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Cody C Andrews,1 Geoffrey Siegel,2 Sean Smith1 1Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA; 2Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USACorrespondence: Cody C AndrewsDepartment of Physical Medicine and Rehabilitation, University of Michigan, 325 E. Eisenhower Pkwy, Ann Arbor, MI 48108, USATel +1 734-936-7175Fax +1 734-615-6713Email coan@med.umich.eduAbstract: 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.Keywords: soft tissue sarcoma, bone sarcoma, rehabilitation, sarcoma rehabilitation, function, quality of life, limb salvage, amputation

Purpose: This study aimed to investigate the relationship between various clinical factors and physical function in the early postoperative period in patients with soft tissue sarcomas (STSs) by subjective and objective evaluations., Materials and Methods: The 90 patients enrolled in this study were classified into five groups according to tumor location: retroperitoneal, gluteal, groin, thigh, and lower leg. The Musculoskeletal Tumor Society (MSTS) score was evaluated at discharge; the timed up-and-go test (TUGT) was performed preoperatively and at discharge. Group comparisons by tumor location were performed. To identify significant factors associated with physical dysfunction, multivariate analysis was performed using an MSTS score of <80% and a change in pre and postoperative TUGT score., Results: There were no significant differences between the tumor location and physical function. The change in pre- and postoperative TUGT scores was significantly associated with an MSTS score of <80%. Quadriceps and tibialis anterior muscle resections were significantly associated with the change in pre- and post-operative TUGT scores., Conclusions: The quadriceps and tibialis anterior muscles may affect physical dysfunction after surgery for STSs. Early postoperative rehabilitation should include the identification of resected muscles and functional improvement of residual muscles, possibly with orthotic support for knee extension and ankle dorsiflexion.

Objective: Sarcoma is a rare cancer that imposes a significant burden on the lives of patients. Many survivors have long-term disability as a result of treatment and the disease. Patients often experience functional issues, poorer mental health, reduced quality of life, and interpersonal issues. There is a need to explore the unmet needs of sarcoma patients as it is unclear how these issues are being addressed. The aim of this study was to explore the unmet needs of patients who have been diagnosed with sarcoma., Methods: The participants were individuals previously diagnosed with a sarcoma (n = 22). Participants completed a semi-structured interview about their unmet needs relating to sarcoma. The transcripts were analyzed using thematic analysis., Results: Five overarching themes were identified: daily living, financial needs, lack of information, need for a community, and navigating the healthcare system. Participants reported a range of practical needs, including transport, limited understanding of their treatments, and financial issues. Participants also described a need to connect with people who had gone through similar experiences., Conclusions: Sarcoma patients have fundamental needs that affect their capacity to live their life in the best possible way. Health services need to better facilitate sarcoma patients at each stage of their experience by providing individualized referrals, support, and coordination. Support interventions are needed to help patients adjust to sarcoma and to improve their quality of life as an outpatient. Connecting patients with sarcoma support groups may provide them with more relevant and intimate support., (© 2020 John Wiley & Sons, Ltd.)

Introduction: The aim of this case series was to assess sports activity levels in long-term survivors of soft-tissue sarcomas after multimodal treatment including limb salvaging surgical resection and radio-chemotherapy. Methods: Thirty-two patients (17 f/15 m) with a mean age of 29 (range 10-44) years at the time of diagnosis and a mean follow-up time of 9 (range 3-21) years following sarcoma were included. Ten patients had been diagnosed with liposarcoma, seven with synovial sarcoma, four with fibrosarcoma, three with undifferentiated pleomorphic sarcomas and the remaining eight patients with different soft-tissue sarcoma entities. Sarcoma location of twenty-four (75%) patients was in the thigh, eight (25%) in the lower leg. Eleven (34%) tumors were located epifascial, 21 (66%) in deeper tissue layers. Sports activity was measured by the University of California, Los Angeles (UCLA) Activity Score. Results: One year before treatment 30 patients (94%) and >3 years post-treatment 29 patients (91%)had been pursuing athletic activity regularly. They were performing 5.5 h/week prior and 4.2 h/week >3 years post surgery. The mean UCLA score in case of subfascial sarcomas was 8.0 and thereby lower ( p  < 0.05) than those of epifascial sarcomas, which were 9.3. Furthermore, the mean UCLA score after subfascial sarcoma resection 3 years postoperative was still below preoperative UCLA levels ( p  < 0.05), whereas patients after epifascial tumor resection showed no loss of sports activity. No relation between complications and postoperative sports activity level was found. Conclusions: Healthy long-term survivors can achieve high levels of sports activity following limb salvage after soft-tissue sarcomas. The concerned muscle groups may influence the functional and sports outcome and draw attention to this topic in future rehabilitation. This knowledge may be of high value for patients counseling, physicians and orthopedists treating patients, as well as for patients inquiring information regarding post-treatment activity levels.Implication for rehabilitationSport is possible after soft tissue sarcoma treatment and longer-term rehabilitation which is usually three yearsRehabilitation is best undertaken in specialized centersIt is important to maintain contact with surgeons in order to optimize mobilizationHigh impact sports may be affected by deep muscle resections.

Actuality: The modern method of treating patients with tumor lesions of the bones is the replacement of large bones and joints with the inclusion of reconstructive plastic component. The main functional postoperative disorders of this method (limitation of mobility in the operated joint, pain, muscle hypotrophy and edema of the operated limb) obstruct the ability of patients to return to a full life, which makes their early rehabilitation extremely urgent. Orthopedics uses a number of physical factors for this. The literature presents data on the absence of negative effects of low-frequency electro- and magnetotherapy in the treatment of late complications of oncopedic surgery on a number of bone sarcomas, which allowed them to be included in early rehabilitation for the first time., Aim of Study: Development of a complex of early rehabilitation of patients with bone tumors after arthroplasty of large bones and joints and evaluation of its effectiveness., Materials and Methods: A prospective, open, nonrandomized, controlled study included 36 patients aged 19-67 years (Me 42 years old) with primary malignant and metastatic bone tumors who underwent endoprosthesis replacement of large bones and joints with the inclusion of reconstructive plastic component (plastic by displaced muscles, synthetic mesh) and received local low-frequency magnetotherapy, low-intensity infrared laser radiation, electroneuromyostimulation and therapeutic exercises. Physiotherapy began from the first day after the operation and lasted for 10 days. To assess the functional result, the international MSTS scale was used., Results: The combined use of the reconstructive plastic component during radical surgery and physiotherapy made it possible to obtain good functional result at 63,9% of patients, satisfactory functional results in 36.1% of patients according to the MSTS scale at the time of discharge. The function of the saved limb in 10 patients after distal femoral resection with knee replacement was 80% of normal function, in 7 patients after proximal tibia resection - 72%; in 13 patients after proximal resection of the femur with hip replacement - 59%; in 5 patients after proximal resection of the humerus with endoprosthetics of the shoulder joint - 61.3%; and in 1 patient after proximal resection of the ulna with endoprosthetics of the elbow joint - 70%., Conclusion: The multidisciplinary approach to the early rehabilitation of patients with bone tumors made it possible to achieve functional results in a short time, reduce the time spent by patients in the surgical department without increasing the number of postoperative complications. Based on the preliminary obtained results, it is necessary to continue the study on a larger number of patients and with a longer follow-up period.

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., Competing Interests: The authors report no conflicts of interest in this work., (© 2019 Andrews et al.)

Background: We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation., Methods: Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain., Results: Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively., Conclusions: Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP., (© 2019 Wiley Periodicals, Inc.)

As the number of survivors of extremity soft tissue sarcoma increases, so does the need to understand the experience of survivors and develop measures, systems and services that support rehabilitation into normal life roles. Survivorship includes considerations of the physical, psychological and social domains, of which the physical sequelae of treatment are the best characterised in the literature. The survivorship experience may include disability, pain, lymphoedema, psychological problems, as well as difficulty with employment, relationships and lower quality of life. Rehabilitation strategies for extremity sarcoma patients must be personalised, holistic and begin early in the pathway, ideally before the first treatment intervention. The International Classification of Functioning, Disability and Health model is a useful framework for combining assessments, including objective outcome measures, which can be combined into a rehabilitation prescription. Research is needed to develop an evidence base for rehabilitation interventions to support patients with extremity soft tissue sarcoma., (Copyright © 2017. Published by Elsevier Ltd.)

Aims: The aim of the study was to investigate the controversial issue of whether the pelvic ring should be reconstructed following resection of the sarcomas of the ilium., Patients and Methods: From our database, we identified 64 patients who underwent excision of a tumour involving the ilium between 1976 and 2015. A total of 35 underwent complete resection, of whom 24 were reconstructed with a non-vascularised fibula graft, and four with extracorporeal irradiation and reimplantation. A total of 29 patients had a partial resection. The mean follow-up was 9.2 years (1.1 to 25.6). Functional outcomes were assessed using the Toronto Extremity Salvation Score (TESS) at final follow-up. In all, 32 patients (50%) had a chondrosarcoma., Results: The mean TESS for all patients was 71.6% (17% to 100%). The mean TESS for those who underwent total resection with reconstruction was 72.0% (17% to 100%) and without reconstruction it was 53.3% (20% to 90%) and for those who underwent partial resection it was 76.3% (31.3% to 100%). The rate of local recurrence was 42.2% and this was more common in those treated by partial resection (p = 0.048). The risk of local recurrence was related to the margin achieved at resection., Conclusions: Given the high rate of local recurrence following excision of a tumour from the ilium, obtaining wide surgical margins should be a priority even if this requires more aggressive surgery. In young patients, where late recurrence may occur, more radical complete resection should be considered. When total resection of the ilium is considered, reconstruction should also be considered as it confers a higher functional outcome than total resection without reconstruction. Cite this article: Bone Joint J 2017;99-B:538-43., (©2017 The British Editorial Society of Bone & Joint Surgery.)

Background: Musculoskeletal sarcomas comprise 1% of all malignancies in adults. Unfortunately, sometimes they are addressed in non-appropriate way requiring a more invasive procedure to achieve radical surgery at a later date. Due to incomplete predictability of their extension, scheduled reconstruction cannot be performed at times, forcing plans to change or clogging up immediate reconstruction. In this paper, the authors provide an insight in the treatment of musculoskeletal sarcomas, particularly focusing on the preoperative planning of reconstructive strategies, which is crucial in order to prevent unpleasant surprises during reconstruction., Methods: Fifty-six consecutive patients requiring reconstructive procedures following the extirpation of tumors were recruited. All data collected during the diagnostic phase were analyzed collectively during a multi-disciplinary meeting where the surgical procedure was planned. A score system was created and results were then classified into "excellent", "good", "sufficient" and "poor"., Results: After a minimum follow up of 12 months, we recorded the following results: excellent in 10 patients (17.9%), good in 28 patients (50%), sufficient in 12 cases (21.4%) and poor in 6 cases (10.7%)., Conclusions: The improvement of treatment and the long-lasting survival in musculoskeletal sarcoma have shifted the goal of therapeutic protocol to obtaining radical tumor removal and maximum functional restoration. When facing unpredictable extension of the resections, reconstruction may be a challenging or even impossible task to fulfil. Only meticulous preoperative planning can prevent surgeons from falling into all sorts of surgical traps following wide resections.

Sarcomas are a relatively rare cancer that, depending on the location, can cause significant neuromusculoskeletal dysfunction and require rehabilitation interventions to reduce pain, restore function, and improve quality of life. This review focuses on sarcoma subtypes that frequently cause these complications: bony and soft tissue sarcomas leading to limb salvage or amputation, desmoid tumors, and malignant peripheral nerve sheath tumors. Rehabilitation approaches and outcomes are discussed, as well as considerations for childhood sarcoma survivors transitioning to adulthood., (Copyright © 2016 Elsevier Inc. All rights reserved.)

We analysed nine patients who had had a megaprosthesis implanted into the distal femur and knee joint for treatment of sarcomas. Data obtained from the leg operated on were compared with those from the contralateral side and healthy volunteers. Gait data, kinematics, ground reaction forces and the EMG from five muscles around the knee joint were analysed by means of a video-based analysis system recording data from reflection markers ; a Kistler-plate recorded the GRF and a ten channel surface EMG the muscle activity. Muscle around the knee showed a cocontraction between the extensor and flexor muscles in the thigh and the calf in the operated leg as well as contralaterally. Gait characteristics exhibited a reduced speed, -cadence, and a shorter step. This correlated with a reduced flexion in the hip and knee joint. The GRF exhibited significant changes in the data representing the reduced gait dynamic.

Background: Enhanced recovery after surgery (ERAS) programs are implemented in multiple fields of surgery, but not yet in soft-tissue sarcoma (STS) surgery. We wondered whether its introduction into STS surgery might have impacted postoperative outcome., Methods: Two hundred and fifty seven adult patients with primary limb or trunk wall STS received ERAS from 2008 to 2012 as a part of the intra-operative management. We evaluated, in retrospect, the intra-operative management, post-operative outcomes, functional and oncological results of these patients and compared them with 459 prior patients treated under a standard recovery after surgery (SRAS) program from 1989 to 2007., Results: The most visible change from SRAS to ERAS in the perioperative management was decrease of wound drainage (72% vs. 15%, p < 0.001) and increase of wound bandaging (16% vs. 66%; p < 0.001), underlining the appliance of the ERAS protocol. Post-operatively, hospital stay dropped from nine (0-74) to three (0-22) days (p < 0.001) without affecting major morbidity (8% vs. 5%, NS) or readmission to the hospital (5% vs. 4%, NS). Functional outcome improved (p = 0.009) but whether this change was due to ERAS remains to be proved because complementary treatments changed over time. Tumour control remained unaffected, with an estimated risk of local recurrence at 5 years of 12% in both groups., Conclusion: Introducing a rapid recovery program was associated with a shorter hospitalization stay without compromising surgical or oncological outcomes. The program appears to be safe and reliable to use in patients undergoing STS surgery., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Although relatively rare, soft tissue sarcomas cause significant morbidity and mortality due to their advanced stage at initial diagnosis. Rehabilitation and surgical outcomes have traditionally focused on physical parameters to assess function and recovery, emphasizing return to ambulation, activities of daily living (ADLs) and community re-integration. Assessments of functional impairment and other quality-of-life parameters are necessary to better understand the experience of the patient with extremity soft tissue sarcoma and thereby improve outcomes., (© 2014 Wiley Periodicals, Inc.)

Background and Objective: The purpose of this study is to establish a standardized postoperative rehabilitation protocol following limb salvage surgery (LSS) in patients with primary bone sarcoma in five major anatomical locations: distal femur, proximal tibia, proximal and total femur, humerus and shoulder girdle and pelvic resections., Setting and Design: Retrospective study., Patients and Methods: All LSSs were performed by an orthopedic oncology surgeon, and rehabilitation of all patients was based on a devised standardized rehabilitation protocol. Patient outcomes were measured using the modified Musculoskeletal Tumor Society-International Symposium on the Limb Salvage (MSTS-ISOLS) scoring system., Results: A total of 59 patients received LSS in the above mentioned locations; endoprostheses were used in 49, bone allograft in five, while no replacements were made in five patients. At a mean follow-up of 24 months, the mean modified MSTS-ISOLS score for all patients was 87% (95% CI; 0.85-0.89). The highest scores were encountered for patients with distal femur replacement: 93% (95% CI; 0.91-0.95). Seven patients had interruption of more than six weeks in their rehabilitation and had a mean score of 71% (95% CI; 0.64-0.82)., Conclusion: The proposed rehabilitation protocol is a comprehensive, organized and applicable guideline to be used after performing LSS at the above mentioned anatomical locations. The use of standardized rehabilitation protocol resulted in improved patient functional outcome., (Copyright © 2013 King Faisal Specialist Centre & Research Hospital. All rights reserved.)

Purpose: To obtain reference values for healthy participants performing the Functional Mobility Assessment (FMA). The FMA is a reliable and valid tool used to examine functional abilities subjectively and objectively in patients with lower-extremity sarcoma in all components of the International Classification of Functioning, Disability, and Health model (body function, activity, and participation)., Methods: Children, adolescents, and young adults who were healthy, representing a sample of convenience (n = 503; 260 females, age 10-21 years), participated in this study., Results: Means and standard deviations for all participants: Timed Up and Down Stairs 6.18 ± 0.8 seconds, Timed Up and Go 3.78 ± 0.6 seconds, 9-minute run/walk 4161 ± 893 feet, and the FMA total 59 ± 3., Conclusion: The reference values provided in this study will allow health care professionals to compare the functional abilities of children, adolescents, and young adults with lower extremity sarcoma to age- and gender-matched healthy peers when using the FMA.

We evaluated the oncological and functional outcome of 27 patients who had limb salvage for a soft-tissue sarcoma of the foot or ankle between 1992 and 2007, with a mean follow-up of 7.5 years (1.05 to 16.2). There were 12 men and 15 women, with a mean age at presentation of 47 years (12 to 84). Referrals came from other hospitals for 16 patients who had previous biopsy or unplanned excision, and 11 presented de novo. There were 18 tumours located in the foot and nine around the ankle. Synovial sarcoma was the most frequent histological diagnosis. Excision was performed in all cases, with 16 patients requiring plastic surgical reconstruction with 13 free and three local flaps. Adjuvant treatment was undertaken in 20 patients, 18 with radiotherapy and two by chemotherapy. Limb salvage was successful in 26 of the 27 patients. There have been two local recurrences and two mesenchymal metastases. Four patients have died of their sarcoma and two of other causes. Function was evaluated with the Toronto Extremity Salvage Score and a mean overall score of 89.40 (52.1 to 100) was obtained. A questionnaire revealed that all surviving patients are able to wear normal shoes and none require a walking aid. Limb salvage can achieve good oncological and functional results with additional treatment.

Objective: To determine the functional outcomes of skeletally immature patients after replacement of the femur and tibia performed by using noninvasive expandable endoprostheses., Design: Case series., Setting: A hospital-based ambulatory care center., Participants: Pediatric patients (N=4) with primary bone tumors of the distal femur and proximal tibia who underwent surgical replacement performed by using the Repiphysis noninvasive expandable endoprosthesis (Wright Medical Technology, Memphis, TN)., Interventions: Wide resection of bone sarcoma and placement of expandable endoprosthesis., Main Outcome Measures: Musculoskeletal Tumor Society (MSTS) scores were assessed at the beginning of the study and at each follow-up visit. Medical Outcomes Study 36-Item Short-Form Health Survey, Version 2 (SF-36); gait; sit-to-stand transition; and range of motion (ROM) were assessed at an average follow-up of 31.5 months., Results: At an average of 31.5 months postoperative, the SF-36 physical component summary scores lagged behind the national mean, whereas the mental component summary scores were satisfactory. MSTS scores indicated low levels of pain and supports use with high emotional acceptance and walking ability but persisting difficulties with function and gait. Patients also showed altered patterns of sit-to-stand transition including decreased peak vertical force in the operated limb and increased center of mass momentum in a shorter amount of time. Parts of gait functioning were found to be decreased, including gait velocity, stride length, and cadence. Some patients displayed alternate weight-bearing strategies that accompanied increased double-limb support and stance phase during walking. ROM and strength were diminished at both the hip and knee joints in the operated limb and in the nonoperated limb., Conclusions: Reconstruction with a noninvasive expandable endoprosthesis produces satisfactory functional outcomes in pediatric patients with primary tumors of the bone. Patients in our study displayed some persisting physical difficulties including decreased ROM and strength and altered gait and sit-to-stand patterns, yet they maintained high levels of emotional acceptance and coping.

The optimal management of adult soft-tissue sarcomas is not clearly established. To assess prognostic factors and survival, the experience of 45 recent successive cases was reviewed. Data were collected from a retrospective database (1993-2005) and statistically analyzed. Rhabdomyosarcomas were excluded. The mean age was 50.1 years; there were 24 men and 21 women. The main histological subtypes were undifferentiated sarcoma (14) and angiosarcoma (10); 21 tumours were grade 3 (46%). The most frequent primary sites were neck muscles (15, 33%) and scalp (11, 24%). At presentation, 5 (20%) cases with lymph-node involvement and another 11 cases (24%) with distant metastasis were observed. The treatment was with curative intent in 33 cases (73%). This entailed surgery, with adjuvant radiotherapy in 15 cases and adjuvant chemotherapy in 5 cases. The 5-year overall survival was 52% (+/-8%). In univariate analysis, the poor prognostic factors were high grade, initial metastasis or lymph nodes, absence of surgery, and number of surgical procedures. In multivariate analysis, two factors remained significant: grade (P=0.006) and absence of surgery (P=0.005). After taking into account grade and metastasis at presentation, quality of surgery has prognostic value. The primary aim of a multidisciplinary approach to these tumours must favour complete resection.

We evaluated the construct validity of the Musculoskeletal Tumour Society rating scale (Enneking score) as a functional measure for patients with sarcoma involving the upper limb. We compared the Enneking score by examining the correlation between two patient-derived outcome measures, the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Medical Outcomes Study Short Form-36 (SF-36) as indicators of functional status in 40 patients with malignant or aggressive benign bone and soft-tissue tumours of the upper limb who had undergone surgical treatment. The frequency distributions were similar among the three scoring systems. As for the validity, Spearman's rank correlation coefficient of the Enneking score to the DASH questionnaire was -0.79 and that of the Enneking to the SF-36 subscales ranged from 0.38 to 0.60. Despite being a measure from the surgeon's perspective, the Enneking score was shown to be a valid indicator of physical disability in patients with malignant or aggressive benign tumours of the upper limb and reflected their opinion.

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.

Background and Objectives: Unplanned excisions of soft-tissue sarcomas of the extremities occur commonly. Our goal was to evaluate the presence of residual disease, the treatment outcomes as they relate to local and distant recurrence and 5-year survival, and the limb functional outcomes in patients with unplanned sarcoma excision who were treated with re-excision and adjuvant therapy., Methods: Between 1993 and 1999, 42 patients presented to our institution after unplanned excision of soft-tissue sarcomas. Of those 42 patients, 38 without gross residual disease or metastatic lesions formed the basis of this review. All 38 patients underwent revision wide excision; most (31) also received adjuvant therapy (radiation and/or chemotherapy). Clinical data were obtained from analysis of patient records and radiographic studies. Univariate analysis was performed with logistical regression, and multivariate analysis was performed with Cox modeling., Results: The overall 5-year survival rate was 91.3% and the disease-free 5-year survival rate was 82.2%. Univariate analysis showed that stage-III disease (American Joint Committee on Cancer classification of soft-tissue sarcomas), lesions below the fascia, a histologic high-grade, and the development of organ metastasis were statistically significant factors for mortality. Stage-III disease also was significant for mortality on multivariate analysis. Only stage-III disease was significant for the development of local recurrence. Eighty-four percent of the patients had good to excellent functional outcomes., Conclusions: Re-excision with adjuvant therapy proved to be a safe and effective method for treating the disease and preserving limb function., (Copyright 2005 Wiley-Liss, Inc.)

The current standard of care for soft tissue sarcoma (STS) is limb salvage surgery and adjuvant radiotherapy, with long-term survival rates of approximately 70%. However, the extensive surgical resection and subsequent reconstruction result in 50% of survivors living with chronic disability. Rehabilitation aims to optimize functional independence and quality of life, and is routinely offered to patients undergoing surgical treatment for STS. Unfortunately, there is a dearth of research related to rehabilitation in this area. We propose a model for assessing disability, for designing treatment interventions and for evaluating rehabilitative outcomes in STS. The World Health Organization's (WHO) international classification of functioning, disability, and health (ICF) is divided into three domains: 1) impairments (related to body structure and function), 2) activity limitations (related to usual self-care activities/activities of daily living), and 3) participation restrictions (related to social roles). A literature review of STS rehabilitation reveals that most studies have focused on disability assessment, with few papers describing or evaluating rehabilitation interventions commonly employed in STS. Clinicians are forced to extrapolate findings from other patient populations in order to evaluate the effectiveness of specific rehabilitation strategies (ie, those used for particular sequelae of STS, such as lymphedema or impaired exercise tolerance). There is strongest support for complex decongestive physiotherapy (targeting lymphedema) and aerobic exercise interventions (aimed at alleviating cancer-related fatigue and psychosocial sequelae). The most poorly researched topic is rehabilitation for genitourinary disability (both incontinence and sexual dysfunction). Most studies related to oncologic rehabilitation are restricted to the impairment level (eg, affecting range of motion, muscle strength) of the ICF, with only a small minority addressing activity limitations (eg, affecting activities of daily living) experienced by patients. A consideration of participation restrictions (eg, fulfillment of vocational roles) is almost wholly absent from the literature. Yet social role reintegration is of fundamental importance to patients. Further research is required in these two domains. The ICF provides a comprehensive framework for future research into rehabilitation interventions for STS.

Background: Treatment for soft tissue sarcoma of the upper extremity has evolved to include limb salvage techniques. We reviewed our experience with limb salvage therapy for upper extremity sarcomas with an emphasis on functional outcomes following the reconstructive surgery., Methods: A retrospective analysis was performed of 81 consecutive patients with soft tissue sarcoma of the upper extremity who had limb salvage therapy with reconstruction by a plastic surgeon. Univariate and multivariate regression analyses of relevant outcome variables were performed. Enneking functional scores were obtained from 43 patients., Results: The study included 16 microvascular reconstructions and 67 non-microvascular reconstructions for a total of 83 reconstructions in 81 patients. The mean defect size was 129 cm(2) (standard deviation: 106 cm(2)). The mean total functional score was 23.1 (range, 9 to 30). Any reconstruction-related complication and preoperative chemotherapy use were associated with a 7.3 point (P = .03) and 4.7 point (P = .01) decrease in total functional score, respectively. Kaplan-Meier product-limit analysis showed 82% 5-year overall survival and 67% 5-year disease-free survival rates., Conclusions: For soft tissue sarcoma of the upper extremity, limb salvage with good functional outcome is possible with a judicious approach to reconstruction.

This study investigated quality of life (QoL) and function of 124 patients with lower extremity sarcoma who underwent either amputation or limb-salvage surgery (LSS) in order to assess potential differences in subjective treatment outcome. The results reflect similar QoL in both treatment groups. However, in contrast to patients with LSS, who described QoL in terms of a high physical performance status with sports and recreational activities, amputees' QoL was strongly associated with their social acceptability. High QoL in amputees brings into question the expectations held with time-consuming advanced technical skills for LSS by physicians.

Background: This retrospective analysis was conducted to evaluate self-reported patient and clinician assessed functional outcomes of patients who have undergone ablative hard palate oncologic resection and microvascular free-flap reconstruction with and without maxillofacial prosthetic intervention., Methods: All Head and Neck Surgery Service, Plastic and Reconstruction Surgery Service, and Dental Service charts and progress notes entered into the Institutional Health Care Information System of 57 patients who underwent hard palate resection and microvascular reconstruction at Memorial Sloan-Kettering Cancer Center (MSKCC) between January 1, 1988, and December 31, 2001 were reviewed retrospectively by three maxillofacial prosthodontists (BJB, JMH, IMZ). Prosthetic and nonprosthetic rehabilitation outcomes for each patient were reported as having normal; limited; or poor esthetics and function according to each prosthodontist's clinical evaluations; patients' self-perceptions; and feedback from friends, family members, and/or spouse. Speech intelligibility was determined in the same manner but reported as normal, hypernasal, and hyponasal., Results: Most of the 26 prosthetically rehabilitated patients were reported as having normal esthetics (81%), normal function (77%), normal speech (96%), and were able to return to per oral full diets (81%) without any restrictions., Conclusions: Acceptable oral rehabilitation outcomes were reported for most prosthetically rehabilitated free-flap patients. Normal speech can be anticipated with a high degree of certainty, and a high percentage of prosthetically restored free-flap patients achieved per oral diets., (Copyright 2003 Wiley Periodicals, Inc.)

The concept of limb-sparing surgery for bony sarcomas has evolved over the past 25 years. Today, more than 90% of patients treated by surgeons with expertise in musculoskeletal oncology undergo successful limb-sparing procedures. Many large centers have abandoned osteochondral allografts and resection arthrodesis for the reconstruction of segmental bone and joint defects in favor of metallic endoprostheses. Endoprosthesis survival rates now exceed 85% at 5 years for reconstructions about the knee, which is the most common site for primary bone sarcomas. In the shoulder girdle, the type of resection and soft-tissue reconstruction is probably more important than the type of implant. Extra-articular resection is recommended for most large stage IIB tumors. New expandable prostheses able to be lengthened nonoperatively hold promise for very young children with lower extremity sarcomas. Allograft-prosthetic composites and proximal femoral prostheses provide reliable and stable hip reconstructions. Acetabular components are not required, but attention to capsular reconstruction is necessary to prevent hip dislocation. Techniques of scapula replacement have advanced and provide better upper extremity function after scapula resection than resection alone.

Background: Advances in oncological practice have reduced the number of major amputations performed for soft-tissue sarcoma, but this remains a valuable, if infrequent, option for both curative and palliative indications., Methods: A review of patients and case-notes was carried out from the prospective sarcoma database at the Royal Marsden Hospital., Results: Over a 10-year interval, 40 major amputations (18 forequarter, 17 hindquarter and five through hip) were performed, predominantly for disease recurring after previous limb-conserving surgery (31 of 40). A wide variety of soft-tissue sarcoma subtypes was seen; they were often large (more than 10 cm; 18 of 40) or multifocal (six), usually high grade (25), and frequently proximal or involving neurovascular structures such that limb salvage was precluded. Median range age of the patients was 59 (17-87) years. The operative 30-day mortality rate was zero. Hospital stay was a median of 10.5 days for forequarter amputation, and 19 days for hindquarter and through-hip amputation. Local recurrence occurred in ten patients, six of whom had concurrent distant metastases. Twenty-seven patients were alive (20 disease free) at a median follow-up of 12 months, nine of whom were alive without evidence of disease beyond 2 years. Ten patients died after a median of 7.5 months; three survived more than 2 years., Conclusion: Major amputation is a useful procedure in carefully selected patients with soft-tissue sarcoma., (Copyright 2002 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd)

Objective: To determine the proportion of patients who experienced altered work status after reconstruction with a modular tumor prosthesis and adjuvant chemotherapy for primary sarcoma of the distal femur., Design: We reviewed an institution's tumor database and patients' charts. Disability and work status data were collected preoperatively, at 1 year and 2 years postoperatively and at final follow-up., Setting: Acute-care teaching hospital in Ontario, Canada., Participants: Thirty-six eligible patients., Interventions: Not applicable., Main Outcome Measures: Work status was plotted over time to identify unexpected deviations (based on age and preoperative status), and subjects were assigned to altered work status (defined by detrimental changes in productivity, eg, change from full-time work to not working) or expected work status (defined by ongoing work or students progressing to higher education). Disability was measured with the Toronto Extremity Salvage Score and the Musculoskeletal Tumor Society score., Results: Nine patients (25%) experienced altered work status. There were no significant differences in disability ratings or demographic information between the 2 groups. Baseline job demand and living environment (rural vs urban, P=.001) were predictive by logistic regression., Conclusions: Patients with physically demanding jobs, and those living rurally, are at greatest risk for altered work status., (Copyright 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Background: Lower-extremity tumors are often treated by amputation rather than limb-sparing excision that sacrifices the sciatic nerve or a branch. This study assessed the functional outcome of major nerve sacrifice during limb-sparing resections for lower-extremity soft tissue sarcoma., Methods: Patients who underwent division of the sciatic, tibial, or peroneal nerve(s) during limb-sparing sarcoma surgery (January 1982 through June 2000) were identified. Eleven surviving patients evaluated their pre- and postoperative functional status by self-administered questionnaire (six sciatic, two tibial, and three peroneal nerve divisions)., Results: Eighteen patients (10 male, 8 female; 14-84 years old) had nine primary and nine locally recurrent tumors. Tumors were high (16) or low grade (two). Five patients died of disease and two died of other causes. Median overall survival was 50 months. One of 11 reported increased pain. Eight had new phantom sensations with a median intensity of 4.5 (1 = least; 10 = most). All patients used an ankle brace to walk after a sciatic (four) or peroneal (one) division. Walking ability and distance after surgery was unchanged (nine), improved (one), and worsened (one). Standing improved in 7 of 11 patients. Proprioception in the affected extremity was retained in six. The median postoperative leg functional score was 8 (1 = worst; 10 = best). No patient developed foot ulcers. One patient underwent amputation for recurrence. All patients preferred their status over having an amputation., Conclusions: Objectively and subjectively, division of the major lower-extremity nerves causes acceptable functional deficits in most patients. Resection of affected sciatic nerve (branches) during limb-sparing tumor surgery is an excellent alternative to amputation.

Decisions based on ethics confront nurses daily. In this account, a cardiac nurse struggles with the challenge of securing health care benefits for Justin, a patient within the American system of health care. An exercise therapy that is important for his well-being is denied. The patient's nurse and an interested insurance agent develop a working relationship, resulting in a relational narrative based on Justin's care. Gadow's concept of a relational narrative and Keller's concept of a relational autonomy guide this particular case. As an ethics framework influenced by feminist ethical theory, Gadow's, Keller's and Tisdale's ideas demonstrate the fluidity with which the nurse and others can work while maintaining both autonomy and engagement without being self-sacrificing.

The studies reporting functional outcome for patients undergoing limb preservation surgery for extremity soft tissue sarcoma (STS) have evaluated mainly impairments, that is, deficits at an anatomic structure level, such as joint range of motion and strength. Disability, activities of daily living, self-care, and mobility have been less frequently evaluated. Review of the literature suggests that approximately 50% of patients treated for STS have significant impairments, whereas the frequency of disability is less. Synthesis of the results is difficult because of the heterogeneity of patient samples, treatment, and the outcomes used to evaluate function. Future studies require the use of standardized definitions and reliable and valid functional outcome measures. Improved patient outcomes can be achieved only by understanding the determinants of these outcomes and by introducing interventions to improve patient functional outcome.

The authors present a 10-year retrospective study of 52 patients with dermatofibrosarcomas (33 cases), sarcomas (13 cases) and desmoid tumours (6 cases) operated in their department. All these tumours were located in the abdomen or adjacent regions. Resection margins were 5 cm for dermatofibrosarcomas and 2 cm for sarcomas and desmoid tumours, with a healthy deep anatomical barrier. Dermatofibrosarcomas were repaired by direct suture in 18% of cases, directed healing in 15%, healing and graft in 45% and flap in 31% of cases. 61% of sarcomas were sutured directly, 7% were treated by directed healing and 23% required cover by a flap. All desmoid tumours were closed by primary suture. The quality of the first surgical resection remains the predominant prognostic factor.

Objective: To quantify the differences in physical disability and handicap experienced by patients with lower extremity sarcoma who required amputation for their primary tumor as compared with those treated by limb-sparing surgery., Design: Matched case-control study. Twelve patients with amputation were matched with 24 patients treated by limb-sparing surgery on the following variables: age, gender, length of follow-up, bone versus soft-tissue tumor, anatomic site, and treatment with adjuvant chemotherapy., Patients: Patients who underwent above-knee amputation (AKA) or below-knee amputation (BKA) for primary soft-tissue or bone sarcoma, who had not developed local or systemic recurrence, and who had been followed up for at least 1 year since surgery., Main Outcome Measures: The Toronto Extremity Salvage Score (TESS), a measure of physical disability; the Shortform-36 (SF-36), a generic health status measure; and the Reintegration to Normal Living (RNL), a measure of handicap., Results: Mean TESS score for the patients with amputations was 74.5 versus 85.1 for the limb-sparing patients. (p = .15). Only the physical function subscale of the SF-36 showed statistically significant differences, with means of 45 and 71.1 for the amputation versus limb-sparing groups, respectively (p = .03). The RNL for the amputation group was 84.4 versus 97 for the limb-sparing group (p = .05). Seven of the 12 patients with amputations experienced ongoing difficulty with the soft tissues overlying their stumps., Conclusions: There was a trend toward increased disability for those in the amputation group versus those in the limb-sparing group, with the amputation group showing significantly higher levels of handicap. These data suggest that the differences in disability between amputation and limb-sparing patients are smaller than anticipated. The differences may be more notable in measuring handicap.

1. Adequate complete surgical resection with a oncologic radical or wide margin of normal tissue represents the most important measure to prevent a local recurrence. Limited excision with "shelling-out" of the tumor, through its "pseudocapsule" almost invariably means positive microscopic margins. The pathohistologically or macroscopically marginal or intralesional positive resection margins make a salvage surgery necessary. 2. A close safety margin of < 1 cm due to neighboured anatomic structures indicates a high risk of local recurrence and makes an adjuvant radiotherapy mandatory. Plastic-reconstructive surgery should prepare the radiotherapy fields, to avoid cavities or ulcerations. 3. Facts should be stated in the clinical record and the operation report, e.g. the safety margin should be defined by the surgeon and the pathologist; the histopathologic stage and grade are absolutely basic requirements. If necessary, a second histopathologic review should be asked for. 4. Tumor resection and reconstructive oncoplastic measures should correspond individually to the oncologic parameters, to the functional demands and to the age of the patient. 5. Multidisciplinary cooperation in a tumorboard is a precondition for an adequate treatment.

Background: Adjuvant chemotherapy and endoprosthetic replacement for bone sarcomas of the lower extremity is well established. The specific long-term consequences of these endoprosthetic reconstructions for the patient's affected limb are unknown., Method: The oncologic results and the survival of the endoprostheses were reviewed in 32 patients with primary bone sarcoma of the femur or proximal tibia. There were 26 high-grade sarcomas, and 6 low-grade sarcomas. A proximal femoral endoprosthesis was used for reconstruction in 4 patients, a total or push-through femoral endoprosthesis in 11 patients, a distal femoral endoprosthesis in 15 patients, and a proximal tibial endoprosthesis in two patients., Results: Median survival was 10 years (range, 1.1 to 18.9 years) for patients with high-grade sarcoma, and 8.1 years (range, 7.1 to 10 years) for patients with low-grade sarcomas. Distant metastases developed in seven patients (22%), all with stage IIB sarcoma, with concomitant local recurrence in 3 patients (9%). Five-year overall and disease-free survival rates for high-grade sarcomas were 81% and 73%, respectively. The overall endoprosthetic survival rate was 87% at 5 years, 80% at 10 years, and 56% at 15 years. Median follow-up of the original endoprostheses was 8.3 years (range, 0.6 to 18.7 years). Endoprosthesis-related complications occurred in 13 patients (41%); most complications were mechanical failures. The highest complication rate was found in distal femoral replacements (60%); amputation was necessary in both patients treated with a proximal tibial endoprosthesis. Five endoprostheses (16%) were revised. An amputation of the involved limb was performed in four patients (13%): in two patients because of local recurrence and in the other two patients because of infection. For patients alive at follow-up, the median functional Enneking evaluation score was 22 points (range, 12 to 28 points), with the highest functional scores in patients with a distal femoral endoprosthesis, and the lowest functional scores in patients with total or push-through femoral replacements., Conclusion: Endoprosthetic reconstructions gave satisfying functional results in most patients after long-term survival. However, the proximal tibial and distal femoral endoprosthesis are particularly at risk for long-term endoprosthetic complications requiring additional surgical procedures.

The advantages of the prosthetic replacement after resection of bone tumours include: 1) relatively simple technique, 2) modularity, 3) immediate function, 4) no disease transmission, 5) arthroplasty is possible. The disadvantages include: 1) late complications-asceptic loosening, bearing failure, fracture, 2) muscle re-attachment, 3) bone stock loss.

A case report is presented on the successful use of a bipedicled scapular osteocutaneous free flap in a young woman, whose hemimandible was resected because of sarcoma, 1 year prior to presentation. The postoperative course was uneventful and donor site morbidity minimal.

Over the past 15 years, reconstruction following excision of malignant oral tumors was performed on 27 patients with segmental resection and five patients with hemiresection of the mandible. Following segmental resection, the mandible was reconstructed using an autogenous bone graft in eight patients in whom the surrounding soft tissues were fairly well preserved. Bony union was achieved in six of them. In the remaining two, the graft was removed because of postoperative infection, and one patient underwent secondary bone grafting. A pedicled myocutaneous flap and bone graft was used in seven patients who underwent extensive resection of the surrounding soft tissue. Bony union was achieved in three patients, and one developed pseudoarthrosis. The graft was removed in the remaining three because of postoperative infection. Reconstruction with only a metallic plate for stabilization of the mandible was carried out in six aged or sarcoma-affected patients. In two of them, the postoperative course was uneventful for 4 to 7 years. In the remaining four patients, plate removal was required because of exposure or tumor recurrence. In 5 of 11 patients in whom reconstruction was carried out with a combination of a pedicled myocutaneous flap and metallic plate, the postoperative course was uneventful for 2 to 8 years. Two of these five patients underwent secondary bone grafting. In four of the remaining six patients, the plate was removed because of exposure or improper adaptation to the stump. Two others died of disseminated intravascular coagulation syndrome within 1 month. A prosthesis was used more frequently by patients when reconstruction was performed using a pedicled osteomyocutaneous flap. The metallic reconstruction plate was helpful for restoring mandibular contour.(ABSTRACT TRUNCATED AT 250 WORDS)

The paper deals with the experience gained in carrying out rehabilitative surgery in 33 infant patients (37 operations) with bone sarcoma within 12 months to 12 years after combined treatment of primary tumor. Twenty-two operations using procedures of compression-distraction osteosynthesis were performed in 18 patients for post-surgery development of bone deformities and shorter limbs. shortening. Advantages of compression-distraction procedures are discussed since their application allows to make incisions and remove bone in areas outside the zone of radiation injury and permanent monitoring of exposed soft tissue condition. Twenty-two infants survived 5 years after orthopedic treatment. Four children died from metastases into the lungs 1-4 years after orthopedic rehabilitation.

Data of 13 patients with tumors of the locomotor system subjected to +interscapular-thoracic resection (ITR) are presented. Main technical aspects of ITR are described. Complications took place in 6 patients, including marginal necrosis of the skin in 4 patients. As a whole the 5-year survival made up 49.9% +/- 13.8%. Data are presented on rehabilitation measures which allow to widen the functional possibilities of the extremity.

Quality of life and limb function were studied in 54 patients who were disease-free 2 or more years after limb-conserving treatment for soft tissue sarcoma of the leg or pelvic girdle. Tumours of the thigh predominated (25 patients) and the mean tumour size was 9.9 cm. 41 patients had been treated with a combination of surgery and radiotherapy (29 with conventional and 12 with high dose), 12 with surgery alone and one with irradiation and intra-arterial doxorubicin. Only 15 patients had a normal range of movement in all lower limb joints and only 12 had normal power in all muscle groups; tumours of the lower leg were particularly unfavourable in this respect. Gait was normal in 42 patients but 8 required a walking aid and 4 a joint support. 16 had detectable lymphoedema but only 2 needed to wear compression hosiery. 35 patients still experienced pain at some time but only 6 required analgesia. However, when assessed by questionnaire for locomotion, grooming and home/leisure/vocational activities, 37 patients (68%) reported excellent function, and only 2 had moderate impairment. Function loss was most marked in leisure (25 patients) and vocational (8) activities, but was mild in 66% of cases. Multivariate analysis was carried out to determine the prognostic factors for poor limb function. The results suggested that overall functional score was predominantly determined by gait (P less than 0.001), muscle power or range of movement (P less than 0.001), with increasing age, female sex and the use of radiotherapy poor prognostic factors. Reduced muscle power or range of movement were the major factors determining gait (P less than 0.02) with the use of radiotherapy the significant prognostic factor for both in the conventionally treated group. Doses in excess of 60 Gy resulted in increased fibrosis and a worse functional outcome. Extent of surgery was not an independent prognostic factor for limb function, although univariate analysis suggested an association with range of movement in the conventionally treated group (P less than 0.025). Despite significant objective loss of range of movement and muscle power patients retain excellent limb function and quality of life following limb conserving treatment. For optimal function, radiotherapy should be given with small fractions to a dose not exceeding 60 Gy.

Amputation is still necessary to achieve disease-free margins in some patients with osteogenic sarcoma. Improving the quality of life for this largely young patient population has become increasingly important considering the dramatic increase in their survival rate. A multidisciplinary approach should include prosthetic devices that are comfortable and lightweight, and produce an energy-efficient gait, an aggressive postoperative rehabilitation, and an objective evaluation of progress. This approach will help improve the high net energy expenditure of ambulation and the asymmetrical stance time experienced by this group of individuals and allow them to gain equal status in society.

The authors devised a new method for making a maxillary prosthesis with a hollow obturator, which was named the Balloon Technique. This new technique has a number of advantages over the conventional method in that it not only facilitates the molding of a soft plastic hollow obturator in a single process, but also simplifies the trial fitting of the completed obturator. Furthermore, it makes possible firm adhesion of the hollow obturator and the denture base by the hot-melt method while the denture base resin is cured. Finally, the completed maxillary prosthesis is extremely light.

The physiatrist's chief concern for the child with an amputation secondary to tumor is that of comprehensive prosthetic rehabilitation. Problems unique to these children, factors which affect restoration favorably or unfavorably, principles of management, and measures of outcome are described and also illustrated by a case history. A multidisciplinary pediatric amputee clinic is recommended as the optimal setting for a prosthetic rehabilitation program.