Horsch A, Baus C, Deisenhofer J, Lunz A, Geisbüsch A, Lehner B. Risk factors for postoperative pathological fractures in lower extremity soft tissue sarcoma patients undergoing limb-sparing surgery. World J Clin Oncol 2026; 17(6): 119535 [DOI: 10.5306/wjco.119535]
Corresponding Author of This Article
Axel Horsch, Associate Professor, Department of Orthopedics, University Hospital Heidelberg, Schillerbachel Street 200a, Heidelberg 69118, Baden-Württemberg, Germany. axel.horsch@med.uni-heidelberg.de
Research Domain of This Article
Orthopedics
Article-Type of This Article
research-article
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Clin Oncol. Jun 24, 2026; 17(6): 119535 Published online Jun 24, 2026. doi: 10.5306/wjco.119535
Risk factors for postoperative pathological fractures in lower extremity soft tissue sarcoma patients undergoing limb-sparing surgery
Axel Horsch, Christopher Baus, Julian Deisenhofer, Andre Lunz, Andreas Geisbüsch, Burkhard Lehner
Axel Horsch, Christopher Baus, Julian Deisenhofer, Andre Lunz, Andreas Geisbüsch, Burkhard Lehner, Department of Orthopedics, University Hospital Heidelberg, Heidelberg 69118, Baden-Württemberg, Germany
Author contributions: Horsch A and Lehner B designed the study and secured funding; Baus C and Horsch A developed the methodology, performed the formal analysis and investigation; Horsch A drafted the original manuscript; Baus C contributed to the materials and methods and results sections; Lehner B, Baus C, Deisenhofer J, Geisbüsch A and Lunz A contributed to review and editing of each subsequent version of the manuscript.
Supported by Heidelberg University.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of the Medical Faculty of Heidelberg.
Informed consent statement: According to the approval of the Ethics Committee and in compliance with German law governing retrospective studies, this study did not require written informed consent from individual patients. The Ethics Committee granted a waiver of informed consent because the study was retrospective in nature, only previously collected clinical data were analyzed, no additional diagnostic or therapeutic procedures were performed, and the study posed no additional risk to the participants.
Conflict-of-interest statement: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement- checklist of items.
Data sharing statement:sharing statement: The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.
Corresponding author: Axel Horsch, Associate Professor, Department of Orthopedics, University Hospital Heidelberg, Schillerbachel Street 200a, Heidelberg 69118, Baden-Württemberg, Germany. axel.horsch@med.uni-heidelberg.de
Received: January 30, 2026 Revised: April 7, 2026 Accepted: May 8, 2026 Published online: June 24, 2026 Processing time: 143 Days and 21.7 Hours
Abstract
BACKGROUND
Soft tissue sarcomas (STSs) of the lower extremities are rare malignancies increasingly treated with limb-sparing surgery combined with radiotherapy (RT). While this approach provides excellent oncologic control and preserves function, it is associated with late skeletal complications. Postoperative pathologic fractures (PPFs) represent a serious and potentially disabling outcome, often requiring additional surgical intervention and impairing quality of life. Reported fracture rates and associated risk factors vary widely, and contemporary data incorporating modern surgical and radiotherapeutic techniques remain limited.
AIM
To identify independent predictors of PPFs following limb-sparing surgery for lower extremity STS.
METHODS
This retrospective cohort study included 266 patients with intermediate- or high-grade lower extremity STS treated with limb-sparing surgery between 2010 and 2020. Clinical, tumor-related, surgical, and treatment variables were collected. PPF was defined as a low-energy fracture occurring within the surgical field. Cumulative fracture incidence was estimated using Kaplan-Meier analysis. Risk factors were assessed using univariable analyses and multivariable Cox regression with Firth’s penalized likelihood.
RESULTS
During a median follow-up of 48.9 months, 23 postoperative pathological fractures occurred. The cumulative fracture incidence was 1.8% at 1 year, 13.0% at 5 years, and 20.6% at 10 years. Fractures most frequently involved the femur. In univariable analyses, older age, arterial hypertension, larger tumor size, RT, and bone-involving surgical procedures were associated with increased fracture risk. In multivariable analysis, bone resection and osteoporosis remained independently associated with PPF, whereas RT, age, and arterial hypertension were not statistically significant. Tumor size was not included in the multivariable model due to lack of significance in univariable analysis but remains clinically relevant.
CONCLUSION
PPFs are a relevant late complication following limb-sparing surgery for STS. Fracture risk is primarily associated with bone-involving surgical procedures and osteoporosis, whereas RT shows an elevated but not statistically significant association.
Core Tip: Postoperative pathologic fractures are an underrecognized late complication following limb-sparing surgery for lower extremity soft tissue sarcoma (STS). In this retrospective cohort of 266 patients with long-term follow-up, fractures occurred predominantly in the femur and often several years after treatment. Partial bone resection and osteoporosis were independently associated with increased fracture risk, whereas radiotherapy showed an elevated but not statistically significant association. These findings underscore the importance of long-term surveillance and careful risk stratification in patients undergoing limb-sparing management for STS.
