Proximal Femoral Replacement Outcomes for Oncologic Versus Non-Oncologic Indications: A Systematic Review and Meta-Analysis.

BACKGROUND: Proximal femoral replacement (PFR) is a modular endoprosthetic reconstruction technique traditionally used for oncologic resections, but increasingly applied to non-oncologic conditions. This systematic review and meta-analysis aimed to compare complications, revision and amputation rates, implant survivorship, and patient survival between oncologic and non-oncologic PFR cases. METHODS: A systematic search of PubMed, Embase, and Scopus was conducted through September 2025. Studies were included if they reported clinical outcomes of PFR with separate data for oncologic and non-oncologic indications. Outcomes such as overall complication rate, dislocation, periprosthetic fracture, and infection rate were collected. Data were pooled using random-effects models, and heterogeneity was quantified with the I2 statistic. There were 42 studies that met inclusion criteria, encompassing 2,804 PFR cases (2,081 oncologic and 723 non-oncologic). Patient mean age was higher in non-oncologic cohorts (72 versus 54 years, P < 0.001). RESULTS: The pooled overall complication rate was 27% (95% confidence interval (CI) [0.21 to 0.32]), without significant difference between groups (P = 0.93). Dislocation or instability occurred more frequently in non-oncologic PFR (9 versus 5%; P = 0.04), while rates of infection, aseptic loosening, and periprosthetic fracture were similar. Revision rates were significantly higher in non-oncologic cases (13% [0.08 to 0.18]) than oncologic (6% [0.04 to 0.09]; P = 0.03). Amputation was rare overall, but more common in oncologic series (1 versus 0%; P = 0.02). Overall implant survivorship was 90.8, 89.4, and 77.1% at one, five, and 10 years, respectively. The five-year patient survival was markedly lower in oncologic cohorts (46 versus 67%; P < 0.001). CONCLUSION: The PFR demonstrates acceptable complication and survivorship rates across indications. While oncologic patients experience higher mortality, non-oncologic cases have greater revision risk. However, given the substantial heterogeneity across included studies, results should be interpreted with caution and underscore the need for future standardized, prospective investigations.