Toronto Extremity Salvage Score (TESS): Comprehensive Guide to Assessment & Scoring

Introduction to the Toronto Extremity Salvage Score (TESS)

The Toronto Extremity Salvage Score (TESS) is an outcome measure designed to assess disability, impairment and handicap following limb salvage procedures for the management of orthopedic oncologic pathologies of bone or soft tissue [1,2]. Limb salvage surgery, or limb sparing surgery, is used to save a limb in the setting of an orthopedic oncologic condition or severe trauma that would otherwise require amputation. Since limb salvage surgery often requires a long, difficult rehabilitation and has a higher likelihood of requiring revision operations, measuring functional outcomes in the postoperative period is essential.

How is the TESS structured?

There are two versions of the TESS survey that are used based on the location of the procedure / pathology: one for the upper extremity (UE) and one for the lower extremity (LE). The surveys are composed of 31 (TESS LE) or 32 (TESS UE) items involving activities of daily living scored on a Likert scale (1 to 5) from “Impossible to do” (1) to “Not at all Difficult” (5) [3]. Both the UE and LE TESS scores range from 0, indicating worst symptom burden, to 100, indicating no symptom burden [4]. 

How to Calculate the TESS Score

The TESS is scored based on the questions completed by the respondent, with questions marked as ‘not applicable’ being left out of the score calculation. To calculate the final TESS score, divide the total item scores (which is equal to the sum of the item scores minus the number of items completed) divided by the possible score range (four times the number of items completed) and multiply the resulting quotient by 100%. As a result, all patients can achieve a score anywhere from 0 to 100 based solely on the questions that are applicable to them individually.

Advantages and Strengths of the TESS Questionnaire

The TESS outcome measures are some of the most broadly utilized PROs in orthopedic oncology. TESS UE and LE are well-validated within the orthopedic oncologic literature [1] and are gaining traction in the literature surrounding limb salvage secondary to orthopedic trauma, though they have yet to be validated for trauma procedures [5,6]. Questions within the TESS questionnaire encompass one’s ability to perform a broad spectrum of activities, ranging from sitting or picking up small objects to doing heavy work or socializing.  Due to the broad scope of the questions asked within the TESS questionnaires, there are limited floor and ceiling effects for TESS UE and TESS LE [3, 4]. Established normative scores for the TESS UE and LE in an unoperated patient population provide further insight into patient outcomes using this measure [2]. 

When compared to other outcome measures, the TESS UE demonstrated reliability in measurements of functional outcomes and a stronger correlation with the 15D and health-related quality of life outcomes than its counterparts, supporting its role in upper extremity oncological research [4].

With a comprehensive spread of questions and inclusion of questions based on importance in daily living, the TESS provides a reliable and robust outcome measurement for this complex patient cohort.

Limitations and Considerations of TESS

The breadth of topics addressed by the survey leads to a longer time required for completion of the 31 items, which may limit capture rate when compared to a shorter outcome measure. And to reiterate, while the TESS is gaining traction in the literature surrounding limb salvage secondary to orthopedic trauma, it has yet to be validated for trauma procedures.

Costs and Licensing of TESS 

This measure does not require purchase or licensure for clinical use.

Conclusion: Why choose TESS?

The TESS UE and LE are robust measures that have been well validated for use in the setting of limb salvage following an orthopedic oncologic pathology. The broad scope of the questions and well-established psychometric properties make this tool ideal for research, however its length may limit its capture rate if used for daily clinical practice.

Sources  |  [[1]]  Development of a measure of physical function for patients with bone and soft tissue sarcoma ]   |  [[2] The Toronto Extremity Salvage Score in Unoperated Controls: An Age, Gender, and Country Comparison]  |  [[3] Patient-Reported Outcomes Measurement Information System physical function correlates with Toronto Extremity Salvage Score in an orthopaedic oncology population]  |  [[4] Measuring functional outcome in upper extremity soft-tissue sarcoma: Validation of the Toronto extremity salvage score and the QuickDASH patient-reported outcome instruments – ScienceDirect]   |   [[5] Upper extremity reconstruction and functional outcome assessment using Toronto Extremity Salvage Score (TESS).]  |  [[6] Total Femoral Replacement for Salvage of Periprosthetic Fractures]