Pathological fractures in predicting clinical outcomes for patients with osteosarcoma

Oncological and functional outcomes of pathological fractures of lower extremities in patients with malignant bone tumors

As managing pathological fractures of the extremities can be difficult, the present study aimed to present a treatment algorithm for lower extremity bone malignancies. A total of 38 patients with impending and pathological fractures were treated at the Department of Orthopedic Surgery in Kindai University Hospital. Age, sex, fracture site, type of primary malignancy, number of metastases, pre-fracture Eastern Cooperative Oncology Group performance status (ECOG-PS) score, adjuvant therapy, treatment modality, operative time, blood loss, postoperative complications, Musculoskeletal Tumor Society (MSTS) score, outcomes, follow-up period and the MSTS scores and ECOG-PS were compared in cases of primary malignant tumors and those cases of metastatic malignant tumors were retrospectively surveyed. Post-treatment MSTS scores in cases of impending and pathological fractures were compared between intramedullary nail fixation and non-intramedullary nail fixation procedures. Disease sites included the sub-trochanteric femur in 10 patients, trochanteric femur in 8, femoral diaphysis in 7, femoral neck in 5, bilateral trochanteric femur in 3, proximal tibia in 3 and distal femur in 2 patients. A total of 10 patients had metastases between 3-20 sites. The median pre-fracture ECOG-PS score was 1. Adjuvant radiotherapy was administered to 5, chemotherapy to 8 and radiotherapy with chemotherapy to 10 patients. Surgical procedures included intramedullary nails in 18 patients, tumor arthroplasty in 4, plate fixation in 3, artificial head replacement in three, compression hip screw (CHS) in 3, conservative treatment in 2, bilateral intramedullary nail fixation in 2 and artificial bone stem with combined intramedullary nail and plate fixation, right-sided artificial head replacement and left-sided CHS in 1 patient each. The MSTS score was 19.9±8.95 for intramedullary nail fixation and 24.3±7.45 for other procedures, with a negative association between the MSTS score and pre-fracture ECOG-PS. The median follow-up period was 8 months. The outcomes were as follows: Alive with disease, 23 patients; continued disease-free, 1 patient; and dead due to disease, 14 patients. The 1-year postoperative overall survival rate was 60.5%. Moreover, the group with metastatic malignant tumors, which had significantly worse ECOG-PS, had significantly lower MSTS scores than the group with primary malignant tumors. The authors' treatment algorithm for malignant bone tumors of the lower extremity was shown to be useful.

Cu-Tremella fuciformis polysaccharide-based tumor microenvironment-responsive injectable gels for cuproptosis-based synergistic osteosarcoma therapy

Cuproptosis affects osteosarcoma locally, and the exploitation of cuproptosis-related biomaterials for osteosarcoma treatment is still in its infancy. We designed and synthesized a novel injectable gel of Cu ion-coordinated Tremella fuciformis polysaccharide (TFP-Cu) for antiosteosarcoma therapy. This material has antitumor effects, the ability to stimulate immunity and promote bone formation, and a controlled Cu2+ release profile in smart response to tumor microenvironment stimulation. TFP-Cu can selectively inhibit the proliferation of K7M2 tumor cells by arresting the cell cycle and promoting cell apoptosis and cuproptosis. TFP-Cu also promoted the M1 polarization of RAW264.7 cells and regulated the immune microenvironment. These effects increased osteogenic gene and protein expression in MC3T3-E1 cells. TFP-Cu could significantly limit tumor growth in tumor-bearing mice by inducing tumor cell apoptosis and improving the activation of anti-CD8 T cell-mediated immune responses. Therefore, TFP-Cu could be a potential candidate for treating osteosarcoma and bioactive drug carrier for further cancer-related applications.

Are Pathologic Fractures in Patients With Osteosarcoma Associated With Worse Survival Outcomes? A Systematic Review and Meta-analysis

BACKGROUND

Pathologic fractures occur in 5% to 10% of patients with osteosarcoma, and prior studies have suggested they are prognostically important. However, because they represent an uncommon event in the setting of an already rare disease, most studies fail to reach conclusive findings, and there is no agreement about how best to treat pathologic fractures.

QUESTIONS/PURPOSES

(1) Is the occurrence of a pathologic fracture in patients with osteosarcoma associated with poorer overall survivorship? (2) Is the occurrence of a pathologic fracture in patients with osteosarcoma associated with poorer local recurrence-free survival or metastasis-free survival? (3) Is the surgical approach (amputation or limb salvage) associated with differences in local recurrence rates in patients with osteosarcoma with pathologic fractures?

METHODS

This systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our study was registered in PROSPERO (ID: 380459). A search of the PubMed and Embase databases resulted in 625 and 747 titles, respectively. After application of the inclusion and exclusion criteria, 21 articles were finally included. Quality assessment of all studies was performed using the Newcastle-Ottawa Quality Assessment Scale. The Risk of Bias In Non-Randomized Studies of Interventions tool was used in the 11 articles that evaluated the effect of an intervention (amputation or limb salvage) on local recurrence rates. The relative risk (RR) was calculated to compare outcomes in patients with osteosarcoma with pathologic fractures and those without. Heterogeneity among studies was calculated using the I 2 statistic. The pooled RR was calculated using the fixed-effects or random-effects model depending on study heterogeneity. The fragility index and the ratio between the fragility index and the total number of participants for each outcome was additionally calculated to assess the robustness of our results. A total of 7604 patients with osteosarcoma, 12% of whom (885) had pathologic fractures, were included in our analysis.

RESULTS

Pathologic fractures in patients with osteosarcoma were associated with lower 3-year (RR 1.53 [95% CI 1.29 to 1.82]; p < 0.001) and 5-year overall survival (RR 1.27 [95% CI 1.16 to 1.40]; p < 0.001). No difference in recurrence rates was found between patients with osteosarcoma with pathologic fractures and those without (RR 1.22 [95% CI 0.91 to 1.64]; p = 0.18). However, having a pathologic fracture was associated with an increased risk of developing metastasis (RR 1.33 [95% CI 1.08 to 1.63]; p = 0.01). Treatment with limb salvage surgery was not associated with a higher rate of local recurrence (RR 1.58 [95% CI 0.88 to 2.85]; p = 0.13).

CONCLUSION

In light of these findings, surgeons should be aware that after appropriate case selection, patients with osteosarcoma and pathologic fractures undergoing limb salvage surgery may have similar rates of local recurrence to those undergoing amputation. Therefore, a pathologic fracture may no longer be an absolute contraindication for limb salvage surgery. Future studies adjusting for potential confounders such as tumor size, tumor location, and response to neoadjuvant therapy would provide further insight into the effect of pathologic fractures on our assessed outcomes.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Activation of PGRN/MAPK axis stimulated by the hypoxia-conditioned mesenchymal stem cell-derived HIF-1α facilitates osteosarcoma progression

BACKGROUND

Progranulin (PGRN) is an important survival factor in the progression of multiple cancers.

PURPOSE

To explore the effects and mechanisms of PGRN on malignant biological behavior of osteosarcoma (OS) cells and the effects of mesenchymal stem cells (MSCs) and the hypoxic microenvironment on PGRN alteration.

MATERIAL AND METHODS

The expression pattern of PGRN in OS were evaluated in OS tissues and cell lines. Next, a loss-of-function assay investigated the function of PGRN on the proliferation, migration and cell death of OS cells. The activation of MAPK signaling in the process was examined by western blot and functional experiments accompanied by skatole. Additionally, we internally silenced hypoxia-inducible factor-1α (HIF-1α) in MSCs along with exogenously added HIF-1α (exo-HIF-1α) to explore how MSCs affect PGRN alteration and the malignant behavior of OS cells.

RESULTS

An aberrantly high expression of PGRN was observed in OS and associated with the poor prognosis of OS patients. PGRN knockdown repressed the proliferation, migration and induced cell death of OS cells, and activating MAPK pathway reversed these effects. Further evidence showed that MSCs regulated PGRN to mediate the malignant biological behavior of OS cells. Hypoxia enhanced HIF-1α expression in MSCs. HIF-1α silencing in MSCs under hypoxia suppressed the oncogenic effects of MSCs and reduced PGRN expression in OS cells, while the treatment of exo-HIF-1α reversed the depressive effects of HIF1α silencing on OS progression.

CONCLUSION

Overall, we concluded that PGRN, which was activated by the increase of hypoxic-MSCs-derived HIF-1α, promoted OS progression through the activation of MAPK signaling.

Meta-analysis of the prognosis after surgical treatment of osteosarcoma complicated by pathologic fracture

AIM

To evaluate the prognosis of surgical treatment of osteosarcoma complicated by pathologic fracture.

MATERIALS AND METHODS

We searched articles in PubMed, Web of Science, and Embase for studies published up to January 1, 2022, that reported the surgical prognosis of osteosarcoma patients complicated with/without pathologic fracture. The specific outcome indicators used in the meta-analysis included the local recurrence rate (LRR), distant metastasis rate (DMR), overall survival (OS) rate and disease-free survival (DFS) rate after surgical treatment such as amputation or limb salvage in the pathologic fracture group and non-pathologic fracture group. Crude and adjusted Odds Ratio (OR) with 95% confidence intervals were used to compare data between the case group and control group. Fifteen studies and 3839 patients were included in the final meta-analysis.

RESULTS

The difference between the pathologic fractures group and the non-pathologic fracture group was not statistically significance in LRR analysis (OR = 1.27, 95% CI: 0.88-1.84, P > 0.05); however, a statistically significant difference was found between two groups in DMR (OR = 1.42, 95% CI: 1.03-1.95, P < 0.05). For survival rates, the following ORs were found: 3-year OS (OR = 1.71, 95% CI: 1.25-2.35, P < 0.05); 5-year OS (OR = 1.41, 95% CI: 1.06-1.87, P < 0.05); 3-year DFS (OR = 1.88, 95% CI: 1.20-2.94, P < 0.05); and 5-year DFS (OR = 1.49, 95% CI: 1.10-2.03, P < 0.05). The pooled estimate of OR is 1.48 (95% CI: 0.72-3.04, P > 0.05) for local recurrence and 1.82 (95% CI: 0.92-3.60, P > 0.05) for distant metastasis in the amputation group and the limb salvage group for osteosarcoma patients with pathologic fractures, respectively. Our analysis indicated that patients with a pathologic fracture have a higher risk of DMR after surgery, but there is no significant difference in LRR between patients with a pathologic fracture and without. Additionally, in osteosarcoma patients with a pathologic fracture, there was no difference in LDR or DMR between limb-salvage surgery and amputation.

CONCLUSION

Complicated with pathologic fracture is a negative prognostic indicator of osteosarcoma, and its poor survival rates (both OS and DFS) may be associated with a higher DMR. For osteosarcoma patients with pathologic fractures treated with standard treatment, LRR and DMR exhibit no significant difference between amputation and limb-salvage surgery.

Diaphanous related formin 3 knockdown suppresses cell proliferation and metastasis of osteosarcoma cells

Osteosarcoma is a malignant osteoblastic tumor that can gravely endanger the lives and health of children and adolescents. Therefore, there is an urgent need to explore new biomarkers for osteosarcoma and determine new targeted therapies to improve the efficacy of osteosarcoma treatment. Diaphanous related formin 3 (DIAPH3) promotes tumorigenesis in hepatocellular carcinoma and lung adenocarcinoma, suggesting that DIAPH3 may be a target for tumor therapy. To date, there have been no reports on the function of DIAPH3 in osteosarcoma. DIAPH3 protein expression in osteosarcoma tissues and healthy bone tissues adjacent to cancer cells was examined by immunohistochemical staining. DIAPH3 mRNA expression correlates with overall survival and reduced disease-free survival. DIAPH3 protein is upregulated in osteosarcoma tissues, and its expression is significantly associated with tumor size, tumor stage, node metastasis, and distant metastasis. Functional in vitro experiments revealed that DIAPH3 knockdown suppressed cell proliferation and suppressed cell migration and invasion of osteosarcoma cell lines MG-63 and HOS. Functional experiments demonstrated that DIAPH3 knockdown inhibited subcutaneous tumor growth and lung metastasis in vivo. In conclusion, DIAPH3 expression can predict the clinical outcome of osteosarcoma. In addition, DIAPH3 is involved in the proliferation and metastasis of osteosarcoma, and as such, DIAPH3 may be a potential therapeutic target for osteosarcoma.

Diagnosis and management of primary malignant tumors in the upper extremity

Bone and soft tissue sarcomas of the upper extremity are relatively uncommon. In many cases, they are discovered incidentally during evaluation of traumatic injuries or common ailments such as rotator cuff tendonitis or tennis elbow. Thus, it is important for all orthopedic surgeons to understand the differential diagnosis, workup, and treatment for upper extremity lesions. An appreciation of the clinical and radiographic features of primary malignant lesions aids in identifying patients that need referral to an orthopedic oncologist and a multidisciplinary team.

Comprehensive Characterization of Prognostic Long Noncoding RNAs in Osteosarcoma

The molecular mechanism of osteosarcoma (OS) based on protein-coding genes has largely been studied in the past decades. However, much remains to be explored when it comes to the role that long noncoding RNAs (lncRNAs) play in the pathogenesis and progression of OS and how they are associated with OS metastasis. In the present study, we collected RNA-seq-based gene expression data of 82 OS samples from the Therapeutically Applicable Research To Generate Effective Treatments (TARGET) database, along with their clinical information. We found that 50 lncRNAs were significantly associated with patients' survival by univariable Cox regression model. Moreover, we built multivariable Cox regression model based on 7 lncRNAs and successfully stratified patients into two risk groups, which exhibited significantly different prognostic outcomes. Significantly enriched Gene Ontology (GO) terms and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways detected by differential expression analysis on DEGs between the two groups with different prognostic outcomes were both immune-related, indicating that such GO terms and pathways are critical for OS survival. Among the seven lncRNA signatures, AC011442.1 was predicted to act as an oncogenic driver in OS by correlation analysis of copy number alteration (CNA) and lncRNA expression, and it was predicted to regulate AMPK and hedgehog signaling pathways. In summary, the identification of novel prognostic lncRNAs in OS could not only improved our understanding of the lncRNAs involved in OS tumorigenesis or progression but also assist the diagnosis and development of molecularly targeted therapies for OS, which in turn benefit patients' survival.

Therapy management in bone sarcoma

Bone sarcomas are rare, representing only 0.2% of all diagnosed cancers. Incidence is higher in children and adolescents, but bone sarcomas are still numerically outnumbered by benign bone tumors in this patient cohort. This article summarizes the management of treatment for bone sarcomas. Systemic therapy, surgical therapy, and radiotherapy are presented. Osteosarcoma, chondrosarcoma, and Ewing sarcoma are among the most frequently occurring bone sarcomas in all age groups. In recent decades, multimodal treatment of these rare entities has increased disease-free survival for these patients. As malignant primary bone tumors are rare cancers, and since management is complex, the standard of treatment should be performed by reference centers. If possible, wide en-bloc resection of the bone sarcoma should be performed. The role of radiotherapy in osteosarcoma and chondrosarcoma is limited, but Ewing sarcoma is a radiation-responsive tumor. In primary bone sarcomas, the efficacy of chemotherapy varies according to histological type. Prognosis is poor in patients with osteosarcoma or Ewing’s sarcoma if surgery without neoaqdjuvant chemotherapy is performed. Despite advances in surgical, medical, and radiation therapy, few significant positive changes in overall survival have been observed in patients with these diseases in recent decades.

Pathological Fracture and Prognosis of High-Grade Osteosarcoma of the Extremities: An Analysis of 2,847 Consecutive Cooperative Osteosarcoma Study Group (COSS) Patients

PURPOSE

The objective of this study was to investigate potential correlations between pathologic fractures (PFs) and prognosis of patients with primary central high-grade osteosarcoma of the extremities.

METHODS

We retrospectively analyzed 2,847 patients registered in the Consecutive Cooperative Osteosarcoma Study Group database with primary central high-grade osteosarcoma of the extremities, treated between 1980 and 2010. Intended treatment included pre- and postoperative chemotherapy and surgery. Univariable and multivariable survival analyses were performed for all patients and then differentiated for adult and pediatric (≤ 18 years at time of diagnosis) patients.

RESULTS

A total of 2,193 patients were ≤ 18 years of age; 11.3% of all patients had PFs. In the overall cohort, presence of PF correlated significantly with tumor site, histologic subtype, relative tumor size, and primary metastases, but not with body mass index or local surgical remission. In univariable analysis, 5-year overall survival (OAS) of patients with and without PF was 63% versus 71%, respectively (P = .007), and 5-year event-free survival (EFS) was 51% versus 58% (P = .026). In pediatric patients, OAS and EFS did not differ significantly between patients with and without PF. In adults, 5-year OAS in patients with and without PF was 46% versus 69% (P < .001), and 5-year EFS was 36% versus 56% (P < .001). In multivariable analysis, PF was not a statistically significant factor for OAS or EFS in the total cohort or in pediatric patients. In adult patients, PF remained an independent prognostic factor for OAS (P = .013; hazard ratio [HR], 1.893). It was not a significant prognostic factor for EFS (P = .263; HR, 1.312).

CONCLUSION

In this largest study to date with extremity osteosarcomas, we observed the occurrence of PF to correlate with inferior OAS expectancies in adult but not in pediatric patients.

Clinical and Molecular Analysis of Pathologic Fracture-associated Osteosarcoma: MicroRNA profile Is Different and Correlates with Prognosis

BACKGROUND

MicroRNAs are small, noncoding RNAs that regulate the expression of posttranslational genes. The presence of some specific microRNAs has been associated with increased risk of both local recurrence and metastasis and worse survival in patients with osteosarcoma. Pathologic fractures in osteosarcoma are considered to be more the manifestation of a neoplasm with a more aggressive biological behavior than the cause itself of worse prognosis. However, this has not been proved at the biological or molecular level. Currently, there has not been a microRNA profiling study of patients who have osteosarcoma with and without pathologic fractures that has described differences in terms of microRNA profiling between these two groups and their correlation with biologic behavior.

QUESTIONS/PURPOSES

(1) In patients with osteosarcoma of the extremities, how do the microRNA profiles of those with and without pathologic fractures compare? (2) What relationship do microRNAs have with local recurrence, risk of metastasis, disease-specific survival, and overall survival in osteosarcoma patients with pathologic fractures?

METHODS

Between 1994 and 2013, 217 patients were diagnosed and treated at our institution for osteosarcoma of the extremities. Patients were excluded if (1) they underwent oncologic resection of the osteosarcoma at an outside institution (two patients) or (2) they were diagnosed with an extraskeletal osteosarcoma (29 patients) or (3) they had less than 1 year of clinical follow-up and no oncologic outcome (local recurrence, metastasis, or death) (four patients). A total of 182 patients were eligible. Of those, 143 were high-grade osteosarcomas. After evaluation of tumor samples before chemotherapy treatment, a total of 80 consecutive samples were selected for sequencing. Demographic and clinical comparison between the sequenced and non-sequenced patients did not demonstrate any differences, confirming that both groups were comparable. Diagnostic samples from the extremities of 80 patients with high-grade extremity osteosarcomas who had not yet received chemotherapy underwent microRNA sequencing for an ongoing large-scale osteosarcoma genome profiling project at our institution. Six samples were removed after a second look by a musculoskeletal pathologist who verified cellularity and quality of samples to be sequenced, leaving a total of 74 patients. Of these, two samples were removed as they were confirmed to be pelvic tumors in a second check after sequencing. The final study sample was 72 patients (11 patients with pathologic fractures and 61 without). Sequencing data were correlated with fractures and local recurrence, risk of metastasis, disease-specific survival, and overall survival through Kaplan-Meier analyses.

RESULTS

Several microRNAs were expressed differently between the two groups. Among the markers with the highest differential expression (edgeR and DESeq algorithms), Hsa-mIR 656-3p, hsa-miR 493-5p, and hsa-miR 381-3p were upregulated in patients with pathologic fractures, whereas hsa-miR 363, hsa-miR 885-5p, and has-miR 20b-5p were downregulated. The highest differential expression fracture and nonfracture-associated microRNA markers also distinguished groups of patients with different metastasis risk, a well as different disease-specific and overall survival. Furthermore, the profile of pathologic fractures demonstrated a higher differential expression for microRNA markers that were previously associated with a higher risk of metastasis and lower survival rates in patients with osteosarcoma.

CONCLUSIONS

In patients who have osteosarcoma, the microRNA profiles of those with pathologic fractures are different than of patients without pathologic fractures. The highest differential expression mircroRNA molecules in patients with pathologic fractures predict also higher risk of metastatic disease as well as worse disease-specific survival and overall survival. Furthermore, we found higher differential expression of microRNAs in the pathologic fracture group previously associated with poor prognosis. The higher risk of metastasis and poorer overall survival in patients with pathologic fractures is inherent to tumor aggressive biologic behavior. It is plausible that the fracture itself is not the direct cause of worse prognosis but another manifestation of tumor biologic aggressiveness. Identification of these molecules through liquid biopsies may help to determine which patients may benefit from surgery before fractures occur. The same technology can be applied to identify patterns of response to conventional chemotherapy, assisting in more specific and accurate systemic therapy.

LEVEL OF EVIDENCE LEVEL

III, prognostic study.

Citrus aurantium Naringenin Prevents Osteosarcoma Progression and Recurrence in the Patients Who Underwent Osteosarcoma Surgery by Improving Antioxidant Capability

Citrus aurantium is rich in flavonoids, which may prevent osteosarcoma progression, but its related molecular mechanism remains unclear. Flavonoids were extracted from C. aurantium and purified by reparative HPLC. Each fraction was identified by using electrospray ionisation mass spectrometry (ESI-MS). Three main components (naringin, naringenin, and hesperetin) were isolated from C. aurantium. Naringenin inhibited the growth of MG-63 cells, whereas naringin and hesperetin had no inhibitory function on cell growth. ROS production was increased in naringin- and hesperetin-treated groups after one day of culture while the level was always lowest in the naringenin-treated group after three days of culture. 95 osteosarcoma patients who underwent surgery were assigned into two groups: naringenin group (NG, received 20 mg naringenin daily, n = 47) and control group (CG, received 20 mg placebo daily, n = 48). After an average of two-year follow-up, osteosarcoma volumes were smaller in the NG group than in the CG group (P > 0.01). The rate of osteosarcoma recurrence was also lower in the NG group than in CG group. ROS levels were lower in the NG group than in the CG group. Thus, naringenin from Citrus aurantium inhibits osteosarcoma progression and local recurrence in the patients who underwent osteosarcoma surgery by improving antioxidant capability.

Screw migration and oesophageal perforation after surgery for osteosarcoma of the cervical spine

Background

Even though internal fixation has expanded the indications for cervical spine surgery, it carries the risks of fracture or migration, with associated potential life threatening complications. Removal of metal work from the cervical spine is required in case of failure of internal fixation, but it can become challenging, especially when a great amount of scar tissue is present because of previous surgery and radiotherapy.

Case presentation

We report a 16 year old competitive basketball athlete who underwent a combined anterior and posterior approach for resection of an osteosarcoma of the sixth cervical vertebra. Fourteen years after the index procedure, the patient eliminated spontaneously one screw through the intestinal tract via an oesophageal perforation and developed a severe dysphagia. Three revision surgeries were performed to remove the anterior plate because of the great amount of post-surgery and post-irradiation fibrosis.

Conclusions

Screw migration and oesophageal perforation after cervical spine surgery are uncommon potentially life-threatening occurrences. Revision surgery may be challenging and it requires special skills.

The effect of pathological fractures on the prognosis of patients with osteosarcoma: a meta-analysis of 14 studies

Osteosarcoma is a leading cause of malignant tumor related death. We conducted a meta-analysis to evaluate the association between pathological fractures and prognosis in patients with osteosarcoma. We searched PubMed, Web of Science, and Embase for studies published until May 15, 2017. Crude and adjusted relative risk (RR) with 95% confidence intervals were used to compare data between the case and control groups. Fourteen studies and 3910 patients were included in the final meta-analysis. No statistically significant difference was detected between the pathological fracture and non-pathological fracture groups in local recurrences analysis (RR = 1.102, 95% CI: 0.813–1.495, P = 0.531); however, a statistically significant difference was found between group in distant metastasis (RR = 1.424, 95% CI: 1.089–1.862, P = 0.01). For survival rates, the following RRs were calculated: 3-year overall survival (OS) (RR = 0.736, 95% CI: 0.593–0.912, P = 0.005); 5-year OS (RR = 0.889, 95% CI: 0.791–0.999, P = 0.049); 3-year event-free survival (EFS) (RR = 0.812, 95% CI: 0.682–0.966, P = 0.018); and 5-year EFS (RR = 0.876, 95% CI: 0.785–0.978, P = 0.019). The pooled estimate of RR was 0.673 (95% CI: 0.364–1.244, P = 0.206) for local recurrence in the amputation and limb salvage groups. In conclusion, our analysis indicated that there were no differences in local recurrence and local recurrence after limb salvage between patients with or without a fracture. Additionally, the patients with pathological fracture had a higher risk of distant metastasis and lower 3-year OS, 5-year OS, 3-year EFS, and 5-year EFS. Considering the limitations of this study, we believe that future large-scale studies should be performed to confirm our conclusions.