Advantage of limb salvage over amputation for proximal lower extremity tumors

Comparison of the incidence of wound complications with preoperative and postoperative radiotherapy in patients with extremity soft tissue sarcoma resection: A meta-analysis

We performed a meta-analysis to compare the effect of preoperative and postoperative radiotherapy on wound complications after resection of extremity soft tissue sarcoma (ESTS). A comprehensive computerised search of the PubMed, Cochrane Library, Web of Science, EMBASE, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang databases was conducted from their inception to August 2023 to identify studies comparing the effect of preoperative and postoperative radiotherapy on wound complications after ESTS resection. Two investigators independently screened the literature, extracted the data, and assessed the quality of the articles. The meta-analysis was performed using RevMan 5.4 software. Nine studies with 1271 patients were included, with 631 and 640 patients in the preoperative and postoperative radiotherapy groups, respectively. The results showed that the incidence of postoperative wound complications after ESTS resection was significantly higher with preoperative radiotherapy than with postoperative radiotherapy (27.26% vs. 12.03%, odds ratio [OR]: 2.88, 95% confidence interval [CI]: 2.12-3.91, p < 0.001). However, the rate of local recurrence of ESTS was significantly lower with preoperative radiotherapy than with postoperative radiotherapy (8.75% vs. 14.81%, OR: 0.57, 95% CI: 0.36-0.91, p = 0.02), and the 3-year overall survival was significantly higher in the preoperative radiotherapy group than in the postoperative radiotherapy group (82.24% vs. 70.04%, OR: 1.97, 95% CI: 1.05-3.71, p = 0.03). This pooled analysis suggests that although preoperative radiotherapy increases the rate of wound complications in ESTS compared with postoperative radiotherapy, it significantly reduces the rate of local recurrence after ESTS resection and improves the overall survival of patients. Owing to the limitations in the number and quality of the included studies, additional prospective cohort studies or randomised controlled trials are required to confirm these findings.

What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report

BACKGROUND

Although pediatric lower extremity sarcoma once was routinely treated with amputation, multiagent chemotherapy as well as the evolution of tumor resection and reconstruction techniques have enabled the wide adoption of limb salvage surgery (LSS). Even though infection and tumor recurrence are established risk factors for early amputation (< 5 years) after LSS, the frequency of and factors associated with late amputation (≥ 5 years from diagnosis) in children with sarcomas are not known. Additionally, the resulting psychosocial and physical outcomes of these patients compared with those treated with primary amputation or LSS that was not complicated by subsequent amputation are not well studied. Studying these outcomes is critical to enhancing the quality of life of patients with sarcomas.

QUESTIONS/PURPOSES

(1) How have treatments changed over time in patients with lower extremity sarcoma who are included in the Childhood Cancer Survivor Study (CCSS), and did primary treatment with amputation or LSS affect overall survival at 25 years among patients who had survived at least 5 years from diagnosis? (2) What is the cumulative incidence of amputation after LSS for patients diagnosed with pediatric lower extremity sarcomas 25 years after diagnosis? (3) What are the factors associated with time to late amputation (≥ 5 years after diagnosis) in patients initially treated with LSS for lower extremity sarcomas in the CCSS? (4) What are the comparative social, physical, and emotional health-related quality of life (HRQOL) outcomes among patients with sarcoma treated with primary amputation, LSS without amputation, or LSS complicated by late amputation, as assessed by CCSS follow-up questionnaires, the SF-36, and the Brief Symptom Inventory-18 at 20 years after cancer diagnosis?

METHODS

The CCSS is a long-term follow-up study that began in 1994 and is coordinated through St. Jude Children's Research Hospital. It is a retrospective study with longitudinal follow-up of more than 38,000 participants treated for childhood cancer when younger than 21 years at one of 31 collaborating institutions between 1970 and 1999 in the United States and Canada. Participants were eligible for enrollment in the CCSS after they had survived 5 years from diagnosis. Within the CCSS cohort, we included participants who had a diagnosis of lower extremity sarcoma treated with primary amputation (547 patients with a mean age at diagnosis of 13 ± 4 years) or primary LSS (510 patients with a mean age 14 ± 4 years). The LSS cohort was subdivided into LSS without amputation, defined as primary LSS without amputation at the time of latest follow-up; LSS with early amputation, defined as LSS complicated by amputation occurring less than 5 years from diagnosis; or LSS with late amputation, defined as primary LSS in study patients who subsequently underwent amputation 5 years or more from cancer diagnosis. The cumulative incidence of late amputation after primary LSS was estimated. Cox proportional hazards regression with time-varying covariates identified factors associated with late amputation. Modified Poisson regression models were used to compare psychosocial, physical, and HRQOL outcomes among patients treated with primary amputation, LSS without amputation, or LSS complicated by late amputation using validated surveys.

RESULTS

More study participants were treated with LSS than with primary amputation in more recent decades. The overall survival at 25 years in this population who survived 5 years from diagnosis was not different between those treated with primary amputation (87% [95% confidence interval [CI] 82% to 91%]) compared with LSS (88% [95% CI 85% to 91%]; p = 0.31). The cumulative incidence of amputation at 25 years after cancer diagnosis and primary LSS was 18% (95% CI 14% to 21%). With the numbers available, the cumulative incidence of late amputation was not different among study patients treated in the 1970s (27% [95% CI 15% to 38%]) versus the 1980s and 1990s (19% [95% CI 13% to 25%] and 15% [95% CI 10% to 19%], respectively; p = 0.15). After controlling for gender, medical and surgical treatment variables, cancer recurrence, and chronic health conditions, gender (hazard ratio [HR] 2.02 [95% CI 1.07 to 3.82]; p = 0.03) and history of prosthetic joint reconstruction (HR 2.58 [95% CI 1.37 to 4.84]; p = 0.003) were associated with an increased likelihood of late amputation. Study patients treated with a primary amputation (relative risk [RR] 2.04 [95% CI 1.15 to 3.64]) and LSS complicated by late amputation (relative risk [RR] 3.85 [95% CI 1.66 to 8.92]) were more likely to be unemployed or unable to attend school than patients treated with LSS without amputation to date. The CCSS cohort treated with primary amputation and those with LSS complicated by late amputation reported worse physical health scores than those without amputation to date, although mental and emotional health outcomes did not differ between the groups.

CONCLUSION

There is a substantial risk of late amputation after LSS, and both primary and late amputation status are associated with decreased physical HRQOL outcomes. Children treated for sarcoma who survive into adulthood after primary amputation and those who undergo late amputation after LSS may benefit from interventions focused on improving physical function and reaching educational and employment milestones. Efforts to improve the physical function of people who have undergone amputation either through prosthetic design or integration into the residuum should be supported. Understanding factors associated with late amputation in the setting of more modern surgical approaches and implants will help surgeons more effectively manage patient expectations and adjust practice to mitigate these risks over the life of the patient.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Return to Work and Quality of Life in Disease-Free Adult Patients with Soft-Tissue and Bone Sarcoma of the Extremity

Treatment of extremital sarcoma patients may be associated with significant functional disabilities and psychosocial distress affecting return to work (RtW) and quality of life (QoL). In this exploratory study we prospectively investigated the RtW rate, explored biomedical and psychosocial predictors of RtW, and compared generic QoL with Swiss population norms. Forty people (89 %) returned to work. Full-time employment before sarcoma diagnosis, high educational level, and low tumor grade showed an increased probability of RtW. The median age was lower in patients who returned to work, and they reported less fear of progression. Generic QoL (SF-36) was reduced in almost all dimensions when compared to a normative Swiss population. Physical functioning and fear of progression have to be addressed in the rehabilitation process.

Outcome satisfaction in long-term survivors of oncologic limb salvage procedures

OBJECTIVE

We present data from our recently completed study that suggests that joint salvage is the key parameter in keeping the limb salvage ethos relevant.

METHODS

We reviewed all patients operated on nationally over 30 years (1978 to 2008). We identified 265 survivors of which 162 were available for evaluation at the time of survey.

RESULTS

There were 92 males and 70 females followed an average 9.1±SD3.1 years. Average age at survey was 38±SD17 years. ANOVA for mental health and TESS degree of importance for ADL identified that all categories of joint preservation were similar to an average group of people from the population. Physical health scores were significantly better amongst joint-preserved versus joint replacement patients (p = 0.003). Nevertheless, there was no significant difference between amputees with respect to physical health scores compared to arthrodesed and joint-replaced individuals. Biological reconstructions scored significantly better than metallic segmentary reconstructions (p < 0.001). Dissatisfaction appeared to correlate best with the presence of pain following reconstruction (p < 0.001).

CONCLUSIONS

While our study supports the finding of amputations being as satisfactory as arthrodeses and joint replacement salvage surgery, joint salvage was superior to all other categories. Assessments of equivalence should incorporate joint salvage and materials used as evaluable parameters.

Decision-making in Orthopaedic Oncology: Does Cognitive Bias Affect a Virtual Patient's Choice Between Limb Salvage and Amputation?

BACKGROUND

The local treatment of extremity sarcomas usually is predicated on a decision between limb salvage and amputation. The manner in which surgical options are presented in the context of shared decision-making may influence this decision. In a population of "simulated" patients-survey respondents presented with a mock clinical vignette and then asked to choose between treatments-we assessed cognitive bias by deliberate alteration of the subjective presentation of the same objective information.

QUESTIONS/PURPOSES

(1) Will the manner in which information is presented to a simulated patient, in the setting of treatment for a bone sarcoma, bias their decision regarding pursuing amputation versus limb salvage? (2) At the time of decision-making, will a simulated patient's personal background, demographics, or mood affect their ultimate decision?

METHODS

Survey respondents (Amazon MTurk platform) were presented with mock clinical vignettes simulating a sarcoma diagnosis and were asked to choose between amputation and limb salvage. Specific iterations were designed to assess several described types of cognitive bias. These scenarios were distributed, using anonymous online surveys, to potential participants aged 18 years or older. Recruitment was geographically restricted to individuals in the United States. Overall, 404 respondents completed the survey. The average age of respondents was 33 years (SD 1.2 years), 60% were male and 40% were female. In all, 12% of respondents worked in healthcare. Each respondent also completed questions regarding his or her demographics and his or her current mood. Associations between the type of bias presented and the respondent's choice of limb salvage versus amputation were examined. Independent sample t-tests were used to compare means. Statistical significance was defined as p < 0.05.

RESULTS

When amputation was presented as an option to mitigate functional loss (framing bias), more patients chose it than when limb salvage was presented as means for increased functional gains (23% [23 of 100] versus 10% [12 of 118], odds ratio [OR], 2.26; p = 0.010). Older simulated patients were more likely to choose limb salvage when exposed to framing bias versus younger patients (mean age 33 years versus 30 years, p = 0.02). Respondents who were employed in healthcare more commonly chose amputation versus limb salvage when exposed to framing bias (24% [eight of 35] versus 9% [17 of 183]; OR, 2.46; p = 0.02). Those who chose amputation were more likely to score higher on scales that measured depression or negative affect.

CONCLUSIONS

Shared decision-making in orthopaedic oncology represents a unique circumstance in which several variables may influence a patient's decision between limb salvage and amputation. Invoking cognitive bias in simulated patients appeared to affect treatment decisions. We cannot be sure that these findings translate to the experience of actual sarcoma patients; however, we can conclude that important treatment decisions may be affected by cognitive bias and that patient characteristics (in this study, age, healthcare profession, and mood) may be associated with an individual's susceptibility to cognitive bias. We hope these observations will assist providers in the thoughtful delivery of highly charged information to patients facing difficult decisions, and promote further study of this important concept.

LEVEL OF EVIDENCE

Level III, economic and decision analyses.

Rehabilitation to Improve the Function and Quality of Life of Soft Tissue and Bony Sarcoma Patients

Sarcomas are bone and soft tissue tumors that can have significant effects on patient function and quality of life. Like most malignancies, treatment includes a combination of chemotherapy, radiation, and surgical resection, all of which also carry risks and long-term effects. A multidisciplinary rehabilitation plan can help minimize symptoms and sequelae which negatively affect the patient function and quality of life, including pain, chemotherapy-induced peripheral neuropathy, radiation fibrosis, activity restrictions following surgical excision, amputation, bowel and bladder dysfunction, and lymphedema. Patients should be evaluated by a rehabilitation specialist at any point during their diagnosis, treatment, and survivorship phase to determine appropriate interventions to minimize the impact of sarcomas and their treatment on patient function and quality of life.

Functional Outcome Measurement in Patients with Lower-Extremity Soft Tissue Sarcoma: A Systematic Literature Review

Background

The importance of functional outcome (FO) in the treatment of patients with extremity soft tissue sarcoma (STS) has been increasingly recognized in the last three decades. This systematic review aimed to investigate how FO is measured in surgically treated lower-extremity STS patients.

Methods

A systematic search of PubMed, Web of Science, and Scopus was performed based on the PRISMA guidelines. The methodologic quality of the publications was measured using the MINORS tool. The results from the included studies examining measurement types, measures, and time of FO measurement were compiled. The FO pooled mean and standard deviation were calculated as a weighted average for the groups. The validity of the applied measures is reported.

Results

The literature search found 3461 publications, 37 of which met the inclusion criteria. The measurement types used were clinician-reported outcomes (n = 27), patient-reported outcomes (n = 20), and observer-reported outcomes (n = 2). The most frequently used measures were the Toronto Extremity Salvage Score (TESS) (n = 16) and the Musculoskeletal Tumor Society (MSTS) score 1993 (n = 12). The postoperative FO was relatively good. The pooled mean TESS and MSTS 1993 scores were respectively 83.3 and 86.2 (out of 100). Of the 10 previously reported measures, 3 provide validated FO scores. The methodologic quality of publications was generally low.

Conclusions

Based on this systematic review, several different methods exist for assessing FO in patients with lower-extremity sarcoma. The most frequently used measure is a validated TESS. The postoperative FO of patients with lower-extremity STS seems to increase to the preoperative baseline level during long-term follow-up evaluation.

A Comparison of Limb Salvage Versus Amputation for Nonmetastatic Sarcomas Using Patient-reported Outcomes Measurement Information System Outcomes

INTRODUCTION

The Patient-reported Outcomes Measurement Information System (PROMIS) is a scoring tool that allows comparisons between patients with rare conditions and more common ailments, or the general US population. PROMIS outcomes were compared between the limb salvage and amputee patients for nonmetastatic sarcomas to the US population.

METHODS

One hundred thirty-eight patients were included in the analysis. Patients were divided into the limb salvage and amputee cohorts, as well as based on the follow-up (1 to 11 or 12+ months).

RESULTS

Seven PROMIS domains were evaluated, and higher scores were found in both the limb salvage group and patients >12 months from surgery. The limb salvage group also had improved emotional health compared with the US population.

DISCUSSION

Improvements in PROMIS values are observed in limb salvage patients and in patients >12 months from surgery. Limb salvage patients demonstrate improved emotional health compared with the US population.

Identifying the prevalence, trajectory, and determinants of psychological distress in extremity sarcoma

Objective. Extremity sarcoma (ES) is a rare cancer that presents with unique challenges. This study was performed to identify the prevalence, trajectory, and determinants of distress and characterise sources of stress in this cohort. Methods. Consecutive patients with ES were prospectively recruited between May 2011 and December 2012. Questionnaires were administered during initial diagnosis and then six months and one year after surgery. Results. Distress was reported by about a third of our cohort and associated with poorer physical function, poorer quality of life, and pain. In addition to fears regarding mortality and life role changes, the most common sources of stress were centered on dissatisfaction with the healthcare system, such as frustrations with a lack of communication with the hospital regarding appointments and lack of education regarding management and outcomes. Conclusions. Psychological distress presents early in the cancer journey and persists up to one year after surgery. Distress is associated with negative outcomes. Active screening and effective interventions are necessary to improve outcomes. Sources of stress have been identified that may be amenable to targeted interventions.

What do we know about survivorship after treatment for extremity sarcoma? A systematic review

OBJECTIVE

The varied presentations and treatments of extremity bone and soft tissue sarcoma mean that the issues faced by survivors are diverse and complex. The aim of this systematic review was to investigate what is known about this topic with a view to identifying areas for further research or service development.

METHODS

This was a review of the English language literature identified from Medline and Ovid and hand searches published between January 2000 and September 2012. Results were compiled according to physical, psychological and social domains of survivorship.

RESULTS

Of 182 studies identified, 22 met the inclusion criteria. There is a wide range of outcome measures used and a need for more objective measures. Unsurprisingly, survivors of extremity sarcoma typically demonstrate lower levels of physical functioning than healthy controls. In addition, survivors demonstrate a substantial psychological morbidity.

CONCLUSIONS

Services for survivors of extremity sarcoma should include rehabilitation and psychological support, sexual health services, expert pain management, and support to return to work.

Quality of life following amputation or limb preservation in patients with lower extremity bone sarcoma

Purpose: Although functional differences have been described between patients with lower extremity bone sarcoma with amputation and limb-preservation surgery, differences have not clearly been shown between the two groups related to quality of life. The purpose of the study was to determine if there is a difference in overall quality of life in lower extremity bone sarcoma survivors related to whether they had an amputation or a limb-preservation procedure while identifying psychological differences for further evaluation. The main hypothesis was that sparing a person’s limb, as opposed to amputating it, would result in a better quality of life.

Patients and Methods: Eighty-two long-term survivors of lower extremity bone sarcoma were studied to make a comparison of the overall quality of life, pain assessment, and psychological evaluations in limb preservation and amputation patients. Forty-eight patients with limb preservation and thirty-four patients with amputations were enrolled in the study. Validated psychometric measures including the Quality of Life Questionnaire (QLQ), the Minnesota Multiphasic Personality Inventory, and visual analog scales were utilized.

Results: The overall quality of life of patients with limb preservation was significantly higher than patients with amputation (p-value < 0.01). Significant differences were noted in the categories of material well-being, job satisfiers, and occupational relations.

Conclusion: The overall quality of life of patients with limb-preservation appears to be better than for those patients with amputation based on the QLQ in patients surviving lower extremity bone sarcoma. Further analysis needs to verify the results and focus on the categories that significantly affect the overall quality of life.

Composite reconstruction of the hip following resection of periacetabular tumors: middle-term outcome

The records of 18 patients with periacetabular tumors who underwent composite reconstruction of the hip following resection of periacetabular tumors were analyzed retrospectively. The mean follow-up period was 49.4 months (range, 28-100 months). During follow-up, 3 patients died and one had recurrence. Fifteen patients achieved favorable walking function; 8 had normal hip function and 7 had partial recovery of flexion function of the hip. The mean MSTS rating for hip function was 76.9%. Two patients had common peroneal nerve injury which was resolved in one of them. Middle-term follow-up showed that composite reconstruction of the hip following resection of periacetabular tumors can effectively remove tumors and provide favorable hip function for these patients. This approach is simple and less costly, and can be widely used.

Pathological fracture of femur secondary to infected synovial sarcoma

Pathological fracture is not uncommon in musculoskeletal oncological surgical practice. When complicated by infection, it is both limb- threatening and life-threatening problem. Pathological fractures require urgent investigation, not urgent treatment. We present the case of a 75-year-old man who presented with an infected sarcoma causing a pathological fracture of his right femur.

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.

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.

Use of an innovative model to evaluate mobility in seniors with lower-limb amputations of vascular origin: a pilot study

BACKGROUND

The mobility of older individuals has often been only partially assessed, without considering all important aspects such as potential (available) versus effective (used) mobilities and the physical and psychosocial factors that modulate them. This study proposes a new model for evaluating mobility that considers all important aspects, applied here to lower-limb amputees with vascular origin. This model integrates the concepts of potential mobility (e.g. balance, speed of movement), effective mobility (e.g. life habits, movements in living areas) and factors that modulate these two types of mobility (e.g. strength, sensitivity, social support, depression). The main objective was to characterize potential and effective mobility as well as mobility modulators in a small sample of people with lower-limb amputations of vascular origin with different characteristics. The second objective of this pilot study was to assess the feasibility of measuring all variables in the model in a residential context.

METHODS

An observational and transversal design was used with a heterogeneous sample of 10 participants with a lower-limb amputation of vascular origin, aged 51 to 83, assessed between eight and 18 months after discharge from an acute care hospital. A questionnaire of participant characteristics and 16 reliable and valid measurements were used.

RESULTS

The results show that the potential mobility indicators do not accurately predict effective mobility, i.e., participants who perform well on traditional measures done in the laboratory or clinic are not always those who perform well in the real world. The model generated 4 different profiles (categories) of participants ranging from reduced to excellent potential mobility and low to excellent effective mobility, and characterized the modulating factors. The evaluations were acceptable in terms of the time taken (three hours) and the overall measurements, with a few exceptions, which were modified to optimize the data collected and the classification of the participants. For the population assessed, the results showed that some of the negative modulators (particularly living alone, no rehabilitation, pain, limited social support, poor muscle strength) played an important role in reducing effective mobility.

CONCLUSION

The first use of the model revealed interesting data that add to our understanding of important aspects linked to potential and effective mobility as well as modulators. The feasibility of measuring all variables in the model in a residential context was demonstrated. A study with a large number of participants is now warranted to rigorously characterize mobility levels of lower-limb amputees with vascular origin.

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.

What is quality of life in children with bone sarcoma?

Quality of life measures have neglected to include a critical self-assessment component in pediatric sarcoma patients. Our report shows how children rate their own quality of life and how that varies over time after surgery. Using the Pediatric Outcomes Data Collection Instrument, quality of life data was prospectively collected and combined with a retrospective review of clinical parameters on 43 children with primary bone sarcoma, with an average followup of 3 years. Children reported good yet variable scores in five of the six domains. Lower scores were noted in the Sports/Physical Functioning domain, particularly in the first 12 months after surgery, with improvement seen up to 24 months after surgery. Tumor specific factors such as size larger than 8 cm and lower extremity location were negative predictors for Sports/Physical Functioning. The only demographic factor that predicted perceived quality of life scores was gender, with girls reporting lower scores in Sports/Physical Functioning, Pain/Comfort, and Global Functioning domains. The Pediatric Outcomes Data Collection Instrument gives discriminatory detailed textured evaluation of the outcome of children treated for skeletal sarcoma. Further development of quality of life measures is needed to allow its use in treatment selection.

Outcome of allogeneic vascularized knee transplants

Transplantation of vascularized knee joints is a novel approach in Composite Tissue Allotransplantation (CTA). In 1996 our group started a clinical knee transplantation project and six transplantations have been performed since. Key problems identified early were the monitoring of acute rejection and choice of an immunosuppressive regime. One graft was lost due to postoperative infection and one due to of noncompliance where the patient discontinued the immunosuppressant regime. In three cases late rejection lead to necrosis and graft dysfunction after 15, 16 and 24 months, respectively. Exit-strategies were arthrodesis in one patient and Above Knee Amputation in two cases. With retrospective analysis after initial five cases the treatment protocol was improved. The immunosuppressive drug regime was altered, femoral diaphysis and knee joint grafting was combined and a vascularized block of donor skin and subcutaneous tissue was harvested with the graft (sentinel skin graft). The sentinel skin graft enabled us to monitor acute rejection by clinical and histological examination and avoid late rejection by rapid treatment with high dose steroids. In summary, over a four-year period, one of six allogeneic vascularized knee transplants has survived, one was lost from a surgical site infection, one by noncompliance and three by late rejection. Analysis of our data leads us to suggest that knee transplantation should be limited to a combined injury consisting of extensive loss of cartilage and bone, deficient extensor mechanism and soft tissue and skin defects without any signs of infection. Transplantation should only be taken into consideration as last option before Above Knee Amputation in an otherwise healthy patient under 35 years of age.

Impact of family structure on long-term survivors of osteosarcoma

GOALS OF WORK

Long-term outcomes of osteosarcoma have dramatically improved with the use of modern combination therapies. Such aggressive treatments, however, entail chronic complications. In the present study, we assessed the functional, psychological, and familial status of long-term survivors of osteosarcoma treated at our institution.

MATERIALS AND METHODS

Fifteen long-term survivors of osteosarcoma were evaluated for functional and psychological sequelae. Functional assessment was based on a method described by Enneking et al. Psychological assessment was based on General Health Questionnaire 28, Inventory Scale for Traumatic Neurosis, and Family System Test.

MAIN RESULTS

Ten patients showed mild functional impairments; only five patients were handicapped more seriously. Depressive symptoms were diagnosed in four patients. A total of six patients revealed unbalanced family structures, including three of the four patients with depressive symptoms, all four patients with symptoms of posttraumatic stress disorder, and five of seven patients who showed poor emotional acceptance.

CONCLUSIONS

Osteosarcoma survivors will generally recover good functional performance. Only a minority of them remain seriously impaired. One third of the patients present depressive symptoms and posttraumatic stress disorder. Poor coping is closely associated with unbalanced family structures. Therefore, the psychological and familial situation of patients with newly diagnosed osteosarcoma should be carefully assessed.

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.