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PubMed2006

Comparison of the action research arm test and the Fugl-Meyer assessment as measures of upper-extremity motor weakness after stroke.

OBJECTIVE: To assess the relative responsiveness of 2 commonly used upper-extremity motor scales, the Action Research Arm Test (ARAT) and the Fugl-Meyer Assessment (FMA), in evaluating recovery of upper-extremity function after an acute stroke in patients undergoing inpatient rehabilitation. DESIGN: Prospective. SETTING: An acute stroke rehabilitation unit. PARTICIPANTS: One hundred four consecutive admissions (43 men, 61 women; mean age +/- standard deviation, 72+/-13y) to a rehabilitation unit 16+/-9 days after acute stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The following assessments were completed within 72 hours of admission and 24 hours before discharge: ARAT, upper-extremity motor domain of the FMA, National Institutes of Health Stroke Scale, FIM instrument total score, and FIM activities of daily living (FIM-ADL) subscore. RESULTS: The Spearman rank correlation statistic indicated that the 2 upper-limb motor scales (ARAT, FMA) correlated highly with one another, both on admission (rho = .77, P < .001) and on discharge (rho = .87, P < .001). The mean change in score from admission to discharge was 10+/-15 for the ARAT and 10+/-13 for the FMA motor score. The responsiveness to change as measured by the standard response mean was .68 for the ARAT and .74 for the FMA motor score. The Spearman rank correlation of each upper-limb motor scale with the FIM-ADL at the time of admission was as follows: ARAT, rho equal to .32 (P < .001) and FMA motor score, rho equal to .54 (P < .001). CONCLUSIONS: Both the FMA motor score and the ARAT were equally sensitive to change during inpatient acute rehabilitation and could be routinely used to measure recovery of upper-extremity motor function.

Aged↗
PubMed2005

Muscle strength is a determinant of bone mineral content in the hemiparetic upper extremity: implications for stroke rehabilitation.

Individuals with stroke have a high incidence of bone fractures and approximately 30% of these fractures occur in the upper extremity. The high risk of falls and the decline in bone and muscle health make the chronic stroke population particularly prone to upper extremity fractures. This was the first study to investigate the bone mineral content (BMC), bone mineral density (BMD), and soft tissue composition of the upper extremities and their relationship to stroke-related impairments in ambulatory individuals with chronic stroke (onset >1 year). Dual-energy X-ray absorptiometry (DXA) was used to acquire total body scans on 56 (22 women) community-dwelling individuals (>or=50 years of age) with chronic stroke. BMC (g) and BMD (g/cm2), lean mass (g), and fat mass (g) for each arm were derived from the total body scans. The paretic upper extremity was evaluated for muscle strength (hand-held dynamometry), impairment of motor function (Fugl-Meyer motor assessment), spasticity (Modified Ashworth Scale), and amount of use of the paretic arm in daily activities (Motor Activity Log). Results showed that the paretic arm had significantly lower BMC (13.8%, P<0.001), BMD (4.5%, P<0.001), and lean mass (9.0%, P<0.001) but higher fat mass (6.3%, P=0.028) than the non-paretic arm. Multiple regression analysis showed that lean mass in the paretic arm, height, and muscle strength were significant predictors (R2=0.810, P<0.001) of the paretic arm BMC. Height, muscle strength, and gender were significant predictors (R2=0.822, P<0.001) of lean mass in the paretic arm. These results highlight the potential of muscle strengthening to promote bone health of the paretic arm in individuals with chronic stroke.

Adipose Tissue↗
PubMed2005

Erysipelas of the upper extremity following locoregional therapy for breast cancer.

Cellulitis is a well-known complication of lymphedema of the lower extremities. Erysipelas of the upper extremity complicating breast cancer therapy has never been reported in the English-language literature. We describe seven breast cancer patients with erysipelas of the upper extremity. Five had a predisposing injury to the extremity. All patients responded very well to intravenous antibiotics without any sequelae. They had rapid resolution with typical desquamation. No long-term sequelae were seen except for mild increase of lymphedema. Erysipelas should be listed as a rare complication after locoregional therapy for breast cancer. Intravenous penicillin should be used as the initial therapy. Prevention of arm lymphedema and avoidance of any trauma to the arm are important prophylactic measures. Sentinel lymph node biopsy reduces the rate of axillary lymph node dissection and thus should reduce the incidence of lymphedema and erysipelas.

Adult↗
PubMed2005

Modifying center of mass trajectory during sit-to-stand tasks redistributes the mechanical demand across the lower extremity joints.

OBJECTIVE: Sit-to-stand tasks are commonly facilitated by modifying the initial position of the center of mass relative to the feet. It was hypothesized that modifications in the center of mass trajectory during sit-to-stand tasks altered the total body momentum at seat departure and redistributed the lower extremity net joint moments. DESIGN: Between-task within-subject comparison was employed using a robust statistical method to accommodate for small sample size. METHODS: Six individuals performed four sit-to-stand tasks with systematic modifications in the initial center of mass position by varying the orientation of the lower extremity segments. The momentum of the center of mass and lower extremity net joint moments were quantified and compared. RESULTS: Reducing the horizontal center of mass displacement significantly reduced horizontal total body momentum required at seat departure. Sit-to-stand tasks initiated with more horizontal shank and thigh positions required significantly greater knee and hip extensor net joint moments than those with more vertical shank and thigh positions. Sit-to-stand tasks initiated with vertical shank positions also required significantly greater hip extensor net joint moments as compared to those with more horizontal shank orientations. INTERPRETATION: When changes in initial center of mass position are made, alteration in center of mass horizontal momentum and the orientation of the lower extremity segments relative to the reaction force are observed. Consequently, mechanical demand imposed on the ankle, knee, and hip joint is redistributed. The magnitude of the net joint moments is dependent on the segment orientation, the reaction force, and the adjacent net joint moment.

Adaptation, Physiological↗
PubMed2006

An identification technique for evaluating body segment parameters in the upper extremity from manipulator-hand contact forces and arm kinematics.

OBJECTIVE: To show that it is possible to determine segment masses and segment centers of mass by measuring manipulator-hand contact forces and joint angles during upper extremity movement. BACKGROUND: The method serves as a quick subject specific body segment parameter evaluation technique. Clinically we see this method as an alternative upper extremity body segment parameter evaluation study especially useful in rehabilitation treatment activities. METHODS: The experiment is based on coupling the human arm with a robotic manipulator which is then used for imposing a specified sagittal plane trajectory. Joint angles and forces in the contact point serve as input to the identification procedure. For verification purposes the proposed identification procedure was first performed on a mechanical arm. Afterwards a low velocity trajectory was imposed into all joints of the human upper extremity, with very small angular deviations. Within this small angular region the arm was assumed to be represented as a linear system. FINDINGS: The outcome of the identification procedure is an estimate of masses and center of mass coordinates for the lower arm and palm segments, their products for the upper arm and the passive moments around the measured angle of all joints in the sagittal plane. The results obtained for three particular human arms are eventually compared to the average population based literature. CONCLUSION: From the clinical point of view the study can become useful for biomechanical evaluation and for evaluating biomechanical properties of lower extremities or other body segments. This method may also provide a foundation to measuring body segment moments of inertia and joint viscoelastic parameters.

Adult↗
PubMed2006

The effect of lower extremity fatigue on shock attenuation during single-leg landing.

BACKGROUND: The forces that are imposed on the body due to landings must be attenuated primarily in the lower extremity. Muscles assist in the absorption of these forces, and it has been shown that a fatigued muscle decreases the body's ability to attenuate shock from running. The purpose of the study was to determine the effect of lower extremity fatigue on shock attenuation and joint mechanics during a single-leg drop landing. METHODS: Ten active male participants were recruited (eight used for analysis). Each participant took part in a fatigue landing protocol. This protocol included cycles of a drop landing, a maximal countermovement jump, and five squats, repeated until exhaustion. Accelerometers attached to the skin measured tibia and head accelerations. Lower extremity kinematics were collected using an electromagnetic tracking system and kinetics were collected using a forceplate. A repeated-measures ANOVA (P<0.05) was performed on each of the dependent variables across the cycles of the fatigue protocol. FINDINGS: Fatigue was induced, however there was no significant change in shock attenuation throughout the body. Hip and knee flexion increased and ankle plantarflexion decreased at touchdown with fatigue. Hip joint work increased and ankle work decreased. INTERPRETATION: This change in work distribution is thought to be a compensatory response to utilize the larger hip extensors that are better suited to absorb the mechanical energy of the impact. The results suggested that the lower extremity is able to adapt to fatigue though altering kinematics at impact and redistributing work to larger proximal muscles.

Acceleration↗
PubMed2006

Low field MRI: a review of the literature and our experience in upper extremity imaging.

Since its introduction to medical imaging in the early 1980s, MRI has become essential in diagnosis and treatment of musculoskeletal conditions. Most imaging in the United States is performed on high-field whole-body scanners (>1.0 T). Imaging on low (<0.5 T) and medium (0.5-1.0 T) field strengths using small, low-cost, easily installed scanners in physicians' offices or imaging centers has gained popularity. These scanners can be useful in imaging the upper extremity from the shoulder to the fingers. This article provides an overview of the different extremity scanners available and their advantages and disadvantages, a brief review of the literature regarding their use, and a discussion of our experience in using the low-field extremity scanners in evaluating the upper extremity.

Humans↗
PubMed2006

The role of ultrasound in the evaluation of sports medicine injuries of the upper extremity.

The two major imaging modalities used for assessment of soft tissue injuries are ultrasound and MRI. Although ultrasound of the extremities is used only to a limited extent in the United States, it is widely used in many other countries for evaluation of extremity injuries. This article first considers the advantages and disadvantages of MRI and ultrasound. Understanding these differences will help the reader understand the role of ultrasound as compared with MRI in evaluating upper extremity injuries. The uses of ultrasound for evaluating sports medicine injuries in specific regions of the upper extremity are then reviewed. Where the data are available, the reported accuracy of ultrasound is compared with MRI for each type of injury.

Athletic Injuries↗
PubMed2004

Evaluation of the long term outcome of patients with extremity desmoids.

BACKGROUND: The optimum management and long-term outcome for patients with extremity desmoids remains unclear. The aim of this study was to evaluate the long-term outcome of patients with extremity desmoids and to compare patient episodes treated with surgery alone with those treated by radiotherapy either alone or with surgery at any stage of the patient's disease. METHODS: All patients with extremity desmoids followed at an oncology clinic with an interest in soft tissue tumours and treated between 1959 and 1996 were identified. All were traced back to their primary presentation and first treatment episode. RESULTS: During the study period 42 patients, 29 females and 13 males were identified. Median follow-up of the patient population was 12.5 years (range 3-30.9). Median age at presentation was 27 years (range 1-69). The lesion was in the upper limb or shoulder in 18, lower limp or pelvis 17 and head and neck 7. Forty patients underwent operation as their primary treatment, 25 of whom developed recurrent tumour. In all there were 41 recurrences following 78 episodes of surgery alone. This compared to 10 recurrences following 16 episodes of radiotherapy or radiotherapy with surgery (p = 0.467). There was no association between primary, first or second recurrence and the development of a further relapse. The median interval to recurrence after surgery alone was 12 months (interquartile range (IQR) 6-13) as opposed to 52 months (IQR 33-62) for patients treated with primary or adjuvant radiotherapy (p= 0.004). CONCLUSION: Results are poor after both radiotherapy and surgery for extremity desmoids and research into other methods of managing this rare condition need to be considered.

Adolescent↗
PubMed2005

The role of preoperative radiotherapy in nonmetastatic high-grade osteosarcoma of the extremities for limb-sparing surgery.

PURPOSE: To assess the role of preoperative radiotherapy in patients with nonmetastatic high-grade osteosarcoma of the extremities for limb-sparing surgery and to compare the response of neoadjuvant therapies, local control, and survival with the literature results. METHODS AND MATERIALS: Forty-six patients with osteosarcoma of the limbs who were treated within a limb salvage protocol including preoperative radiotherapy and chemotherapy between 1987 and 2002, were retrospectively analyzed. Median age was 17 years (range, 14-66 years). Treatment was started with neoadjuvant chemotherapy. Cisplatin, epidoxorubicin, ifosfamide, and methotrexate were used in different combinations. Preoperative radiotherapy was applied, usually between the second and third cycle of chemotherapy. Radiotherapy was given (35 Gy in 10 fractions) to 44 patients. Two patients were treated with 46 Gy at 2 Gy/day. Definitive surgery was administered after the third course of chemotherapy. Chemotherapy was complete 6 courses postsurgery. RESULTS: Median follow-up time was 44 months (range, 2-154 months). Forty-four patients had limb-sparing surgery, whereas 2 had amputation. Tumor necrosis rate was >/=90% in 87% of the patients (Huvos Grade 3-4). Two patients had local failures, and 26 patients (56.5%) had distant metastases. The 5-year local control and overall survival rates were 97.5% and 48.4%, respectively. On univariate analysis, age </=18 years, Huvos Grade 4, lower-extremity localization, and surgery within 1 month significantly survived better than the others. On multivariate analysis, Huvos grade (p = 0.01), age (p = 0.01), interval between neoadjuvant chemotherapy and surgery (p = 0.02), and extremity localization (p = 0.02) were significant prognostic factors for actuarial survival. Severe complication developed in 20% of the patients. CONCLUSION: Preoperative radiotherapy helps to increase the chance of extremity-sparing surgery with good local control and necrosis rate when combined with chemotherapy.

Adolescent↗
PubMed2006

Intraoperative electron boost radiation followed by moderate doses of external beam radiotherapy in limb-sparing treatment of patients with extremity soft-tissue sarcoma.

PURPOSE: To analyze long-term prognosis and morbidity after limb-sparing treatment of patients with extremity soft-tissue sarcoma, with intraoperative electron boost radiotherapy (IOERT) followed by a moderate dose of external beam radiotherapy (EBRT). METHODS AND MATERIALS: A total of 153 patients who were treated in a single center from 1991 to 2004 were evaluated. Median IOERT dose was 15 Gy, mean EBRT dose 43 Gy (range, 40-50.4 Gy) in conventional fractionation (1.8-2 Gy). Median duration of follow-up was 33 months. Acute toxicity was assessed with Common Toxicity Criteria; late toxic effects were scored according to European Organization for Research and Treatment of Cancer/Radiation Therapy Oncology Group criteria. RESULTS: Five-year overall survival and 5-year local control rates were 77% and 78%, respectively. Whereas tumor size, patient age, and EBRT dose did not significantly affect outcome, resection status and grading were significant for survival; resection status and IOERT dose were significant for local control. Extremity salvage until death or time of follow-up was achieved in 90% of our patients, 86% of whom showed excellent limb function without impairment in activities of daily life. Acute toxicity Grade 2-4 was observed in 23% and late toxicity Grade 2-4 in 17% of patients. CONCLUSIONS: Treatment with IOERT combined with moderate doses of external beam irradiation yields high local control and extremity preservation rates in resected extremity soft-tissue sarcoma.

Adolescent↗
PubMed2006

Demographic, social and economic variables that affect lower extremity injury outcomes.

While behavioral, demographic and vocational factors are commonly know as risk factors for sustaining a traumatic injury, less is known about the social, demographic and economic determinants of outcome following injury. The Lower Extremity Assessment Project (LEAP) identified a prospective cohort of 601 patients who were admitted to eight level I trauma centers in the United States for treatment of severe lower extremity trauma. Prospective data was accumulated on these individuals throughout their initial hospitalization and at regular follow-up intervals including a cohort at seven years post-injury. The results of the LEAP investigations showed that even at five to seven years following injury, reconstruction for the treatment of injuries to the lower extremity typically result in functional outcomes equivalent to those of the amputation. Clearly, factors other than the traditional variables such as fracture healing, joint function, and ability to ambulate have a profound effect on the patient's estimation of improvement. The purpose of this report is to summarize the data from the LEAP study and other investigations related to demographic, social and behavioral factors which impact outcome following lower extremity injury.

Adolescent↗
PubMed2006

Motor assessment of upper extremity function and its relation with fatigue, cognitive function and quality of life in multiple sclerosis patients.

OBJECTIVES: The aim of this study was to assess the motor function of upper extremity and its relation with fatigue, cognitive function and quality of life in Multiple Sclerosis (MS) patients. DESIGN: Cross-sectional and controlled study. SETTING: Outpatient clinic in a university hospital. SUBJECTS: Thirty-one patients with MS (25 women, 6 men; mean age 39.74 +/- 10.10 years; mean EDSS, 2.56 +/- 1.91) and 30 healthy subjects (20 women, 10 men; mean age 33.56 +/- 8.85 years) were enrolled into the study. MAIN MEASURES: Nine-hole peg test (9-HPT) and Valpar Component Work Sample Test (VCWS-4), Upper Extremity Index (UEI), Paced Auditory Serial Addition Test (PASAT), Fatigue Severity Scale (FSS), and the Multiple Sclerosis Quality of Life-54 (MSQOL-54). RESULTS: MS patients showed significant impairment in upper extremity motor functions, cognitive function and excessive fatigue compared to controls (p < 0.05). 9-HPT in MS group correlated with EDSS, UEI and MSQOL-54 physical health and cognitive function, whereas VCWS-4 scores (assembly right, assembly left and disassembly) correlated only with EDSS and UEI. No correlation was found between the VCWS-4 and cognitive function and fatigue in both of the groups. Compared to control group, a strong correlation existed between the 9-HPT and VCWS-4 in MS patients (p < 0.05). CONCLUSION: The results indicate that disability level (EDSS), UEI and cognitive function in MS patients are related with impairment in upper extremity motor function. This again contributes to an impairment in physical domain of quality of life. A strong correlation of the 9-HPT with VCWS-4 supports the use of the 9-HPT as a measure of manual dexterity and gross motor functions.

Adult↗
PubMed2005

Effects of a workplace physical exercise intervention on the intensity of headache and neck and shoulder symptoms and upper extremity muscular strength of office workers: a cluster randomized controlled cross-over trial.

The purpose of the study was to examine the effects of a workplace physical exercise intervention on the perceived intensity of headache and the intensity of symptoms in the neck and shoulders, as well as on the extension and flexion strength of the upper extremities. The study was a cluster randomized controlled trial. The cross-over design consisted of physical exercise intervention (15 weeks) and no-intervention (15 weeks). The subjects (n=53) were office workers (mean age 46.6 (SD 8.4)) who reported headache (n=41) symptoms in the neck (n=37) or shoulders (n=41), which had restricted their daily activities during the last 12 months. Pain symptoms were measured using the Borg CR10 scale and muscular strength with a 5RM test. Statistical analyses were based on linear mixed models. Physical exercise intervention resulted in a slight, but statistically significant, decrease in the intensity of headache and neck symptoms, as well as an increase in the extension strength of the upper extremities. The mean decrease in headache during the 5-week period was 0.64 CR10 (95% CI 0.28-1.00) (P=0.001) or 49% (95% CI 22-77), and 0.42 CR10 (95% CI 0.11-0.72) (P=0.002) or 49% (95% CI 13-85) in the intensity of neck symptoms. The mean increase in the extension strength of the upper extremities was 1.3 kg (95% CI 0.5-2.1) (P=0.001) or 4% (95% CI 1-6). The intervention had no effect on the intensity of shoulder symptoms or the flexion strength of the upper extremities. Specific exercise may be clinically important to alleviate headache and neck symptoms.

Activities of Daily Living↗
PubMed2005

A new scanning approach for limb extremities using a water bag in freehand 3-D ultrasound.

3-D ultrasound (US) can significantly improve the visualization of musculoskeletal tissues, such as residual limbs, feet and hands. Traditionally, mechanical scanning is normally required to obtain the entire volume of these limb extremities. In this paper, a new scanning approach using a water bag was described to collect the complete volume of various tissues surrounding bones. The water bag was used to contain the limb extremity and the scanning was conducted on its external surface from different directions. The recorded 2-D US images containing complete anatomic information surrounding the bones from different directions were used to form full 3-D volumes of the limb extremities. A plastic auxiliary apparatus was designed to hold the water bag and support the subject's limb part with an armrest. A corresponding algorithm was proposed to remove invalid image information within each sweep by a separating plane defined semiautomatically. Two phantoms were used to test the repeatability and accuracy of the imaging. The distance between two plastic bands attached to a plastic tube filled with US gel measured by a micrometer and from the four reconstructed volumes were 39.03 +/- 0.36 mm and 39.2 +/- 0.5 mm, respectively. The diameter, height and volume of a silicone cylinder phantom measured for the 10 reconstructed volumes were 40.2 +/- 1.4 mm, 12.9 +/- 1.0 mm and 16400 +/- 1600 mm(3), respectively. They agreed with the corresponding results obtained by the micrometer, which were 41.29 +/- 0.13 mm, 12.98 +/- 0.17 mm and 17370 +/- 140 mm(3), respectively. The reconstructed volumes of the two phantoms, a chicken leg in vitro, and human fingers in vivo were also reported. The preliminary results obtained in this study demonstrated that this new scanning approach should have potential for the 3-D US imaging of musculoskeletal extremities using freehand scanning.

Algorithms↗
PubMed2000

Preoperative staging, prognostic factors, and outcome for extremity rhabdomyosarcoma: a preliminary report from the Intergroup Rhabdomyosarcoma Study IV (1991-1997).

BACKGROUND: During the fourth Intergroup Rhabdomyosarcoma (RMS) Study (IRS IV, 1991-97), a preoperative staging system was evaluated prospectively for the first time. The authors evaluated this staging system and the role of surgery in extremity RMS in contemporary multimodal therapy. METHODS: A total of 139 patients (71 girls; median age, 6 years) were entered in IRS IV with extremity-site RMS. Stage was assigned by the IRSG Preoperative Staging System. Postsurgical group was determined by tumor status after initial surgical intervention. Multivariate analysis was performed using all pretreatment factors that were significant by univariate analysis, including clinical Group (i.e., I through IV), tumor invasiveness (T1,T2), nodal status (N0,N1), and tumor size (< or > or =5 cm). Failure-free survival rates (FFS) and survival rates were estimated using the Kaplan and Meier method. RESULTS: Preoperative staging and clinical group distribution were as follows: Stage 2, n = 34; Stage 3, n = 73; Stage 4, n = 32; Group I, n = 31; Group II, n = 21; Group III, n = 54; Group IV, n = 33. Three-year FFS was 55%, and the overall survival rate was 70%. Eighty-seven patients had either unresectable, gross residual disease (Group III) or metastases (Group IV). FFS was significantly worse for these patients with advanced disease, compared with that for patients with complete resection or with only microscopic residual tumor (i.e., Group I or II; Group I, 3-year FFS, 91%; Group II, 72%; Group III, 50%; Group IV, 23%; P<.001). Lymph nodes were evaluated surgically in 76 patients with positive results in 38. Clinically, 13 additional patients had nodal disease. Both stage and group were highly predictive of outcome and were highly correlated. By multivariate analysis, none of the other variables were predictors of FFS. CONCLUSIONS: This review confirms the utility of pretreatment staging for stratification of patients with extremity RMS with widely different risks of relapse, thereby paving the way for development of risk-based therapy. Group (operative staging) remains the most important predictor of FFS, emphasizing the importance of complete gross resection at initial surgical intervention, when feasible without loss of limb function. The high incidence of nodal disease in the patients who had lymph node biopsy confirms the need for surgical evaluation of lymph nodes to ensure accurate staging in children with extremity rhabdomyosarcoma.

Child↗
PubMed2000

Adjuvant radiotherapy for margin-positive high-grade soft tissue sarcoma of the extremity.

PURPOSE: Adjuvant radiotherapy (RT) has been shown to improve local control in patients with soft tissue sarcoma of the extremities (STS). The specific impact of adjuvant radiation on patients with positive margins, however, has not been clearly defined. The purpose of this study was to determine if adjuvant RT improves local control in patients with high-grade STS who had positive margins of resection. METHODS AND MATERIALS: Between 8/82 and 2/97, 110 adult patients with primary high-grade STS of an extremity underwent limb sparing surgery and were found to have a histologically positive microscopic surgical margin. Ninety-one (83%) received RT and 19 (17%) had no RT. The two groups were balanced with regard to size, site, location, and tumor depth. Adjuvant RT was delivered with brachytherapy (BRT) alone in 34 patients, external beam radiotherapy (EBRT) alone in 33 patients, or BRT+EBRT in 24 patients. The BRT dose was 45 Gy when used alone and 15-20 Gy when used as a boost. The EBRT dose was 60-70 Gy when used alone and 45-50 Gy when given with BRT. The median follow-up time was 41 months (range, 3-186 months). RESULTS: The overall 5 year local control rate was 71%. This rate was significantly higher in the RT group compared to the no RT group (74% vs. 56%, respectively) (p = 0.01). On univariate analysis, lower extremity site and proximal location were also found to be predictors of improved local control (p = 0.03 and 0.03, respectively). However, only proximal location and the use of RT retained their significance as predictors of improved local control on multivariate analysis (p = 0.003 and 0.01, respectively). The overall 5-year distant relapse-free survival, disease-free survival, and overall survival rates were 54%, 44%, and 53%, respectively. No statistical differences were found in these survival rates between RT and no RT groups. CONCLUSION: Based on this study, adjuvant radiotherapy seems to improve local control in patients with high-grade STS of the extremity with positive margins. However, local recurrence still occurs in a substantial proportion of patients, mandating further need for improvement.

Adolescent↗
PubMed2003

Tolerance of tissue transfers to adjuvant radiation therapy in primary soft tissue sarcoma of the extremity.

PURPOSE: Treatment of extremity sarcomas occasionally requires tissue transfer in the form of pedicle flaps, free flaps, or skin grafts to repair surgical defects. These tissues are often subject to radiation (RT) and are therefore at risk for wound breakdown requiring reoperation. This study reviews a single center's experience with tissue transfer and postoperative RT. METODS AND MATERIALS: Between 1983 and 2000, 43 adult patients (>16 years old) with primary high-grade soft tissue extremity sarcomas underwent limb-sparing surgery and reconstruction of their surgical defects, followed by adjuvant RT. The reconstructions were as follows: pedicle flaps (n = 14), free flaps (n = 10), skin grafts (n = 4), or a combination (n = 15). Postoperative external beam radiation therapy (EBRT) (median dose: 63 Gy) alone was given to 27 patients (63%). Adjuvant brachytherapy (BRT) was given to 16 patients (37%); BRT alone (median dose: 45 Gy) was given to 12 patients and combined with EBRT for 4 patients (EBRT: 45 Gy; BRT: 20 Gy). Comorbid conditions such as diabetes, hypertension, tobacco use, and obesity (calculated using body mass index >or=30) were present in 30 patients (70%). Tumor characteristics were as follows: 26 were >5 cm in size, 37 were deep, and 30 were in the lower extremity. The median follow-up time, calculated from the date of operation, was 32 months. Five of 43 patients suffered wound complications necessitating reoperation; however, 3 patients developed complications before initiation of RT and were therefore excluded from the analysis. Two of 43 patients (5%) required reoperation for wound complications after RT; 1 of these patients ultimately required amputation for necrosis. The 5-year overall wound reoperation rate was 6% (95% confidence interval: 0-14%). The influence of patient and tumor characteristics, as well as the type of RT, on the wound reoperation rates is as follows: BRT vs. EBRT (17% vs. 0%, p = 0.06); upper vs. lower extremity (0% vs. 8%, p = 0.41); 5 cm (8% vs. 4%, p = 0.9); comorbidity vs. no comorbidity (3% vs. 13%, p = 0.8); age 50 (8% vs. 4%, p = 0.8). CONCLUSION: Based on this review, most tissue transfers (95%) tolerated subsequent adjuvant radiation therapy well. Although more wound complications necessitating reoperation were seen in patients who received BRT, whether this is because of the inherent susceptibility of flaps and skin grafts to breakdown in the immediate postoperative period vs. the direct result of BRT needs further investigation.

Adolescent↗