historically , the presence of a pathologic fracture in osteosarcoma has been associated with a poor outcome and has also been considered a contraindication for limb salvage . recent studies have however refuted these claims and suggested that the presence of a pathological fracture does not impact on outcomes and the possibility of safe limb salvage surgery ( lss ) for appropriately selected pathologic fractures when combined with neoadjuvant chemotherapy . the eastern asian musculoskeletal oncology group reviewed the data from three large volume asian orthopedic oncology centers to determine whether the presence of a pathologic fracture affected outcomes in osteosarcoma patients . we analyzed local control rates and overall survival as outcome measures in these cases and compared them with a group of patients without a pathologic fracture treated during the same time period . a retrospective review of the data of three asian orthopedic oncology centers was carried out . inclusion criteria included treatment - naive solitary nonmetastatic osteosarcoma of the extremity with pathologic fracture . a control group of similar osteosarcoma patients without a pathologic fracture treated during the same time period at each institute was also analyzed for comparison . ninety - five cases of nonmetastatic extremity osteosarcoma with pathological fracture were enrolled , and 887 cases without fracture were compared as the control group . the ethnic distribution included chinese , indians , and filipinos ; the baseline demographic criteria of the two groups were similar , the age and gender in two groups had no difference significantly but the lss rate was higher in non - fracture group [ table 1 ] . prior to surgery , all patients underwent a thorough oncological assessment to determine the extent of local disease and exclude the presence of distant metastases . staging studies included plain radiographs and magnetic resonance imaging of the limb , computed tomography scans of the chest , and total body scintigraphy . all patients with pathological fracture neoadjuvant chemotherapy was given according to the respective hospital protocol , and immobilization was continued during this period . limb - sparing resection was planned only if oncologically free margins could be achieved while yet retaining useful limb function . these were based on the type of resection , amount of residual bone , individual surgeon preference , and the functional desires of the patient as assessed during preoperative counseling . statistical analysis was performed using spss version 13.0 ( spss , chicago , il , usa ) . with categorical variables compared using chi - squared tests with a 95% confidence interval . overall survival was taken from the date of diagnosis to the last date when the patient was documented to be alive or the date of death . statistical analysis was performed using spss version 13.0 ( spss , chicago , il , usa ) . with categorical variables compared using chi - squared tests with a 95% confidence interval . overall survival was taken from the date of diagnosis to the last date when the patient was documented to be alive or the date of death . in the fracture group , the lss rate was 62.1% , and the rate of amputation was 37.9% . in the nonfracture group , the lss rate was 74.7% , and the amputation was 25.3% . all the patients were followed up according to each center 's methods . the groups were well - matched in terms of follow - up period [ table 2 ] . the local recurrence ( lr ) rate and the 5-year survival of the 2 groups are shown in table 2 and figure 1 , there was no significant difference between two groups in lr and survival . in patients with a pathologic fracture , the rate of lr for lss and amputation groups was 8.5% and 2.8% , respectively ( p = 0.41 ) . in this group , follow - up of patients kaplan  meier curve for overall survival of all patients with and without pathologic fractures . meier curve for the survival of all patients with pathologic fractures treated by amputation or limb salvage surgery . the incidence of pathologic fractures in our series was 9.7% , which is similar to that reported by other authors . pathological fracture through an osteosarcoma occurs either spontaneously or as a result of minimal trauma , due to their high cellularity , poor differentiation , and loss of matrix . it was believed that the hematoma of fracture may spread and contaminate the adjacent soft tissue hence leading to failure of local control in case limb - sparing surgery was attempted . with the advent of effective neoadjuvant chemotherapy , improved imaging and refinement of surgical techniques several studies have reported that lss can be safely employed even in appropriately selected cases of pathological fracture . . reported on the outcome of 18 patients with pathologic fractures in osteosarcoma , and concluded that the risk of lr in limb salvage is not higher in the presence of a pathologic fracture , and that adequate margins can still be achieved without compromising survival . reported 46 cases of nonmetastatic osteosarcoma of the extremity with pathologic fracture at presentation who had been treated in their institution . they concluded that these rates were similar to their larger control group of 689 patients without pathologic fracture . examined 484 patients with localized , high - grade extremity sarcomas and found no difference in the local control rates between groups with and without pathologic fracture . ferguson et al . reported 31 cases of osteosarcoma with a fracture and 201 cases without fracture . in the pathologic fracture group undergoing lss , there were 2 lrs ( 10% ) , while in the group without pathologic fracture undergoing lss , the lr rate was 8% . our local control rates were marginally better in patients with a pathologic fracture compared to those without ( lr = 10.5% vs. 12.1% ) but this did not reach statistical significance . being a retrospective study , there is always an element of selection bias , and it is possible that a greater proportion of patients with a fracture underwent an amputation resulting in more radical margins which translated into better local control . this small improvement in local control did not however translate into improved survival with overall survival being similar in both the fracture and the nonfracture group . found that their 5-year disease - free and overall survival rates of 59% and 65% , respectively , were not different from their group of patients without pathologic fracture . , in a cohort of 384 patients , found that presentation with a pathologic fracture showed a trend toward poorer survival , and it failed to reach significance . in the same paper , there was no difference in overall survival between a case  control study of 37 fractures and 74 matched nonfractured patients . contrary to these studies , there have been reports that have documented poorer survival in patients with a fracture thus ensuring that the debate regarding outcomes in these patients remains unresolved . further analyzing our group of patients with a pathologic fracture , we found that the rate of lr was higher for the lss group when compared with the amputation groups ( 8.5% and 2.8% , respectively ) though it failed to reach statistical significance ( p = 0.41 ) . scully et al . had similar results in a multi institutional retrospective study reviewing 52 patients with a fracture . the 5-year survival in the lss group was significantly better as against the amputation group ( 66% vs. 46.8% ) ( p = 0.038 ) . though lr may be a harbinger of poorer survival , the significance of lr has not yet been investigated in a suitable multifactorial model and lr is not usually quoted as an independent bad prognostic factor for overall survival . the improved survival in patients undergoing limb salvage could again be a reflection of selection bias in that patients showing a better response to neoadjuvant chemotherapy ( in terms of fracture healing ) were chosen for limb salvage while others underwent an amputation . it is a retrospective review and suffers from the inherent shortcomings of such a study . while comparing the groups with and without a pathologic fracture , we have not analyzed the effect of confounding factors such as tumor volume , margins , and response to chemotherapy while comparing outcomes . in spite of these shortcomings , we believe that this multi institutional study with large numbers does add to the increasing understanding of the outcome of patients with a pathologic fracture in osteosarcoma , a cohort that is relatively uncommon . though retrospective , such multi institutional reviews help in generating and supplementing outcome data which eventually may help establish guidelines for the management of these lesions . in conclusion , our study suggests that surgically treated patients with pathologic fractures in osteosarcoma have adequate local control and do not have a poorer outcome compared to patients without a fracture . though osteosarcoma with a pathologic fracture is not a contraindication for limb salvage , appropriate case selection is important when deciding local control options ( limb salvage vs. amputation ) to ensure adequate oncologic clearance .
background : recent studies have suggested that the presence of a pathological fracture does not impact on oncologic outcomes and the feasibility of limb salvage surgery ( lss ) in appropriately selected patients when combined with neoadjuvant chemotherapy . 
 these have largely been single institutional studies with limited numbers . 
 the eastern asian musculoskeletal oncology group reviewed the data from three large volume asian orthopedic oncology centers to determine whether the presence of a pathologic fracture affected outcomes in osteosarcoma patients.methods:a retrospective review of the data was conducted . 
 ninety - five cases of nonmetastatic extremity osteosarcoma with a pathological fracture and 887 cases without fracture treated during the same period were compared.results:in the fracture group , the lss rate was 62.1% , and the rate of amputation was 37.9% . 
 in the nonfracture group , the lss rate was 74.7% , and the amputation was 25.3% . in patients with a pathologic fracture , 
 the rate of local recurrence for lss and amputation groups was 8.5% and 2.8% , respectively . in this group , the 5-year survival in the lss group was 66% as against . 
 46.8% in the amputation group.conclusions:our study suggests that surgically treated patients with pathologic fractures in osteosarcoma have adequate local control and do not have a poorer outcome compared to patients without a fracture . 
 though osteosarcoma with a pathologic fracture is not a contraindication for limb salvage , appropriate case selection is important when deciding local control options to ensure adequate oncologic clearance .