This meta-analysis of 13 retrospective studies (2,884 patients) compared limb salvage surgery to amputation in limb osteosarcoma patients treated with neoadjuvant chemotherapy. The primary question: does surgical approach affect 5-year overall survival, disease-free survival, or local recurrence?
The headline number here — nearly twice the odds of 5-year overall survival with limb salvage surgery — demands scrutiny before it shapes your practice.
The absence of any disease-free survival difference is the tell. If limb salvage surgery were truly causally superior, you would expect both overall survival and disease-free survival to diverge. The fact that only overall survival differs strongly suggests the amputation group had worse baseline disease, not that amputation itself shortens life.
This is a textbook example of selection bias in retrospective oncologic surgery literature. Patients who cannot achieve wide margins — those with large tumors, vascular encasement, pathologic fractures, or poor chemotherapy response — are the ones who get amputated. Comparing their outcomes to limb salvage patients without controlling for these factors produces a biased estimate.
The practical takeaway for boards and for clinic: limb salvage surgery is the preferred approach when wide negative margins can be achieved. Amputation remains indicated when margins would be compromised. The surgical decision is driven by achievable margins and tumor biology, not by a survival advantage of one technique over the other.
This meta-analysis of 13 retrospective studies (2,884 patients) compared limb salvage surgery to amputation in limb osteosarcoma patients treated with neoadjuvant chemotherapy. The primary question: does surgical approach affect 5-year overall survival, disease-free survival, or local recurrence?
The headline number here — nearly twice the odds of 5-year overall survival with limb salvage surgery — demands scrutiny before it shapes your practice.
The absence of any disease-free survival difference is the tell. If limb salvage surgery were truly causally superior, you would expect both overall survival and disease-free survival to diverge. The fact that only overall survival differs strongly suggests the amputation group had worse baseline disease, not that amputation itself shortens life.
This is a textbook example of selection bias in retrospective oncologic surgery literature. Patients who cannot achieve wide margins — those with large tumors, vascular encasement, pathologic fractures, or poor chemotherapy response — are the ones who get amputated. Comparing their outcomes to limb salvage patients without controlling for these factors produces a biased estimate.
The practical takeaway for boards and for clinic: limb salvage surgery is the preferred approach when wide negative margins can be achieved. Amputation remains indicated when margins would be compromised. The surgical decision is driven by achievable margins and tumor biology, not by a survival advantage of one technique over the other.