Orthopaedic Surgery and the Use of Artificial Intelligence

The increasing use of artificial intelligence (AI) in surgery has supporters and opponents. Advantages may include precision, speed, and research advances whilst disadvantages may include accountability, ethical and safety considerations. Orthopedic surgery is a field of Medicine rapidly advancing in its use of artificial intelligence to achieve exciting progress. The question is how far can and should it go?

AI has gained tremendous popularity in recent years, and some AI techniques such as search engines, voice recognition software, and autonomous driving vehicles are now part of our daily lives. AI research is also being conducted in many medical fields, and shows great promise in promoting practice efficacy, personalizing patient management, and improving research capacity.

AI techniques have made impressive advances in the medical imaging pathway, from acquisition and reconstruction to analysis and interpretation. By incorporating information from the patient's medical records (including symptoms, laboratory results, and physical examination findings), AI identifies the most appropriate patient-specific imaging examination and determines the most appropriate protocol. AI can also potentially increase the speed of magnetic resonance imaging (MRI) data acquisition and decrease the computed tomography (CT) radiation dose.

The use of artificial intelligence has acted as a remote diagnostic measure for infection cases treatable outside of hospitals. Clark and Therese Canares, MD, assistant professor in pediatric emergency medicine at the Johns Hopkins University School of Medicine, believe artificial intelligence could help better diagnose and manage ear infections, even remotely from a patient’s home. They are co-inventors of OtoPhoto, the world’s first smart otoscope, a device that takes images of the inner ear and uses machine learning to determine whether or not an infection exists. OtoPhoto’s visuals are analyzed by a proprietary algorithm that makes the diagnosis. The images can be shared with a specialist in real time during a telehealth appointment, which is particularly useful during the ongoing coronavirus pandemic. This allows patients to get both the diagnosis and treatment at home, without potential exposure to Covid-19.

Orthopedic surgeons provide procedures such as traction, amputation, hand reconstruction, spinal fusion, and joint replacements. They also treat strains and sprains, broken bones, and dislocations. Their work involves adding foreign material to the body in the form of screws, wires, pins, tongs, and prosthetics to hold damaged bones in their proper alignment or to replace damaged bone or connective tissue. Such surgeons utilize advances in the development of artificial limbs and joints, and in the materials available to repair damage to bones and connective tissue aiming to duplicate the natural functions of bones, joints, and ligaments, and to accurately restore damaged parts to their original ranges of motion.

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Orthopedic surgery began to use AI robotic technology in 1992, with the introduction of the ROBODOC system for the planning and performance of total hip replacement. Most orthopedic robots, such as the Mako system, are used for joint replacements such as knee and hip surgery. The robots’ technique in achieving limb alignment can reduce operation time and blood loss. The Renaissance robot and the ROSA robot have the advantages of improved pedicle screw accuracy and reduced radiation exposure for patients and clinical staff, compared with conventional spine surgery.

The Tianji robot is a multi-indication orthopedic surgical robot that can be used for all types of spinal and fracture surgeries. The Tianji robot combines a robotic arm with a real-time navigation system and has a high degree of surgical precision. Compared with freehand surgery, the Tianji robot can improve the accuracy of instrument placement and improve clinical results. In July 2019, Professor Wei Tian (President of Beijing Jishuitan Hospital) performed the world's first multi-center 5th generation (5G) remote orthopedic surgery using 5G technology. This success suggested the combination of 5G technology and robotic technology can improve the safety and quality of remote surgery.

In terms of diagnosis prior to surgery, artificial intelligence can support radiologists, improving diagnostic accuracy, and preventing errors observer fatigue. Artificial intelligence algorithms have been applied to the diagnosis of fractures, osteoarthritis, bone age, and bone strength. Arguably, the most accurate diagnosis is likely to be achieved when artificial intelligence is used in combination with, not instead of, a radiologist. Despite the impressive advances in AI orthopedic surgery, realistically there will always be the need for a human element in the practice of surgery and medicine in general.

Conversely, there are disadvantages related to an increase in AI usage. Artificial intelligence in orthopedic surgery is expensive to use, time consuming in its preparation for surgery and lacks the support of long term follow up studies. There are also ethical considerations regarding the use of artificial intelligence in orthopedic surgery which include increased risks to patient confidentiality and consent unless safeguards are in place. In cases of misdiagnosis or maloperation, it is unclear whether the doctor or the robot are responsible. Currently surgical robots can only be used to perform relatively simple procedures and possess little autonomy and decision-making authority in treatment. There is the potential for future advancements in Artificial intelligence-assisted procedures to be self-learning with full surgical independence. However, there may be circumstances where human clinicians are unable to control or override procedures made by an artificial intelligence device, which raises serious ethical and safety questions.

The Nuffield Council on Bioethics published an article ‘AI in Healthcare and Research’ in May 2018, reminding us of the ethical issues raised by the use of AI in healthcare in general (that may restrict the AI advances in orthopedic surgery), such as: the potential for AI to make erroneous decisions; who is responsible when AI is used to support decision-making; difficulties in validating the outputs of AI systems; the risk of inherent bias in the data used to train AI systems; ensuring the security and privacy of potentially sensitive data; securing public trust in the development and use of AI technology; effects on people’s sense of dignity and social isolation in care situations; effects on the roles and skill-requirements of healthcare professionals; and the potential for AI to be used for malicious purposes.

It would seem the use of AI and its further advancement in orthopedic surgery must be in tandem with patient centered confidentiality, ethical and safety-first healthcare, with overarching accountability and transparency, keeping human physicians ultimately responsible and in charge. It is these considerations which will ultimately dictate how far and how fast orthopedic surgery can go on a practical and ethical basis. However, for future orthopedic surgeons with interest and imagination in the potential of engineering and technology in patient diagnosis and treatment, the future progress of artificial intelligence in surgery is very exciting.