Functional outcomes after megaprosthesis for neglected proximal femur pathological fractures: a retrospective case series

Technical Summary: Functional Outcomes After Megaprosthesis for Neglected Proximal Femur Pathological Fractures

Problem Statement
Pathological fractures secondary to cancer significantly increase morbidity, reduce quality of life, and are associated with poor clinical outcomes. While the management of acute pathological fractures in the proximal femur is relatively well-established, the treatment of "neglected" pathological fractures—defined as fractures left untreated for extended periods—remains poorly defined. This clinical scenario is particularly prevalent in low- and middle-income countries (LMICs) or among populations with limited access to timely care, where delays in diagnosis and treatment lead to extensive bone destruction and soft tissue involvement. In these cases, standard internal fixation is often unsuitable, leaving a gap in standardized management protocols for patients presenting with severe functional impairment and pain.

Methodology
This study is a retrospective case series analyzing 12 adult patients (≥18 years) with neglected proximal femur pathological fractures (NPFPF) treated between January 2018 and December 2022.

• Definition of NPFPF: Pathological fractures secondary to primary or metastatic cancer that had not received surgical treatment for over twelve weeks since occurrence or identification.
• Inclusion Criteria: Patients presenting with extensive bone destruction and/or soft tissue extension rendering internal fixation unsuitable. All patients underwent en bloc proximal femur resection followed by reconstruction using a modular megaprosthesis.
• Patient Demographics: The cohort included 8 females and 4 males with a median age of 57 years. The underlying etiologies included breast metastasis (33.3%), lung metastasis (25.0%), chondrosarcoma (25.0%), angiosarcoma metastasis (8.3%), and malignant giant cell tumor of bone (8.3%).
• Data Collection: The study assessed demographic, clinical, and pathological data, alongside functional outcomes (ECOG performance status and a subjective mobility classification), pain levels (Visual Analog Scale - VAS), and oncological outcomes (resection margins, survival status, and overall survival).
• Statistical Analysis: Non-parametric signed-rank tests were used to compare pre- and post-operative functional and pain scores. Overall survival was analyzed using Kaplan-Meier methods.

Key Results

• Functional Improvement: Prior to surgery, 75% of patients were bedridden and 25% were wheelchair-bound (median pre-operative ECOG score: 4). Post-operatively, 66.7% of patients were able to walk with crutches, and 33.3% remained in a wheelchair (median post-operative ECOG score: 2). This represented a statistically significant improvement in functional status (p = 0.002).
• Pain Relief: Pain levels decreased significantly from a median pre-operative VAS of 9 to a median post-operative VAS of 3 (p = 0.002).
• Oncological Outcomes: Resection margins were R0 in 25% of cases, R1 in 66.7%, and R2 in 8.3%. The median overall survival was 25 months. At final follow-up, 25% of patients were alive and disease-free, 25% were alive with disease, and 50% had died due to the underlying cancer.
• Complications: Post-operative anemia requiring blood transfusion occurred in 100% of patients. One patient (8.3%) experienced a major complication involving megaprosthesis dislocation and subsequent infection, requiring revision surgery.

Significance and Claims
The authors claim this study is the first to report patient clinical outcomes specifically for the scenario of neglected proximal femur pathological fractures managed with modular megaprosthesis. The paper argues that despite the high-risk nature of these patients—often characterized by advanced disease, large tumor volumes, and significant delays in care—surgical reconstruction with a modular megaprosthesis offers a viable strategy to improve function and alleviate pain.

The study highlights that while complications such as anemia are expected given the patient profile, the functional gains (transitioning from bedridden to ambulatory with aids) and pain relief provide sufficient motivation to recommend surgery for this specific, neglected population. The authors emphasize that their experience offers unique insights into managing complex clinical scenarios where standardized protocols are absent, particularly for patients from underserved regions or those with delayed diagnoses. The findings support the use of megaprosthesis reconstruction as a method to restore mobility and quality of life in patients who would otherwise be considered for ablative surgery or palliative care only.