Soft tissue sarcomas (STS) are rare malignant tumors often associated with poor outcomes and high local recurrence rates. Current tools for intraoperative and definitive margin assessment include intraoperative frozen section and permanent pathology, respectively. Indocyanine green dye (ICG) is a historically safe fluorophore dye that has demonstrated efficacy for intraoperative margin assessment in the surgical management of both breast and gastrointestinal cancers. The utility of ICG in the surgical management of sarcoma surgery has primarily been studied in pre-clinical mouse models and warrants further investigation as a potential adjunct to achieving negative margins. This study is a prospective, non-randomized clinical study conducted on patients with confirmed or suspected STS. Patients younger than 18 years, with a prior adverse reaction to iodine or fluorescein, or with renal disease were excluded from the study. Intravenous ICG was infused approximately three hours prior to surgery at a dosage of 2.0–2.5 mg/kg, and following tumor resection, the excised tumor and tumor bed were imaged for fluorescence intensity. When scanning the tumor bed, a threshold of 77% calibrated to the region of maximum intensity in the resected tumor was defined as a positive ICG margin, according to published protocols from the breast cancer literature. ICG results were then compared with the surgeon’s clinical impression of margin status and permanent pathology results. Out of 26 subjects recruited for the original study, 18 soft tissue sarcomas (STS) were included for analysis. Three subjects were excluded for having bone sarcomas, and five subjects were excluded due to final pathology, which was ultimately inconsistent with sarcoma. The average age of patients was 64.1 years old (range: 28–83), with an average ICG dose of 201.8 mg. In 56% (10/18) of patients, ICG margins were consistent with the permanent pathology margins, with 89% specificity. The use of ICG as an intraoperative adjunct to obtaining negative margins in soft tissue sarcoma surgery is promising. However, studies with larger sample sizes are warranted to further delineate the accuracy, optimal dosage, timing, and types of sarcoma in which this diagnostic tool may be most useful.

Functional dissatisfaction following total knee replacement (TKR) is recorded as high as 20%. The majority of these patients report anterior knee pain (AKP) as the main source of dissatisfaction. Elevated patellofemoral compression forces and soft tissue extensor hood strain have been implicated in the generation of significant AKP. A novel method of assessing and measuring patellofemoral compression forces dynamically in the native and resurfaced patella for TKR in four different quadrants of the patella is described. Results are reported from an in vitro model and cadaveric studies in the native and resurfaced knee. Patellofemoral compression forces are shown to be characteristic and consistent over repeated assessments in the native knee. Placement of a TKR significantly alters this pattern. Furthermore, over-stuffing or under-stuffing the resurfaced patella also significantly alters the nature and magnitude of patellofemoral compression forces. These studies may lead to an improved understanding of the nature of AKP following TKR, and using this assessment tool presents an opportunity to more effectively balance the third space, reproduce the native patellofemoral forces, and subsequently reduce AKP following TKR.

Background: The average professional soccer team experiences 1 to 2 traumatic leg fractures per season, with unknown effects on player performance. Purpose: To (1) determine the rate and time to return to play (RTP) following leg fracture, (2) investigate the rate of reinjury following RTP, and (3) investigate long-term effects that lower extremity (LE) fracture may have on elite soccer player performance. Study Design: Cohort study; Level of evidence, 3. Methods: Using publicly available records, we identified athletes sustaining a traumatic leg fracture across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2016. Athletes with leg fracture (femur, tibia, and/or fibula) were matched 1:2 to controls by demographic characteristics and performance metrics 1 season before the index timepoint. Investigations included the RTP rate, reinjury rate, player characteristics associated with RTP within 2 seasons, long-term player retention, performance metrics during the 4 following seasons, and subgroup analysis by player position. Results: A total of 112 players with LE fracture and 224 controls were identified. Players with LE fractures were absent for a mean of 157 days (range, 24-601 days) and 21 games (range, 2-68 games). The rate of RTP within 1 season was 80%, with 4% experiencing subsequent refracture. Injured players remained active in the league at a higher rate than their uninjured counterparts. As compared with controls, injured athletes played 309 fewer total minutes ( P < .05), scored 0.09 more assists per game ( P < .01) 1 season after injury, and scored 0.12 more points per game 4 seasons after injury ( P < .01). Defenders were most affected by an LE fracture, playing 5.24 fewer games ( P < .05), 603 fewer total minutes ( P < .01), and recording 0.19 more assists per 90 minutes of play as compared with controls 1 season after injury ( P < .001). Attackers and midfielders demonstrated no significant difference in metrics after RTP when compared with controls. Conclusion: Most players sustaining an LE fracture returned to elite soccer at the same level after a significant loss of playing time, with a 4% rate of refracture. Player retention was higher for those sustaining an LE fracture versus uninjured controls. Overall, injured players did not experience a decline in performance after recovery from an LE fracture.

Background: Trapezius palsy can occur due to traumatic or idiopathic spinal accessory nerve injury. As a result of trapezius palsy, shoulder girdle imbalance can develop and present as lateral scapular winging and diminished shoulder range of motion and function. The modified Eden-Lange triple-tendon transfer procedure is a notable salvage operation which can treat chronic trapezius palsy after failure of conservative and nonsalvage interventions. Indications: A 42-year-old right-hand dominant woman who underwent a cervical lymph node biopsy 3 years before presents with chronic left shoulder weakness, severe shoulder pain, and scapular winging. On presentation, she has failed conservative treatments and operative interventions including attempted spinal accessory nerve exploration and repair with ansa cervicalis autograft. Technique Description: A modified Eden-Lange triple-tendon transfer, using the Elhassan modification, was performed to treat the patient’s chronic trapezius palsy. The levator scapulae, rhomboid minor, and rhomboid major were sequentially transferred to the lateral scapular spine, central scapular spine, and medial scapular spine, respectively. Results: At interval follow-up, the patient was recovering well from her operation and with progressively improving range of motion and strength. Discussion/Conclusion: The modified Eden-Lange triple-tendon transfer technique is a salvage procedure for treating chronic trapezius palsy by anatomically reconstructing the force vectors of the native trapezius muscle. Effective restoration of proper scapular and shoulder kinematics via the triple-tendon transfer technique can result in improved pain and shoulder girdle function. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

BackgroundDespite the clerkship being crucial in the training of a future doctor, no widely accepted education model has been proposed. This study devised a new model for clinical clerkship rotations, titled “LEARN” for Lecture, English-video, Advisor, Real-case and Notion, and evaluated whether the LEARN model is appropriate for medical education in China.MethodsA cross-sectional study was performed among 101 fourth-year students from the Xiangya School of Medicine during an Orthopaedic Surgery clerkship rotation in the Third Xiangya Hospital. They were divided into seven groups and took clerkship based on the LEARN model. A questionnaire was collected at the conclusion to measure learning outcomes.ResultsThe LEARN model was highly accepted with the acceptance of five sessions being 95.92% (94/98), 93.88% (92/98), 96.98% (97/98), 100% (98/98) and 96.94% (95/98). The outcomes of two genders were comparable, whereas a difference was observed in the test score among groups (group 3 scored 93.93 ± 5.20, higher than others). Quantitative analysis showed that positive correlations existed in participation in the Notion (Notion means students’ case discussion) section with leadership (r = 0.84, 95% CI: 0.72–0.94, p &lt; 0.001), participation in the Real-case section with leadership (r = 0.66, 95% CI: 0.50–0.80, p &lt; 0.001), participation in the Real-case section with mastery of inquiring skills (r = 0.57, 95% CI: 0.40–0.71, p &lt; 0.001) and participation in the Notion section with mastery of physical examination skills (r = 0.56, 95% CI: 0.40–0.69, p &lt; 0.001). Further qualitative analysis demonstrated that high-level participation in the English-video section indicated better outcomes in mastery of inquiring (p &lt; 0.01), physical examination (p &lt; 0.001), film reading (p &lt; 0.01) and clinical reasoning (p &lt; 0.01) skills.ConclusionOur results support the LEARN model is a promising method for medical clerkship in China. Further research involving more participants and more meticulous design is planned to test its efficacy. For refinement, educators may try to promote students’ participation in the English-video session.