Abstract
Aims
To evaluate mid-to long-term patient-reported outcome measures (PROMs) of endoprosthetic reconstruction after resection of malignant tumours arising around the knee, and to investigate the risk factors for unfavourable PROMs.
Methods
The medical records of 75 patients who underwent surgery between 2000 and 2020 were retrospectively reviewed, and 44 patients who were alive and available for follow-up (at a mean of 9.7 years postoperatively) were included in the study. Leg length discrepancy was measured on whole-leg radiographs, and functional assessment was performed with PROMs (Toronto Extremity Salvage Score (TESS) and Comprehensive Outcome Measure for Musculoskeletal Oncology Lower Extremity (COMMON-LE)) with two different aspects. The thresholds for unfavourable PROMs were determined using anchor questions regarding satisfaction, and the risk factors for unfavourable PROMs were investigated.
Results
The thresholds for favourable TESS and COMMON were 64.8 and 70.4 points, respectively. Multivariate analysis showed that age at surgery (p = 0.004) and postoperative leg length discrepancy (p = 0.043) were significant risk factors for unfavourable TESS results, while age at surgery (p < 0.001) was a significant risk factor for unfavourable COMMON-LE results. Following receiver operating characteristic analysis, the threshold for both TESS and COMMON-LE was 29 years of age at surgery. Additionally, a leg length discrepancy of 8.2 mm was the threshold for unfavourable TESS.
Conclusion
Patients aged > 29 years at the time of surgery require appropriate preoperative counselling and adequate postoperative physical and socioemotional support. Reconstruction equivalent to the length of the resected bone can reduce the risk of functional disabilities in daily living.
Cite this article: Bone Jt Open 2023;4(12):906–913.
Take home message
Age at surgery and postoperative leg length discrepancy were associated with patient-reported outcomes after endoprosthetic knee arthroplasty.
Introduction
Improvement in multimodal treatment for musculoskeletal malignancies has enabled higher patient survival and limb-salvaging procedures.1,2 Endoprosthetic reconstruction following the resection of malignant tumours arising in the limbs has been an established and widely used procedure for limb-salvaging.3-6 A particularly common site for malignancies of the lower limbs is the knee; the oncological outcomes of patients with knee endoprosthetic reconstruction have improved. Therefore, evaluation of long-term postoperative functional outcomes around the knee is becoming increasingly important.
Recently, patient-reported outcome measures (PROMs) have been used to evaluate postoperative physical function, activity, and satisfaction after various musculoskeletal surgeries.7-9 The Toronto Extremity Salvage Score (TESS) is the most commonly used PROM in lower limb salvage surgery,10 and has been validated in languages worldwide.11-13 The TESS evaluates physical function using a questionnaire on difficulties in activities of daily living. Health-related quality of life (HRQoL), including body image, mental status, and social activities, has also been the focus in recent years.14,15 The Comprehensive Outcome Measure for Musculoskeletal Oncology Lower Extremity (COMMON-LE), a disease-specific PROM developed in Japan, comprehensively evaluates HRQOL in terms of pain, activities of daily living (ADLs), socioemotional conditions, and general health domain.16 These PROMs have been used to compare cohorts with different treatment strategies4,17 and observe changes over time.18 However, the distribution, characteristics, success thresholds, and determinants of favourable PROMs remain unclear.
Despite good oncological achievements, the surgical procedure for endoprosthetic knee arthroplasty is invasive and requires resection of massive volumes of bone and soft-tissue around the tumour. This surgery often results in complications, such as infection, aseptic loosening, and prosthetic fractures, leading to revision surgery.3,19-22 Furthermore, younger patients frequently have leg length discrepancies even with the use of expandable prostheses such as the Kotz Modular Femur Tibia Reconstruction system (Stryker, UK). Massive volumes of bone and soft-tissue resection and postoperative leg length differences may make ADLs more difficult and adversely affect PROMs.17,23 However, few studies have assessed factors affecting PROMs in knee tumour endoprostheses.
In this study, we evaluated mid- to long-term postoperative PROMs after endoprosthetic knee arthroplasty and investigated the following clinical question: what are the risk factors for unfavourable PROMs after endoprosthetic knee arthroplasty? We studied two types of PROMs (TESS and COMMON-LE) with different evaluation aspects.
Methods
Patient selection and data acquisition
This study included 75 consecutive patients (75 knees) who underwent endoprosthetic reconstruction after resection of malignant tumours arising around the knee joint between January 2000 and December 2020. The exclusion criteria were as follows: 14 patients due to death, 12 due to hospital transfer, one due to secondary amputation for postoperative tumour recurrence, and four due to disagreement with the PROMs. After eligibility assessment, 44 patients were included in this study (Figure 1). For all enrolled patients, the following information was retrospectively obtained from the medical records: age at surgery, height, weight, BMI, tumour diagnosis, site of tumour origin (distal femur or proximal tibia), distant metastasis at surgery, bone resection length, follow-up duration, recurrence, postoperative complications, additional surgery, postoperative chemotherapy, and postoperative radiation therapy. All patients were Japanese, and informed consent was obtained before participation in the study. This retrospective study was approved by the local institutional review board for clinical research (No. 2020-184) and was conducted in accordance with the Declaration of Helsinki.24 Demographic and radiological parameters and PROMs of the patients are shown in Table I.
Fig. 1
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) diagram for inclusion process.
Table I.
Patient demographic and radiological data (n = 44).
| Parameters | Value |
|---|---|
| Mean age, yrs (SD) | 29.9 (19.5) |
| Sex, n | |
| Male | 26 |
| Female | 18 |
| Mean height, cm (SD) | 162.2 (10.1) |
| Mean body weight, kg (SD) | 57.9 (12.8) |
| Mean BMI, kg/m2 (SD) | 21.8 (4.0) |
| Diagnosis, n | |
| Osteosarcoma | 28 |
| Giant cell tumour | 6 |
| Chondrosarcoma | 5 |
| Leiomyosarcoma | 2 |
| Ewing’s sarcoma | 1 |
| Synovial sarcoma | 1 |
| Diffuse large B-cell lymphoma | 1 |
| Metastasis at surgery, n | |
| Yes | 4 |
| No | 40 |
| Localization, n | |
| Distal femur | 28 |
| Proximal tibia | 16 |
| Bone | 41 |
| Soft-tissue | 3 |
| Mean resected bone length, cm (SD) | 14.4 (3.1) |
| Adjuvant treatment | |
| Chemotherapy, n | |
| Yes | 30 |
| No | 14 |
| Radiation, n | |
| Yes | 0 |
| No | 44 |
| Mean follow-up, yrs | 9.7 (6.2) |
| Recurrence, n | 1 |
| Complications, n | |
| Surgical site infection | 7 |
| Implant-related complication | 6 |
| Additional surgeries, n | |
| Yes | 15 |
| No | 29 |
| Mean leg length discrepancy, mm (SD) | 10.1 (21.3) |
| Mean difference of JLH, mm (SD) | 4.4 (4.0) |
| Satisfaction, n | |
| 1 | 1 |
| 2 | 3 |
| 3 | 5 |
| 4 | 22 |
| 5 | 13 |
| Mean TESS (SD) | 74.8 (21.7) |
| Mean COMMON-LE score (SD) | 72.2 (20.9) |
-
COMMON-LE, Comprehensive Outcome Measure for Musculoskeletal Oncology: Lower Extremity; JLH, joint line height; SD, standard deviation; TESS, Toronto Extremity Salvage Score.
Radiological and clinical evaluation
Postoperative whole-leg anteroposterior (AP) radiographs were obtained for all patients at the latest follow-up. Radiological images were imported into digital image processing software (OP-A; FUJIFILM Medical, Japan), and leg length was measured. Leg length was measured as the distance between the top of the femoral head and the centre of the ankle joint,25 and the leg length discrepancy with the opposite lower leg was calculated (Figure 2a). The joint line height (JLH) was measured according to previous reports,26,27 (Figure 2b) and the difference between the operative side and the opposite side was also calculated.
Fig. 2
a) Leg length was measured as the distance between the top of the femoral head and the centre of the ankle joint. The leg length discrepancy with the opposite lower leg was calculated. b) Measurement of joint line height. On the operative side, the distance from the fibular head to a line connecting the most distal points of the medial and lateral femoral condyle (white dashed line) was measured. On the opposite side, the distance from the fibular head to the mid-line through the joint space (black dashed line) was measured.
Questionnaires were administered at the latest follow-up to assess the TESS and COMMON-LE PROMs. The TESS, which is a rating system for physical function developed to evaluate physical and functional disability in daily living, consists of 30 questionnaires with a total score ranging from 0 to 100, with higher scores indicating better outcomes.10,12 COMMON-LE is also a rating system for HRQOL in patients with musculoskeletal tumours and consists of a series of 27 questionnaires (three questions on pain, 15 questions on ADL, and nine questions in the socioemotional condition and general health domain) with a total score ranging from 0 to 100, with higher scores indicating better outcomes.16 In addition, an anchor question for patient-acceptable symptomatic state (PASS) analysis was asked: “Do you have difficulty with your ability to perform these activities for all the activities you perform in your daily life?” They were asked to rate their satisfaction on a five-point scale (1: Unacceptable, 2: Poor, 3: Fair, 4: Good, 5: Excellent – the higher the score, the higher the level of satisfaction). The PASS is defined as a value within the range in which the patient perceives the condition of the lower limb as good.8,28 One way to determine the PASS is to analyze the answers to anchor questions using a receiver operating characteristic (ROC) curve.8,28 Anchor questions are recommended to be intuitive and correlated with target PROMs.8,29 In this study, after examining the correlation between the anchor question score and the total scores of the TESS and COMMON-LE, a score of 4 or 5 was defined as ‘good’. The TESS and COMMON-LE threshold values for good anchor question results were calculated using ROC curve analysis.
Statistical analysis
Correlations between the anchor question and each PROMs were evaluated using Spearman’s correlation coefficients. ROC analysis was performed to determine the PASS thresholds for TESS and COMMON-LE. Using the determined thresholds, TESS and COMMON-LE classified patients as above (favourable) or below (unfavourable) the threshold. Parameters were compared between groups achieving PASS (favourable) and those not achieving PASS (unfavourable) to screen for risk factors for unfavourable PROMs (TESS and COMMON-LE, respectively). Fisher’s exact test and the chi-squared test were used as appropriate for categorical parameters, and the Mann-Whitney U test and independent-samples t-test were used as appropriate to compare continuous parameters. Statistical significance was set at p < 0.05. Variables with p-values < 0.05 were included in a multivariable model to identify the independent influence of each factor. ROC curves were plotted to calculate the sensitivity, specificity, and cutoff values of the independent factors of unfavourable PROMs. Continuous variables are presented as mean and standard deviation (SD). Statistical analyses were performed using the JMP statistical analysis software (version 15.0; SAS Institute, USA).
Results
The correlation between the anchor question and the TESS was good (r = 0.80; p < 0.001, Spearman’s correlation coefficients), and the correlation between the anchor question and the COMMON-LE was also good (r = 0.82; p < 0.001, Spearman’s correlation coefficients). ROC analysis showed that the PASS thresholds for TESS and COMMON were 64.8 and 70.4 points, respectively (Table II, Figure 3). The demographic and radiological parameters were compared between the two groups of patients who achieved PASS (Table III). The group with unfavourable TESS was older (p < 0.001, Mann-Whitney U test), shorter (p = 0.013, Mann-Whitney U test), and had a large leg length discrepancy (p = 0.001, Mann-Whitney U test). The group with unfavourable COMMON-LE scores was older (p = 0.003, Mann-Whitney U test). Tumour location, additional surgery due to complications, chemotherapy, and follow-up duration had no significant effect on PROMs (Supplementary Tables i to iv). Multivariate analysis showed that older age at surgery and larger postoperative leg length discrepancy (p = 0.004 and 0.043, variables with p < 0.05 in comparison in the univariate model were included in the multivariate analysis) were risk factors for unfavourable TESS results, whereas older age at surgery (p < 0.001, variables with p < 0.05 in comparison in the univariate model were included in the multivariate analysis) was a risk factor for unfavourable COMMON-LE results (Table IV). Following ROC analysis, the threshold for both TESS and COMMON-LE was 29 years. The area under the curve (AUC) was 0.83 for TESS and 0.79 for COMMON-LE. A leg length discrepancy of more than 8.2 mm was the threshold for unfavourable TESS (AUC = 0.82) (Figure 4).
Fig. 3
Receiver operating characteristic curve for favourable Toronto Extremity Salvage Score (TESS) and Comprehensive Outcome Measure for Musculoskeletal Oncology: Lower Extremity (COMMON-LE). a) The threshold for TESS was 64.8 (sensitivity 86%, specificity 89%, area under the curve 0.91). b) The threshold for COMMON-LE was 70.4 (sensitivity 84%, specificity 89%, area under the curve 0.87).
Fig. 4
Receiver operating characteristic (ROC) curve for setting thresholds for a) age at surgery and b) leg length discrepancy for unfavourable Toronto Extremity Salvage Score; c) ROC curve for setting thresholds for age at surgery for unfavourable Comprehensive Outcome Measure for Musculoskeletal Oncology: Lower Extremity. a) The threshold for age at surgery was 29 (sensitivity 77%, specificity 94%, area under the curve 0.83). b) The threshold for postoperative leg length discrepancy was 8.2 mm (sensitivity 77%, specificity 84%, area under the curve 0.82). c) The threshold for age at surgery was 29 (sensitivity 69%, specificity 90%, area under the curve 0.79).
Table II.
Distributions and thresholds of patient-reported outcome measures after surgery.
| PROM | Mean score (SD) | Threshold value | Favourable outcomes, n (%) |
|---|---|---|---|
| TESS | 74.8 (21.7) | ≥ 64.8 | 31 (69) |
| COMMON-LE | 72.2 (20.9) | ≥ 70.4 | 31 (69) |
-
COMMON-LE, Comprehensive Outcome Measure for Musculoskeletal Oncology - Lower Extremity; PROM, patient-reported outcome measure; SD, standard deviation; TESS, Toronto Extremity Salvage Score.
Table III.
Patient demographic and radiological data.
| Parameter | Favourable | Unfavourable | p-value |
|---|---|---|---|
| TESS | ≥ 64.8 (n = 31) | < 64.8 (n = 13) | |
| Mean age, yrs (SD) | 21.2 (9.5) | 50.8 (21.8) | < 0.001* |
| Sex, n | 0.098† | ||
| Male | 21 | 5 | |
| Female | 10 | 8 | |
| Mean height, cm (SD) | 164.8 (7.2) | 156.0 (13.2) | 0.013* |
| Mean body weight, kg (SD) | 60.3 (11.3) | 52.0 (14.5) | 0.173‡ |
| Mean BMI, kg/m2 (SD) | 22.1 (3.6) | 21.0 (4.8) | 0.529* |
| Metastasis, n | 1.000† | ||
| Yes | 3 | 1 | |
| No | 28 | 2 | |
| Localization, n | |||
| DF | 19 | 9 | 0.739† |
| PT | 12 | 4 | |
| Bone | 28 | 13 | 0.544† |
| Soft-tissue | 3 | 0 | |
| Mean resected bone length, cm (SD) | 14.6 (3.0) | 13.9 (3.5) | 0.271* |
| Chemotherapy, n | 1.000† | ||
| Yes | 21 | 9 | |
| No | 10 | 4 | |
| Mean follow-up, yrs (SD) | 10.5 (6.6) | 7.7 (5.2) | 0.185* |
| Recurrence, n | 0.296† | ||
| Yes | 0 | 1 | |
| No | 31 | 12 | |
| Additional surgeries, n | 0.162† | ||
| Yes | 13 | 2 | |
| No | 18 | 11 | |
| Mean leg length discrepancy, mm (SD) | 5.6 (5.4) | 20.7 (37.1) | 0.001* |
| Mean difference of JLH, mm (SD) | 4.1 (3.6) | 5.1 (4.8) | 0.411‡ |
| Mean TESS (SD) | 86.2 (9.6) | 47.6 (17.8) | < 0.001* |
| COMMON-LE | ≥ 70.4 (n = 31) | < 70.4 (n = 13) | |
| Mean age, yrs (SD) | 22.7 (13.1) | 47.1 (22.0) | 0.003* |
| Sex, n | 0.098† | ||
| Male | 21 | 5 | |
| Female | 10 | 8 | |
| Mean height, cm (SD) | 163.5 (10.9) | 159.2 (7.4) | 0.057* |
| Mean body weight, kg (SD) | 58.5 (13.4) | 56.4 (11.7) | 0.787‡ |
| Mean BMI, kg/m2 (SD) | 21.7 (3.9) | 22.2 (4.2) | 0.546* |
| Metastasis, n | 0.071† | ||
| Yes | 1 | 3 | |
| No | 30 | 10 | |
| Localization, n | |||
| Distal femur | 19 | 9 | 0.738† |
| Proximal tibia | 12 | 4 | |
| Bone | 29 | 12 | 1.000† |
| Soft-tissue | 2 | 1 | |
| Mean resected bone length, cm (SD) | 14.5 (3.3) | 14.2 (3.0) | 0.816* |
| Chemotherapy, n | 1.000† | ||
| Yes | 21 | 9 | |
| No | 10 | 4 | |
| Mean follow-up, yrs (SD) | 10.9 (6.6) | 6.8 (4.2) | 0.059* |
| Recurrence, n | 1.000† | ||
| Yes | 1 | 0 | |
| No | 30 | 13 | |
| Additional surgeries, n | 0.162† | ||
| Yes | 13 | 2 | |
| No | 18 | 11 | |
| Mean leg length discrepancy, mm (SD) | 10.5 (25.3) | 9.0 (4.8) | 0.068* |
| Mean difference of JLH, mm (SD) | 3.8 (3.3) | 5.6 (5.5) | 0.231‡ |
| Mean COMMON-LE score (SD) | 83.7 (7.8) | 47.5 (18.6) | < 0.001* |
-
*
Mann-Whitney U test.
-
†
Fisher's exact test.
-
‡
Independent-samples t-test.
-
COMMON-LE, Comprehensive Outcome Measure for Musculoskeletal Oncology - Lower Extremity; JLH, joint line height; SD, standard deviation; TESS, Toronto Extremity Salvage Score.
Table IV.
Multivariate analysis of factors associated with unfavourable Toronto Extremity Salvage Score and Comprehensive Outcome Measure for Musculoskeletal Oncology - Lower Extremity.
| Parameters | Odds ratio (95% CI) | p-value |
|---|---|---|
| TESS | ||
| Age, yrs | 1.12 (1.04 to 1.21) | 0.004 |
| Height, cm | 0.96 (0.81 to 1.15) | 0.674 |
| Leg length discrepancy, mm | 1.22 (1.01 to 1.47) | 0.043 |
| COMMON-LE | ||
| Age, yrs | 1.07 (1.02 to 1.12) | < 0.001 |
-
CI, confidence interval; COMMON-LE, Comprehensive Outcome Measure for Musculoskeletal Oncology - Lower Extremity; TESS, Toronto Extremity Salvage Score.
Discussion
We evaluated mid- to long-term postoperative outcomes in 44 patients who underwent endoprosthetic knee arthroplasty using PROMs. An important finding of this study was that the postoperative PROMs of endoprosthetic knee arthroplasty were analyzed from two different perspectives, identifying factors that reduce the outcomes. Age at surgery and leg length discrepancy were associated with unfavourable PROMs.
Age at the time of surgery has been reported to be a factor leading to unfavourable PROMs.4,30,31 Postoperative TESS decreases with advancing age due to less motivation for rehabilitation and higher use of analgesics and walking aids in daily life.4 We established a threshold for age at surgery as a risk factor for unfavourable PROMs in the cohort (median 21, interquartile range 16 to 40). Interestingly, the results were similar for PROMs, TESS, and COMMON-LE, with age at surgery > 29 years resulting in unfavourable outcomes. From a physical perspective, young patients adapt to their changing physical circumstances and learn to live with their disabilities.4 From a mental health perspective, the life stage of 18- to 29-year-olds is called “emerging adulthood”, and after marriage, childbirth, and finding a stable job, they are said to transition to “adult” at age 30.32,33 This mental health transition may explain the results of the current study, which showed similar thresholds in COMMON-LE, reflecting HRQoL. Appropriate preoperative coe anchor question aunselling should be provided to patients aged over 29 years, and adequate physical and socioemotional support may be important after surgery.
We identified postoperative leg length discrepancy as a risk factor for decreased TESS with a threshold of 8.2 mm. In postoperative total hip arthroplasty patients, leg length discrepancies of less than 10 mm have been acceptable,23 while those greater than 10 mm cause limping and uneven weight distribution, decreasing patient satisfaction.34-36 Although there are no reports on the relationship between leg length discrepancy and postoperative PROMs after endoprosthetic knee arthroplasty, patients with endoprosthetic knee arthroplasty following wide tumour resection might have unfavourable PROMs because the processes are similar. In the current study, postoperative leg length discrepancy significantly decreased TESS, whereas the resected bone length had no significant influence on TESS, suggesting that reconstructing a length equivalent to the resected length may reduce the risk of unfavourable functional outcomes. Leg length discrepancy was a risk factor for unfavourable TESS, but not for COMMON-LE, because of the differences in the characteristics of each PROMs. The TESS investigates the specific limitations of physical activities, whereas the COMMON-LE includes many categories that reflect mental status, health status, and overall HRQoL. The large leg length discrepancy made ADLs difficult, but did not affect HRQoL. These differences in outcomes may be explained by the different aspects assessed in each PROM.
Short stature at surgery was significant in univariate analysis but not a significant factor for unfavourable TESS in multivariate analysis. Younger age and short stature at the time of surgery may increase leg length differences with growth,37 resulting in worse PROMs; however, in the present cohort, two patients (age at surgery: 11 and 13 years) underwent additional surgery to extend the prosthesis for improvement of leg length discrepancy due to postoperative growth, and their PROMs achieved favourable outcomes (TESS: 86, 87, and COMMON-LE: 91, 85). These cases have been treated with extendable prostheses (the Kotz Growing type) in light of the potential need for leg lengthening, so that additional surgery could be performed with less invasive procedures. In cases with common rotating-hinge knee prostheses, additional surgery is highly invasive, requiring stem replacement and polyethylene bearing replacement, especially in cases of excessive leg length. For mild leg length discrepancies, shoe lifts should be recommended if the patient is symptomatic.
This study has several limitations. First, we used a retrospective study design to analyze clinical data. Second, we investigated only a small number of patients from a single institution. Third, the study did not evaluate preoperative PROMs. The relatively long follow-up period of ten years for the patients studied is a strength of this study; however, the common use of PROMs has been established relatively recently (the Japanese version of the TESS was developed in 2015 and COMMON-LE in 2019). Patients with long-term follow-up had undergone surgery before these PROMs were developed. TESS and COMMON-LE have been used to evaluate postoperative disability following limb salvage surgery,38,39 indicating that preoperative function of most patients with tumour around the knee might be almost normal. New findings could be added if the minimal clinically important difference (MCID) is calculated by comparing preoperative and postoperative PROMs. Fourth, the follow-up duration in this study had a large level of variance, and the follow-up duration for some patients was relatively short. van Egmond-van Dam et al18 reported that two years of postoperative follow-up is necessary to observe complications and minor life disabilities, but improvement in functional outcomes is relatively stable after that. In the present study, a follow-up period > two years was defined as the inclusion criterion. There were no significant differences in follow-up duration between the favourable and unfavourable PROM groups. In addition, there was no significant difference in PROMs between cases with a follow-up period of less than ten years and more than ten years (Supplementary Table iv). Finally, this study population was limited to Japanese subjects. Patients with an average BMI of 21.8 are standard for Asian populations,40 but not the same for other races, therefore the results may not generalize to different races.
In summary, mid- to long-term postoperative PROMs for endoprosthetic knee arthroplasty after tumour resection were assessed. Age at surgery > 29 years and postoperative leg length discrepancy greater than 8.2 mm were associated with unfavourable PROMs. Appropriate counselling should be provided to preoperative patients, as well as adequate physical and postoperative socioemotional support. Depending on the extent of soft-tissue and bone resection for the treatment of tumours, reconstruction equivalent to the length of the resected bone may reduce the risk of functional disability in daily living.
References
1. Bielack SS , Kempf-Bielack B , Delling G , et al. Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols . J Clin Oncol . 2002 ; 20 ( 3 ): 776 – 790 . Crossref PubMed Google Scholar
2. Nagarajan R , Clohisy DR , Neglia JP , et al. Function and quality-of-life of survivors of pelvic and lower extremity osteosarcoma and Ewing’s sarcoma: the Childhood Cancer Survivor Study . Br J Cancer . 2004 ; 91 ( 11 ): 1858 – 1865 . Crossref PubMed Google Scholar
3. Fujiwara T , Ebihara T , Kitade K , et al. Risk factors of periprosthetic infection in patients with tumor prostheses following resection for musculoskeletal tumor of the lower limb . J Clin Med . 2020 ; 9 ( 10 ): 3133 . Crossref PubMed Google Scholar
4. Tunn PU , Pomraenke D , Goerling U , Hohenberger P . Functional outcome after endoprosthetic limb-salvage therapy of primary bone tumours--a comparative analysis using the MSTS score, the TESS and the RNL index . Int Orthop . 2008 ; 32 ( 5 ): 619 – 625 . Crossref PubMed Google Scholar
5. Kokubu Y , Fujiwara T , Nakagawa K , et al. Postoperative clinical and functional outcomes in patients with tumor and tumor-like lesion of foot and ankle . J Foot Ankle Res . 2022 ; 15 ( 1 ): 75 . Crossref PubMed Google Scholar
6. Shimada E , Matsumoto Y , Endo M , et al. Clinical benefits of vessel sealing system (LigaSure™) during surgery for soft tissue sarcoma: a propensity score matching analysis . Jpn J Clin Oncol . 2021 ; 51 ( 8 ): 1242 – 1247 . Crossref PubMed Google Scholar
7. Vajapey SP , Morris J , Li D , Greco NG , Li M , Spitzer AI . Outcome reporting patterns in total hip arthroplasty: A systematic review of randomized clinical trials . JBJS Rev . 2020 ; 8 ( 4 ): e0197 . Crossref PubMed Google Scholar
8. Nakashima Y , Ishibashi S , Kitamura K , et al. 20-year hip survivorship and patient-reported outcome measures after transpositional osteotomy of the acetabulum for dysplastic hips . Bone Joint J . 2022 ; 104-B ( 7 ): 767 – 774 . Crossref PubMed Google Scholar
9. Kamal AF , Rubiansyah P . Clinical outcome of various limb salvage surgeries in osteosarcoma around knee: Megaprosthesis, extracorporeal irradiation and resection arthrodesis . Ann Med Surg (Lond) . 2019 ; 42 : 14 – 18 . Crossref PubMed Google Scholar
10. Davis AM , Wright JG , Williams JI , Bombardier C , Griffin A , Bell RS . Development of a measure of physical function for patients with bone and soft tissue sarcoma . Qual Life Res . 1996 ; 5 ( 5 ): 508 – 516 . Crossref PubMed Google Scholar
11. Iwata S , Uehara K , Ogura K , et al. Reliability and validity of a Japanese-language and culturally adapted version of the Musculoskeletal Tumor Society Scoring System for the lower extremity . Clin Orthop Relat Res . 2016 ; 474 ( 9 ): 2044 – 2052 . Crossref PubMed Google Scholar
12. Ogura K , Uehara K , Akiyama T , et al. Cross-cultural adaptation and validation of the Japanese version of the Toronto Extremity Salvage Score (TESS) for patients with malignant musculoskeletal tumors in the lower extremities . J Orthop Sci . 2015 ; 20 ( 6 ): 1098 – 1105 . Crossref PubMed Google Scholar
13. Saraiva D , de Camargo B , Davis AM . Cultural adaptation, translation and validation of a functional outcome questionnaire (TESS) to Portuguese with application to patients with lower extremity osteosarcoma . Pediatr Blood Cancer . 2008 ; 50 ( 5 ): 1039 – 1042 . Crossref PubMed Google Scholar
14. Haraldstad K , Wahl A , Andenæs R , et al. A systematic review of quality of life research in medicine and health sciences . Qual Life Res . 2019 ; 28 ( 10 ): 2641 – 2650 . Crossref PubMed Google Scholar
15. Ow N , Mayo NE . Health-related quality of life scores of typically developing children and adolescents around the world: a meta-analysis with meta-regression . Qual Life Res . 2020 ; 29 ( 9 ): 2311 – 2332 . Crossref PubMed Google Scholar
16. Ogura K , Uehara K , Akiyama T , et al. Development of a patient-oriented disease specific outcome measure of health-related quality of life (HRQOL) for musculoskeletal oncology patients . J Orthop Sci . 2019 ; 24 ( 3 ): 539 – 547 . Crossref PubMed Google Scholar
17. Li W-C , Yang R-S , Tsauo J-Y . Knee proprioception in patients with osteosarcoma around the knee after modular endoprosthetic reconstruction . J Bone Joint Surg Am . 2005 ; 87-A ( 4 ): 850 – 856 . Crossref PubMed Google Scholar
18. van Egmond-van Dam JC , Bekkering WP , Bramer JAM , Beishuizen A , Fiocco M , Dijkstra PDS . Functional outcome after surgery in patients with bone sarcoma around the knee; results from a long-term prospective study . J Surg Oncol . 2017 ; 115 ( 8 ): 1028 – 1032 . Crossref PubMed Google Scholar
19. Zhang C , Hu J , Zhu K , Cai T , Ma X . Survival, complications and functional outcomes of cemented megaprostheses for high-grade osteosarcoma around the knee . Int Orthop . 2018 ; 42 ( 4 ): 927 – 938 . Crossref PubMed Google Scholar
20. Morgan HD , Cizik AM , Leopold SS , Hawkins DS , Conrad EU . Survival of tumor megaprostheses replacements about the knee . Clin Orthop Relat Res . 2006 ; 450 : 39 – 45 . Crossref PubMed Google Scholar
21. Henderson ER , O’Connor MI , Ruggieri P , et al. Classification of failure of limb salvage after reconstructive surgery for bone tumours: a modified system Including biological and expandable reconstructions . Bone Joint J . 2014 ; 96-B ( 11 ): 1436 – 1440 . Crossref PubMed Google Scholar
22. Wu C-C , Henshaw RM , Pritsch T , Squires MH , Malawer MM . Implant design and resection length affect cemented endoprosthesis survival in proximal tibial reconstruction . J Arthroplasty . 2008 ; 23 ( 6 ): 886 – 893 . Crossref PubMed Google Scholar
23. McWilliams AB , Grainger AJ , O’Connor PJ , Redmond AC , Stewart TD , Stone MH . A review of symptomatic leg length inequality following total hip arthroplasty . Hip Int . 2013 ; 23 ( 1 ): 6 – 14 . Crossref PubMed Google Scholar
24. World Medical Association . World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects . JAMA . 2013 ; 310 ( 20 ): 2191 – 2194 . Crossref PubMed Google Scholar
25. Kim SH , Rhee S-M , Lim J-W , Lee H-J . The effect of leg length discrepancy on clinical outcome after TKA and identification of possible risk factors . Knee Surg Sports Traumatol Arthrosc . 2016 ; 24 ( 8 ): 2678 – 2685 . Crossref PubMed Google Scholar
26. Wyss TF , Schuster AJ , Münger P , Pfluger D , Wehrli U . Does total knee joint replacement with the soft tissue balancing surgical technique maintain the natural joint line? Arch Orthop Trauma Surg . 2006 ; 126 ( 7 ): 480 – 486 . Crossref PubMed Google Scholar
27. Kawamura H , Bourne RB . Factors affecting range of flexion after total knee arthroplasty . J Orthop Sci . 2001 ; 6 ( 3 ): 248 – 252 . Crossref PubMed Google Scholar
28. Rosinsky PJ , Chen JW , Lall AC , Shapira J , Maldonado DR , Domb BG . Can we help patients forget their joint? Determining a threshold for successful outcome for the Forgotten Joint Score . J Arthroplasty . 2020 ; 35 ( 1 ): 153 – 159 . Crossref PubMed Google Scholar
29. Florissi I , Galea V , Shin D , et al. External validation of achieving the patient acceptable symptom state for the EuroQol-5 Dimension 1 year after total hip arthroplasty . J Bone Joint Surg Am . 2021 ; 103-A ( 2 ): e5 . Crossref PubMed Google Scholar
30. Bamdad K , Hudson S , Briggs T . Factors associated with functional outcome in patients having limb salvage surgery for primary malignant bone sarcoma using TESS . J Clin Orthop Trauma . 2019 ; 10 ( 5 ): 986 – 990 . Crossref PubMed Google Scholar
31. Kask G , Uimonen MM , Barner-Rasmussen I , Tukiainen EJ , Blomqvist C , Repo JP . Further validation of the Toronto extremity salvage score for lower extremity soft tissue sarcoma based on Finnish patients . J Plast Reconstr Aesthet Surg . 2021 ; 74 ( 1 ): 71 – 78 . Crossref PubMed Google Scholar
32. Arnett JJ . Emerging adulthood. A theory of development from the late teens through the twenties . Am Psychol . 2000 ; 55 ( 5 ): 469 – 480 . PubMed Google Scholar
33. Arnett JJ , Žukauskienė R , Sugimura K . The new life stage of emerging adulthood at ages 18-29 years: implications for mental health . Lancet Psychiatry . 2014 ; 1 ( 7 ): 569 – 576 . Crossref PubMed Google Scholar
34. Röder C , Vogel R , Burri L , Dietrich D , Staub LP . Total hip arthroplasty: leg length inequality impairs functional outcomes and patient satisfaction . BMC Musculoskelet Disord . 2012 ; 13 : 95 . Crossref PubMed Google Scholar
35. Edeen J , Sharkey PF , Alexander AH . Clinical significance of leg-length inequality after total hip arthroplasty . Am J Orthop (Belle Mead NJ) . 1995 ; 24 ( 4 ): 347 – 351 . PubMed Google Scholar
36. Swaminathan V , Cartwright-Terry M , Moorehead JD , Bowey A , Scott SJ . The effect of leg length discrepancy upon load distribution in the static phase (standing) . Gait Posture . 2014 ; 40 ( 4 ): 561 – 563 . Crossref PubMed Google Scholar
37. Beebe K , Song KJ , Ross E , Tuy B , Patterson F , Benevenia J . Functional outcomes after limb-salvage surgery and endoprosthetic reconstruction with an expandable prosthesis: a report of 4 cases . Arch Phys Med Rehabil . 2009 ; 90 ( 6 ): 1039 – 1047 . Crossref PubMed Google Scholar
38. Tsauo J-Y , Li W-C , Yang R-S . Functional outcomes after endoprosthetic knee reconstruction following resection of osteosarcoma near the knee . Disabil Rehabil . 2006 ; 28 ( 1 ): 61 – 66 . Crossref PubMed Google Scholar
39. Carty CP , Dickinson IC , Watts MC , Crawford RW , Steadman P . Impairment and disability following limb salvage procedures for bone sarcoma . Knee . 2009 ; 16 ( 5 ): 405 – 408 . Crossref PubMed Google Scholar
40. No authors listed . The Asia-Pacific perspective: redefining obesity and its treatment . World Health Organization . https://apps.who.int/iris/bitstream/handle/10665/206936/0957708211_eng.pdf ( date last accessed 7 November 2023 ). Google Scholar
Author contributions
Y. Kokubu: Conceptualization, Data curation, Investigation, Writing – original draft, Writing – review & editing.
T. Fujiwara: Conceptualization, Data curation, Investigation, Writing – original draft, Writing – review & editing.
Y. Matsumoto: Conceptualization, Data curation, Writing – review & editing.
M. Endo: Conceptualization, Data curation, Writing – review & editing.
N. Setsu: Conceptualization, Data curation, Writing – review & editing.
K. Iida: Conceptualization, Data curation, Writing – review & editing.
A. Nabeshima: Conceptualization, Data duration, Writing – review and editing.
Y. Nakashima: Conceptualization, Writing – review & editing.
Funding statement
The authors disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: this work was partially supported by the Grants-in-Aid for Young Scientists (grant number JP22K09359) from the Japan Society for the Promotion of Science.
ICMJE COI statement
Each author certifies that he has no commercial associations that might pose a conflict of interest in connection with the submitted article.
Data sharing
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.
Acknowledgements
The authors would like to thank Editage (www.editage.jp) for the English language review.
Ethical review statement
This study approval was obtained from the Institutional Review Board of our institution (No. 2020-184). The study was conducted in accordance with the Declaration of Helsinki.
Open access funding
The open access fee for this article was funded by the Japan College of Rheumatology Grant for Promoting Basic Rheumatology.
Supplementary material
Tables showing comparison of the patient characteristics by localization, additional surgeries, chemotherapy, and follow-up period.
© 2023 Fujiwara et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
