Background: It has been recognized that cancer is associated with a higher risk of suicide or accidental death. Earlier studies have evidenced that patients with malignant bone tumors usually experience psychological dysfunction and physical disability following surgery, which are shared risk factors between suicidal and accidental deaths. To our knowledge, there is no large population-based study on the risk of suicide or accidental death among patients with malignant bone tumors. Questions/purposes: This study aimed to determine whether patients with primary malignant bone tumors are at a higher risk of suicide and accidental death than the general population and to identify the demographic and tumour-related characteristics and type of surgery associated with a higher risk of suicide and accidental death among these patients. Methods: Overall, 50,817 patients diagnosed with primary malignant bone tumors between 1973 and 1975 were identified from the Surveillance, Epidemiology, and End Results database. The standardised mortality ratio (SMR) was calculated based on the general population?s mortality data, gathered by the National Center for Health Statistics. The Cox regression model was developed to determine risk factors associated with a higher risk of suicide and accidental death. Results: Patients with primary malignant bone tumors had a higher risk of suicide and accidental death than the general population in the United States (US) (SMR = 2.17; 95% confidence interval (CI) [1.80? 2.62] and SMR = 1.73; 95% CI [1.54?1.95]). Compared with limb salvage, amputation significantly increased the risk of suicide (SMR = 3.99; 95% CI [2.52?6.34], hazard ratio (HR) = 2.32; 95% CI [1.31? 4.09]; P < 0.01) but did not increase the risk of accidental death (SMR = 1.61; 95% CI [1.07?2.42], HR = 1.11; 95% CI [0.71?1.74]; P = 0.65). Higher suicide risk was observed among older patients whose age at diagnosis was more than 60 years (HR = 4.04; 95% CI [1.98?8.26]; P < 0.001), males (HR = 3.48; 95% CI [2.16?5.62]; P < 0.001), and whites (HR = 3.71; 95% CI [1.17?11.73]; P < 0.001). The risk of suicide and accidental death was highest in the first year after diagnosis (SMR = 2.95; 95% CI [1.86?4.69] and SMR = 2.02; 95% CI [1.48?2.74]). Conclusion: We first reported that patients with primary malignant bone tumors had a higher risk of suicide and accidental death than the general US population. Therefore, clinicians should pay more attention to the psychological status, physical function, and cognitive level of these survivors. ? 2021 Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).