Acute Pyogenic Arthritis of the Hip: An Operation Giving Free Access and Effective Drainage

Gathorne Robert Girdlestone was born in 1881, the son of the Rev. R.B. Girdlestone, Honorary Canon of Christ Church, Oxford [3]. 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,” [3] 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 [4]. 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 [3].) 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 [1] and the second (reprinted here), from 1942, a related and perhaps at times even more radical operation for pyogenic infections [2]. 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” [1]. 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” [2]. 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.