Cross-cultural adaptation and validation of the Turkish version of the Musculoskeletal Tumor Society scoring system in patients with musculoskeletal tumors.

OBJECTIVE: This study aimed to translate and cross-culturally adapt the musculoskeletal tumor society (MSTS) scoring system into Turkish and to determine the reliability and validity of the translated version for the functional evaluation of patients with musculoskeletal tumors. METHODS: A total of 36 patients (16 women, 20 men; mean age=36.6; age range=13-75 years) who underwent limb-salvage surgery owing to benign aggressive or malignant musculoskeletal tumors were included in the study. Translation and back translations of the MSTS were performed according to the published guidelines. Short form (SF) 36 physical component, Western Ontario and McMaster Universities Arthritis Index (WOMAC), disabilities of the arm, shoulder, and hand (DASH), and range of motion scale (ROMS) that were previously analyzed for Turkish validation were used for validity. Reliability of MSTS Turkish version was evaluated by calculating test-retest reliability and internal consistency. Intraclass correlation coefficient (ICC) was used to evaluate the inter-observer consistency and test-retest reliability. Alpha coefficient (Cronbach's alpha) was used to evaluate the internal consistency. RESULTS: It was observed that total MSTS score has a strong negative correlation with DASH (r=-0.689; p<0.001) and WOMAC scores (r=-0.634; p<0.001) and moderate correlation with the ROMS score (r=0.521; p<0.001). Total MSTS score also had a statistically significant strong correlation with SF-36 scores (r values ranging from 0.425 to 0.609, p<0.001). Inter and intra-observer reliability of the MSTS scale was found to be excellent (Cronbach's α=0.97 p<0.001; ICC: 0.97 (0.96-0.99; p<0.001). Unlike other subscales, statistical correlation between dexterity and hand-positioning subscales of MSTS with DASH scores was found to be insignificant (r=-0.533, p =0.061 and r=-0.336, p=0.261, respectively). CONCLUSION: The Turkish version of the MSTS scoring system seems to be a valid and reliable scale that measures the correct and desired values in the evaluation of health-related quality of life in orthopedic oncology. Reliability coefficients of the Turkish version of MSTS were determined to be strong. LEVEL OF EVIDENCE: Level II, Diagnostic Study.

Limb salvage surgery of primary and metastatic bone tumors of the lower extremity: Functional outcomes and survivorship of modular endoprosthetic reconstruction.

OBJECTIVE: The study was aimed to determine the survivorship and functional outcomes of modular endoprosthetic reconstruction in the management of primary and metastatic bone tumors of the lower limbs and to investigate the rate and causes of implant failure. METHODS: A total of 84 limbs of 82 patients (49 male, 33 female; mean age=48 years, age range=13-78 years) with a minimum follow-up of 12 months in whom resection and modular endoprosthetic reconstructions were performed for primary or metastatic bone tumors of the lower extremity were retrospectively reviewed and included in the study. The mean follow-up was 43 (range=13-119) months. Functional status was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system at the final follow-up. Implant survival was defined as the time from implantation until partial or complete exchange of the prosthesis secondary to mechanical or nonmechanical causes or amputation. The effects of the anatomical site on functional scores and implant survival were statistically analyzed. Additionally, the effects of diagnosis and adjuvant treatments on functional scores, implant survival, and failure rates were investigated. RESULTS: At the time of the study, 55 patients were still alive with a mean follow-up of 48 (range=15-119) months. The mean MSTS scores resulting from the final follow-up of all patients and of those surviving were 87.9% (range=16%-100%) and 86.8% (range=16%-100%), respectively. Overall implant survival was 95.2%, 89.2%, 87%, and 87% at 1, 2, 3, and 4 years, respectively. Statistically, both functional scores and implant survival analysis in different anatomical sites were found similar. In 15 of the patients (17.8%), endoprosthetic reconstructions had failed. The causes of failure were soft tissue failure (dislocation) in 5 patients, infection in 5, structural/mechanical failure in 2, local recurrence in two, and aseptic loosening in one. The diagnosis and receiving preoperative and/or postoperative adjuvant treatment did not affect functional scores, implant survival or failure rates. CONCLUSION: The results of this study have shown that modular endoprosthetic replacement can provide satisfactory functional results and a durable mid-term limb salvage option in the management of patients with primary and metastatic bone tumors of the lower limbs. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Identifying Factors Most Important to Lower Extremity Trauma Patients: Key Concepts from the Development of a Patient-Reported Outcome Instrument for Lower Extremity Trauma, The LIMB-Q.

BACKGROUND: Severe lower extremity injuries are challenging to treat. The aspects of limb salvage and amputation most important to patients are not well-defined. This study's aim is to develop a conceptual framework for a patient-reported outcome instrument for lower extremity trauma patients, by defining issues and concepts most important to this patient population. METHODS: This is an interpretative description of transcripts collected from semistructured qualitative interviews at a single institution. High-energy lower extremity trauma patients were recruited by means of purposeful sampling to maximize variability. Thirty-three participant interviews were needed to reach content saturation. These participants were aged 19 to 79 years; 21 were men (63.6 percent); participation was after reconstruction [n= 15 (45.5 percent)], after amputation [n = 11 (33.3 percent)], or after amputation after failed reconstruction [n = 7 (21.2 percent)]. Interviews were recorded, transcribed, and coded line-by-line. Concepts were labeled with major and minor themes and refined through a process of constant comparison. Analysis led to the development of a conceptual framework and item pool to inform the development of a patient-reported outcome measure. RESULTS: In total, 2430 unique codes were identified and used to generate the conceptual framework covering 10 major themes: appearance, environment, finances, physical, process of care, prosthesis, psychological, sexual, social, and treatment. CONCLUSIONS: This study establishes a comprehensive set of concepts, identifying what is most important to severe lower extremity trauma patients. These findings can be used to inform and focus research and clinical care, and provides the framework to develop a lower extremity trauma-specific patient-reported outcome instrument: the LIMB-Q.

Validation process of Toronto Exremity Salvage Score in Italian: A quality of life measure for patients with extremity bone and soft tissue tumors.

BACKGROUND AND OBJECTIVES: Limb salvage surgery remains the standard treatment in bone and soft tissue tumors. Toronto Extremity Salvage Score (TESS) is the most used quality of life measure. Our objective was to perform cross-cultural adaptation and validation in Italian, testing test-retest reliability, construct validity, and responsiveness. METHODS: We interviewed patients already treated for content validity. A total of 124 patients completed TESS and other questionnaires presurgery, at 3 months, 3 months + 2 weeks, and 6 months follow-up. We calculated intraclass correlation coefficients (ICCs) for reliability, associations with Pearson's r, and change over time with paired T tests. RESULTS: A new item regarding touch-screen devices was added to the upper extremity (UE) questionnaire. ICC resulted of 0.99 for lower extremity (LE) and 0.98 for UE patients, Pearson's r between TESS and Musculoskeletal Tumor Society was .66 and .64, EuroQol-5D-5L r was .62 and .61, and r between TESS and short form-36 physical function subscale was .76 and .71 for LE and UE groups, respectively. Paired T test results were statistically significant to detect change over time (0.03, 0.04, and 0.04 for LE groups and 0.03, 0.01, and 0.04 for UE groups). CONCLUSION: The Italian version of TESS can be used for the bone and soft tissue sarcoma population in clinical trials in Italy and with Italian speaking patients abroad to ensure patients' perspectives for efficacy and efficiency of treatments.

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.

The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study: Outcomes of Amputation Compared with Limb Salvage Following Major Upper-Extremity Trauma.

BACKGROUND: Severe upper-extremity injuries account for almost one-half of all extremity trauma in recent conflicts in the Global War on Terror. Few long-term outcomes studies address severe combat-related upper-extremity injuries. This study's objective was to describe long-term functional outcomes of amputation compared with those of limb salvage in Global War on Terror veterans who sustained severe upper-extremity injuries. Limb salvage was hypothesized to result in better arm and hand function scores, overall functional status, and quality of life, with similar pain interference. METHODS: This retrospective cohort study utilized data from the Military Extremity Trauma Amputation/Limb Salvage (METALS) study for a subset of 155 individuals who sustained major upper-extremity injuries treated with amputation or limb salvage. Participants were interviewed by telephone 40 months after injury, assessing social support, personal habits, and patient-reported outcome instruments for function, activity, depression, pain, and posttraumatic stress. Outcomes were evaluated for participants with severe upper-extremity injuries and were compared with participants with concomitant severe, lower-extremity injury. The analysis of outcomes comparing limb salvage with amputation was restricted to the 137 participants with a unilateral upper-extremity injury because of the small number of patients with bilateral upper-extremity injuries (n = 18). RESULTS: Overall, participants with upper-extremity injuries reported moderate to high levels of physical and psychosocial disability. Short Musculoskeletal Function Assessment (SMFA) scores were high across domains; 19.4% screened positive for posttraumatic stress disorder (PTSD), and 12.3% were positive for depression. Nonetheless, 63.6% of participants were working, were on active duty, or were attending school, and 38.7% of participants were involved in vigorous recreational activities. No significant differences in outcomes were observed between patients who underwent limb salvage and those who underwent amputation. CONCLUSIONS: Severe, combat-related upper-extremity injuries result in diminished self-reported function and psychosocial health. Our results suggest that long-term outcomes are equivalent for those treated with amputation or limb salvage. Addressing or preventing PTSD, depression, chronic pain, and associated health habits may result in less disability burden in this population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is amputation in the elderly patient with critical limb ischemia acceptable in the long term?

PURPOSE: Despite high amputation rates, data on patient-reported outcomes is scarce in the elderly population with critical limb ischemia. The aim of this study was to provide mortality rates and long-term changes of the following patient-reported outcomes in elderly critical limb ischemia amputees: quality of life (QoL), health status (HS), and symptoms of depression. PATIENTS AND METHODS: In this prospective observational cohort study, amputated critical limb ischemia patients ≥70 years were included. The follow-up period was two years. Within the follow-up period patients completed the following questionnaires: the World Health Organization Quality Of Life -abbreviated version of the WHOQOL 100 (WHOQOL-BREF), the 12-Item Short Form Health Survey, and the Center for Epidemiological Studies Depression Scale. RESULTS: A total of 49 elderly patients with critical limb ischemia had undergone major limb amputation within two years after inclusion. In these patients, the one-year mortality rate was 39% and the two-year mortality rate was 55%. The physical QoL was the only domain of the WHOQOL-BREF that improved significantly across time after amputation (p≤0.001). In the long-term, there was no difference in the ability to enjoy life (p=0.380) or the satisfaction in performing daily living activities (p=0.231) compared to the scores of the general elderly population. After amputation, the physical HS domain (p≤0.001) and the mental HS domain (p=0.002) improved. In the first year, amputees experienced less symptoms of depression (p=0.004). CONCLUSION: Elderly critical limb ischemia amputees are a fragile population with high mortality rates. Their QoL and HS increased after major limb amputation as compared to the baseline situation and they experienced less symptoms of depression. Moreover, our results show that, in the long-term, major limb amputation in the elderly patients with critical limb ischemia shows an acceptable QoL, which, in some aspects, is comparable to the QoL of their peers. These results can improve the shared-decision making process that does not delay the timing of major limb amputation.

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.

Psychosocial reactions to upper extremity limb salvage: A case series.

STUDY DESIGN: Case series. INTRODUCTION: A salvaged limb is one that has undergone a major traumatic injury, followed by repeated surgical attempts in order to avoid amputation. Psychological recovery for individuals with lower extremity limb salvage has been examined in a number of studies. However, psychosocial reactions for individuals with upper extremity (UE) limb salvage are understudied in the literature. PURPOSE OF THE STUDY: The purpose of this study was to explore the process of psychosocial adaptation for 3 trauma cases after UE limb salvage. METHODS: The Reactions to Impairment and Disability Inventory was used to assess psychosocial adaptation. Physical function outcomes (pain, range of motion, edema, sensation, and dexterity) are presented. The Disabilities of the Arm, Shoulder, and Hand measure was used to assess perceived disability. Medical and rehabilitation history are discussed for each case, in order to provide in-depth understanding of the impact of these injuries. RESULTS: Reactions to injury varied across the cases; however, outcomes suggest that psychosocial adaptation may be influenced by the experience of pain, the ability to participate in valued roles and activities, and having a supportive social network. DISCUSSION: For this population, therapists may consider emphasizing pain management, focusing on client-centered goals and interventions, and facilitating peer support. Providers should closely monitor patients for signs of poor adaptation, such as hand-hiding behaviors. CONCLUSIONS: This study is among the first to examine psychological outcomes for the UE limb salvage population. Future research would be beneficial to provide deeper understanding of the psychosocial challenges for these individuals.

Amputation versus conservative treatment in severe open lower-limb fracture: A functional and quality-of-life study.

INTRODUCTION: Severe lower-limb trauma is a major event in a patient's life, and treatment is a challenge that has not been sufficiently studied. The main objective of the present study was to assess the difference in disability between amputees and patients who kept their leg after severe open lower-limb fracture. HYPOTHESIS: The study hypothesis was that amputation allows better functional recovery and quality of life, in the same time-frame. MATERIALS AND METHODS: All male and female patients aged over 18 years admitted to one of the trauma centers of Marseille (France) for major lower-limb trauma with Gustilo IIIb or IIIc fracture were included. Minimum follow-up was 2 years. Two groups were distinguished according to primary treatment: lower-limb salvage, or amputation. Rates of infection and of surgical revision, hospital stay, functional parameters (walking distance, standing, use of canes, running, jumping, driving, and physical and occupational activity) and quality of life (MOS SF-36 score) were compared between groups. RESULTS: The conservative treatment group comprised 27 patients, and the amputation group 24. Rates of infection and of surgical revision and hospital stay were significantly lower in the amputation group (P<0.02). All functional parameters (except return to work) and overall quality of life were significantly better in the amputation group. There was no significant inter-group difference in MOS mental score. CONCLUSION: In severe lower-limb trauma, amputation seems to give better functional and quality-of-life results. It did not, however, improve return to work, and was not better accepted psychologically than long and complex conservative management. LEVEL OF EVIDENCE: IV, retrospective study.

Psychosocial reactions to upper extremity limb salvage: A cross-sectional study.

STUDY DESIGN: Descriptive cross-sectional survey study. INTRODUCTION: Limb salvage spares an extremity at risk for amputation after a major traumatic injury. Psychosocial recovery for individuals with lower extremity limb salvage has been discussed in the literature. However, to date, psychosocial reactions for individuals with upper extremity (UE) limb salvage have not been examined. PURPOSE OF THE STUDY: To determine which factors may influence psychosocial adaptation to UE limb salvage. METHODS: Participants (n = 30; 28 males) were adults (mean, 30.13; range, 18-61) who sustained an UE limb salvage from a traumatic event. Adaptation was measured using a modified version of the Reactions to Impairment and Disability Inventory. RESULTS: A linear mixed-effects regression found that worse psychosocial adaptation was associated with having less than a college degree, being less than 6 months post-injury, being older than 23 years, and having more pain. Dominant hand injuries were found to influence poor adaptation on the denial Reactions to Impairment and Disability Inventory subscale only. DISCUSSION: The results of this study indicate that there is potential for nonadaptive reactions and psychological distress with certain variables in UE limb salvage. Therapists may use these results to anticipate which clients may be at risk for poor psychosocial outcomes. CONCLUSIONS: This study indicates the need for early consideration to factors that affect psychological prognosis for the UE limb salvage population. However, future research is indicated to better understand the unique psychosocial challenges and needs of these individuals. LEVEL OF EVIDENCE: 4.

Multiple limb salvage attempts for diabetic foot infections: is it worth it?

AIMS: Limb salvage for diabetic foot infections often require multiple procedures. Some patients will eventually end up with below knee amputation (BKA) when all limb salvage attempts fail. We seek to study the patients' ability to return to normal life, functional status, prosthesis usage and perspectives on multiple limb salvage procedures that culminated in BKA to review if they would undertake a similar path if their situation was repeated. PATIENTS AND METHODS: A total of 41 patients who underwent BKA between July 2011 and June 2013 were reviewed. They were divided into primary and creeping (prior multiple salvage procedures) amputations. The Barthel's Index (BI) and the Reintegration to Normal Living Index (RNLI) were used. A questionnaire was used to identify whether the patient would undergo the same multiple attempts at limb salvage again if faced with the same problem. RESULTS: All patients had a good mean BI of 14.2 (3 to 20) and RNLI of 73.2 (31 to 100). There was no difference in prosthesis usage, BI and RNLI between both groups. We found that 16 (94.1%) out of 17 patients with creeping amputation would undergo the same multiple salvage procedures if given a similar option. Conversely, only 15 (62.5%) patients with primary amputation would do the same again while the other nine (37.5%) patients choose to do everything possible to save their leg if faced with a similar situation (p = 0.001). CONCLUSION: Most patients preferred to undergo multiple procedures to salvage the limb from diabetic foot infection even if it ultimately concluded with a BKA. All the patients had a moderately good functional outcome and ability to return to normal living after BKA. Cite this article: Bone Joint J 2017;99-B:1502-7.

Factors associated with reduced functional outcome and quality of life in patients having limb-sparing surgery for soft tissue sarcomas - a national multicenter study of 128 patients.

BACKGROUND: Limb-sparing surgery for sarcomas has become possible in most cases. However, the impact of the procedure on the functional outcome has only been investigated in a few studies. The aim of this study has been to identify tumor- and patient-related factors associated with reduced functional outcome and quality of life after limb-sparing surgery in soft tissue sarcoma patients. MATERIAL AND METHODS: In total, 128 patients (mean age = 58, female/male = 54/74) who were treated with limb-sparing surgery without bone resection for soft tissue sarcomas in Denmark during the period 1 January 2009 to 31 December 2011 were included. Patients were asked to participate at least one year after surgery, and patients who had experienced local recurrence or metastatic disease were excluded. The Toronto Extremity Salvage Score (TESS) measured functional disability, while the Musculoskeletal Tumor Society Score (MSTS) measured functional impairment. European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 measured quality of life. Tumor- and patient-related factors (age, gender, tumor depth, tumor size, malignancy, comorbidity, location, and radiotherapy) were extracted from the Danish National Sarcoma Database. Wilcoxon rank-sum test and Kruskal-Wallis were used for univariable analysis. Adjusted odds ratios were estimated by using multiple logistic regression models. RESULTS: In the multiple regression analysis, it was found that female gender (p = 0.03), lower extremity tumors (p < 0.01) and radiotherapy (p = 0.02) resulted in an increased risk of a lower TESS score. Initial reduced postoperative function was found to be associated with a lower functional outcome. Patients with reduced functional outcome have increased risk for reduced quality of life (p < 0.01). CONCLUSION: The results of this study show that patient- and tumor-related factors have an important role in the functional outcome.

Amputation: Not a failure for severe lower extremity combat injury.

INTRODUCTION: The use of improvised explosive devices is a frequent method of insurgents to inflict harm on deployed military personnel. Consequently, lower extremity injuries make up the majority of combat related trauma. The wounding pattern of an explosion is not often encountered in a civilian population and can lead to substantial disability. It is therefore important to study the impact of these lower extremity injuries and their treatment (limb salvage versus amputation) on functional outcome and quality of life. PATIENTS AND METHODS: All Dutch repatriated service members receiving treatment for wounds on the lower extremity sustained in the Afghan theater between august 2005 and August 2014, were invited to participate in this observational cohort study. We conducted a survey regarding their physical and mental health using the Short Form health survey 36, EuroQoL 6 dimensions and Lower Extremity Functional Scale questionnaires. Results were collated in a specifically designed electronic database combined with epidemiology and hospital statistics gathered from the archive of the Central Military Hospital. Statistical analyses were performed to identify differences between combat and non-combat related injuries and between limb salvage treatment and amputation. RESULTS: In comparison with non-battle injury patients, battle casualties were significantly younger of age, sustained more severe injuries, needed more frequent operations and clinical rehabilitation. Their long-term outcome scores in areas concerning well-being, social and cognitive functioning, were significantly lower. Regarding treatment, amputees experienced higher physical well-being and less pain compared to those treated with limb salvage surgery. CONCLUSION: Sustaining a combat injury to the lower extremity can lead to partial or permanent dysfunction. However, wounded service members, amputees included, are able to achieve high levels of activity and participation in society, proving a remarkable resilience. These long-term results demonstrate that amputation is not a failure for casualty and surgeon, and strengthen a life before limb (damage control surgery) mindset in the initial phase. For future research, we recommend the use of adequate coding and injury scoring systems to predict outcome and give insight in the attributes that are supportive for the resilience that is needed to cope with a serious battle injury.

Smoking cessation advice in limb reconstruction: An opportunity not to be missed.

The adverse health effects of smoking are well known, including its effects on the musculoskeletal system. Limb reconstruction using external fixators is a high intensity process with high levels of patient contact time, complications and cost. The aim of this study was to examine smoking patterns in this group and in particular to assess trends in smoking cession. Data was collected from 41 patients all undergoing treatment using circular frame external fixation, for a variety of pathologies, most commonly acute tibial trauma. A patient reported questionnaire was used. Data was collected over a six-month period. In our population 56.1% of patients were smokers. During the study 47.8% patients stopped smoking and a further 39.1% decreased their smoking behaviour. 78.3% of patients could recall being given smoking cessation advice. In our group, 87% of patients were unaware of the effects of smoking on bone healing. Once made aware during discussion of proposed treatment, 73.9% stated that it was, in part, this knowledge that prompted them to positively change their smoking habits. The results of this study show that advice regarding smoking cessation during limb reconstruction treatment can potentially have a positive impact on patients smoking habits. The effect of smoking should be linked to the patient pathology and discussed during the consent process. Taking the time with the patient for this simple free intervention can have a positive impact on patient health, and potentially on the outcome of their current treatment, and is an opportunity not to be missed.

Cross-cultural adaptation and validation of the Japanese version of the Toronto Extremity Salvage Score (TESS) for patients with malignant musculoskeletal tumors in the upper extremities.

BACKGROUND: The Toronto Extremity Salvage Score (TESS) is a widely used disease-specific patient-completed questionnaire for the assessment of physical function in patients with musculoskeletal tumors; however, there had not been the validated Japanese version of the TESS. The aim of this study was to validate the Japanese version of the TESS in patients with musculoskeletal tumors in the upper extremity. METHODS: After developing a Japanese version of the TESS, the questionnaire was administered to 53 patients to examine its reliability and validity in comparison with the Musculoskeletal Tumor Society (MSTS) scoring system and Short Form-36 (SF-36). RESULTS: Test-retest reliability with intraclass correlation coefficient (0.93) and internal consistency with Cronbach's alpha (0.90) were excellent. Factor analysis showed that the construct structure consisted of 3-item clusters, and the Akaike Information Criterion network also demonstrated that the items could be divided into 3 domains according to their content. The TESS strongly correlated with the MSTS rating scale (r = 0.750; P < 0.001) and the SF-36 physical functioning scale (r = 0.684; P < 0.001). However, as expected, the TESS had low correlations with the SF-36 mental health and role-emotional subscales and the MSTS scoring system manual dexterity domain. CONCLUSIONS: Our study suggests that the TESS is a reliable and valid instrument to measure patient-reported physical functioning in patients with upper extremity sarcoma.

Influence of Immediate and Delayed Lower-Limb Amputation Compared with Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation in the U.K. Military.

BACKGROUND: Medical practitioners face difficult decisions over whether to amputate or to salvage a lower limb that has undergone trauma. To our knowledge, there has been little evidence reporting the impact of different surgical decisions on functional and mental health outcomes following intensive rehabilitation that might inform decision-making. METHODS: This study is a retrospective, independent-group comparison of rehabilitation outcomes from a U.K. military complex trauma rehabilitation center. There were 100 procedures examined: 36 unilateral amputations (11 immediate-below-the-knee amputations, 15 delayed below-the-knee amputations, and 10 immediate above-the-knee amputations), 43 bilateral amputations, and 21 single-limb salvages (including 13 below-the-knee limb salvages); the patients had a mean age (and standard deviation) of 29 ± 6 years and a mean New Injury Severity Score of 34 ± 15 points. The outcome measures at completion of rehabilitation included a 6-minute walk test (6MWT), Defence Medical Rehabilitation Centre mobility and activities of daily living scores, screening for depression (Patient Health Questionnaire [PHQ-9]) and general anxiety disorder (General Anxiety Disorder 7-item scale [GAD-7]), mental health support, and pain scores. RESULTS: On completion of their rehabilitation, the unilateral amputation group walked significantly farther in 6 minutes (564 ± 92 m) than the limb-salvage group (483 ± 108 m; p < 0.05) and the bilateral amputation group (409 ± 106 m; p < 0.001). The delayed below-the-knee amputation group (595 ± 89 m) walked significantly farther than the group with limb salvage below the knee (472 ± 110 m; p < 0.05), and there was no significant difference between the group with delayed below-the-knee amputation and the group with immediate below-the-knee amputation (598 ± 63 m; p > 0.05). The limb-salvage group was less capable of running independently compared with all amputee groups. No significant differences (p > 0.05) were reported in mean mental health outcomes between the below-the-knee injury groups, and depression and anxiety scores were comparable with population norms. At discharge, 97% of all patients were able to control their pain. CONCLUSIONS: After completing a U.K. military interdisciplinary rehabilitation program, the unilateral amputation group demonstrated a significant functional advantage over the limb-salvage and bilateral amputation groups. We found that patients electing for delayed amputation below the knee after attempted limb salvage achieved superior functional gains in mobility compared with patients who underwent limb salvage below the knee and experienced no functional disadvantage compared with patients who underwent immediate amputation. The mental health outcomes were comparable with general population norms, optimizing the prospect of full integration back into society. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mental disorder in limb reconstruction: Prevalence, associations and impact on work disability.

OBJECTIVE: This cross-sectional survey aimed to assess the prevalence of depression, anxiety, post-traumatic stress disorder (PTSD), and drug and alcohol dependence in a limb reconstruction population and examine associations with demographic and functional variables. METHODS: As part of routine clinical care, data were collected from 566 patients attending a tertiary referral centre for limb reconstruction between April 2012 and February 2016. Depression, anxiety, post-traumatic stress disorder (PTSD), and alcohol and drug dependence were measured using standardised self-report screening tools. RESULTS: 173 patients (30.6% CI 26.7-34.4) screened positive for at least one of the mental disorders assessed. 110 (19.4% CI 16.2-22.7) met criteria for probable major depression; 112 (19.9% CI 16.6-23.2) patients met criteria for probable generalised anxiety disorder; and 41 (7.6% CI 5.3-9.8) patients met criteria for probable PTSD. The prevalence of probable alcohol dependence and probable drug dependence was 1.6% (CI 0.6-2.7) and 4.5% (CI 2.7-6.3), respectively. Patients who screened positive for depression, anxiety and PTSD reported significantly higher levels of pain, fatigue, and functional impairment. Depression and anxiety were independently associated with work disability after adjustment for covariates (OR 1.98 (CI 1.08-3.62) and OR 1.83 (CI 1.04-3.23), respectively). CONCLUSION: The high prevalence and adverse associations of probable mental disorder in limb reconstruction attest to the need for routine psychological assessment and support. Integrated screening and management of mental disorder in this population may have a positive impact on patients' emotional, physical and occupational rehabilitation. A randomised controlled trial is needed to test this hypothesis.

Functional and psychological outcomes of delayed lower limb amputation following failed lower limb reconstruction.

PURPOSE: The purpose of this study was to evaluate the functional and psychological outcomes of patients who underwent delayed lower limb amputation following failed limb salvage surgery. METHODS: This retrospective, descriptive study evaluated functional outcomes using the Sickness Impact Profile (SIP) and Short Form-36 (SF-36) in 12 patients. Inclusion criteria included patients who underwent limb reconstruction and delayed amputation between July 2006 and December 2014, with an age range between 18 and 80 years of age, the ability to ambulate independently, a time interval between the last salvage procedure and amputation greater than six months, and a minimum follow-up of 24 months. Patients were contacted via telephone by the principal investigator and both the Sickness Impact Profile (SIP) and Short Form-36 (SF-36) were completed. Descriptive analysis (means and standard deviation) was used to determine outcomes for both SIP and SF-36 health profiles. RESULTS: Ten patients who had amputations following failed reconstruction (2006-2014) with a mean age of 53±10years were interviewed. Six patients had a SIP <5, three patients scored between five and 10 points and one scored >10 points. The main deficit on the SF-36 was in the physical component. The SF-36 scores demonstrated a mean score of 40.8±11.5 for the physical component, and 57.4±7.9 for the mental component. Three patients returned to work after amputation and continued performing their pre-injury duties as farmers. Three other patients returned to work, but were allocated to administrative duties. Two patients were pensioners at the time of their injuries, and the only female patient was a housewife. One patient went into early retirement. CONCLUSION: The results of this study strongly suggest that delayed amputation following failed limb salvage surgery can still result in good and satisfactory outcomes in the majority of patients and achieves results similar to early amputation and limb reconstruction techniques.

Striving for Normalcy after Lower Extremity Reconstruction with Free Tissue: The Role of Secondary Esthetic Refinements.

BACKGROUND: Many patients with successful lower extremity salvage have postoperative functional and esthetic concerns. Such concerns range from contour irregularity preventing proper shoe-fitting to esthetic concerns involving color, contour, and texture match. The purpose of this study is to determine the overall incidence as well as factors associated with an increased likelihood of undergoing secondary, esthetic refinements of lower extremity free flaps and to review current revision techniques. METHODS: All patients undergoing lower extremity soft tissue coverage for limb salvage procedures between January 2007 and June 2013 at a single institution were included in the analysis. Patients who underwent secondary refinements for lower extremity free flaps were compared with patients not undergoing secondary procedures. RESULTS: During the study period, 152 patients underwent reconstruction and were eligible for inclusion. Of these, 32 (21.1%) patients underwent secondary, esthetic revisions. Few differences in patient or case characteristics were noted, although revision patients trended toward being younger, having lower body mass index, with defects secondary to acute trauma located below the ankle. The most common revision was complex soft tissue rearrangement or surgical flap debulking/direct excision (87.5% of patients), followed by scar revision (12.5%), suction-assisted lipectomy (3.1%), laser scar revision (3.1%), and tissue expansion with local tissue rearrangement (3.1%). CONCLUSION: A significant portion of patients desire secondary revisions following the initial procedure. This is especially true of younger patients with below ankle reconstruction. In many patients, an esthetic consideration should not be of secondary concern, but should be part of the ultimate reconstructive algorithm for lower extremity limb salvage.