Orthopaedic Trauma Surgery Research Articles

Evaluation of Sleep Quality and Its Relationship With Pain, Mood, and Physical Function After Orthopaedic Trauma Surgery: A Prospective Cohort Study.

Sleep disturbances are associated with pain and mental health. We prospectively compared a cohort of patients with orthopaedic trauma with a control group to establish the prevalence and duration of sleep disturbance and associations between sleep disturbance and pain, mood scores, and functional outcome scores. Subjects were patients with orthopaedic trauma undergoing in-patient surgical procedures and healthy control subjects from the community. Questionnaires completed by all subjects included the VAS numerical pain rating scale, the abbreviated profile of mood states, Patient-Reported Outcomes Measurement Information System Physical Function, and Patient-Reported Outcomes Measurement Information System Sleep Disturbance. Control subjects completed the surveys once, and subjects with trauma completed them at 2, 6, and 24 weeks postoperatively. Healthy control subjects (28.6 ± 13.2) were significantly younger than patients with trauma (41.8 ± 18.9) ( P < 0.001). Compared with control subjects, at 2-week follow-up visit, patients with trauma had worse sleep ( P < 0.001) and worse mood ( P = 0.006). Across the study period, patients with trauma showed improvements in physical function ( P < 0.001) and pain (at rest [ P = 0.02], during activity [ P = 0.02], and at night [ P = 0.002]). In patients with trauma, better sleep disturbance scores were associated with better mood and less pain for all pain metrics ( P < 0.001). Patients with orthopaedic trauma have worse sleep disturbance scores at 2 weeks postoperatively compared with normal control subjects; this difference attenuated at 6 weeks. Sleep disturbance was found to markedly correlate with pain and mood, with worse sleep quality associated with higher pain and worse mood. Improvement in sleep quality across 24 weeks postoperatively was associated with improvement in mood scores. Patients should be counseled about the likely development of sleep disturbance and the possible association with worse emotional/mental health with worse sleep. Physicians should consider incorporating a multidisciplinary approach to the management of these select patients.

Large-scale, pragmatic randomized trials in the era of big data, precision medicine and machine learning. Valid and necessary, or outdated and a waste of resources?

During the past decade, more and more large-scale pragmatic clinical trials have been carried out in orthopedic trauma surgery. This trend is fueled by the common belief that the larger the numbers in a trial, the broader the eligibility criteria, and the less strict the regimentation of local treatment standards by protocol, the more trustworthy the findings would be. However, it must also be taken into account that the precision of an outcome measurement does not depend on the sample size alone, but the homogeneity of the studied population. Consequently, a small trial with stringent entry and assessment criteria may offer similarly precise answers as a large trial with less strict entry and assessment criteria because of the basic mathematical correlation between standard deviation and standard error of the mean. There is now a lively and controversial debate about the role of randomized controlled trials (RCT) in an era of stratified medicine driven by the ever increasing understanding and clinical measurability of molecular pathways, making a certain intervention more effective in patients who show a distinct genetic variant. Cluster and pattern recognition by artificial intelligence (AI) and its methodological variety applied to huge datasets and population-based cohorts further propel the spiral of knowledge. Advanced adaptive RCT concepts like enrichment designs, basket and bucket trials, master protocols etc. were developed to combine classic principles of the scientific method with big data, the latter of which have not arrived yet in trauma care.In spite of all biomedical and methodological achievements made, surprisingly such key questions remain unanswered as a) is a certain treatment causally responsible for making a difference in patient-centered outcomes compared to placebo, a control treatment, or the standard of care, b) do the results of a controlled experiment are relevant enough to change clinical practice, and c) under which conditions and assumptions shall we conduct large-scale pragmatic RCTs, focused confirmatory RCTs, or personalized analyses with or without AI support.

Clinical Importance of Sarcopenia And How It Impacts Orthopaedic-Trauma Patients and The Surgical Outcomes

Highlights: Sarcopenia can cause deleterious effects on patients. The Asian Working Group for Sarcopenia (AWGS) and the European Working Group on Sarcopenia in Older People (EWGSOP) provide the most widely used criteria to diagnose sarcopenia. Knowledge of sarcopenia should be a trigger for clinicians and surgeons to evaluate the treatment plan and anticipate the implications experienced by the patients. Abstract: Sarcopenia is a condition of low muscle strength, mass, and low physical performance that is affected by age (primary sarcopenia) and one or combination of systemic diseases, physical inactivity, and insufficient intake of energy (secondary sarcopenia). This condition affects one in ten healthy adults aged ≥60 years. There are two widely used criteria to diagnose sarcopenia, the Asian Working Group for Sarcopenia (AWGS) and the European Working Group on Sarcopenia in Older People (EWGSOP). These working groups created algorithms to facilitate the diagnosis. Establishing the diagnosis is crucial because it has deleterious impacts on patients, such as increasing risks of mortality, morbidity, falls, complications during and after surgery, disability, prolonged hospitalization, and fractures. Sarcopenia is considered an independent mortality risk. It is paramount for physicians to assess this condition before treating the patients because it can predict the risk and plan better treatment options to achieve better outcomes. Early assessment is crucial, even for surgeons. Sarcopenia also negatively impacts patients who had surgery. Up to 44% patients who underwent orthopedic trauma surgery had sarcopenia. The high percentage was affected by the increased risk of falls and fractures. On that account, this condition needs to be treated. The main treatments for this condition are exercise dan adequate nutrition intake. The recommended exercise as a first-line treatment is resistance or strength training. Overall, knowledge on sarcopenia can prepare clinicians and surgeons in anticipating the implications of sarcopenia.

Development and external validation of automated detection, classification, and localization of ankle fractures: inside the black box of a convolutional neural network (CNN)

PurposeConvolutional neural networks (CNNs) are increasingly being developed for automated fracture detection in orthopaedic trauma surgery. Studies to date, however, are limited to providing classification based on the entire image—and only produce heatmaps for approximate fracture localization instead of delineating exact fracture morphology. Therefore, we aimed to answer (1) what is the performance of a CNN that detects, classifies, localizes, and segments an ankle fracture, and (2) would this be externally valid?MethodsThe training set included 326 isolated fibula fractures and 423 non-fracture radiographs. The Detectron2 implementation of the Mask R-CNN was trained with labelled and annotated radiographs. The internal validation (or ‘test set’) and external validation sets consisted of 300 and 334 radiographs, respectively. Consensus agreement between three experienced fellowship-trained trauma surgeons was defined as the ground truth label. Diagnostic accuracy and area under the receiver operator characteristic curve (AUC) were used to assess classification performance. The Intersection over Union (IoU) was used to quantify accuracy of the segmentation predictions by the CNN, where a value of 0.5 is generally considered an adequate segmentation.ResultsThe final CNN was able to classify fibula fractures according to four classes (Danis-Weber A, B, C and No Fracture) with AUC values ranging from 0.93 to 0.99. Diagnostic accuracy was 89% on the test set with average sensitivity of 89% and specificity of 96%. External validity was 89–90% accurate on a set of radiographs from a different hospital. Accuracies/AUCs observed were 100/0.99 for the ‘No Fracture’ class, 92/0.99 for ‘Weber B’, 88/0.93 for ‘Weber C’, and 76/0.97 for ‘Weber A’. For the fracture bounding box prediction by the CNN, a mean IoU of 0.65 (SD ± 0.16) was observed. The fracture segmentation predictions by the CNN resulted in a mean IoU of 0.47 (SD ± 0.17).ConclusionsThis study presents a look into the ‘black box’ of CNNs and represents the first automated delineation (segmentation) of fracture lines on (ankle) radiographs. The AUC values presented in this paper indicate good discriminatory capability of the CNN and substantiate further study of CNNs in detecting and classifying ankle fractures.Level of evidenceII, Diagnostic imaging study.

The role of geographic disparities in outcomes after orthopaedic trauma surgery

IntroductionHealthcare disparities linked to patient rurality and socioeconomic status are known to exist, but few studies have examined the effect of urban versus rural status on outcomes after orthopedic trauma surgery. The aim of this study was to examine the correlation between patient rurality, socioeconomic status, and outcomes after orthopedic trauma. Materials and methodsThis is a retrospective cohort study of patients diagnosed with a hip or long bone fracture between January 2016 and December 2017. Data were collected from the Nationwide Inpatient Sample (NIS), a 20% weighted sample of 95% of the U.S. inpatient population. Patients were stratified into 3 groups: isolated hip fracture, isolated long bone fracture, and polytrauma. Bivariate analysis was completed using chi-squared tests for categorical variables and t-tests for continuous variables. Multivariable analysis was completed using population-weighted logistic regression models, based on a conceptual model derived selection of covariates. ResultsWe included 235,393 patients diagnosed with a hip or extremity fracture. These were weighted to represent 1,176,965 patients nationally. In the hip fracture group, rural patient status was associated with higher odds of mortality (OR 1.32, P < 0.001) but not complications (OR 0.95, P = 0.082). In the extremity fracture and polytrauma groups, rural patient status was not associated with significantly higher odds of mortality or complications. In the urban polytrauma group, zip code with below-median income was associated with increased odds of mortality (OR 1.23, P = 0.002) but not complications. In the rural polytrauma group, zip code with below-median income was not associated with significantly increased odds of mortality or complications. In the hip fracture and extremity fracture groups, below-median income was not associated with significantly higher odds of mortality. ConclusionWe found that rural patients with hip fracture have higher mortality compared to urban patients and that socioeconomic disparities in mortality after a polytrauma exist in urban settings. These results speak to the ongoing need to develop objective measures of disparity-sensitive healthcare and optimize trauma systems to better serve low-income patients and patients in rural areas.

A meta-analysis showing the quantitative evidence base of perineural nalbuphine for wound pain from upper-limb orthopaedic trauma surgery.

The adjuvant effectiveness of nalbuphine in context of brachial plexus block (BPB) in patients undergoing upper-limb orthopaedic trauma surgery has remained uncertain. The purpose of this meta-analysis was to evaluate the analgesic benefit of mixing nalbuphine into local anaesthetics in BPB for wound pain from upper-limb trauma surgery. Primary outcome was the duration of analgesia. Seventeen trials (1104 patients) were analysed. Patients receiving nalbuphine have an increased weighted mean difference (WMD) 95% confidence interval of the duration of analgesia by 186.91 minutes (133.67 to 240.16) (P <0.001). Compared to placebo, nalbuphine shorten the onset time of sensory and motor block by WMD of 2.59 (1.27 to 3.92) and 3.06 minutes (1.65 to 4.48) (P <0.001), respectively. Meanwhile, nalbuphine prolonged the durations of sensory and motor block (P <0.001). Qualitative and quantitative synthesis revealed no differences with regard to the outcomes related to side-effects. There is moderate-quality evidence that the addition of nalbuphine to local anaesthetics for BPB in patients undergoing upper-limb orthopaedic trauma surgery significantly prolongs the duration of analgesia, while preserving a similar safety-profile compared with local anaesthetics alone. However, these benefits should be further weighed against nalbuphine-related neurological safety in future studies.

Fracture-related infection.

Musculoskeletal trauma leading to broken and damaged bones and soft tissues can be a life-threating event. Modern orthopaedic trauma surgery, combined with innovation in medical devices, allows many severe injuries to be rapidly repaired and to eventually heal. Unfortunately, one of the persisting complications is fracture-related infection (FRI). In these cases, pathogenic bacteria enter the wound and divert the host responses from a bone-healing course to an inflammatory and antibacterial course that can prevent the bone from healing. FRI can lead to permanent disability, or long courses of therapy lasting from months to years. In the past 5 years, international consensus on a definition of these infections has focused greater attention on FRI, and new guidelines are available for prevention, diagnosis and treatment. Further improvements in understanding the role of perioperative antibiotic prophylaxis and the optimal treatment approach would be transformative for the field. Basic science and engineering innovations will be required to reduce infection rates, with interventions such as more efficient delivery of antibiotics, new antimicrobials, and optimizing host defences among the most likely to improve the care of patients with FRI.

Use of negative pressure wound therapy in patients with fracture-related infection more than doubles the risk of recurrence

PurposeFracture-related infection (FRI) is one of the most serious complications in orthopedic trauma surgery. Despite its widespread use, the role of Negative Pressure Wound Therapy (NPWT) remains controversial in the management pathway of FRI. The aim of this study was to assess the relationship between the application of NPWT and its duration and recurrence of infection in operatively treated FRI patients. Patients and MethodsThis is a retrospective cohort study based on the FRI database of three level 1 Trauma Centres. Included patients had to be at least 16 years of age and surgically treated for FRI between January 1st 2015 and September 1st 2020. Patients were subdivided in either the NPWT group, when NPWT was applied as part of the FRI treatment, or in the control group, when no NPWT had been applied. To limit confounding, patients were excluded if they (also) underwent NPWT prior to the diagnosis of FRI. The relation between the duration of NPWT during FRI treatment and the recurrence rate of infection was analyzed using a multivariable logistic regression model. ResultsA total of 263 patients were included, 99 in the NPWT group and 164 in the control group. The median duration of NPWT was 18.0 (IQR 15.8) days. In the NPWT group, 28 patients (28.3%) developed a recurrent FRI. In the control group, 19 patients (11.6%) had a recurrent FRI (p = 0.001, 95% CI [0.174 – 0.635]). In the NPWT group there were no significant differences in baseline characteristics between the recurrence and non-recurrence group. The duration of NPWT was associated with a higher risk of recurrence of infection (p = 0.013, OR 1.036, 95% CI [1.008 – 1.066]). ConclusionDelayed wound closure with the application of NPWT increased the risk of recurrence of infection in patients with soft tissue defects after FRI treatment. Therefore, it is advised to consider NPWT only as a short-term (e.g. few days) necessity to bridge the period until definitive wound closure can be established.

Influence of direct radiography in decision making during orthopaedic trauma surgery: A prospective study

ObjectiveTo evaluate the effects of intraoperative direct radiography on the change in the patient's treatment and the reliability of fluoroscopy in orthopaedic trauma surgery operations. MethodsA total of 773 fractures were evaluated prospectively. The surgeons involved in the case were divided into three groups according to their experiences: less than 5 years, 5–10 years and over 10 years. After each case, the fracture classification, whether any interventions were made after the X-ray, and the interventions were recorded. ResultsThere were 312(40%) intra-articular, 200(26%) metaphyseal, 161(21%) diaphyseal, 81(10%) pelvis-acetabulum, and 19(3%) vertebrae fractures. Surgeons needed to intervene in 71(9.2%) cases after direct-radiography. There was a significant difference between the location of the fracture and the number of interventions (p < 0.001). The most frequent interventions were intra-articular distal radius, acetabulum and intra-articular calcaneus fractures, respectively. Surgeons with more than 10 years of the experience felt the need to make fewer changes, it was statistically significant compared to the other two groups (p = 0.001 for both). ConclusionIt was found that the final evaluation with x-ray images before the operation was completed in trauma surgery affected the surgeon's decision. In particular, intra-articular fractures, acetabular fractures, and vertebral fractures are recommended to evaluate fixation with direct radiography in addition to fluoroscopy images before ending the operation. Level of evidenceLEVEL III.

Letter to the Editor: Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment.

Letter to the Editor: Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment.

From Diagnosis to Therapy: The Role of Virtual and Augmented Reality in Orthopaedic Trauma Surgery.

By reducing procedure-related problems, advancements in computer-assisted surgery (CAS) and surgical training aim to boost operative precision and enhance patient safety. Orthopaedic training and practice have started to change as a result of the incorporation of reality technologies like virtual reality (VR), augmented reality (AR), and mixed reality (MR) into CAS. Today's trainees can engage in realistic and highly involved operational simulations without supervision. With the coronavirus disease 2019 (COVID-19) pandemic, there is a greater need for breakthrough technology adoption. VR is an interactive technology that enables personalised care and could support successful patient-centered rehabilitation. It is a valid and trustworthy evaluation method for determining joint range of motion, function, and balance in physical rehabilitation. It may make it possible to customise care, encourage patients, boost compliance, and track their advancement. AR supplementation in orthopaedic surgery has shown promising results in pre-clinical settings, with improvements in surgical accuracy and reproducibility, decreased operating times, and less radiation exposure. As little patient observation is needed, this may lessen the workload clinicians must bear. The ability to use it for home-based therapy is often available commercially as well.The objectives of this review are to evaluate the technology available, comprehend the available evidence regarding the benefit, and take into account implementation problems in clinical practice. The use of this technology, its practical and moral ramifications, and how it will affect orthopaedic doctors and their patients are also covered. This review offers a current and thorough analysis of the reality technologies and their uses in orthopaedic surgery.

Intraoperative revision rates due to three-dimensional imaging in orthopedic trauma surgery: results of a case series of 4721 patients

PurposeIntraoperative 3D imaging has become a valued tool in assessing the quality of reduction and implant placement in orthopedic trauma surgery. In our institution, 3D imaging is used routinely since 2001. To evaluate the intraoperative findings and consequences of this technique, intraoperative revision rates in cases with 3D imaging were analyzed.MethodsAll operative procedures carried out with intraoperative 3D imaging between August 2001 and December 2016 were included. The scans were assessed intraoperatively and documented thereafter. In case of malreduction or misplaced implants, an immediate revision was performed. The number of scans per case as well as the findings and consequences drawn regarding the anatomical region were analyzed.Results4721 cases with 7201 3D scans were included in this study. The most common anatomical regions were the ankle (22.3%), the calcaneus (14.8%) and the tibial head (9.5%).In 19.1% of all cases, an intraoperative revision was performed. The highest revision rates were found with 36.0% in calcaneal fractures, 24.8% in fractures of the tibial plateau, 22.3% in injuries of the ankle.In 52.0% of revisions, the reduction was improved regarding intra-articular steps or joint congruency. In 30.5% an implant was corrected.ConclusionIntraoperative revision due to results of 3D imaging was performed in almost one-fifth of cases. This illustrates the improved possibilities to detect malreduction and implant misplacements intraoperatively and thus the abilities to improve surgical outcome.Level of evidenceIII.

Outcomes After Orthopedic Trauma Surgery - What is the Role of the Anesthesia Choice?

The body of literature concerning the influence of anesthetic type on many perioperative outcomes has grown considerably in recent years. Most studies have suggested that particularly in orthopedic patients, regional anesthesia may be associated with improved perioperative outcomes. Orthopedic trauma presents itself as a field that might benefit from increased utilization of regional techniques with the goal to improve outcomes. This narrative review concludes that, indeed, regional anesthesia seems to provide benefits for morbidity, pain control, and improved return to function in hip fracture, rib fracture, and isolated extremity fracture patients.

Patient-reported Outcomes of SARS-CoV-2 Positive Adult Orthopedic Trauma Patients Treated During the Ongoing Pandemic

Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has become a matter of concern all over the world. It has resulted in delay in surgery or, at times, preference for nonoperative treatment for SARS-CoV-2 positive orthopedically injured adult patients which may adversely affect the clinical outcomes. In this study, we report the outcomes of orthopedic adult trauma patients who tested positive for SARS-CoV-2 at admission. Methods: We retrospectively reviewed the prospectively collected data from the period between April 1, 2020 and December 31, 2020. We reviewed 521 out of total 2435 patients presenting in the casualty that required orthopedic trauma surgery. Thirty-eight out of total 521 patients, that tested positive for SARS-CoV-2, were followed-up using telecommunication for final outcome of fracture treatment. A telecommunication patient satisfaction score after injury (TPSSI) was used to evaluate the patient satisfaction. Results: The mean age was 37.94 years (range: 18–72 years). They were followed-up for mean duration of 8.18 months (range: 6–13 months). Out of total 38, 23 underwent orthopedic trauma surgeries and rest 15 were managed nonoperatively. There was a mean delay in surgery of 5 weeks (range: 3–12 weeks). Five patients lost their lives and seven others had nonunion. The median TPSSI score was three. Conclusions: Nonoperative and delayed surgical management of adult orthopedic trauma patients, who tested positive for SARS-CoV-2 at admission, result adversely in activities of daily living and return to original occupation and, thus, have poor patient satisfaction.

Evolution of Negative Pressure Wound Therapy in Orthopaedic Trauma.

Negative Pressure Wound Therapy (NPWT) has evolved from open wound management to now include closed incision management. It has been a major advance in the management of open wounds and closed incisional wounds especially in orthopaedic trauma surgery. Because of the success of NPWT in the late 1990s and early 2000s, surgeons began using NPWT with adjuncts on closed incisions as a way to help prevent surgical wound dehiscence especially in at-risk patients for wound problems. It has been well established that obesity, diabetes, and smoking in addition to other comorbidities increase the risk of wound dehiscence and surgical site infections in orthopaedic patients. It is widely used for open wound management, often associated with open fractures, and in the mitigation of risk of surgical site infections over closed incisions (incisional negative pressure wound therapy). Newer systems allow the use of various topical wound solutions to be instilled in conjunction with NPWT, termed NPWTi-d. This has shown promising results in difficult wounds that may be resistant to standard NPWT. This article reviews the evolution and use of NPWT in orthopaedic trauma.

Safety and efficacy of perioperative tranexamic acid infusion in acetabular fracture fixation: A randomized placebo-controlled double-blind prospective study

IntroductionOpen reduction and internal fixation of acetabular fracture is associated with significant blood loss. Although Tranexamic acid (TXA) infusion effectively reduces perioperative blood loss and transfusion requirements in elective orthopedic surgery, its efficacy in major orthopedic trauma surgery is controversial. Material and methodsSixty-three patients undergoing open reduction and internal fixation of acetabular fracture were randomized into either TXA (n = 36) or placebo (n = 27) group. TXA group received a bolus dose of TXA (10 mg/kg) 15 min prior to incision, followed by another similar dose after 3 h of surgery. The placebo group received the same volume of normal saline similarly. All patients were operated on by a single pelviacetabular surgeon with a uniform perioperative protocol. The intraoperative blood loss, drain output, the number of blood transfusions, postoperative hemoglobin (Hb) drop, and hematocrit (Hct) drop were calculated. ResultsBoth groups were similar in relation to age, sex, BMI, preoperative Hb, the timing of surgery, fracture pattern, operative time, and surgical approaches. The mean postoperative Hb was 10.35 ± 1.36 gm% in TXA group and 9.74 ± 1.98 gm% in placebo group (p-value 0.158). There were no differences in intraoperative blood loss (438.11 ml vs. 442.81, p=.947), drain output (131.94 ml vs. 129.63, p=.870), and blood transfusion (8 patients vs. five patients, p=.719) between the groups. The drop in Hb and Hct in the postoperative period was also statistically not significant between the groups. ConclusionThere is no significant reduction in blood loss and blood transfusion with the use of intravenous Tranexamic acid in open reduction and internal fixation of acetabular fractures.

Application of Digital Orthopedic Technology in Orthopedic Trauma.

In order to solve the limitation of auxiliary treatment means in the process of orthopedic trauma surgery, and further improve the effective integration of orthopedic trauma clinical surgery and computer technology, a new orthopedic trauma auxiliary treatment means based on digital orthopedic technology was proposed with the aid of virtual digital technology. The method builds a 3D model of fracture fragments through 3D orthopedic modeling and obtains a high-quality 3D model through processing. Later clinical tests verify the feasibility of this auxiliary treatment method. The test results show that the precision of the 3D reconstruction model based on custom option fitting is higher than that based on optimal option fitting, and the precision difference is within 0.2%. This result also indicates that the 3D model obtained by 3D reconstruction has higher accuracy. The results show that three-dimensional finite element modeling technology can accurately simulate the stress of the spine of orthopedic patients and can reduce the incidence of complications through preoperative diagnosis, curative effect prediction, and trauma surgery, which has a good aid for postoperative recovery.

Development and clinical application of robot-assisted technology in traumatic orthopedics

To review and evaluate the basic principles and advantages of orthopedic robot-assisted technology, research progress, clinical applications, and limitations in the field of traumatic orthopedics, especially in fracture reduction robots. An extensive review of research literature on the principles of robot-assisted technology and fracture reduction robots was conducted to analyze the technical advantages and clinical efficacy and shortcomings, and to discuss the future development trends in this field. Orthopedic surgical robots can assist orthopedists in intuitive preoperative planning, precise intraoperative control, and minimally invasive operations. It greatly expands the ability of doctors to evaluate and treat orthopedic trauma. Trauma orthopedic surgery robot has achieved a breakthrough from basic research to clinical application, and the preliminary results show that the technology can significantly improve surgical precision and reduce surgical trauma. However, there are still problems such as insufficient evaluation of effectiveness, limited means of technology realization, and narrow clinical indications that need to be solved. Robot-assisted technology has a broad application prospect in traumatic orthopedics, but the current development is still in the initial stage. It is necessary to strengthen the cooperative medical-industrial research, the construction of doctors' communication platform, standardized training and data sharing in order to continuously promote the development of robot-assisted technology in traumatic orthopedics and better play its clinical application value.

Letter to the Editor: Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment.

Letter to the Editor: Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment.

Surface Bio-Functionalization of Anti-Bacterial Titanium Implants: A Review

Titanium (Ti) and titanium alloy have been widely used in orthopedics. However, the successful application of titanium implants is mainly limited due to implant-associated infections. The implant surface contributes to osseointegration, but also has the risk of accelerating the growth of bacterial colonies, and the implant surfaces infected with bacteria easily form biofilms that are resistant to antibiotics. Biofilm-related implant infections are a disastrous complication of trauma orthopedic surgery and occur when an implant is colonized by bacteria. Surface bio-functionalization has been extensively studied to better realize the inhibition of bacterial proliferation to further optimize the mechanical functions of implants. Recently, the surface bio-functionalization of titanium implants has been presented to improve osseointegration. However, there are still numerous clinical and non-clinical challenges. In this review, these aspects were highlighted to develop surface bio-functionalization strategies for enhancing the clinical application of titanium implants to eliminate implant-associated infections.