cardiopulmonary disease 2, 4
• Spinal cord injury patients with autonomic dysfunction and pressure ulcer complications 1, 3
• Immunocompromised patients including those with rheumatoid arthritis or on immunosuppressive therapy 2
• Patients with active or recent infection requiring ongoing antibiotic therapy 1, 4

Intraoperative Hemodynamic Management

Maintain systolic blood pressure within 20% of pre-induction values throughout surgery using vasopressors and/or fluids. 5, 6

Key Monitoring Requirements:

• Invasive arterial blood pressure monitoring is indicated for patients at higher risk (elderly, male sex, significant cardiopulmonary disease, diuretic use) 5
• Ensure adequate hydration before induction and maintain throughout the procedure 5, 6
• Have vasopressors immediately available (metaraminol/adrenaline) for cardiovascular collapse 5

Fat Embolism and Bone Cement Implantation Syndrome (BCIS) Risk

Although the Girdlestone procedure does not involve cement insertion, femoral canal instrumentation still carries risk of fat embolism and cardiovascular events similar to cemented arthroplasty. 5, 6

Critical Timing for Vigilance:

• Heightened vigilance is required once the femoral head is removed and during femoral canal instrumentation 5
• Confirm with the surgeon when they are about to instrument the femoral canal to prepare for potential cardiovascular events 5
• Adverse cardiovascular events occur in approximately 20% of hip procedures involving femoral canal manipulation 5

Severity Grading of Potential Events:

• Grade 1 (20%): SpO₂ <94% or >20% fall in systolic BP 5
• Grade 2 (3%): SpO₂ <88% or >40% fall in systolic BP or loss of consciousness 5
• Grade 3 (1%): Cardiopulmonary resuscitation required 5

Specific Intraoperative Protocol

Implement a structured communication protocol with the surgical team:

1. Confirm verbally when the surgeon indicates intent to instrument the femoral canal 5
2. Administer supplemental oxygen and consider maintaining for 24 hours postoperatively 6
3. Ensure thorough washing and drying of the femoral canal before any intramedullary device insertion to minimize fat embolism 6
4. Monitor continuously for cardiovascular instability during bone manipulation 5

Anesthetic Technique Selection

Regional vs. General Anesthesia

Regional anesthesia is preferred when feasible, though general anesthesia is often required given the extensive nature of the procedure and patient positioning needs. 5

• Regional techniques may have higher failure rates in certain populations (obese, anatomical abnormalities) 5
• A definitive airway management plan is mandatory regardless of technique chosen 5
• Consider combined spinal-epidural for postoperative pain control in appropriate candidates 5

Special Considerations for Spinal Cord Injury Patients

Autonomic dysreflexia risk must be assessed in patients with spinal cord injuries above T6. 1, 3

• These patients may have unpredictable hemodynamic responses to surgical stimulation
• Temperature regulation is often impaired requiring active warming measures
• Pressure point protection is critical given existing pressure ulcer complications 1, 3

Postoperative Management

Duration of Monitoring

Plan for extended postoperative monitoring (24-48 hours) given the high-risk patient population and potential for delayed complications. 6, 1

• Monitor for fat embolism syndrome (confusion, petechiae, respiratory distress) 6
• Watch for compartment syndrome and neurovascular compromise 6
• Assess for signs of ongoing or recurrent infection 1, 4

Pain Management Strategy

Multimodal analgesia with opioid-sparing techniques is preferred, particularly in elderly and spinal cord injury patients. 5

• Regional techniques (epidural, peripheral nerve blocks) should be considered for postoperative analgesia 5
• Avoid excessive opioids in patients with obstructive sleep apnea or respiratory compromise 5
• Plan for 24-48 hours of parenteral analgesia before transitioning to oral medications 6

Mobilization and Thromboprophylaxis

Patients typically require prolonged bed rest (2-4 weeks) with limb traction, necessitating aggressive VTE prophylaxis. 1, 4

• Mechanical prophylaxis should be initiated immediately postoperatively
• Pharmacologic prophylaxis must be balanced against bleeding risk in the surgical site
• Early mobilization protocols should be implemented once traction is discontinued 1

Common Pitfalls and How to Avoid Them

Underestimating Cardiovascular Risk

Do not assume the absence of cement means absence of BCIS risk—femoral canal manipulation alone can cause significant cardiovascular events. 5, 6

• Always prepare for Grade 2-3 events even in seemingly stable patients 5
• Have emergency drugs drawn up and immediately available 5

Inadequate Communication with Surgical Team

Failure to establish clear verbal communication protocols leads to delayed recognition of critical moments. 5

• Use the WHO surgical checklist to discuss specific risks preoperatively 5
• Confirm readiness before each critical surgical step 5

Insufficient Postoperative Planning

These patients require prolonged postoperative care (4-6 weeks of antibiotics, wound management, rehabilitation). 1, 3

• Coordinate with infectious disease for antibiotic management 1
• Plan for potential wound complications (30% failure rate requiring reoperation) 1, 3
• Arrange appropriate level of postoperative care based on comorbidities, not just the procedure itself 5

Overlooking Infection Control

Active or recent infection is common in these patients and requires specific anesthetic considerations. 1, 2

• Verify appropriate antibiotic coverage is administered preoperatively 1
• Consider implications for central neuraxial techniques in bacteremic patients
• Plan for potential hyperbaric oxygen therapy coordination if available 1