This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Davis, A.M. Articles by Zee, B. Search for Related Content PubMed PubMed Citation Articles by Davis, A.M. Articles by Zee, B. Social Bookmarking                            What's this?

Function and Health Status Outcomes in a Randomized Trial Comparing Preoperative and Postoperative Radiotherapy in Extremity Soft Tissue Sarcoma

From the Toronto Rehabilitation Institute, Princess Margaret Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario; Hopital Maisonneuve-Rosemont and Montreal General Hospital, Montreal, Quebec; London Regional Cancer Center, London, Ontario; British Columbia Cancer Agency, Vancouver, British Columbia; and National Cancer Institute of Canada–Clinical Trials Group, Kingston, Ontario, Canada.

Address reprint requests to Aileen M. Davis, PhD, Toronto Rehabilitation Institute, Rm 1119, 550 University Ave, Toronto, Ontario, Canada M5G 2A2; email: davis.aileen{at}torontorehab.on.ca

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: Morbidity associated with wound complications may translate into disability and quality-of-life disadvantages for patients treated with radiotherapy (RT) for soft tissue sarcoma (STS) of the extremities. Functional outcome and health status of extremity STS patients randomized in a phase III trial comparing preoperative versus postoperative RT is described.

PATIENTS AND METHODS: One hundred ninety patients with extremity STS were randomized after stratification by tumor size dichotomized at 10 cm. Function and quality of life were measured by the Musculoskeletal Tumor Society Rating Scale (MSTS), the Toronto Extremity Salvage Score (TESS), and the Short Form-36 (SF-36) at randomization, 6 weeks, and 3, 6, 12, and 24 months after surgery.

RESULTS: One hundred eighty-five patients had function data. Patients treated with postoperative RT had better function with higher MSTS (25.8 v 21.3, P < .01), TESS (69.8 v 60.6, P = .01), and SF-36 bodily pain (67.7 v 58.5, P = .03) scores at 6 weeks after surgery. There were no differences at later time points. Scores on the physical function, role-physical, and general health subscales of the SF-36 were significantly lower than Canadian normative data at all time points. After treatment arm was controlled for, MSTS change scores were predicted by a lower-extremity tumor, a large resection specimen, and motor nerve sacrifice; TESS change scores were predicted by lower-extremity tumor and prior incomplete excision. When wound complication was included in the model, patients with complications had lower MSTS and TESS scores in the first 2 years after treatment.

CONCLUSION: The timing of RT has minimal impact on the function of STS patients in the first year after surgery. Tumor characteristics and wound complications have a detrimental effect on patient function.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
LIMB PRESERVATION surgery, frequently in conjunction with adjuvant radiotherapy, is the recognized standard of treatment for patients with extremity soft tissue sarcoma (STS).^1-8 Although optimal local tumor control is achieved with these modalities, it is recognized that treatment may result in significant functional disability and reduced quality of life for patients. The volume of functional soft tissue resected, including structures such as major motor nerves, is dictated by both the need to excise the tumor surrounded by a margin of normal tissue and by the anatomic location of the tumor. External-beam radiotherapy may be given preoperatively or postoperatively. Preoperative radiotherapy has advantages, including a potentially lower dose of radiation to a smaller volume of tissue⁹ and, hence, less fibrosis and tissue damage. Preoperative radiotherapy should theoretically provide favorable conditions for enhancing patient function. Unfortunately, this functional advantage may be negated because preoperative radiotherapy has been associated with an increased incidence of severe wound complications that seem to detrimentally affect function.^10,11 Therefore, we evaluated the physical function and general health status of patients randomized to receive preoperative radiotherapy followed by surgery versus the function of patients randomized to receive surgery followed by postoperative radiotherapy in a longitudinal fashion. The hypothesis was that patients treated by preoperative radiotherapy followed by surgery would have better function than those treated with postoperative radiotherapy.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Patient Sample
The methodologic details of this multicenter, randomized trial are presented in the article by O’Sullivan et al¹² that describes the results of the primary outcome of the study: the incidence of major wound complications (defined as return to the operating room and/or continued deep packing at 4 months after surgery.) Subjects with potentially curable extremity STS were eligible for this trial if they required combined radiotherapy and limb-preserving surgery (based on an inability to excise tumor or surgically contaminated tissues with a minimum of 2 cm of normal tissue), had a diagnosis of a primary or recurrent STS by an approved reference pathologist, were older than 16 years of age, were staged by chest computed tomography and local computed tomography or magnetic resonance imaging, and provided written informed consent in accordance with the human subject’s review approval at each participating center. Exclusion criteria included the following: prior chemotherapy; prior radiotherapy to the local site; previous or concurrent malignancy; presence of regional or distant metastasis; benign histologic diagnoses, including aggressive fibromatosis; histologic subtypes generally treated with chemotherapy; and specific histologic diagnosis of embryonal or alveolar rhabdomyosarcoma, soft tissue osteosarcoma or Ewing’s sarcoma, or primitive neuroectodermal tumor or dermatofibrosarcoma protuberans. Patients were stratified by tumor size (dichotomized at 10 cm) before randomization to preoperative radiotherapy followed by surgery or to surgery followed by postoperative radiotherapy. Preoperative radiotherapy consisted of 50 Gy in 25 fractions with a boost dose of 16 Gy after operation if the resection margins were microscopically positive or 20 Gy if the margins were grossly positive for tumor on pathologic review of the surgical specimen. All patients in the postoperative radiotherapy group received 66 Gy in 33 fractions.

One hundred ninety patients were randomized, but three were subsequently found to be ineligible and a further two eligible patients never underwent an operation. Of these 185 patients, 13 patients did not participate in the patient-completed functional outcome component of the study because of language issues (six patients in the preoperative arm and seven in the postoperative radiotherapy group). However, all had clinician-completed functional scores. Ninety-one subjects randomized to preoperative radiotherapy and 94 subjects randomized to postoperative radiotherapy were included in the analysis of functional outcome. Function and general health status was evaluated within 14 days of randomization and at 6 weeks and 3, 6, 12, and 24 months after surgery.

Outcome Measures
The Musculoskeletal Tumor Society Rating Scale (MSTS),¹³ The Toronto Extremity Salvage Score (TESS),^14,15 and the Short Form-36 (SF-36)¹⁶ were used to evaluate function and general health status. The MSTS is a seven-item scale rated by the clinician and evaluates mainly clinical measures (pain, joint range of motion, strength, joint stability, joint deformity, overall function, and general acceptance of the treatment). The summary score ranges from 0 to 35. The TESS is a measure of physical disability developed specifically for patients with extremity sarcoma; the score ranges from 0 to 100. Patients rate the difficulty they experience performing routine daily activities. The SF-36 is also completed by the patient and has eight subscales (physical function, role-physical, bodily pain, general health, vitality role-emotional, social function, and mental health). The scores range from 0 to 100 on each subscale. Normative data for Canada have been published.¹⁷ For all measures, higher scores indicate a higher level of function. The reliability and validity of the MSTS, TESS, and SF-36 were previously evaluated in the extremity sarcoma population.^14,15

Data Quality
Data completeness was monitored as a measure of quality assurance. Compliance with form completion by clinicians and patients was calculated as the number of forms received divided by the number of forms expected for each evaluation time. With the exception of the 3-month postoperative radiotherapy arm with compliance of 90% on the TESS, compliance was greater than 95% for all measures at all times. However, as shown in Table 1, the sample size varied across the evaluation times because some patients experienced disease recurrence and were unable to complete forms; others died of nontumor-related causes (see O’Sullivan et al¹² for complete details).

Because the MSTS, TESS, and SF-36 subscale scores were not normally distributed, the Wilcoxon test was used to compare the differences between the preoperative and postoperative radiotherapy groups on each measure at each time of evaluation. The study sample SF-36 data and Canadian normative data were similarly compared using the Wilcoxon test. Each outcome measure was also modeled by repeated-measures analysis using treatment arm-by-time interaction as covariates in order to evaluate whether the functional profiles between the treatment arms were significantly different over time.

Finally, treatment arm, age, specimen size (in cubic centimeters), lower versus upper extremity, superficial versus deep tumors, prior incomplete excision (ie, incomplete tumor excision before referral to a subspecialty treatment center), bone resection, resection of a major motor nerve (ie, femoral, sciatic, obturator, peroneal, axillary, radial, musculocutaneous, and posterior interosseous nerves), and radiation field length were chosen as a priori candidate variables for predicting the MSTS, TESS and SF-36 scores. Stepwise multiple regression was used to model the change score from baseline (within 14 days of randomization) to each postoperative time point. A criterion of P < .10 was used to retain a variable in the multivariate analysis.

	RESULTS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Sample Characteristics
The sample patient demographics are listed in Table 2. The preoperative and postoperative radiotherapy groups were balanced for age, sex, comorbidity, local recurrence at presentation, tumor size, tumor depth, and intra- versus extracompartmental disease. However, the two groups were significantly different for the wound complication outcome,¹² with the preoperative radiotherapy treatment arm having a 35% complication rate as compared with 17% in the postoperative radiotherapy arm (P = .01).

The SF-36 subscale scores for each treatment arm were also compared with the Canadian normative data.¹⁷ The physical function, role-physical, and general health subscale scores of the SF-36 for both treatment groups were significantly lower than Canadian normative data at all time points (Table 4). The vitality, social, and mental health subscale scores at 2 years for both treatment groups approximated the reported normative values. The bodily pain and role-emotional subscale scores at all time points remained below the normative values, although the difference was statistically significant for only the postoperative radiotherapy group on the role-emotional scale. The extent of variability in the role-physical and role-emotional subscale scores was notable; these large SDs resulted from a large proportion of the sample reporting scores at the extremes of the scales.

Variables Predictive of Outcome
The mixed-effects model, repeated-measures analysis confirmed these observed patterns. For the MSTS, treatment arm (with the preoperative radiotherapy group having lower scores) was significant only as an interaction with evaluation time at 6 weeks after surgery (P = .0003), and at 3 months, only evaluation time as compared with the pretreatment score was significant (P = .02). The mixed-effects model of the TESS showed that evaluation time was a significant covariate at 6 weeks (P = .001), 3 months (P = .001), 6 months (P = .0018), and 1 year (P = .0024) after operation when compared with the pretreatment score. As with the MSTS, preoperative radiotherapy had a negative effect on the TESS score only as an interaction with evaluation time at 6 weeks after surgery (P = .0024). The physical function subscale of the SF-36 showed a pattern similar to that of the MSTS and TESS, with postoperative scores continuing to improve up to 1 year after surgery. Time was the only significant covariate in the repeated-measures model, with all times being significantly different than the pretreatment scores (P < .001 at all times). For the bodily pain subscale, the preoperative radiotherapy group as an interaction with evaluation time at 6 weeks was significant (P = .0001). Scores on the remaining subscales of the SF-36 (role-physical, general health, vitality, role-emotional, social function, and mental health) did not vary significantly over time and were unaffected by treatment arm or the interaction of treatment and evaluation time.

The MSTS change scores from baseline for postoperative evaluations were negatively affected by the presence of a lower-extremity tumor (Table 5). Treatment with preoperative radiotherapy was a significant predictor at 6 weeks only. Large specimen size had a negative effect at 6, 12, and 24 months but not in the early time period. Resection of a major motor nerve seemed to have a lasting negative impact on MSTS scores. Age, tumor depth, prior incomplete excision, bone resection, and radiation field length were not consistently predictive of the change scores over time.

An adverse change in the physical functioning subscale score of the SF-36 was consistently predicted by having a lower-extremity tumor and by prior incomplete tumor excision before referral to a specialty center. Large surgical specimen size was an adverse predictor in the early months after surgery but lost its effect by 6 months. Bodily pain was consistently predicted by having a lower-extremity tumor and prior tumor excision. Preoperative radiotherapy was an adverse predictor only at 6 weeks after surgery. The change scores of the remaining SF-36 scales were not consistently predicted by any of the candidate variables (data not shown).

To evaluate the effect of wound complications on function and general health status, complication (no/yes) replaced radiotherapy treatment arm in the above models of the change scores for each measure. A wound complication had a negative impact on the MSTS at 6 weeks and 3, 6, and 12 months after surgery (P < .007) and at 24 months after surgery (P = .09). Wound complications predicted increased disability compared with baseline TESS scores up to 6 months after surgery (P < .01) but lost statistical significance from 12 months onward. Wound complications were not predictive of the SF-36 physical function score and inconsistently predicted change scores for the other subscales at the various times. For example, complications were a significant predictor for bodily pain at 6 weeks and 6 months but not at 3, 12, or 24 months.

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
This is the first randomized trial to evaluate the timing of radiotherapy and the implied benefits and risks of preoperative versus postoperative radiotherapy effects on patient function and health status in a longitudinal fashion. The results of this study demonstrate that the timing of external-beam radiotherapy in treating extremity STS has minimal impact on patient function and quality of life beyond the initial 6 weeks after surgery. At 6 weeks after surgery, patients treated with postoperative radiotherapy had superior function as measured by the MSTS, TESS, and bodily pain subscale of the SF-36. At 2 years after surgery, the function of patients from the two treatment arms was similar, with virtually identical scores on the various functional outcome measures.

The overall pattern of functional recovery over time observed in this study replicates previous findings.^11,15 Patients had relatively high levels of function before treatment with significant decrement in function at 6 weeks after surgery. Function improved slowly, reaching a plateau at 6 months. Patients generally recovered to a high level of function, as indicated by the mean 12- and 24-month scores on the various measures used in this study. This finding is in agreement with those from other authors^10,18-22 who found that approximately one half to two thirds of extremity STS patients report near-normal or excellent function. A variety of functional measures were used in these studies.

This study evaluated function and health status using three conceptually different outcome measures. The MSTS¹³ is completed by the clinician and evaluates clinical parameters mainly at the anatomic level, eg, joint range of motion and muscle strength. In contrast, the TESS¹⁸ and SF-36¹⁶ are completed by the patient and measure physical disability in performing daily tasks and general health status, respectively. Consequently, a spectrum of patient function has been evaluated, and it is not surprising that the factors predictive of the change scores of the different measures vary somewhat. Clinical parameters as measured by the MSTS¹³ were negatively affected by large, lower-extremity tumors, particularly when motor nerve sacrifice was required. Physical disability as measured by the TESS was increased in patients with lower-extremity tumors who had undergone prior unplanned excision of the mass. For the MSTS¹³ and the TESS,¹⁴ the timing of radiotherapy had minimal impact. However, wound complications adversely affected function as measured by the MSTS for up to 2 years, whereas the impact was only in the earlier phase of recovery as measured by the TESS. The MSTS conceptually evaluates effects at a local anatomic level, including range of motion, muscle strength, pain, joint stability, and deformity, and it is clinically reasonable that the sequelae of wound complications through the scarring that occurs with final healing would have ongoing effects at this level. In contrast, the TESS as a measure of disability that reflects ratings of an individual’s ability to perform daily activities was affected only in the early stages of recovery (ie, to 6 months after surgery), when many people have healed and have adapted in performing their activities.

Wound complications have a negative impact on patient function. In a previous retrospective study, the use of vascularized tissue transfers for wound closure following preoperative radiation seemed to reduce the risk of wound-healing complications.²³ In this prospective, multicenter trial, surgeons were free to select wound closure methods—including tissue transfers—deemed appropriate for individual patients without regard for the radiation treatment arm. More patients (30 of 91; 33%) received vascularized tissue transfers in the preoperative radiotherapy treatment arm as compared with the postoperative radiotherapy treatment arm (22 of 94; 23%). Despite this inherent treatment bias, vascularized tissue transfer did not reduce the risk of wound complications in the group receiving preoperative irradiation treatment in this trial.¹²

Comparison of predictive models of functional outcome with the published literature is difficult because this is the first longitudinal evaluation of function using change scores for the measures based on pretreatment status. This method of analysis was selected because work in other diseases has suggested that baseline functional status is a significant factor in predicting posttreatment outcome.²⁴

In a cross-sectional study, Stinson et al²⁰ evaluated the acute and long-term effects of radiotherapy in relation to outcome and found that joint contracture was predicted by inclusion of a joint in the radiotherapy field and by radiotherapy treatment based on pre-1980 protocols; radiation fields longer that 35 cm and having a lower-extremity tumor were predictive of strength deficits and swelling. Timing of radiotherapy and radiation field length were the only radiotherapy parameters included in the current study, and only preoperative radiotherapy had an early adverse effect on the clinical measures that might be considered in relation to the work of Stinson et al. The lack of significance of radiation field length may be the result of two factors. Specimen size was included in the models and may serve as a surrogate predictor of field length. Alternately, the lack of effect of radiation field length in the current study may result from differences in radiotherapy technique in the current era of treatment.

Finding in the current study were similar to those of Bell et al.¹⁰ In a retrospective review of 88 extremity STS patients, Bell et al found that large tumor size, motor nerve sacrifice, and wound complications were adverse univariate predictors of MSTS scores¹³ in patients with a minimum of 1 year of follow-up since surgery. Large tumor size and motor nerve sacrifice maintained their significance in the multivariate analysis.¹⁰

In a cross-sectional study of 172 patients with lower-extremity STS,¹¹ lower MSTS scores¹³ were predicted by large tumor size, bone resection, motor nerve resection, and complications. This model is very similar to the current work in that tumor size and specimen size were highly correlated and could be considered as surrogate variables. Bone excision was not a significant predictor in the current study. However, this was likely because none of these patients had bony defects requiring reconstruction, whereas some of the patients in the study by Davis et al¹¹ had bone excision and reconstruction with intercallary allografts. As in the study by Davis et al, patients in this study with wound complications were negatively affected. Hence, the previous retrospective studies that evaluated predictors of MSTS¹³ and TESS¹⁴ scores have been validated by the results of this randomized trial.

The SF-36 is a generic health status measure that is intended for use across multiple disease entities. In the current study, many of the subscales, with the exception of physical function and bodily pain, showed minimal change over time and did not demonstrate differences between the treatment arms. This is not surprising because many of the subscales of the SF-36 do not have content that is specific to the extremity STS population that would allow the measure to detect differences between the patient groups. However, comparison of the SF-36 data for these patients treated with limb preservation surgery and adjuvant radiotherapy to normative data from Canada demonstrates that these patients treated for extremity STS perceive themselves to have significantly lower physical function, role-physical, and general health as measured by the SF-36.

In conclusion, this longitudinal study of function and health status in the extremity sarcoma population has demonstrated that the timing of radiotherapy does not have an impact on the function of patients in the 2 years following surgery. Rather tumor characteristics and treatment morbidity specifically in the form of wound complications have been shown to have a significant detrimental effect on patient function. The challenge of improving patient function in the first 2 years after surgery and adjuvant radiotherapy is in discovering innovative methods to decrease complications.

	ACKNOWLEDGMENTS

 
Supported by the National Cancer Institute of Canada–Clinical Trials Group. A.M.D. is supported by a Health Career Award from the Canadian Institutes of Health Research.

	REFERENCES

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
1. Consensus Conference: Limb-sparing treatment of adult soft-tissue sarcomas and osteosarcomas. JAMA 254: 1791-1794, 1985[Abstract/Free Full Text]

2. Brennan MF, Caspar ES, Harrison LB, et al: The role of multimodality therapy in soft-tissue sarcoma. Ann Surg 214:328-336; discussion 336-338, 1991

3. Pisters PW, Harrison LB, Leung DH, et al: Long-term results of a prospective randomized trial of adjuvant brachytherapy in soft tissue sarcoma. J Clin Oncol 14: 859-868, 1996[Abstract/Free Full Text]

4. Karakousis CP, Emrich LJ, Rao U, et al: Feasibility of limb salvage and survival in soft tissue sarcomas. Cancer 57: 484-491, 1986[CrossRef][Medline]

5. Karasek K, Constine LS, Rosier R: Sarcoma therapy: Functional outcome and relationship to treatment parameters. Int J Radiat Oncol Biol Phys 24: 651-656, 1992[Medline]

6. Lindberg RD, Martin RG, Romsdahl MM, et al: Conservative surgery and postoperative radiotherapy in 300 adults with soft-tissue sarcomas. Cancer 47: 2391-2397, 1981[CrossRef][Medline]

7. Suit HD, Mankin HJ, Wood WC, et al: Preoperative, intraoperative, and postoperative radiation in the treatment of primary soft tissue sarcoma. Cancer 55: 2659-2667, 1985[CrossRef][Medline]

8. Wilson AN, Davis A, Bell RS, et al: Local control of soft tissue sarcoma of the extremity: The experience of a multidisciplinary sarcoma group with definitive surgery and radiotherapy. Eur J Cancer 30A: 746-751, 1994[CrossRef][Medline]

9. Nielsen OS, Cummings B, O’Sullivan B, et al: Preoperative and postoperative irradiation of soft tissue sarcomas: Effect of radiation field size. Int J Radiat Oncol Biol Phys 21: 1595-1599, 1991[Medline]

10. Bell RS, O’Sullivan B, Davis A, et al: Functional outcome in patients treated with surgery and irradiation for soft tissue tumours. J Surg Oncol 48: 224-231, 1991[Medline]

11. Davis AM, Sennik S, Griffin AM, et al: Predictors of functional outcomes following limb salvage surgery for lower-extremity soft tissue sarcoma. J Surg Oncol 73: 206-211, 2000[CrossRef][Medline]

12. O’Sullivan B, Davis AM, Turcotte R, et al: Preoperative versus postoperative radiotherapy in soft tissue sarcoma of the limbs: A randomized trial. Lancet 359: 2235-2241, 2002[CrossRef][Medline]

13. Enneking W: Modification of the system for functional evaluation in the surgical management of musculoskeletal tumors, in Enneking W (ed): Limb Salvage in Musculoskeletal Oncology. New York NY, Churchill Livingston, 1987, pp 626-639

14. Davis AM, Wright JG, Williams JI, et al: Development of a measure of physical function for patients with bone and soft tissue sarcoma. Qual Life Res 5: 508-516, 1996[CrossRef][Medline]

15. Davis AM, Bell RS, Badley EM, et al: Evaluating functional outcome in patients with lower extremity sarcoma. Clin Orthop Jan( 358): 90-100, 1999

16. Ware J: Health Survey: Manual and Interpretation Guide. Boston MA, Nimrod Press, 1993

17. Hopman WM, Towheed T, Anastassiades T, et al: Canadian normative data for the SF-36 health survey: Canadian Multicentre Osteoporosis Study Research Group. CMAJ 163: 265-271, 2000[Abstract/Free Full Text]

18. Davis AM: Measuring Physical Disability Following Limb Preservation for Lower Extremity Sarcoma. Toronto Ontario Canada, University of Toronto, 1997

19. Lampert MH, Gerber LH, Glatstein E, et al: Soft tissue sarcoma: Functional outcome after wide local excision and radiation therapy. Arch Phys Med Rehabil 65: 477-480, 1984[Medline]

20. Stinson SF, DeLaney TF, Greenberg J, et al: Acute and long-term effects on limb function of combined modality limb sparing therapy for extremity soft tissue sarcoma. Int J Radiat Oncol Biol Phys 21: 1493-1499, 1991[Medline]

21. Robinson MH, Spruce L, Eeles R, et al: Limb function following conservation treatment of adult soft tissue sarcoma. Eur J Cancer 27: 1567-1574, 1991[Medline]

22. Keus RB, Rutgers EJ, Ho GH, et al: Limb-sparing therapy of extremity soft tissue sarcomas: Treatment outcome and long-term functional results. Eur J Cancer 30A: 1459-1463, 1994[Medline]

23. Peat BG, Bell RS, Davis A, et al: Wound-healing complications after soft-tissue sarcoma surgery. Plast Reconstr Surg 93: 980-987, 1994[Medline]

24. Mahomed N, Katz JN: Revision: Total hip arthroplasty—Indications and outcomes. Arthritis Rheum 39: 1939-1950, 1996[Medline]

Submitted March 15, 2002; accepted July 26, 2002.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				E. Robinson, R. R. Bleakney, P. C. Ferguson, and B. O'Sullivan Oncodiagnosis Panel: 2007: Multidisciplinary Management of Soft-Tissue Sarcoma1 RadioGraphics, November 1, 2008; 28(7): 2069 - 2086. [Full Text] [PDF]

				K. M. Skubitz and D. R. D'Adamo Sarcoma Mayo Clin. Proc., November 1, 2007; 82(11): 1409 - 1432. [Abstract] [Full Text] [PDF]

				A. Pradhan, Y. C. Cheung, R. J. Grimer, A. Abudu, D. Peake, P. C. Ferguson, A. M. Griffin, J. S. Wunder, B. O'Sullivan, R. Hugate Jr, et al. Does the method of treatment affect the outcome in soft-tissue sarcomas of the adductor compartment? J Bone Joint Surg Br, November 1, 2006; 88-B(11): 1480 - 1486. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Davis, A.M. Articles by Zee, B. Search for Related Content PubMed PubMed Citation Articles by Davis, A.M. Articles by Zee, B. Social Bookmarking                            What's this?