What Abductor Repair Technique Provides the Best Functional Outcomes after Proximal Femur Endoprosthetic Reconstruction for Oncologic Indications? A Systematic Review

Abstract

There is conflicting data regarding the optimal abductor mechanism (AM) repair technique after resection of proximal femur tumors. We sought to compare functional outcomes following tumor resection and reconstruction with proximal femoral replacement (PFR) based on the AM repair technique utilized. We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We established two study groups based on AM repair technique: soft-tissue reattachment (STr) and greater trochanter preservation (GTp). In the STr group, the gluteus medius and minimus were reattached to the endoprosthesis, whereas in the GTp group, the greater trochanter and gluteal tendons were preserved. The STr group was further subdivided into direct and indirect reattachment, with the latter involving the use of a Trevira tube, Prolene mesh, or synthetic ligament. Weighted means adjusting for sample size were calculated. A total of 658 patients from 12 articles were included. Patients who had STr displayed higher MSTS scores (75 versus 67.3%, P < 0.001), and lower rates of Trendelenburg gait (33.9 versus 52.4%, P < 0.01) and ambulation with assistive devices (AD) (30.4 versus 54.9%, P < 0.001) compared to the GTp group. Within the STr group, indirect reattachment was associated with higher Musculoskeletal Tumor Society scores (87.2 versus 70.1%, P < 0.001) and lower rates of Trendelenburg gait (3.8 versus 36.3%, P < 0.001) and ambulation with AD (0 versus 42.4%, P < 0.001) compared to direct reattachment. Reattachment hardware failure rate in GTp was 15%. A STr provided superior functional outcomes compared to GTp in tumor-related PFR. From a functional outcome perspective, use of indirect STr was better compared to direct STr.