FUNCTIONAL OUTCOMES FOLLOWING AMPUTATION AND LIMB-SALVAGE SURGERY AT DIFFERENT LEVELS IN THE LOWER EXTREMITY. Poonam K. Pardasaney*1; Patricia E. Sullivan1; Leslie G. Portney1; Henry J. Mankin2 1. Physical Therapy, MGH Institute of Health Professions, Boston, MA; 2. Orthopedic Oncology, Massachusetts General Hospital, Boston, MA PURPOSE: The purpose of this descriptive study was to report long-term psychological and physical function by level of surgery following amputation or limb- salvage for a lower extremity sarcoma. We hypothesized that a difference in outcomes following amputation and limb-salvage would be progressively more evident the higher the level of surgery, with amputation resulting in greater limitation of function. BACKGROUNDS/SIGNIFICANCE: Over the past two decades, limb-salvage surgery has replaced amputation as the standard procedure for extremity musculoskeletal sarcomas, unless it is expected to compromise the patient’s oncological or functional outcome. Although function and quality of life following amputation and limb-salvage have been previously compared, few studies have reported outcomes at distinct levels of surgery in the lower extremity. Because of different anatomical consequences and functional demands at different surgical levels, comparison of outcomes by level of surgery is needed to improve validity of results and clinical applicability. Availability of functional outcome data at specific levels of surgery may facilitate more informed pre-operative decision-making based on patients’ functional needs and desired outcomes. In addition, such data may enable physical therapists to more accurately estimate long-term functional prognosis of patients following surgery. SUBJECTS: The study included 408 subjects, of whom 65 had undergone amputation and 343 had undergone a limb-salvage procedure. Mean age of subjects was 49.3 ± 19.2 years, with a range of 11 to 96 years. Mean length of follow-up was 8.9 ± 5.2 years, with a range of 2 to 27 years. There was an equal number of males and females in the sample. METHODS AND MATERIALS: A secondary analysis was conducted on data collected by the Orthopedic Oncology Service at Massachusetts General Hospital (MGH). During 1999-2000, 1,199 persons who had undergone surgery at the Oncology Service for a primary malignant bone or soft-tissue tumor completed a study-specific self-report questionnaire regarding their function and quality of life. Subjects were included in this study if they had had a sarcoma of the lower extremity, and had a post- operative follow-up of at least 2 years. Subjects were classified into below-knee, above-knee, hip and pelvic levels of surgery. Twelve dichotomous variables concerning general health status, psychological and physical function were analyzed at each level of surgery. ANALYSES: Descriptive analyses were performed on demographic and tumor characteristics of the amputation and limb-salvage groups. Independent samples t- test was used to compare age at surgery, age at the time of questionnaire response, and length of follow-up for the two groups. Chi-square analysis was used to examine the influence of gender distribution in the two groups. To assess the relative risk associated with long-term psychological and physical limitation following amputation and limb- salvage at the four levels of surgery, we used relative risk and chi-square analyses. A relative risk (RR) value of 1 indicates neutral risk, a value greater than 1 indicates increased risk, and a value less than 1 indicates decreased risk. RESULTS: At the below-knee level of surgery, similar psychological and physical outcomes were observed following amputation and limb-salvage. Differences in outcomes were observed at the above-knee level of surgery, in agreement with our hypothesis. Anxiety (RR = 2.4), presence of a limp (RR = 1.6), use of a walking aid (RR = 2.1), and inability to drive (RR = 3.0) were more common following above-knee amputation; muscular weakness was less common following amputation (RR = 0.57). Employment and sports participation were similar. Outcomes following the two surgical procedures at the hip and pelvic levels could not be statistically compared due to a small number of amputations. However, limitations following both procedures were similar to those reported at the above-knee level of surgery, with a greater proportion of limitations in the amputation group. Within the amputation group, presence of a limp, use of a walking aid, and difficulty negotiating stairs were progressively more common the higher the level of surgery; muscular weakness was less commonly reported the higher the level of surgery. Within the limb-salvage group, muscular weakness, presence of a limp, and use of a walking aid were progressively more common the higher the level of surgery. CONCLUSIONS: The difference in results at the four levels of surgery validates the importance of distinguishing among surgical levels. The findings provide objective data to guide clinicians when counseling patients regarding functional prognosis based on type and level of surgery. The findings support our hypothesis that with progressively higher levels of surgery, relatively greater functional limitation would be observed following amputation. The functional advantage of limb-salvage is thus evident at proximal tumor locations. FUNDING SOURCE: Not applicable KEYWORDS: function, level of surgery, amputation, limb-salvage, lower extremity Copyright 2009 by the American Physical Therapy Association. Requests for reprints should be directed to the corresponding author of the article. 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