Validated self-reporting tools are required to evaluate the functional outcome and health-related quality of life (HRQOL) for Egyptians who had extremity bone sarcomas in their childhood or adolescence. Thus, we pursued cross-cultural adaptation and validation of the pediatric Toronto Extremity Salvage Score (pTESS) and Toronto Extremity Salvage Score (TESS) to assess the physical function of children and adult survivors following surgeries of extremity bone sarcomas. Modified versions of pTESS and TESS, which contain additional mental domains, were developed to allow the evaluation of HRQOL using a specific instrument for childhood bone cancer. The internal consistency of the original pTESS and TESS as well as their modified versions was assessed with Cronbach's alpha. The intraclass coefficients (ICC) were calculated for test-retest reliability, and the correlations between scores of the generic Pediatric Quality of Life Inventory (PEDSQL 4.0) and each of the pTESS and TESS scores were used to confirm convergent validity. Exploratory Factor Analysis (EFA) was only feasible for pTESS-leg; therefore, the construct validity of the remaining versions was assessed by calculating the average inter-item correlation coefficients. The pTESS/TESS scores were also compared based on various patients’ characteristics. In a total sample of 233 included participants, 134 responded to pTESS leg, 53 to TESS-leg, 36 to pTESS-arm, and only 10 to TESS-arm. All versions of pTESS and TESS showed excellent internal consistency (Cronbach’s alpha > 0.9), good test-retest reliability (ICC >0.8), moderate to strong correlations with PEDSQL, and acceptable average inter-item correlation coefficients (≥0.3). Based on the scree plot, 3 factors were extracted for pTESS-leg in which all mental items were loaded on a separate factor with acceptable factor loadings (>0.4). Using the original versions of pTESS/TESS-leg only, adults showed significantly higher scores than younger participants. In the large group representing limb salvage surgery in lower extremities, those who were still receiving chemotherapy, had done primary surgery within only one year, or had tumors located in the tibia showed significantly inferior pTESS/TESS scores. In conclusion, the culturally adapted pTESS and TESS are shown to be valid and reliable self-reporting tools for assessing the functional outcome in Egyptians affected with extremity bone sarcomas. The added mental domains enabled the assessment of the overall health status of this particular population. Future studies should evaluate the ability of pTESS and TESS to track progress over time and include more participants, especially those with upper extremity tumors.


School of Sciences and Engineering


Institute of Global Health & Human Ecology

Degree Name

MA in Global Public Health

Graduation Date

Fall 2-15-2023

Submission Date


First Advisor

Sungsoo Chun

Second Advisor

Ahmed El-Ghoneimy

Third Advisor

Mohamed Salama

Committee Member 1

Anwar Abd Elnaser

Committee Member 2

Mohamed Saad Zaghloul

Committee Member 3

Hassan El-Fawal


66 p.

Document Type

Master's Thesis

Institutional Review Board (IRB) Approval

Approval has been obtained for this item