Symptoms and their Relationship to Disability Following Treatment for Lower Extremity Tumours

Feasibility of using low-cost markerless motion capture for assessing functional outcomes after lower extremity musculoskeletal cancer surgery

BACKGROUND

Physical limitations are frequent and debilitating after sarcoma treatment. Markerless motion capture (MMC) could measure these limitations. Historically expensive cumbersome systems have posed barriers to clinical translation.

RESEARCH QUESTION

Can inexpensive MMC [using Microsoft KinectTM] assess functional outcomes after sarcoma surgery, discriminate between tumour sub-groups and agree with existing assessments?

METHODS

Walking, unilateral stance and kneeling were measured in a cross-sectional study of patients with lower extremity sarcomas using MMC and standard video. Summary measures of temporal, balance, gait and movement velocity were derived. Feasibility and early indicators of validity of MMC were explored by comparing MMC measures i) between tumour sub-groups; ii) against video and iii) with established sarcoma tools [Toronto Extremity Salvage Score (TESS)), Musculoskeletal Tumour Rating System (MSTS), Quality of life-cancer survivors (QoL-CS)]. Statistical analysis was conducted using SPSS v19. Tumour sub-groups were compared using Mann-Whitney U tests, MMC was compared to existing sarcoma measures using correlations and with video using Intraclass correlation coefficient agreement.

RESULTS

Thirty-four adults of mean age 43 (minimum value-maximum value 19-89) years with musculoskeletal tumours in the femur (19), pelvis/hip (3), tibia (9), or ankle/foot (3) participated; 27 had limb sparing surgery and 7 amputation. MMC was well-tolerated and feasible to deliver. MMC discriminated between surgery groups for balance (p<0.05*), agreed with video for kneeling times [ICC = 0.742; p = 0.001*] and showed moderate relationships between MSTS and gait (p = 0.022*, r = -0.416); TESS and temporal outcomes (p = 0.016* and r = -0.0557*), movement velocity (p = 0.021*, r = -0.541); QoL-CS and balance (p = 0.027*, r = 0.441) [* = statistical significance]. As MMC uncovered important relationships between outcomes, it gave an insight into how functional impairments, balance, gait, disabilities and quality of life (QoL) are associated with each other. This gives an insight into mechanisms of poor outcomes, producing clinically useful data i.e. data which can inform clinical practice and guide the delivery of targeted rehabilitation. For example, patients presenting with poor balance in various activities can be prescribed with balance rehabilitation and those with difficulty in movements or activity transitions can be managed with exercises and training to improve the quality and efficiency of the movement.

SIGNIFICANCE

In this first study world-wide, investigating the use of MMC after sarcoma surgery, MMC was found to be acceptable and feasible to assess functional outcomes in this cancer population. MMC demonstrated early indicators of validity and also provided new knowledge that functional impairments are related to balance during unilateral stance and kneeling, gait and movement velocity during kneeling and these outcomes in turn are related to disabilities and QoL. This highlighted important relationships between different functional outcomes and QoL, providing valuable information for delivering personalised rehabilitation. After completing future validation work in a larger study, this approach can offer promise in clinical settings. Low-cost MMC shows promise in assessing patient's impairments in the hospitals or their homes and guiding clinical management and targeted rehabilitation based on novel MMC outcomes affected, therefore providing an opportunity for delivering personalised exercise programmes and physiotherapy care delivery for this rare cancer.

Free-living monitoring of ambulatory activity after treatments for lower extremity musculoskeletal cancers using an accelerometer-based wearable - a new paradigm to outcome assessment in musculoskeletal oncology?

PURPOSE

Ambulatory activity (walking) is affected after sarcoma surgery yet is not routinely assessed. Small inexpensive accelerometers could bridge the gap. Study objectives investigated, whether in patients with lower extremity musculoskeletal tumours: (A) it was feasible to conduct ambulatory activity assessments in patient's homes using an accelerometer-based wearable (AX3, Axivity). (B) AX3 assessments produced clinically useful data, distinguished tumour sub-groups and related to existing measures.

METHODS

In a prospective cross-sectional pilot, 34 patients with musculoskeletal tumours in the femur/thigh (19), pelvis/hip (3), tibia/leg (9), or ankle/foot (3) participated. Twenty-seven had limb-sparing surgery and seven amputation. Patients were assessed using a thigh-worn monitor. Summary measures of volume (total steps/day, total ambulatory bouts/day, mean bout length), pattern (alpha), and variability (S₂) of ambulatory activity were derived.

RESULTS

AX3 was well-tolerated and feasible to use. Outcomes compared to literature but did not distinguish tumour sub-groups. Alpha negatively correlated with disability (walking outside (r=-418, p = 0.042*), social life (r=-0.512, p = 0.010*)). Disability negatively predicted alpha (unstandardised co-efficient= -0.001, R²=0.186, p = 0.039*).

CONCLUSIONS

A wearable can assess novel attributes of walking; volume, pattern, and variability after sarcoma surgery. Such outcomes provide valuable information about people's physical performance in their homes, which can guide rehabilitation. Implications for rehabilitationRoutine capture of ambulatory activity by sarcoma services in peoples' homes can provide important information about individuals "actual" physical activity levels and limitations after sarcoma surgery to inform personalised rehabilitation and care needs, including timely referral for support.Routine remote ambulatory monitoring about out of hospital activity can support personalised care for patients, including identifying high risk patients who need rapid intervention and care closer to home.Use of routine remote ambulatory monitoring could enhance delivery of evidence-based care closer to peoples' homes without disrupting their daily routine and therefore reducing patient and carer burden.Collection of data close to home using questionnaires and objective community assessment could be more cost effective and comprehensive than in-hospital assessment and could reduce the need for hospital attendance, which is of importance to vulnerable patients, particularly during the Covid-19 pandemic.

Changes in Functional Outcome and Quality of Life in Soft Tissue Sarcoma Patients within the First Year after Surgery: A Prospective Observational Study

Soft tissue sarcoma (STS) patients undergoing surgery may experience reduced functional outcome (FO) and quality of life (QoL) compared to the general population. The aim of this study was to evaluate the development of FO and QoL in patients with STS in the extremities within the first year after first-time limb-sparing surgery. Twenty-nine out of 40 eligible patients were included in the present study. QoL and FO were evaluated by questionnaires while FO was also evaluated by objective tests. Patients were assessed before surgery and at fixed time points within the first year after surgery. Patients with STS in the extremities had an average strength of 82.34% (95% CI: 68.57-96.11) of the expected strength at one year post surgery. Multivariate, repeated ANOVA showed statistically significant reductions in strength in the disease-affected extremity when compared with the healthy side after surgery. Multivariate, repeated ANOVA showed a statistically significant improvement in FO and QoL within the first year post surgery. Limb-sparing surgery for STS significantly reduced strength in the disease-affected extremity and generally reduced FO and QoL in the first months after surgery. Improvements were observed for FO and QoL at one year after surgery.

Management of soft-tissue sarcomas; treatment strategies, staging, and outcomes

Soft-tissue sarcomas (STS) are a rare group of malignant tumors which can affect any age group. For the majority of patients who present with a localized STS, treatment involves a multidisciplinary team decision-making approach ultimately relying on surgical resection with or without adjuvant radiation for successful limb salvage. The goals of treatment are to provide the patient with a functional extremity without local tumor relapse. The purpose of this article is to review the treatment of extremity STS, with a focus on staging, treatment options, and outcomes.

Changes in the body image of bone sarcoma survivors following surgical treatment--A qualitative study

Background and Objectives

Among several long‐term effects, people treated for cancer may experience an altered appearance. Our study aims to identify how visible body changes following surgical treatment affect the life and identity of primary bone sarcoma survivors 3–10 years after diagnosis. A qualitative, phenomenological, and hermeneutic design was applied.

Methods

Sarcoma survivors (n = 18) who were previously treated at Norwegian Radium Hospital, Oslo University Hospital, participated in the study. In‐depth and semi‐structured interviews were conducted and analyzed using inductive thematic analysis.

Results

The main finding of this study concerned how altered appearance after bone cancer treatment in the hip/pelvis or lower extremities affected the participants’ self‐esteem. Half of the participants expressed concerns about their visible differences, particularly those with functional impairment. They felt that it is important to hide the bodily signs of changes to appear as normal as possible, as well as attractive and healthy. They describe, with specific examples, how these changes influence their self‐realization, especially their social life.

Conclusions

Healthcare providers who guide bone sarcoma survivors during follow‐up should develop a comprehensive understanding of what it means to cope with a changed and challenging body. J. Surg. Oncol. 2016;113:229–234. © 2015 The Authors. Journal of Surgical Oncology Published by Wiley Periodicals, Inc.

Cured of primary bone cancer, but at what cost: a qualitative study of functional impairment and lost opportunities

Purpose. Our study aims to explore how former cancer patients experience physical and psychosocial late effects 3–7 years after they underwent treatment for primary bone sarcoma in the hip/pelvic region. A qualitative, phenomenological, and hermeneutic design was applied. Methods. Sarcoma survivors (n = 10) previously treated at Oslo University Hospital, Norwegian Radium Hospital were selected to participate. In-depth and semistructured interviews were conducted. The interviews were analysed using inductive thematic analysis. Results. The participants reported that the late effects had three core spheres of impact: “their current daily life,” “their future opportunities,” and “their identity.” They expressed negative changes in activity, increased dependence on others, and exclusion from participation in different areas. Their daily life, work, sports activities, and social life were all affected. Several of their experiences are similar to those described by people with functional impairment or disability. Conclusion. Patients cured of bone cancer in the hip/pelvic region pay a significant price in terms of functional impairment, practical challenges, exclusion from important aspects of life, and loss of previous identity. It is important to appreciate this in order to help bone cancer survivors who struggle to reorient their life and build a secure new identity.

[Long-term functional results after sarcoma resection]

Multimodal treatment of malignant tumors of the musculoskeletal system with R0 in sano resection plays a key role in prevention of local recurrence in soft tissue and bone sarcoma. In cases of unavoidable neuromuscular or osseous defects, current plastic and orthoplastic reconstruction techniques avoid limb amputation in the majority of patients. Clinical long-term results demonstrate that large resection defects do not necessarily result in impaired limb function if multidisciplinary procedures are integrated. In oncologically necessary major limb amputation, segmental resection and replantation of distal limb parts should be considered which provide end-bearing long stump formation. The functional conditions of long-term surviving elderly patients should be integrated into surgical decision-making and rehabilitation efforts.

Distal femoral osteoarticular allografts: long-term survival, but frequent complications

BACKGROUND

Complications are frequent with osteoarticular allografts, and their long-term survivorship in the distal femur is unclear. Thus, the benefits of osteoarticular allografting remain controversial.

QUESTIONS/PURPOSES

We therefore determined the frequency of complications in osteoarticular allografts of the distal femur relative to their potential long-term survival.

METHODS

We retrospectively reviewed 26 patients who had osteoarticular allograft reconstruction of the distal femur after resection of a malignant or aggressive benign tumor of bone. The minimum followup was 15 months (average, 156 months; range, 15-283 months) for all patients and 98 months (average, 191 months; range, 98-283 months) for the surviving patients.

RESULTS

At last followup, 16 of the 26 original allografts were still in place. The overall 5-year and 10-year allograft survival rates were 69% and 63%, respectively. The 5-year and 10-year survival rates of the joint surface were 79% and 65%, respectively. Eleven patients retained their original osteoarticular allograft without a resurfacing procedure, and nine had been converted to allograft-prosthetic composites. Five patients were converted to megaprostheses and one had an amputation for local recurrence. At last followup, 25 of 26 patients retained a functional limb.

CONCLUSIONS

Osteoarticular allograft reconstructions of the distal femur can provide long term survival and restore function but the risk of complications and their physical and monetary costs for patients are not trivial. Lacking the benefit of improved soft tissue attachments inherent in other anatomic sites, we believe this option is most appropriate for restoring bone stock in young patients with expectations of long-term survival.