The presence of pathologic fracture in osteosarcoma raises concerns of tumor dissemination by the fracture hematoma and has been considered a contraindication to limb salvage surgery. Because this is a theoretical concern, there are little clinical data available in the literature on which to base treatment of these patients. Eighteen patients with osteosarcoma who sustained a pathologic fracture and had a minimum of 24 months of followup were reviewed retrospectively. Surgical treatment included nonoperative therapy, amputation, and limb salvage groups. Patients who refused surgical intervention (2) had a uniformly poor outcome. Patients who underwent amputation (6) had no local recurrences and 33% developed metastases. Patients who underwent limb salvage (10) experienced 3 local recurrences and 6 distant recurrences. Although the distant recurrence rate for patients undergoing amputation was no different from the rate for those undergoing limb salvage, the difference in local tumor control approached statistical significance. All patients who developed local recurrence died. Surgical treatment needs to be individualized and based on factors such as fracture displacement, stability, radiographic and histologic response to chemotherapy, and the perceived ability to resect the fracture hematoma completely.