Limb salvage and amputation in survivors of pediatric lower-extremity bone tumors: what are the long-term implications?

Special Considerations for Multiple Limb Amputation

It has been estimated that more than 1.6 million individuals in the United States have undergone at least one amputation. The literature abounds with research of the classifications of such injuries, their etiologies, epidemiologies, treatment regimens, average age of onset (average age of amputation), and much more. The subpopulation that is often overlooked in these evaluations, however, is comprised of individuals who have suffered multiple limb loss. The challenges faced by those with single-limb loss are amplified for those with multiple limb loss. Pain, lifestyle adjustment, and quality of life return are just a few key areas of concern in this population. Along with amputations resulting from trauma, many individuals with multiple amputations have endured them as a result of dysvascular disease. Over recent years, amputations as a result of dysvascular disease have risen to comprise more than 80 % of new amputations occurring in the United States every year. This compares to just 54 % of total current prevalence. Those with diabetes comorbid with dysvascular disease make up 74 % of those with dysvascular amputations, and these individuals with diabetes comorbid with dysvascular disease have a 55 % chance of enduring an amputation of their contralateral limb within 2-3 years of their initial amputation. With the well-documented aging of the nation's population and the similarly skyrocketing prevalence of dysvascular disease and diabetes, it can be expected that the number of individuals with multiple limb loss will continue to increase in the United States. This article outlines the recommended measures of care for this particular subpopulation, including pain management, behavioral health considerations, strategies for rehabilitation for various levels and variations of multiple limb loss, and the assistive technology and adaptive equipment that might be available for these individuals to best enable them to continue healthy, fulfilling lives following amputation.

Functional analysis of cases of tumor endoprostheses with deep infection around the knee: a multi institutional study by the Japanese Musculoskeletal Oncology Group (JMOG)

BACKGROUND

Although intensive studies have been conducted to clarify the incidence, risks, and management methods of deep infection of tumor endoprostheses, limited data have been published in respect of the impact of such deep infection on the function of the corresponding limb.

METHODS

Clinical data of 125 patients (infection group 57, control group 68) with malignant bone and soft tissue tumors around the knee enrolled with the Japanese Musculoskeletal Oncology Group were collected. We analyzed the impact of deep infection of tumor endoprostheses on the limb salvage status together with that on the function of the salvaged limb. The definition of deep infection was based on the recommendations of the Centers for Disease Control and Prevention. The functional evaluation was based on the functional classification system established by the International Society of Limb Salvage and the Musculoskeletal Tumor Society.

RESULTS

Infection together with extracapsular resection was demonstrated to be a risk factor for late amputation. There were no significant differences in the functional scores for "pain," "support," "walking," or "gait" between the infection and control groups. The risk factors identified for a loss of score for "functional activities" were deep infection, age, duration of operation, and extracapsular resection. The infection group also showed a significant lower score loss in "emotion". As for the overall functional scores, the risk factors identified for lower scores were deep infection and age. The mean scores for the infection group and control group were 19.3 (64.3 %) and 21.6 (72 %), respectively. Although the difference was confirmed to be statistically significant, the actual difference was only 2.3 (10.6 % reduction).

CONCLUSIONS

Infection was a major risk factor for late amputation. Limbs salvaged by management of deep infection may show loss of function; however, the impact may be limited.

Current therapeutic strategies and novel approaches in osteosarcoma

Osteosarcoma is the most frequent malignant primary bone tumor and a main cause of cancer-related death in children and adolescents. Although long-term survival in localized osteosarcoma has improved to about 60% during the 1960s and 1970s, long-term survival in both localized and metastatic osteosarcoma has stagnated in the past several decades. Thus, current conventional therapy consists of multi-agent chemotherapy, surgery and radiation, which is not fully adequate for osteosarcoma treatment. Innovative drugs and approaches are needed to further improve outcome in osteosarcoma patients. This review describes the current management of osteosarcoma as well as potential new therapies.

Haptic robot-assisted surgery improves accuracy of wide resection of bone tumors: a pilot study

BACKGROUND

Accurate reproduction of the preoperative plan at the time of surgery is critical for wide resection of primary bone tumors. Robotic technology can potentially help the surgeon reproduce a given preoperative plan, but yielding control of cutting instruments to a robot introduces potentially serious complications. We developed a novel passive ("haptics") robot-assisted resection technique for primary bone sarcomas that takes advantage of robotic accuracy while still leaving control of the cutting instrument in the hands of the surgeon.

QUESTIONS/PURPOSES

We asked whether this technique would enable a preoperative resection plan to be reproduced more accurately than a standard manual technique.

METHODS

A joint-sparing hemimetaphyseal resection was precisely outlined on the three-dimensionally reconstructed image of a representative Sawbones femur. The indicated resection was performed on 12 Sawbones specimens using the standard manual technique on six specimens and the haptic robotic technique on six specimens. Postresection images were quantitatively analyzed to determine the accuracy of the resections compared to the preoperative plan, which included measuring the maximum linear deviation of the cuts from the preoperative plan and the angular deviation of the resection planes from the target planes.

RESULTS

Compared with the manual technique, the robotic technique resulted in a mean improvement of 7.8 mm of maximum linear deviation from the preoperative plan and 7.9° improvement in pitch and 4.6° improvement in roll for the angular deviation from the target planes.

CONCLUSIONS

The haptic robot-assisted technique improved the accuracy of simulated wide resections of bone tumors compared with manual techniques.

CLINICAL RELEVANCE

Haptic robot-assisted technology has the potential to enhance primary bone tumor resection. Further bench and clinical studies, including comparisons with recently introduced computer navigation technology, are warranted.

Physical activity assessment in adolescents with limb salvage

OBJECTIVES

To evaluate ambulatory activity differences between youth with limb salvage procedures and typically developing youth (TDY) and assess differences in self-reported activity levels in the 2 groups, to provide a basis for physical activity assessment in patients who had undergone limb salvage surgery and treatment planning that incorporates regaining normal physical and daily living activities.

STUDY DESIGN

In this cohort comparison study, we compared ambulatory and self-reported activity levels in 20 youth (aged 11.7-20.8 years) who had undergone limb salvage surgery and a sex- and age-matched comparison cohort of 20 TDY. StepWatch activity monitor and Activity Scale for Kids data were used to answer these questions.

RESULTS

Significant differences were found between the youth who had undergone limb salvage surgery and the TDY in total time active each day (43% vs 48%; P = .03), median total strides per day (4487 vs 7671; P = .001), and amount of time per day at high activity levels (20 minutes vs 47 minutes; P = .001). Self-reported overall physical activity, locomotion, and standing Activity Scale for Kids subscale scores were significantly lower in the youth undergoing limb salvage surgery compared with the TDY (summary score, 88.3 vs 97.7; P = .001).

CONCLUSION

Patients undergoing limb salvage surgery exhibit reduced physical activity compared with normal age-matched controls.

Nutritional status of children and young adults with Ewing sarcoma or osteosarcoma at diagnosis and during multimodality therapy

OBJECTIVE

Objective of our study was to evaluate the nutritional status and growth of children and adolescents with common malignancies of the musculoskeletal system at diagnosis, and undergoing multimodality therapy.

METHODS

A retrospective analysis of data from 2001 to 2009 was conducted. Hospital charts were used as a source of clinical data. Primary endpoint of the analyses was to identify variations in anthropometric parameters at diagnosis and during the first 2 years of follow-up in children and adolescents with osteosarcoma or Ewing sarcoma. Factors contributing to disorders of growth in this population were sought.

RESULTS

A total of 139 children were registered, 62 with Ewing sarcoma and 77 with osteosarcoma. At diagnosis 72.7% of all patients were classified as adequately nourished (BMI 5th to <85th percentiles). During treatment all anthropometric parameters were markedly reduced (P < 0.001) in both groups with extreme changes in body weight from -30% to +44%. This was pronounced in children affected by osteosarcoma (P < 0.05). During follow-up, recovery of body weight was noted in both groups. Height Z-scores remained low (P < 0.001) in comparison to the general population. After the observation period 43.4% of the children with osteosarcoma and 25.5% of the patients with Ewing sarcoma demonstrated an altered body mass.

CONCLUSIONS

Pediatric patients with Ewing sarcoma or osteosarcoma are at an increased risk for developing malnutrition, in the form of either over- or underweight during multimodality therapy. Early recognition of abnormal body mass is required to prevent and to treat long-term comorbidities caused by malnutrition.

A systematic review of the recent quality of life studies in adult extremity sarcoma survivors

Background. Extremity sarcoma represents a heterogeneous group of rare cancers that carries a relatively high morbidity with regards to physical function. Quality of Life (QoL) as an outcome is an important consideration in this cohort. We aimed to identify the correlates of QoL in extremity sarcoma cohorts. Methods. A systematic review of the literature on extremity sarcoma in adults from five databases over the last ten years was undertaken. Results. Twelve articles were chosen and assessed for quality. Physical and social function of extremity sarcoma survivors is below that of the general population. Overall QoL scores of these patients are comparable to those of the general population. Studies that used more recently treated cohorts found that patients who had limb sparing surgery displayed superior functional outcomes over those that underwent amputations. Pain and perceiving that the cancer negatively influenced opportunities was associated with poor outcomes. Conclusion. The available literature regarding QoL in extremity sarcoma patients is heterogeneous in terms of aims and assessment tools. Results need to be interpreted in light of the improved management of extremity sarcoma in more recent patient cohorts.

Translation and preliminary validation of the English version of the DUX questionnaire for lower extremity bone tumor patients (Bt-DUX): a disease-specific measure for quality of life

PURPOSE

To translate the Dutch DUX questionnaire for lower extremity bone tumor patients (Bt-DUX), a disease-specific quality of life (QoL) instrument, into the English (UK) language and preliminary validate the English version in patients who were treated for lower-extremity bone tumors.

METHODS

Adaptation and translation process included forward translation, back-translation, and a review of the back-translation by an expert committee. Internal consistency and validity of the translated questionnaire were examined in a sample of adolescents treated for lower extremity osteosarcoma in the United Kingdom. Assessments included the Bt-DUX, the Toronto Extremity Salvage Score (TESS), the Short Form (SF)-36, and the TNO-AZL Questionnaire for Adult's Quality of Life (TAAQOL).

RESULTS

Seventeen patients (7 ♂ and 10 ♀), median age 19.9 (range: 16-25) years completed the questionnaires. Mean Bt-DUX score was 38.8 (range: 23-78), with Cronbach's α being 0.95 domain-total correlations ranged between 0.84 and 0.93 (P < 0.01). Spearman's correlation coefficients between the Bt-DUX total and domain scores and corresponding TAAQOL and SF-36 scores were overall moderate to good and reaching statistical significance in a most cases.

CONCLUSION

Preliminary evidence suggests that the English Bt-DUX translation is a valid disease-specific instrument for evaluating QoL of adolescents with lower extremity bone cancer.

Late effects in adult survivors of pediatric cancer: a guide for the primary care physician

Because of significant medical advances in the past 50 years, the number of adult survivors of childhood/adolescent cancer has increased dramatically. Unfortunately, more than 60% of these survivors will have at least 1 long-term side effect from treatment. This growing population requires dedicated care by their primary physicians because they have specific risk factors depending on their initial cancer diagnosis and the treatment modalities they received. Internists and family physicians play an integral role in providing appropriate screening, treatment, and counseling to prevent morbidity and mortality in these patients.

Does limb-salvage surgery offer patients better quality of life and functional capacity than amputation?

INTRODUCTION

Patients with aggressive lower extremity musculoskeletal tumors may be candidates for either above-knee amputation or limb-salvage surgery. However, the subjective and objective benefits of limb-salvage surgery compared with amputation are not fully clear.

QUESTIONS/PURPOSES

We therefore compared functional status and quality of life for patients treated with above-knee amputation versus limb-salvage surgery.

METHODS

We reviewed 20 of 51 patients aged 15 years and older treated with above-knee amputation or limb-salvage surgery for aggressive musculoskeletal tumors around the knee between 1994 and 2004 as a retrospective cohort study. At last followup we obtained the Physiological Cost Index, the Reintegration to Normal Living Index, SF-36, and the Toronto Extremity Salvage Score questionnaires. The minimum followup was 12 months (median, 56 months; range, 12-108 months).

RESULTS

Compared with patients having above-knee amputation, patients undergoing limb-salvage surgery had superior Physiological Cost Index scores and Reintegration to Normal Living Index. The Toronto Extremity Salvage scores and SF-36 scores were similar in the two groups.

CONCLUSION

These data suggest that limb-salvage surgery offers better gait efficiency and return to normal living compared with above-knee amputation, but does not improve the patient's perception of quality of life.

A prospective study on quality of life and functional outcome in children and adolescents after malignant bone tumor surgery

BACKGROUND

Few longitudinal data are available concerning quality of life (QoL) and functioning of young patients undergoing surgical procedures for malignant bone tumors around the knee joint. Aim of the present study was to evaluate patients' quality of life, functional ability, and physical activity during a 2-year postoperative period.

METHODS

This prospective study included patients who underwent surgery for a malignant bone tumor around the knee joint between 2004 and 2008. Assessments were done at 3, 6, 9, 12, 18, and 24 months after surgery. QoL was measured with the TNO-AZL Children's or Adult's Quality of Life Questionnaires (TACQOL and TAAQOL), the Short Form-36 (SF-36) and Bone tumor (Bt)-DUX; functional ability with the Toronto Extremity Salvage Scale (TESS), the 6-minute walk test (6 MWT) and four functional performance tests; and physical activity with the Baecke questionnaire and the ActiLog® activity monitor. Statistical analysis included linear mixed model analysis.

RESULTS

Forty-four patients (27 males, 17 females, mean age 14.9 (SD 4.8) years) were included, 27 (61%) underwent limb-salvage and 17 (39%) ablative surgery. Twenty patients were lost during the 2 years follow-up as a consequence of oncological complications. Over the first year, survivors showed significant improvement of QoL, functional ability and physical activity, except for the mental dimension of the SF-36 and the activity monitor results. Over the second year, these improvements were less pronounced.

CONCLUSIONS

In the first 2 years after bone tumor surgery, survivors improved significantly with respect to QoL, functional ability, and physical activity levels.

Outcome of lower-limb preservation with an expandable endoprosthesis after bone tumor resection in children

BACKGROUND

The optimal treatment of malignant pediatric lower-extremity bone tumors is controversial. Expandable endoprostheses allow limb preservation, but the revision rate and limited function are considered barriers to their use. This study investigated the functional, emotional, and oncologic outcomes of thirty-eight patients treated with an expandable endoprosthesis.

METHODS

A retrospective chart review was performed, and surviving patients were asked to complete the Musculoskeletal Tumor Society (MSTS) outcomes instrument and the Pediatric Outcomes Data Collection Instrument (PODCI). Additional data including the range of hip and knee motion, limb-length discrepancy, and total lengthening were also obtained.

RESULTS

Thirty-eight patients were treated with an expandable endoprosthesis, and twenty-six of these patients were alive at the time of the study. The mean global MSTS score was 26.1, and the mean global PODCI score was 85.8. The mean emotional acceptance and happiness subscores were high. The mean sagittal-plane hip motion in patients who had undergone replacement of the proximal aspect of the femur was 103°. The mean knee motion in patients who had undergone replacement of the proximal aspect of the femur, the distal aspect of the femur, or the proximal aspect of the tibia was 127°, 97°, and 107°, respectively. The mean lengthening at the time of skeletal maturity was 4.5 cm, and the mean limb-length discrepancy was 0.7 cm. Forty-two percent of the patients experienced complications, with ten patients requiring prosthesis revision and two of these patients requiring amputation.

CONCLUSIONS

Current technology does not offer a single best reconstruction option for children. Previous studies and the present series have indicated that physical and emotional functioning in patients treated with an expandable endoprosthesis are good but that complication rates remain high. Amputation and rotationplasty are alternative treatments if patients and their families are amenable to these procedures. The literature supports no single superior treatment among these three options with regard to physical or emotional health.

Health related quality of life in adolescent and young adult survivors of lower extremity bone tumors

BACKGROUND

Dramatic increases in survival rates have led to increased interest regarding the health related quality of life (HRQOL) of adolescent and young adult survivors of bone tumors. This study investigated HRQOL and physical disability in adolescent and young adult survivors of lower extremity bone tumors as a function of type of surgical intervention, gender, and age at assessment.

PROCEDURE

Twenty-eight participants (age range 18-32 years) completed three generic and one disease-specific measures of HRQOL and a measure of physical disability. For analysis, surgical intervention was grouped into limb sparing surgeries (LS; allograft fusion and endoprosthesis) and ablative surgeries (AMP; amputation or Van Nes rotationplasty). Age at study was grouped into ≤ 25 years of age and ≥ 26 years of age. The MOS-SF-36, HUI2, HUI3, and EORTC-QLQ-C30 were used to measure HRQOL and the TESS was used to assess physical disability.

RESULTS

Survivors reported HRQOL equivalent to the general population, with the exception of physical functioning. LS reported poorer HRQOL than AMP participants for emotional functioning and fatigue. Males reported better HRQOL compared with females for overall HRQOL, general health, physical functioning, and social functioning. Finally, younger participants generally reported better HRQOL than older participants for overall HRQOL and physical functioning.

CONCLUSIONS

This study identifies LS surgical intervention, female gender and older age as risk factors for reduced HRQOL in adolescent and young adult survivors of lower extremity bone tumors. This study also provides information about what instrument may be most useful in identifying these specific difficulties and subgroups.

Follow-up of treated osteosarcoma patient

Objective

To evaluate the value of post-treatment follow-up in osteosarcoma patients.

Methods

Data were collected through a clinical record, with socio-demographic and clinical data, and information relating to the medical appointment. Descriptive analysis of the data was carried out. The Chi-squared test was used to associate the independent variables with attendance at scheduled follow-up appointments.

Results

We found a recurrence in 59.6% of cases, of which 58% were lung related; 44% presented clinical complaints and arrived on the scheduled date of the appointment. There was no statistically significant association between the demographic characteristics and early attendance of follow-up visits. 81.3% of the cases who came for the appointment earlier than originally scheduled presented complaints compared to those who did not (p=0.005). Of the cases who presented recurrence, 12.9% attended an appointment late and those who did not present recurrence, 47.6% were late for the appointment (p=0.006).

Conclusion

It is seen that the patients who came for an earlier appointment presented more complaints and were associated with the positive result of the exams carried out. The patients who had recurrence and came for an earlier appointment did not present a statistically significant difference in recurrence-free survival. It was observed that distance was not a predominant factor in late attendance at appointments. Level of Evidence II, Retrospective Study.

Quality of life, functional ability and physical activity after different surgical interventions for bone cancer of the leg: A systematic review

PURPOSE

To systematically review published studies comparing Quality of Life (QoL), functional ability and/or physical activity between different surgical interventions due to a malignant bone tumour of the leg.

METHODS

A systematic literature search, covering the years 2000-2010 was performed using the PubMed, Embase, Web of science and Cochrane databases. Studies were included if they described and statistically compared QoL, functional ability and/or physical activity of at least two surgical interventions for lower extremity bone cancer. In addition, the methodological quality of the selected studies was evaluated by using a 24-point scale. Where appropriate, a qualitative analysis or meta-analysis was performed.

RESULTS

The search strategy resulted in a list of 246 citations. Based on titles and abstracts 50 full-text articles were selected, of which 13 articles describing 12 studies, were finally included. Overall, the methodological quality of the studies was moderate. Studies were heterogeneous with respect to their categorisation of surgical interventions, average age of patients and average duration of follow-up. Overall, results regarding differences between ablative and limb-sparing surgery varied largely. Meta-analysis was considered to be not appropriate due to clinical heterogeneity, methodological differences and flaws.

CONCLUSION

Twelve studies comparing the outcomes of QoL, functional ability and physical activity between limb-sparing and ablative surgery groups were identified, with an overall moderate methodological quality. Their largely varying outcomes suggest that no general conclusions on the advantage of either limb-sparing or ablative surgery in patients with malignant bone tumours of the lower extremity can be drawn.

Twenty years of follow-up of survivors of childhood osteosarcoma: a report from the Childhood Cancer Survivor Study

BACKGROUND

Osteosarcoma survivors have received significant chemotherapy and have undergone substantial surgeries. Their very long-term outcomes (20 year) are reported here.

METHODS

The authors assessed the long-term outcomes of 733 5-year survivors of childhood osteosarcoma diagnosed from 1970 to 1986 to provide a comprehensive evaluation of medical and psychosocial outcomes for survivors enrolled in the Childhood Cancer Survivor Study (CCSS). Outcomes evaluated included overall survival, second malignant neoplasms (SMNs), recurrent osteosarcoma, chronic health conditions, health status (general and mental health and functional limitations), and psychosocial factors. Outcomes of osteosarcoma survivors were compared with general-population statistics, other CCSS survivors, and CCSS siblings.

RESULTS

Survivors had a mean follow-up of 21.6 years. The overall survival of children diagnosed with osteosarcoma who survived 5 years at 20 years from original diagnosis was 88.6% (95% confidence interval [CI], 86.6%-90.5%). The cumulative incidence of SMNs at 25 years was 5.4%, with a standardized incidence ratio of 4.79 (95% CI, 3.54-6.33; P<.01). Overall, 86.9% of osteosarcoma survivors experienced at least 1 chronic medical condition, and >50% experienced ≥2 conditions. Compared with survivors of other cancers, osteosarcoma survivors did not differ in their reported general health status (odds ratio [OR], 0.9; 95% CI, 0.7-1.2), but were more likely to report an adverse health status in at least 1 domain (OR, 1.9; 95% CI, 1.6-2.2), with activity limitations (29.1%) being the most common.

CONCLUSIONS

Childhood osteosarcoma survivors in this cohort did relatively well, considering their extensive treatment, but are at risk of experiencing chronic medical conditions and adverse health status. Survivors warrant life-long follow-up.

Treatment of pain in children after limb-sparing surgery: an institution's 26-year experience

A significant proportion of patients report long-term pain that is ≥5 on a 0-10 intensity scale after limb-sparing surgery for malignancies of the long bones. Patients experience several distinct types of pain after limb-sparing surgery which constitute a complex clinical entity. This retrospective study examined 26 years of experience in a pediatric institution (1981-2007) in pain management as long as 6 months after limb-sparing surgery and reviewed the historical evolution of pain interventions. One hundred fifty patients underwent 151 limb-salvage surgeries for bone cancer of the extremities in this series. Pain treatment increased progressively in complexity. Therapies included opioids, nonsteroidal antiinflammatory drugs, acetaminophen-opioid combinations, postoperative continuous epidural infusion, anticonvulsants and tricyclic antidepressants for neuropathic pain, local anesthetic wound catheters, and continuous peripheral nerve block catheters. Management of pain after limb-sparing surgery has evolved over the 26 years of this review. It currently relies on multiple "layers" of pharmacologic and nonpharmacologic strategies to address the complex mixed nociceptive and neuropathic mechanisms of pain in this patient population.

Psychosocial and functional outcomes in long-term survivors of osteosarcoma: a comparison of limb-salvage surgery and amputation

BACKGROUND

Traditionally, physicians have believed that limb-salvage surgery has functional and cosmetic advantages over amputation, yet the literature is equivocal. Therefore, we sought to compare the psychosocial and functional outcomes in osteosarcoma survivors after limb-salvage surgery and amputation. We hypothesized there to be neither psychosocial nor functional outcome differences between groups.

PROCEDURE

Participants received treatment of extremity osteosarcoma, had received their cancer diagnosis at least 2 years prior, and were at least 16 years old. A comprehensive set of validated psychosocial and functional measures was used to assess outcome.

RESULTS

Fifty-seven patients participated in this study (33 who underwent limb-salvage surgery and 24 who underwent amputation). Participants had gone 12-24 years since diagnosis and were 16-52 years old at study participation. We used multiple linear regression models to examine differences in quality of life, body image, self-esteem, and social support between the two groups and found no differences. Lower limb function was a significant predictor of quality of life (P < 0.001), whereas surgery type did not impact this relationship. Body image was rated significantly worse by those who underwent late amputation, amputation after failed limb salvage, than by those who did not.

CONCLUSIONS

Participants with more functional lower limbs had better quality of life than did those with less functional lower limbs regardless of whether they underwent amputation or limb-salvage surgery.

Quality of life in young patients after bone tumor surgery around the knee joint and comparison with healthy controls

BACKGROUND

This study aimed to compare the health related quality of life (HRQoL) of children and adolescents after malignant bone tumor surgery of the leg with healthy controls.

PROCEDURE

Patients between 8 and 25 years old were cross-sectional recruited. Patients under 16 years of age received the TNO (Netherlands Organization for Applied Scientific Research) and AZL (Leiden University Medical Center) Children's Quality of Life Questionnaire (TACQOL), patients aged 16 years and older received the TNO-AZL Questionnaire for Adult's Quality of Life (TAAQOL) and the Short Form-36 (SF-36). Three age- and sex-matched normative random samples, drawn from large, nationwide studies, were used for the comparison with healthy controls. Patients were interviewed regarding their most important problems related to the disease and its treatment.

RESULTS

Eighty-one patients with a mean age of 16.9 years (SD 4.2) were included (41 female). Limb sparing surgery was executed in 38 patients, ablative surgery in 43 patients. In comparison with healthy controls, patients had significantly poorer HRQoL within the domains autonomy and motor function of the TACQOL, gross motor function, cognitive functioning, daily functioning and sexuality of the TAAQOL, and physical functioning, role physical, general health, and the physical and mental component summary scales of the SF-36. Patients reported limitations in physical activities, participation in sports, and cosmetic aspects as the most detrimental consequences of their disease and its treatment.

CONCLUSION

In children and adolescents who underwent surgery for a malignant tumor of the leg physical, functioning was significantly impaired as compared to healthy controls.

Survivorship: childhood cancer survivors

Late effects of therapy for childhood cancer are frequent and serious. Fortunately, many late effects are also modifiable. Proactive and anticipatory risk-based care can reduce the frequency and severity of treatment-related morbidity. The primary care clinician should be an integral component in risk-based care of survivors. Continued communication between the "late effects" staff at the cancer center and the primary care clinician is essential for optimum care of this high-risk population.

Health-related Quality of Life in Children with Cancer Undergoing Treatment: A First Look at the Singapore Experience

Introduction: With intensive chemotherapy and increased survival, quality of life in our paediatric population is of increasing concern. The aim of this study was to assess the children’s quality of life during the treatment process. Materials and Methods: Patients between the ages of 7 and 18 years old who are undergoing cancer treatment in the Division of Paediatric Haematology-Oncology, Department of Paediatrics, National University Health System, were identified. The child self-reported his/her health-related quality of life (HRQOL) using the PedsQL Paediatric Quality of Life Inventory and Cancer module as a validated assessment tool. Results: Thirty-two patients were enrolled over a 3-week period in November 2007. The median age was 11 years (range, 7 to 17). There was 1 non-responder (3%). Fourteen (45%) boys and 17 (55%) girls were interviewed. There were 8 (26%) and 23 (74%) patients with solid and haematologic malignancies, respectively. For the Cognitive Problem Dimension score, 86% of patients with haematologic malignancy and 50% of those with solid malignancy scored below the 75th percentile (82), [OR 0.72 (0.01-0.8), P = 0.03]. For the Physical Health Summary score, patients with solid malignancy scored worse, 25% below the 10th percentile, as compared to 4.3% of patients with haematologic malignancy. This is reflected by a worse Pain and Hurt Dimension score for patients with solid malignancy. For the Perceived Appearance Dimension score, patients with solid malignancy (75%) scored lower than the median score (67) compared to those with haematologic malignancy (44%). Conclusions: The domains of HRQOL are affected to different extents for the patients with solid and those with haematologic malignancy. This is most likely to be due to the differences in treatment strategies and clinical course. Healthcare professionals should be aware of the effects of treatment on HRQOL and take practical steps to address these issues. Key words: Childhood cancer, Self-reported health and well-being

Vascular reconstruction in lower limb musculoskeletal tumours

BACKGROUND

Individual experience in the investigative, planning and operative aspects of lower limb musculoskeletal tumours is often small, making comparison between results difficult. The aim of the study was to describe the recent experience of a single tertiary referral unit performing limb salvage surgery, to identify areas of concern that are amenable to intervention and to provide clinicians an understanding of the surgical options.

METHODS

Nine patients with peripheral limb musculoskeletal tumours are described. Four patients had a leiomyosarcoma, and one each of osteosarcoma, synovial chondrosarcoma, synovial sarcoma, liposarcoma and recurrent malignant peripheral nerve sheath tumour.

RESULTS

Thirty-day mortality was nil. Two patients (one with a leiomyosarcoma and one with an osteosarcoma) died at 6 months follow-up because of pulmonary metastases. One patient with synovial chondrosarcoma developed a local recurrence and underwent an above-knee amputation. Six patients at 18 months follow-up are alive with no evidence of local recurrence and a functional lower limb.

CONCLUSION

These cases are a challenge to the clinicians, radiologists and pathologists. Review by a multidisciplinary team can produce successful results with low post-operative morbidity and mortality. Longer follow-up is required to determine the long-term implications.

The Bt-DUX: development of a subjective measure of health-related quality of life in patients who underwent surgery for lower extremity malignant bone tumor

BACKGROUND

To examine the practical applicability, internal consistency, and validity of the Bt-DUX, a disease-specific Health Related Quality of Life (HRQoL) instrument. The Bt-Dux was developed to examine patients' individual values of their life after a malignant bone tumor of the lower extremity at four domains (cosmetic, social, emotional, and functional).

PROCEDURE

Patients were eligible for this cross-sectional, multicenter study if they underwent surgery for a malignant tumor of the leg in a period ranging between 12 and 60 months before the recruitment. Assessments included: Bt-DUX, Toronto Extremity Salvage Score (TESS) Short Form (SF)-36, TNO-AZL Questionnaire for Adult's Quality of Life (TAAQOL), and TNO-AZL Children's Quality of Life Questionnaire (TACQOL).

RESULTS

Seventy-two patients (35 male, 37 female), mean age 17 (SD 4) years were included. Limb sparing surgery took place in 32 patients and ablative surgery in 40 patients. The Bt-DUX was completed in less than 5 min and easy to comprehend. The mean Bt-DUX score was 69.8 (SD 15.5), with Cronbach's alpha being 0.92. Domain-total correlations ranged between 0.84 and 0.88 (P < 0.01). Correlations between Bt-DUX Total score and TESS, SF-36 Physical and Mental Component Summary scales and selected TACQOL and TAAQOL scores were statistically significant (P < 0.05), except for the social scale of the TACQOL. The Bt-DUX was able to discriminate between patients with higher and lower TESS scores (P < 0.05).

CONCLUSION

The Bt-DUX was found to be a practical and valid instrument. Its added value compared with existing HRQoL measures needs to be further established.

Quality of life (QOL) in patients with osteosarcoma

Patients with osteosarcoma undergo extensive treatment using aggressive chemotherapy and surgery and this can have substantial acute and long-term effects on patients. In particular, quality of life (QOL) can be affected. It is important that QOL be examined to see how it is influenced. It is also important to determine who is at highest risk for impaired QOL and develop appropriate interventions. QOL is one of several outcomes that are influenced by the diagnosis and treatment of osteosarcoma. Other outcomes include function, disability, and body image. Currently, gaps exist in our knowledge of QOL in osteosarcoma patients and prospective studies are needed.

Functional, psychosocial and professional outcomes in long-term survivors of lower-extremity osteosarcomas: amputation versus limb salvage

As the number of osteosarcoma survivors increases, the impact of quality of life and function needs to be addressed. Limb salvage is the preferred treatment when patients have treatment options; yet, the questionable long-term durability and complications of prostheses, combined with ambiguous function, leave some doubt regarding the best clinical and surgical options. Comparisons between limb salvage patients, amputees and controls also require further investigation. Amputation would leave the patients with a lifelong requirement for an external prosthetic leg associated with an overall limited walking distance. While artificial limbs are much more sophisticated than those used in the past, phantom limb sensations remain a substantial and unpredictable problem in the amputee. Complications such as stump overgrowth, bleeding, and infection, also require further elucidation. Limb salvage surgery using endoprosthesis, allografts or reconstruction is performed in approximately 85% of patients affected by osteosarcoma located in the middle and/or distal femur. One drawback in limb-salvage surgery in the long-term survivor is that endoprostheses have a limited life span with long-term prosthetic failure. The inherent high rate of reoperation remains a serious problem. Replacing a damaged, infected or severely worn-out arthroplastic joint or its intramedullary stem is difficult, especially in the long-stem cemented endoprostheses used in the 1980s. Limb lengthening procedures in patients who have not reached maturity must also be addressed. Periprosthetic infections, compared to other indications for joint reconstruction, were found to be more frequent in patients treated for neoplastic conditions and their outcome can be devastating, resulting in total loss of joint function, amputation, and systemic complications. Quality of life in terms of function, psychological outcome and endpoint achievements such as marriage and employment apparently do not differ significantly between amputee and nonamputee osteosarcoma survivors. Amputee patients nonetheless appear to have made satisfactory adjustments to their deficits with or without a functional external prosthesis. It also appeared that amputee patients had a similar psychological and quality of life outcome as limb salvage patients. There was no evidence of excessive anxiety or depression or deficits in self-esteem compared with the normal population or matched controls. A number of long-term survivors also achieved high ranking in the professional and commercial work place. These positive aspects should be recognized and emphasized to patients and their parents when discussing the outcome.

International collaboration is feasible in trials for rare conditions: the EURAMOS experience

The introduction of multi-agent chemotherapy dramatically improved the outcome for patients with osteosarcoma. However, we appear to have reached a plateau in outcome with a long-term event-free survival of 60-70%. Therefore, detection of further improvements will likely require larger numbers of patients. This goal is best achieved via randomized clinical trials (RCTs) requiring large-scale cooperation and collaboration. With this background, four multinational groups agreed on the merits of collaboration: Children's Oncology Group (COG), Cooperative Osteosarcoma Study Group (COSS), European Osteosarcoma Intergroup (EOI) and Scandinavian Sarcoma Group (SSG); they designed a study to determine whether altering postoperative therapy based on histological response improved the outcome. The study design includes a backbone of 10 weeks of preoperative therapy using MAP (methotrexate, Adriamycin and cisplatin). Following surgery, patients are stratified according to histological response. Patients classified as "good responders" (>or=90% necrosis) are randomized to continue MAP or to receive MAP followed by maintenance pegylated interferon, while "poor responders" (<90% necrosis) are randomized to either continue MAP or to receive MAPIE (MAP+ifosfamide, etoposide). The design includes the registration of 1,400 patients over 4 years as well as the evaluation of quality of life using two different instruments. The group has established an efficient infrastructure to ensure successful implementation of the trial. This has included the EURAMOS Intergroup Safety Desk, which has established an international system for SAE, SAR and SUSAR reporting to the relevant competent authorities and ethics committees for each participating country. The group has also developed trial site monitoring and data center audits with funding from the European Science Foundation (ESF). The ESF has also funded three training courses to familiarize institutional staff with the requirements of multinational GCP trials. We have established a successful collaboration, and as of February 2008, 901 patients have been enrolled (COG 448; COSS 226; EOI 181; SSG 46) from 249 institutions in 16 different countries. As expected, 80% of the patients are <18 years of age, and accrual into the Quality of Life sub-study is proceeding as planned with 90% of the subjects agreeing to participate. International awareness is increasing and procedures for applicant countries wishing to join the collaboration have been implemented. Details about EURAMOS can be found at www.euramos.org. International trials in rare diseases are practicable with appropriate funding, planning and support. Although the implementation of such trials is difficult and time consuming, it is a worthwhile effort to rapidly complete RCTs and identify interventions that will improve the outcome of all osteosarcoma patients.EURAMOS-1 is the fastest accruing osteosarcoma trial and is already the largest osteosarcoma study conducted.

Self-reported global function among adult survivors of childhood lower-extremity bone tumors: a report from the Childhood Cancer Survivor Study (CCSS)

INTRODUCTION

Adult survivors of childhood lower-extremity bone tumors may experience physical and psychosocial late effects that impact physical performance, global function and quality of life. The identification of survivors at greatest risk for poor outcomes will inform potential intervention targets.

METHODS

Study participants were selected from the Childhood Cancer Survivor Study (CCSS), a multi-institutional study of childhood cancer survivors. Adult survivors (n = 629) of either childhood onset osteosarcoma or Ewing's sarcoma, with a primary tumor location in the lower-extremity were identified and contacted via mail to complete an additional questionnaire. Participants completed the Reintegration into Normal Living Index (RNL) to evaluate global function (maximum score of 22), daily function (maximum score of 16) and self perception (maximum score of 6).

RESULTS

Survivors reported high levels of global function with an adjusted mean overall RNL index score of 20.6 (SE 0.14), mean daily function score of 15.0 (SD 0.10) and mean self perception score of 5.6 (SE 0.05). While female gender and increasing age were associated with lower RNL scores, the magnitude of difference is of questionable clinical significance. Global function was only moderately correlated with physical performance (r = 0.56) and QOL (r = 0.59).

DISCUSSION

Based upon the RNL index, the vast majority of long-term survivors of childhood lower extremity bone tumors adapt well to their environment.

IMPLICATIONS FOR CANCER SURVIVORS

While some long-term survivors of lower-extremity bone tumors may report measurable limitations in physical performance and quality of life, the majority do not report moderate or severe difficulties with social integration.

Limb-sparing surgery preserves more function than amputation: a Scandinavian sarcoma group study of 118 patients

We evaluated the long-term functional outcome in 118 patients treated for osteosarcoma or Ewing's sarcoma in the extremities a minimum of five years after treatment. We also examined if impaired function influenced their quality of life and ability to work. The function was evaluated according to the Musculoskeletal Tumor Society (MSTS) score and the Toronto Extremity Salvage Score (TESS). Quality of life was assessed by using the Short Form-36 (SF-36). The mean age at follow-up was 31 years (15 to 57) and the mean follow-up was for 13 years (6 to 22). A total of 67 patients (57%) initially had limb-sparing surgery, but four had a secondary amputation. The median MSTS score was 70% (17% to 100%) and the median TESS was 89% (43% to 100%). The amputees had a significantly lower MSTS score than those with limb-sparing surgery (p < 0.001), but there was no difference for the TESS. Tumour localisation above knee level resulted in significantly lower MSTS scores and TESS (p = 0.003 and p = 0.02, respectively). There were no significant differences in quality of life between amputees and those with limb-sparing surgery except in physical functioning. Of the patients 11% (13) did not work or study. In multivariate analysis, amputation, tumour location above the knee and having muscular pain were associated with low physical function. We conclude that most of the bone tumour survivors managed well after adjustment to their physical limitations. A total of 105 are able to work and have an overall good quality of life.

Cultural adaptation, translation and validation of a functional outcome questionnaire (TESS) to Portuguese with application to patients with lower extremity osteosarcoma

BACKGROUND

Evaluation of physical functioning is an important tool for planning rehabilitation. Instruments need to be culturally adapted for use in non-English speaking countries. The aim of this study was to culturally adapt, including translation and preliminary validation, the Toronto extremity salvage score (TESS) for Brazil, in a sample of adolescents and young adults treated for lower extremity osteosarcoma.

PROCEDURE

The process included two independent forward translations of TESS questionnaire, consensus between translators on a forward translation, back-translation by two independent translators, and a review of the back-translations. Internal consistency of the TESS and known groups validity were also evaluated.

RESULTS

Internal consistency for the 30 item TESS was high (coefficient alpha = 0.87). TESS score ranges from 0 to 100. Forty-eight patients completed the questionnaire and scores ranged from 56 to 100 (mean score: 89.6). Patients receiving no pain medications scored higher on the TESS than those who were receiving pain medication (P = 0.014), and patients using walking aids had slightly higher but not statistically different scores. Those who were treated with amputation had higher scores than those who were treated with limb salvage procedures (P = 0.003).

CONCLUSION

Preliminary evidence suggests that Brazilian-Portuguese translation is acceptable, understandable, reliable, and valid for evaluating the function in adolescents and young adults with osteosarcoma in lower extremity in Brazil.

Some musculo-skeletal sequelae in cancer survivors

This paper deals with some of the musculo-skeletal complication that can occur after cancer treatment. In particular, we focus on Cancer Treatment Induced Bone Loss (CTIBL) and the musculo-skeletal complications that can occur in patients treated for extremity sarcoma. In addition we discuss peripheral neuropathy, musculo-skeletal pain and briefly mention some of the complications related to radiotherapy. CTIBL is mostly studied in breast cancer and prostate cancer survivors. The cause in these groups is mainly due to treatment induced hypogonadism. Other causes of CTIBL are indirect or direct cause of chemotherapy, physical inactivity and inadequate intake of vitamin D and calcium. Treatment of CTIBL consists of diet and lifestyle changes and pharmacological intervention. Extremity bone sarcomas constitute a special group since they often experience mutilating surgery and heavy combination chemotherapy. The treatment results in worse function than the normal population and the amputated usually have lower physical functioning than patients treated with limb sparing surgery (LSS). However, most studies fail to show differences in quality of life between the amputated and LSS. Most of the studies performed on musculo-skeletal sequelae have been done on survivors of childhood cancer, breast cancer or prostate cancer. More studies among the other cancer groups are needed to reveal the extent and prevalence of these complications.

A comparative analysis of functional outcomes in adolescents and young adults with lower-extremity bone sarcoma

BACKGROUND

Comparison of functional mobility and quality of life is performed in patients with lower-extremity bone sarcoma following either amputation, limb-sparing surgery, or rotationplasty with four different types of outcome measures: (1) an objective functional mobility measure that requires patients to physically perform specific tasks, functional mobility assessment (FMA); (2) a clinician administered tool, Musculoskeletal Tumor Society Scale (MSTS); (3) a patient questionnaire, Toronto Extremity Salvage Scale (TESS); and (4) a health-related quality of life (HRQL) measure, Short Form-36 version 2 (SF-36v.2).

PROCEDURE

This is a prospective multi-site study including 91 patients with lower-extremity bone sarcoma following amputation, limb-sparing surgery, or rotationplasty. One of three physical therapists administered the quality of life measure (SF-36v.2) as well as a battery of functional measures (FMA, MSTS, and TESS).

RESULTS

Differences between patients who had amputation, limb-sparing surgery, or rotationplasty were consistently demonstrated by the FMA. Patients with limb sparing femur surgery performed better than those patients with an above the knee amputation but similarly to a small number of rotationplasty patients. Several of the more conventional self-report measures were shown to not have the discriminative capabilities of the FMA in these cohorts.

CONCLUSION

In adolescents with lower-extremity bone sarcoma, it may be advantageous to consider the use of a combination of outcome measures, including the FMA, for objective functional mobility assessment along with the TESS for a subjective measure of disability and the SF-36v.2 for a quality-of-life measure.

Late toxicity in survivors from adolescent cancers

Nowadays three quarters of adolescents with cancer are cured but half of them experience a late toxic effect of antineoplastic therapy that interferes with their physical and psychosocial health. This review recapitulates late effects associated with radiation therapy, chemotherapy and surgery, reviews risk factors and prognosis and suggests follow-up and management strategies, excluding fertility issues. Adolescents with cancer should be the focus of active clinical research for the optimisation of antineoplastic treatment as well as for breakthroughs in the follow-up, prevention and management of toxic effects.

Assessing functional mobility in survivors of lower-extremity sarcoma: reliability and validity of a new assessment tool

BACKGROUND

Reliability and validity of a new tool, Functional Mobility Assessment (FMA), were examined in patients with lower-extremity sarcoma. FMA requires the patients to physically perform the functional mobility measures, unlike patient self-report or clinician administered measures.

PROCEDURE

A sample of 114 subjects participated, 20 healthy volunteers and 94 patients with lower-extremity sarcoma after amputation, limb-sparing, or rotationplasty surgery. Reliability of the FMA was examined by three raters testing 20 healthy volunteers and 23 subjects with lower-extremity sarcoma. Concurrent validity was examined using data from 94 subjects with lower-extremity sarcoma who completed the FMA, Musculoskeletal Tumor Society (MSTS), Short-Form 36 (SF-36v2), and Toronto Extremity Salvage Scale (TESS) scores. Construct validity was measured by the ability of the FMA to discriminate between subjects with and without functional mobility deficits.

RESULTS

FMA demonstrated excellent reliability (ICC [2,1] >or=0.97). Moderate correlations were found between FMA and SF-36v2 (r = 0.60, P < 0.01), FMA and MSTS (r = 0.68, P < 0.01), and FMA and TESS (r = 0.62, P < 0.01). The patients with lower-extremity sarcoma scored lower on the FMA as compared to healthy controls (P < 0.01).

CONCLUSION

The FMA is a reliable and valid functional outcome measure for patients with lower-extremity sarcoma. This study supports the ability of the FMA to discriminate between patients with varying functional abilities and supports the need to include measures of objective functional mobility in examination of patients with lower-extremity sarcoma.

Barriers to rehabilitation of patients with extremity sarcomas

The treatment of most extremity bone or soft tissue sarcomas involves either limb salvage surgery with adjuvant chemoradiation therapy or amputation. The rehabilitation of patients with extremity sarcomas is challenging, and the approach differs depending on the choice of surgical procedure as well as potential-associated medical complications. Early, interdisciplinary rehabilitation involvement is helpful in lessening the impact of expected impairments and disability. There is a lack of evidence examining specific rehabilitation interventions in this patient population. Functional outcomes and quality of life studies suggest overall similar findings between limb salvage patients and amputees, but with differences in various subscales. Rehabilitation interventions are therefore individualized; based on the assessment of medical limitations, functional goals and expectations, and modification of environmental factors. Overcoming medical and oncologic barriers to rehabilitation; as well as psychological, structural, cultural, political, and economic barriers; can serve to lessen the degree of disability.

Chronic health conditions in adult survivors of childhood cancer

BACKGROUND

Only a few small studies have assessed the long-term morbidity that follows the treatment of childhood cancer. We determined the incidence and severity of chronic health conditions in adult survivors.

METHODS

The Childhood Cancer Survivor Study is a retrospective cohort study that tracks the health status of adults who received a diagnosis of childhood cancer between 1970 and 1986 and compares the results with those of siblings. We calculated the frequencies of chronic conditions in 10,397 survivors and 3034 siblings. A severity score (grades 1 through 4, ranging from mild to life-threatening or disabling) was assigned to each condition. Cox proportional-hazards models were used to estimate hazard ratios, reported as relative risks and 95% confidence intervals (CIs), for a chronic condition.

RESULTS

Survivors and siblings had mean ages of 26.6 years (range, 18.0 to 48.0) and 29.2 years (range, 18.0 to 56.0), respectively, at the time of the study. Among 10,397 survivors, 62.3% had at least one chronic condition; 27.5% had a severe or life-threatening condition (grade 3 or 4). The adjusted relative risk of a chronic condition in a survivor, as compared with siblings, was 3.3 (95% CI, 3.0 to 3.5); for a severe or life-threatening condition, the risk was 8.2 (95% CI, 6.9 to 9.7). Among survivors, the cumulative incidence of a chronic health condition reached 73.4% (95% CI, 69.0 to 77.9) 30 years after the cancer diagnosis, with a cumulative incidence of 42.4% (95% CI, 33.7 to 51.2) for severe, disabling, or life-threatening conditions or death due to a chronic condition.

CONCLUSIONS

Survivors of childhood cancer have a high rate of illness owing to chronic health conditions.

Primary bone osteosarcoma in the pediatric age: State of the art

The current combination treatment, chemotherapy and surgery, has significantly improved the cure rate and the survival rate of primary bone osteosarcoma. The 5-year survival rate has increased in the last 30 years from 10% to 70%. Even in patients with poor prognosis, such as those with metastases at diagnosis, the 5-year survival rate has reached 20-30% due to chemotherapy and the surgical removal of metastases and primary tumor. However, the most effective drugs are still the same as those employed over the last 20 years as front line neoadjuvant or adjuvant chemotherapy: Doxorubicin, Cisplatin, Methotrexate, Ifosfamide. No standard, second line therapy exists for those who relapse. At relapse, due to the lack of new non-cross-resistant drugs, surgery is still the main option when feasible. Other drugs have been employed in relapsed patients with poor results. This article reviews the state of the art of treatment for bone osteosarcoma in the pediatric age.

Surviving childhood cancer: the impact on life

With modern therapies, most children diagnosed with cancer are expected to reach adulthood. Therefore, there are large and ever-increasing numbers of children and young adults in our population who are survivors of childhood cancer. Many of the therapies responsible for improved cancer survival rates can also damage normal cells and tissues. As more children survive cancer, the physical and emotional costs of enduring cancer therapy become increasingly important. Although most childhood cancer survivors are now expected to survive, they remain at risk for relapse, second malignant neoplasms, organ dysfunction, and a negative psychologic impact. Individual risk is quite variable and is dependent on multiple factors including the type and site of cancer, the therapy utilized, and the individual's constitution. The risks are likely to change as we learn more about the specific long-term effects of cancer therapy, develop more refined and targeted therapies, and develop and apply more effective preventative strategies or therapeutic interventions. Guidelines for long-term follow-up have been established and are available to help facilitate appropriate monitoring of and care for potential late effects.

Relationships among range of motion, functional mobility, and quality of life in children and adolescents after limb-sparing surgery for lower-extremity sarcoma

PURPOSE

The study was designed to examine relationships between range of motion (ROM), functional mobility, and quality of life (QL) in patients with lower-extremity sarcoma (LES) after limb-sparing surgery

METHODS

Sixty-eight patients with LES (age, 10-26 years) participated. The patients performed hip flexion, hip extension, knee flexion, and knee extension, Timed Up and Down Stairs (TUDS), Timed Up and Go (TUG), nine-minute run-walk (9-min), and completed the QL measure, Short-Form-36 version two (SF-36v2).

RESULTS

Significant correlations (p < 0.01) were found between hip extension and SF-36v2 physical component scale (PCS; r = 0.33), TUDS (r = -0.32), TUG (r = -0.33); hip flexion and TUDS (r = -0.31), TUG (r = -0.39), 9-min (r = 0.44); knee flexion and TUDS (r = -0.52), TUG (r = -0.40), 9-min (r = 0.37); SF-36v2 PCS and TUDS (r = -0.56), TUG (r = -0.51), 9-min (r = 0.60).

CONCLUSION

ROM correlates with functional mobility and QL in patients with LES after limb-sparing surgery. ROM exercises are important component of a physical therapy program for children and adolescents with LES.

Acetabular development after bipolar hemiarthroplasty for osteosarcoma in children

A retrospective analysis was performed of eight patients with an open triradiate cartilage, who underwent resection for osteosarcoma and reconstruction of the proximal femur with a hemiarthroplasty, in order to identify changes of acetabular development. An analysis of the centre-edge angle, teardrop-to-medial prosthesis distance, superior joint space, teardrop-to-superior prosthesis distance, degree of lateral translation, and arthritic changes, was performed on serial radiographs. The median age at the time of the initial surgery was 11 years (5 to 14).

All patients developed progressive superior and lateral migration of the prosthetic femoral head. Following hemiarthroplasty in the immature acetabulum, the normal deepening and enlargement of the acetabulum is arrested. The degree of superior and lateral migration of the prosthetic head depends on the age at diagnosis and the length of follow-up.

Quality of life of patients treated during childhood for a bone tumor: assessment by the Child Health Questionnaire

To determine which factors impact on quality of life of patients with bone tumor, we used the Children Health Questionnaire French version. Thirty-seven patients (25 males, 19 osteosarcoma, 18 Ewing sarcoma) were studied. At assessment, median age was 15 years, median follow-up was 4 years. Mean scores were 60, 81, 76, 74, 70, 87 for general health, physical functioning, pain, mental health, self-esteem, and family activity, respectively. Lower results were observed for mental health in girls, for physical functioning, and self-esteem in patients with endoprosthesis, and for family activity and pain in patients who had relapsed.

Function and quality-of-life of survivors of pelvic and lower extremity osteosarcoma and Ewing's sarcoma: the Childhood Cancer Survivor Study

Limb-sparing surgeries have been performed more frequently than amputation based on the belief that limb-sparing surgeries provide improved function and quality-of-life (QOL). However, this has not been extensively studied in the paediatric population, which has unique characteristics that have implications for function and QOL. Using the Childhood Cancer Survivor Study, 528 adult long-term survivors of pediatric lower extremity bone tumours, diagnosed between 1970 and 1986, were contacted and completed questionnaries assessing function and QOL. Survivors were an average of 21 years from diagnosis with an average age of 35 years. Overall they reported excellent function and QOL. Compared to those who had a limb-sparing procedure, amputees were not more likely to have lower function and QOL scores and self-perception of disability included general health status, lower educational attainment, older age and female gender. Findings from this study suggest that, over time, amputees do as well as those who underwent limb-sparing surgeries between 1970 and 1986. However, female gender, lower educational attainment and older current age appear to influence function, QOL and disability.

Surgical options for children with osteosarcoma

Osteosarcoma is the most common solid tumour of childhood. Chemotherapy has substantially improved survival, but surgical resection remains essential for cure. Limb-salvage surgery is now common and can be done for up to 85% of children with osteosarcoma. The main surgical challenge in children is how to reconstruct the limb after removal of the tumour. Knowledge of probable outcomes, risks, and benefits of each surgical option is essential for comparison of reconstruction with amputation, which is still the safest and most suitable option in some children.