Abstract
BACKGROUND: The proximal femur is a common site for benign bone tumors and tumor-like lesions, which often lead to pathological fractures and structural instability. However, these lesions are highly heterogeneous, and in some cases, conventional internal fixation cannot adequately meet surgical requirements. Currently, there is no consensus on the optimal surgical strategy for such conditions. This study aimed to evaluate whether a lesion-categorization-based surgical approach could improve postoperative functional recovery and to explore the feasibility of joint-preserving treatment in cases with severe structural destruction. METHODS: A retrospective analysis was conducted on 100 patients who underwent surgical treatment for benign tumors of the proximal femur between 2020 and 2024. Tumors were classified based on lesion location, size, extent of femoral head destruction, and the presence of deformities. Surgical strategies were selected according to this classification. Postoperative function was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system. A Bayesian linear regression model and intergroup comparisons were employed to evaluate the impact of the classification on clinical outcomes. RESULT: In this study, a modified surgical strategy was proposed to categorize benign proximal femoral bone lesions into five types, with corresponding surgical strategies developed for each type. Type 1 and 2 lesions were characterized by mild cortical involvement and relatively stable structures suitable for curettage, bone grafting, with or without internal fixation. Type 3-5 showed progressive bone loss and deformity requiring limited internal fixation combined with external fixation (LIFEF), corrective osteotomy, or endoprosthetic replacement (EPR). The cohort had a mean age of 37.3 years (range 17–69) and a mean follow-up duration of 25.0 ± 14.9 months (range 3–54 months). The MSTS-93 score at the final follow-up was 26.1 ± 1.0. Bayesian analysis revealed statistically credible differences in postoperative MSTS scores among the three groups: Type 1, Type 2, and "Other types" (Types 3-5). The overall complication rate was 5%, including mild limping, transient pain, and mild avascular necrosis. CONCLUSIONS: The lesion-categorization-based surgical strategy provides a practical and effective framework for managing benign tumors of the proximal femur. This approach optimizes postoperative functional recovery, supports joint preservation where feasible, and may serve as a reference for standardized surgical decision-making. LEVEL OF EVIDENCE: IV; Retrospective observational study. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12891-026-09544-z.