Age Matters: A Systematic Review of Limb-Salvage Surgery Outcomes in Pediatric Versus Adult Osteosarcoma

Limb-salvage surgery (LSS) is the cornerstone of modern osteosarcoma management, yet outcomes appear to differ substantially between pediatric and adult patients. Variability in tumor biology, chemotherapy tolerance, treatment intensity, and reconstructive durability may contribute to age-related disparities; however, comparative evidence has not been previously synthesized. This study aimed to systematically evaluate oncologic, functional, and prognostic differences in limb-salvage outcomes between pediatric and adult patients with osteosarcoma. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review was performed across major databases. Studies were eligible if they reported limb-salvage outcomes separately for pediatric and adult patients. Data extraction encompassed survival, recurrence, functional scores, chemotherapy response, and prognostic factors. Risk of bias was assessed using the Newcastle-Ottawa Scale. Seven studies met the inclusion criteria, representing over 12,000 patients from cooperative trials, national registries, and institutional cohorts. Pediatric patients consistently demonstrated superior oncologic outcomes, with higher five-year overall survival (55%-73% vs. 41%-69%) and lower distant recurrence rates compared with adults. Local recurrence remained low but was slightly more frequent in adults. Functional outcomes favored pediatric groups, who achieved higher MSTS scores and lower revision rates. Histologic response to chemotherapy ≥90% was substantially more common in children, reflecting stronger systemic treatment tolerance. Predictors of poor outcome, such as axial site, metastatic disease, comorbidities, and poor necrosis, were disproportionately represented in adult cohorts. Risk of bias was low to moderate for most studies, with consistent age-related patterns across all evidence sources. Age significantly influences outcomes following LSS for osteosarcoma. Pediatric patients show superior survival, lower recurrence, improved function, and more favorable prognostic indicators compared with adults, even within similar surgical pathways. Biological differences, treatment intensity, and systemic therapy responsiveness likely contribute to these disparities. Future research should focus on optimizing chemotherapy strategies and reconstructive approaches for adults and on identifying biologic drivers that underlie these age-dependent patterns.