Cross-cultural Adaptation, Validation, and Reliability of the Persian version of the Toronto Extremity Salvage Score (TESS) for Lower Extremity

Document Type : RESEARCH PAPER

Authors

1 Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran

2 Medical ethics and law research center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran

3 School of Medicine, Iran University of Medical Sciences, Tehran, Iran

10.22038/abjs.2025.80920.3691

Abstract

Objectives: The Toronto Extremity Salvage Score for the lower extremity (LE-TESS) is a commonly used patient-reported outcome measure (PROM) designed to assess physical disability in patients following lower limb salvage surgery for bone or soft tissue tumors. Although the TESS has been widely translated and culturally adapted for clinical and research purposes in many countries, it has not yet been translated into Persian (Farsi) or validated for use in Iranian society. This study aims to provide a validated and reliable Persian version of the TESS questionnaire.
Methods: The LE-TESS questionnaire was adapted for the Iranian (Persian) society in accordance with international translation and cultural adaptation guidelines. The reliability and validity of the Persian LE-TESS were assessed in patients referred to Shafa Yahyaeian Hospital who underwent lower limb salvage procedures for malignant tumors between 2016 and 2022. Cronbach's alpha was used to measure internal consistency, and test-retest reliability was assessed within two weeks to calculate the intraclass correlation coefficient (ICC). Construct validity was evaluated using Spearman's rank correlation with the Short Form-36.
Results: In this study, 31 patients (54.8% male) were included, with a mean age of 26.16 ± 9.61 years. The internal consistency evaluated by Cronbach’s alpha was 0.887, and the intraclass correlation coefficient (ICC) assessed by the test-retest reliability was 0.872. This research’s SEM and MDC 0.95 values were as much as 11.63 and 32.23, respectively. The construct validity analysis revealed a strong correlation between the Persian LE-TESS and the SF-36.
Conclusion: The Persian version of the LE-TESS demonstrated reliability and validity in assessing the physical function of patients who underwent lower limb salvage surgery for bone and soft tissue tumors.
        Level of evidence: IV                                         

Keywords

Main Subjects

References

  1. Wafa H, Grimer RJ. Surgical options and outcomes in bone sarcoma. Expert Rev Anticancer Ther. 2006;6(2):239-248. doi:10.1586/14737140.6.2.239.
  2. Smeland S, Bielack SS, Whelan J, et al. Survival and prognosis with osteosarcoma: outcomes in more than 2000 patients in the EURAMOS-1 (European and American Osteosarcoma Study) cohort. Eur J Cancer. 2019; 109:36-50. doi:10.1016/j.ejca.2018.11.027.
  3. Mann GN. Less is (usually) more: when is amputation appropriate for treatment of extremity soft tissue sarcoma? Ann Surg Oncol. 2005; 12(1):1-2. doi:10.1245/ASO.2005.10.907.
  4. Botter SM, Neri D, Fuchs B. Recent advances in osteosarcoma. Curr Opin Pharmacol. 2014; 16:15-23. doi:10.1016/j.coph.2014.02.002.
  5. Solooki S, Mostafavizadeh Ardestani SM, Mahdaviazad H, Kardeh B. Function and quality of life among primary osteosarcoma survivors in Iran: amputation versus limb salvage. Musculoskelet Surg. 2018; 102(2):147-151. doi:10.1007/s12306-017-0511-y.
  6. Mavrogenis AF, Abati CN, Romagnoli C, Ruggieri P. Similar survival but better function for patients after limb salvage versus amputation for distal tibia osteosarcoma. Clin Orthop Relat Res. 2012; 470(6):1735-1748. doi:10.1007/s11999-011-2238-7.
  7. Ottaviani G, Robert RS, Huh WW, Jaffe N. Functional, psychosocial and professional outcomes in long-term survivors of lower-extremity osteosarcomas: amputation versus limb salvage. Cancer Treat Res. 2009; 152:421-436. doi:10.1007/978-1-4419-0284-9_23.
  8. Malek A, Esmati A, Hamedi A, Vahedi M. Critical Diagnoses to Consider in the Assessment of Pediatric Patients Presenting with Limp in the Rheumatology Ward: A Cross-Sectional Study. Archives of Bone and Joint Surgery. 2024;12(12):854.
    9. Brazier JE, Harper R, Jones NM, et al. Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ. 1992; 305(6846):160-164. doi:10.1136/bmj.305.6846.160.
  9. 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. doi:10.1007/BF00540024.
  10. Davis AM, Bell RS, Badley EM, Yoshida K, Williams JI. Evaluating functional outcome in patients with lower extremity sarcoma. Clin Orthop Relat Res. 1999 ;(358):90-100.
  11. Fernandes L, Holm CE, Villadsen A, Sørensen MS, Zebis MK, Petersen MM. Clinically Important Reductions in Physical Function and Quality of Life in Adults with Tumor Prostheses in the Hip and Knee: A Cross-sectional Study. Clin Orthop Relat Res. 2021; 479(10):2306-2319. doi:10.1097/CORR.0000000000001797.
  12. Farid N, Chun S, Hassanain O, et al. Cross-cultural adaptation and validation of a self-reporting tool to assess health-related quality of life for Egyptians with extremity bone sarcomas in childhood or adolescence. Health Qual Life Outcomes. 2023; 21(1):81. doi:10.1186/s12955-023-02165-3.
  13. Bolia IK, Savvidou OD, Kang HP, et al. Cross-cultural adaptation and validation of the Musculoskeletal Tumor Society (MSTS) scoring system and Toronto Extremity Salvage Score (TESS) for musculoskeletal sarcoma patients in Greece. Eur J Orthop Surg Traumatol. 2021; 31(8):1631-1638. doi:10.1007/s00590-021-02921-5.
  14. Ocaktan B, Deveci MA, Yapar A, Tokgöz MA, Şimşek A. Cross-cultural adaptation and validation of the Turkish version of the Toronto Extremity Salvage Score in patients with musculoskeletal tumors. Acta Orthop Traumatol Turc. 2021; 55(5):428-434. doi:10.5152/j.aott.2021.20432.

16.Ramezani K, Sarzaeem MM, Feizi D, Bonakdar M, Ramezani M, Sarzaeem M, Movahedinia M. Evaluation of the Validity and Reliability of a Persian Version of the Forgotten Joint Score in Patients Undergoing Total Hip Arthroplasty. Archives of Bone and Joint Surgery. 2023;11(12):752.

17.Tran DN, Huang YW, Kuo YJ, Nguyen TT, Cheng SJ, Chen YP. A Novel Transosseous Suture Repair Technique for Inferior Pole Patella Fractures Using a Suture Anchor: A Case Series and Technical Note. The Archives of Bone and Joint Surgery. 2025 Jul 1;13(7):435-41.

  1. Davis AM, Devlin M, Griffin AM, Wunder JS, Bell RS. Functional outcome in amputation versus limb sparing of patients with lower extremity sarcoma: a matched case-control study. Arch Phys Med Rehabil. 1999; 80(6):615-618.
  2. Lins L, Carvalho FM. SF-36 total score as a single measure of health-related quality of life: Scoping review. SAGE open Med. 2016;4:2050312116671725. doi:10.1177/2050312116671725.
  3. Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short Form Health Survey (SF-36): translation and validation study of the Iranian version. Qual life Res. 2005; 14(3):875-882. doi:10.1007/s11136-004-1014-5.
  4. Beaton D, Bombardier C, Guillemin F, Ferraz M. Guidelines for the Process of Cross-Cultural Adaption of Self-Report Measures. Spine (Phila Pa 1976). 2001; 25:3186-3191. doi:10.1097/00007632-200012150-00014.
  5. Taherdoost H. Validity and reliability of the research instrument; how to test the validation of a questionnaire/survey in a research. International journal of academic research in management (IJARM). 2016; 5.
  6. Bujang MA, Omar ED, Baharum NA. A Review on Sample Size Determination for Cronbach’s Alpha Test: A Simple Guide for Researchers. Malays J Med Sci. 2018; 25(6):85-99. doi:10.21315/mjms2018.25.6.9.
  7. Atkinson G, Nevill AM. Statistical methods for assessing measurement error (reliability) in variables relevant to sports medicine. Sports Med. 1998; 26(4):217-238. doi:10.2165/00007256-199826040-00002.
  8. Mokkink LB, Terwee CB, Patrick DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual life Res.2010; 19(4):539-549. doi:10.1007/s11136-010-9606-8.
  9. Terwee CB, Prinsen CAC, Chiarotto A, et al. COSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study. Qual life Res.2018; 27(5):1159-1170. doi:10.1007/s11136-018-1829-0.
  10. Koo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med. 2016; 15(2):155-163. doi:10.1016/j.jcm.2016.02.012.
  11. Roozrokh Arshadi Montazer M, Zahediannasab R, Nami M, Tahamtan M, Sharifian R, Nasiri M. Psychometric Evaluation of Self-assessment Persian Version of the Alzheimer Questionnaire (AQ). Basic Clin Neurosci. 2022; 13(4):477-488. doi:10.32598/bcn.2021.2238.1.
  12. Willeumier JJ, van der Wal CWPG, van der Wal RJP, Dijkstra PDS, Vliet Vlieland TPM, van de Sande MAJ. Cross-Cultural Adaptation, Translation, and Validation of the Toronto Extremity Salvage Score for Extremity Bone and Soft Tissue Tumor Patients in Netherlands. Sarcoma. 2017; 2017:6197525. doi:10.1155/2017/6197525.
  13. 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. doi:10.1007/s00776-015-0767-8.
  14. Kim H-S, Yun J, Kang S, Han I. Cross-cultural adaptation and validation of the Korean Toronto Extremity Salvage Score for extremity sarcoma. J Surg Oncol. 2015;112(1):93-97. doi:10.1002/jso.23947.
  15. Enneking WF, Spanier SS, Goodman MA. A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res. 1980 ;( 153):106-120.
  16. Trost C, Hofer C, Stamm T, Windhager R, Hobusch GM. Cross-cultural adaption, translation and validation of the Toronto extremity salvage score (TESS) for patients in German-speaking countries. Wien Klin Wochenschr. 2021; 133(11-12):536-542. doi:10.1007/s00508-021-01865-4.

 

 

 

 

The Archives of Bone and Joint Surgery
Volume 13, Issue 8
August 2025
Pages 509-516

Files

History

  • Receive Date: 03 July 2024
  • Revise Date: 18 February 2025
  • Accept Date: 23 February 2025

Share

How to cite

Statistics