Machine learning in orthopaedic surgery

Artificial intelligence and machine learning in orthopaedic surgery has gained mass interest over the last decade or so.In prior studies,researchers have demonstrated that machine learning in orthopaedics can be used for different applications such as fracture detection,bone tumor diagnosis,detecting hip implant mechanical loosening,and grading osteoarthritis.As time goes on,the utility of artificial intelligence and machine learning algorithms,such as deep learning,continues to grow and expand in orthopaedic surgery.The purpose of this review is to provide an understanding of the concepts of machine learning and a background of current and future orthopaedic applications of machine learning in risk assessment,outcomes assessment,imaging,and basic science fields.In most cases,machine learning has proven to be just as effective,if not more effective,than prior methods such as logistic regression in assessment and prediction.With the help of deep learning algorithms,such as artificial neural networks and convolutional neural networks,artificial intelligence in orthopaedics has been able to improve diagnostic accuracy and speed,flag the most critical and urgent patients for immediate attention,reduce the amount of human error,reduce the strain on medical professionals,and improve care.Because machine learning has shown diagnostic and prognostic uses in orthopaedic surgery,physicians should continue to research these techniques and be trained to use these methods effectively in order to improve orthopaedic treatment.

A New Computer Assisted Orthopaedic Surgery System:WATO

Background:The traditional manual orthopaedic technology heavily relies on a surgeon's experience,so it certainly increases the instability of the surgery.Therefore,computer assisted orthopaedic surgery(CAOS) is becoming a hot research topic for its high accuracy and stability.We developed a new CAOS system WATO,which is mainly designed for total knee replacement(TKR).Methods:WATO system provides the interactive software for a surgeon's preoperative planning.Based on its two infrared cameras,infrared markers and infrared probe,WATO system gives a simple surgical positioning procedure of femur and tibia without additional surgery for the placement of fiducial markers.According to the reference alignment axis from positioning procedure,a surgeon can move the robot of WATO system to do accurate bone resection.Safety checking is also considered in WATO system.Results:Extensive experiments were conducted on phantoms and cadaver bones to verify the accuracy and stability of WATO system.Experimental results showed that TKR using WATO system had better performance compared with traditional and navigated TKR.Conclusion:WATO system shows its superiority in TKR,and has a broad application prospect in the future.We will develop its new functions for other orthopaedic surgery such as total hip replacement(THR).Current disadvantages such as bigger skin incision have to be resolved in the future.

Three-dimensional printing in paediatric orthopaedic surgery

Three-dimensional(3D)printing is a rapidly evolving and promising field to improve outcomes of orthopaedic surgery.The use of patient-specific 3D-printed models is specifically interesting in paediatric orthopaedic surgery,as limb deformity corrections often require an individual 3D treatment.In this editorial,various operative applications of 3D printing in paediatric orthopaedic surgery are discussed.The technical aspects and the imaging acquisition with computed tomography and magnetic resonance imaging are outlined.Next,there is a focus on the intraoperative applications of 3D printing during paediatric orthopaedic surgical procedures.An overview of various upper and lower limb deformities in paediatrics is given,in which 3D printing is already implemented,including posttraumatic forearm corrections and proximal femoral osteotomies.The use of patient-specific instrumentation(PSI)or guiding templates during the surgical procedure shows to be promising in reducing operation time,intraoperative haemorrhage and radiation exposure.Moreover,3D-printed models for the use of PSI or patient-specific navigation templates are promising in improving the accuracy of complex limb deformity surgery in children.Lastly,the future of 3D printing in paediatric orthopaedics extends beyond the intraoperative applications;various other medical applications include 3D casting and prosthetic limb replacement.In conclusion,3D printing opportunities are numerous,and the fast developments are exciting,but more evidence is required to prove its superiority over conventional paediatric orthopaedic surgery.

Trends in leadership at orthopaedic surgery sports medicine fellowships

BACKGROUND Fellowship directors(FDs)in sports medicine influence the future of trainees in the field of orthopaedics.Understanding the characteristics these leaders share must be brought into focus.For all current sports medicine FDs,our group analyzed their demographic background,institutional training,and academic experience.AIM To serve as a framework for those aspiring to achieve this position in orthopaedics and also identify opportunities to improve the position.METHODS Fellowship programs were identified using both the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America Sports Medicine Fellowship Directories.The demographic and educational background data for each FD was gathered via author review of current curriculum vitae(CVs).Any information that was unavailable on CV review was gathered from institutional biographies,Scopus Web of Science,and emailed questionnaires.To ensure the collection of as many data points as possible,fellowship program coordinators,orthopaedic department offices and FDs were directly contacted via phone if there was no response via email.Demographic information of interest included:Age,gender,ethnicity,residency/fellowship training,residency/fellowship graduation year,year hired by current institution,time since training completion until FD appointment,length in FD role,status as a team physician and H-index.RESULTS Information was gathered for 82 FDs.Of these,97.5%(n=80)of the leadership were male;84.15%(n=69)were Caucasian,7.32%(n=6)were Asian-American,2.44%(n=2)were Hispanic and 2.44%(n=2)were African American,and 3.66%(n=3)were of another race or ethnicity.The mean age of current FDs was 56 years old(±9.00 years),and the mean Scopus H-index was 23.49(±16.57).The mean calendar years for completion of residency and fellowship training were 1996(±15 years)and 1997(±9.51 years),respectively.The time since fellowship training completion until FD appointment was 9.77 years.17.07%(n=14)of FDs currently work at the same institution where they completed residency training;21.95%(n=18)of FDs work at the same institution where they completed fellowship training;and 6.10%(n=5)work at the same institution where they completed both residency and fellowship training.Additionally,69.5%(n=57)are also team physicians at the professional and/or collegiate level.Of those that were found to currently serve as team physicians,56.14%(n=32)of them worked with professional sports teams,29.82%(n=17)with collegiate sports teams,and 14.04%(n=8)with both professional and collegiate sports teams.Seven residency programs produced the greatest number of future FDs,included programs produced at least three future FDs.Seven fellowship programs produced the greatest number of future FDs,included programs produced at least four future FDs.Eight FDs(9.75%)completed two fellowships and three FDs(3.66%)finished three fellowships.Three FDs(3.66%)did not graduate from any fellowship training program.The Scopus H-indices for FDs are displayed as ranges that include 1 to 15(31.71%,n=26),15 to 30(34.15%,n=28),30 to 45(20.73%,n=17),45 to 60(6.10%,n=5)and 60 to 80(3.66%,n=3).Specifically,the most impactful FD in research currently has a Scopus H-index value of 79.By comparison,the tenth most impactful FD in research had a Scopus H-index value of 43(accessed December 1,2019).CONCLUSION This study provides an overview of current sports medicine FDs within the United States and functions as a guide to direct initiatives to achieve diversity equality.

Social media growth of orthopaedic surgery residency programs in response to the COVID-19 pandemic

BACKGROUND In the Spring of 2020,residency programs across the country experienced rapid and drastic changes to their application process as a result of the coronavirus disease 2019(COVID-19)pandemic.In response,residency programs shifted to virtual events and began harnessing social media to communicate with applicants.AIM To analyze the changes in social media usage by orthopaedic surgery programs in response to the COVID-19 pandemic.METHODS Based on the 2019 residency and fellowship electronic database,accredited US orthopaedic surgery programs were reviewed for social media presence on Instagram and Twitter.Approximately 47000 tweets from 2011-2021 were extracted through the Twitter application programming interface.We extracted:Total number of followers,accounts following,tweets,likes,date of account creation,hashtags,and mentions.Natural language processing was utilized for tweet sentiment analysis and classified as positive,neutral,or negative.Instagram data was collected and deemed current as of August 11,2021.The account foundation date analysis was based on the date recognized as the start of the COVID-19 outbreak in the United States,before or after March 1,2020.RESULTS A total of 85(42.3%)orthopaedic surgery residency program Twitter handles were identified.Thirty-five(41.2%)programs joined Twitter in the nine months after the 2020 covid outbreak.In 2020,there was a 126.6%increase in volume of tweets by orthopaedic surgery residency accounts as compared to 2019.The median number of followers was 474.5(interquartile range 205.0-796.5).The account with the highest number of tweets was Hospital for Special Surgery(@HSpecialSurgery)with 13776 tweets followed by University of Virginia(@UVA_Ortho)with 5063 and Yale(@OrthoAtYale)with 899.Sentiment analysis before 2020 revealed 30.4%positive,60.8%neutral,and 8.8%negative sentiments across tweets.Interestingly,the positive sentiment percentage increased in 2020 from 30.4%to 34.5%.Of the 201 ACGME-accredited orthopaedic residency programs on Fellowship and Residency Electronic Interactive Database,115(57.2%)participate on Instagram,with 101(87.8%)identified as“resident”-managed vs 14(12.2%)identified as“department”-managed.Over three quarters(77.4%)of Instagram accounts were created after March 1,2020.The average number of followers per account was 1089.5 with an average of 58.9 total posts.CONCLUSION Our study demonstrates a substantial growth of Instagram and Twitter presence by orthopaedic surgery residency programs during the COVID-19 pandemic.These data suggest that orthopaedic residency programs have utilized social media as a new way to communicate with applicants and showcase their programs in light of the challenges presented by the pandemic.

Use of three-dimensional printing in preoperative planning in orthopaedic trauma surgery: A systematic review and meta-analysis

BACKGROUND With the increasing complexity of surgical interventions performed in orthopaedic trauma surgery and the improving technologies used in threedimensional(3D)printing,there has been an increased interest in the concept.It has been shown that 3D models allow surgeons to better visualise anatomy,aid in planning and performing complex surgery.It is however not clear how best to utilise the technique and whether this results in better outcomes.AIM To evaluate the effect of 3D printing used in pre-operative planning in orthopaedic trauma surgery on clinical outcomes.METHODS We performed a comprehensive systematic review of the literature and a metaanalysis.Medline,Ovid and Embase were searched from inception to February 8,2018.Randomised controlled trials,case-control studies,cohort studies and case series of five patients or more were included across any area of orthopaedic trauma.The primary outcomes were operation time,intra-operative blood loss and fluoroscopy used.RESULTS Seventeen studies(922 patients)met our inclusion criteria and were reviewed.The use of 3D printing across all specialties in orthopaedic trauma surgery demonstrated an overall reduction in operation time of 19.85%[95%confidence intervals(CI):(-22.99,-16.71)],intra-operative blood loss of 25.73%[95%CI:(-31.07,-20.40)],and number of times fluoroscopy was used by 23.80%[95%CI:(-38.49,-9.10)].CONCLUSION Our results suggest that the use of 3D printing in pre-operative planning in orthopaedic trauma reduces operative time,intraoperative blood loss and the number of times fluoroscopy is used.

Factors associated with subsequent surgery after septic arthritis of the knee in children

BACKGROUND Septic arthritis of the knee in children is a challenging problem.Surgical debridement is an established treatment,but there is a paucity of literature on long-term prognosis.AIM To determine the rates and factors associated with return to surgery(RTS)and readmission after index surgical debridement for septic arthritis of the knee in children.METHODS This is a retrospective cohort study that utilizes data from the Healthcare Cost and Utilization Project(HCUP).We included patients between ages 0 to 18 years that underwent surgical debridement for septic arthritis of the knee between 2005 and 2017.Demographic data included age,gender,race,hospital type and insurance type.Clinical data including index admission length of stay(LOS)and Charlson Comorbidity Index(CCI)were available from the HCUP database.Descriptive statistics were used to summarize the data and univariate and multivariate analyses were performed.RESULTS Nine-hundred thirty-two cases of pediatric septic knee were included.This cohort was 62.3%male,with mean age of 9.0(±6.1)years.Approximately 46%of patients were white and approximately half had Medicaid insurance.Thirty-six patients(3.6%)required RTS at a minimum of 2 year after index surgery,and 172 patients(18.5%)were readmitted at any point.The mean readmission LOS was 11.6(±11.3)d.Higher CCI was associated with RTS(P=0.041).There were no significant associations in age,gender,race,insurance type,or type of hospital to which patients presented.Multivariate analysis showed that both increased CCI(P=0.008)and shorter LOS(P=0.019)were predictive of RTS.CONCLUSION Septic arthritis of the knee is an important condition in children.The CCI was associated with RTS at a minimum of 2 years after index procedure.No association was found with age,gender,race,insurance type,or hospital type.Shorter LOS and CCI were associated with RTS in multivariate analysis.Overall,risk of subsequent surgery and readmission after pediatric septic knee arthritis is low,and CCI and shorter LOS are predictive of RTS.

A Target-Orientated Marker Image Binarization Method for Orthopaedic Surgical Navigation System

Camera calibration is the key technique in a C-arm based orthopaedic surgical navigation system. The extraction of marker location information is a necessary step in the calibration process. Ideal marker images should possess uniform background and contain marker shadow only, but in fact marker images always possess nonuniform background and are contaminated by noise and unwanted anatomic information, making the extraction very difficult. A target-orientated marker shadow extraction method was proposed. With this method a proper threshold for marker image binarization can be determined.

Post-operative protein supplementation following orthopaedic surgery: A systematic review

Decreased mechanical loading after orthopaedic surgery predisposes patients to develop muscle atrophy.The purpose of this review was to assess whether the evidence supports oral protein supplementation can help decrease postoperative muscle atrophy and/or improve patient outcomes following orthopaedic surgery.A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and MetaAnalysis(PRISMA).PubMed(MEDLINE),Embase,Scopus,and Web of Science were searched for randomized controlled trials that assessed protein or amino acid supplementation in patients undergoing orthopaedic surgery.Two investigators independently conducted the search using relevant Boolean operations.Primary outcomes included functional or physiologic measures of muscle atrophy or strength.Fourteen studies including 611 patients(224 males,387 females)were analyzed.Three studies evaluated protein supplementation after ACL reconstruction(ACLR),3 after total hip arthroplasty(THA),5 after total knee arthroplasty(TKA),and 3 after surgical treatment of hip fracture.Protein supplementation showed beneficial effects across all types of surgery.The primary benefit was a decrease in muscle atrophy compared to placebo as measured by muscle cross sectional area.Multiple authors also demonstrated improved functional measures and quicker achievement of rehabilitation benchmarks.Protein supplementation has beneficial effects on mitigating muscle atrophy in the postoperative period following ACLR,THA,TKA,and surgical treatment of hip fracture.These effects often correlate with improved functional measures and quicker achievement of rehabilitation benchmarks.Further research is needed to evaluate long-term effects of protein supplementation and to establish standardized population-specific regimens that maximize treatment efficacy in the postoperative period.

Oxysterols as promising small molecules for bone tissue engineering: Systematic review

BACKGROUND Bone tissue engineering is an area of continued interest within orthopaedic surgery,as it promises to create implantable bone substitute materials that obviate the need for autologous bone graft.Recently,oxysterols–oxygenated derivatives of cholesterol-have been proposed as a novel class of osteoinductive small molecules for bone tissue engineering.Here,we present the first systematic review of the in vivo evidence describing the potential therapeutic utility of oxysterols for bone tissue engineering.AIM To systematically review the available literature examining the effect of oxysterols on in vivo bone formation.METHODS We conducted a systematic review of the literature following PRISMA guidelines.Using the PubMed/MEDLINE,Embase,and Web of Science databases,we queried all publications in the English-language literature investigating the effect of oxysterols on in vivo bone formation.Articles were screened for eligibility using PICOS criteria and assessed for potential bias using an expanded version of the SYRCLE Risk of Bias assessment tool.All full-text articles examining the effect of oxysterols on in vivo bone formation were included.Extracted data included:Animal species,surgical/defect model,description of therapeutic and control treatments,and method for assessing bone growth.Primary outcome was fusion rate for spinal fusion models and percent bone regeneration for critical-sized defect models.Data were tabulated and described by both surgical/defect model and oxysterol employed.Additionally,data from all included studies were aggregated to posit the mechanism by which oxysterols may mediate in vivo bone formation.RESULTS Our search identified 267 unique articles,of which 27 underwent full-text review.Thirteen studies(all preclinical)met our inclusion/exclusion criteria.Of the 13 included studies,5 employed spinal fusion models,2 employed critical-sized alveolar defect models,and 6 employed critical-sized calvarial defect models.Based upon SYRCLE criteria,the included studies were found to possess an overall“unclear risk of bias”;54%of studies reported treatment randomization and 38%reported blinding at any level.Overall,seven unique oxysterols were evaluated:20(S)-hydroxycholesterol,22(R)-hydroxycholesterol,22(S)-hydroxycholesterol,Oxy4/Oxy34,Oxy18,Oxy21/Oxy133,and Oxy49.All had statistically significant in vivo osteoinductive properties,with Oxy4/Oxy34,Oxy21/Oxy133,and Oxy49 showing a dose-dependent effect in some cases.In the eight studies that directly compared oxysterols to rhBMP-2-treated animals,similar rates of bone growth occurred in the two groups.Biochemical investigation of these effects suggests that they may be primarily mediated by direct activation of Smoothened in the Hedgehog signaling pathway.CONCLUSION Present preclinical evidence suggests oxysterols significantly augment in vivo bone formation.However,clinical trials are necessary to determine which have the greatest therapeutic potential for orthopaedic surgery patients.

Multimodality Treatment in Adult Patients with High-risk Soft-tissue Sarcomas

Objective： We enrolled retrospective data to determine the efficacy of combined chemotherapy and surgery for local tumour control and survival in patients with high-risk soft-tissue sarcomas. Methods： We collected data from 25 patients with high-risk soft-tissue sarcomas treated with four cycles of etoposide, ifosfamide and doxorubicin （EIA） followed by definitive surgery with or without postoperative radiotherapy and adjuvant chemotherapy. 21 patients received chemotherapy in a neoadjuvant/adjuvant clinical setting; eighteen of them completed adjuvant chemotherapy. Four patients received chemotherapy in an adjuvant setting only. Results： The objective response rate of neoadjuvant chemotherapy assessable in 21 patients was 43%. Including NED （n=7） and partial remissions （n=3）, the radiographic response rate was 47.6% with additional 42.9% stable diseases （n=9）. Surgery was performed in two patients before completing four neoadjuvant chemotherapy cycles because of disease progression. Median overall survival for all patients was 21.6＋ months. After completion of chemotherapy, in 62% of patients R0-resection could be performed. Conclusion： High proportion of R0-resections supports the idea of tumour down-staging after neoadjuvant treatment. Response to neoadjuvant chemotherapy is predictive for improved local tumour control resulting in long-term survival benefit.

Topical use of tranexamic acid:Are there concerns for cytotoxicity?

Tranexamic acid(TXA)has revolutionized modern blood management in orthopaedic surgery,especially in total joint arthroplasty,by significantly reducing blood loss and transfusion rates.It is an antifibrinolytic agent and a synthetic derivative of the amino acid lysine,which can inhibit the activation of plasminogen and the fibrin breakdown process.The administration of TXA can be intravenous(IV),topical,and oral.In patients where the IV administration is contraindicated,topical use is preferred.Topical administration of the drug theoretically increases concentration at the operative site with reduced systemic exposure,reduces cost,and gives the surgeon the control of the administration.According to recent studies,topical administration of TXA is not inferior compared to IV administration,in terms of safety and efficacy.However,there are concerns regarding the possible toxicity in the cartilage tissue with the topical use of TXA mainly in hemiarthroplasty operations of the hip,unilateral knee arthroplasties,total knee arthroplasties where the patella is not resurfaced,and other intraarticular procedures,like anterior cruciate ligament reconstruction.The purpose of the present review is to present all the recent updates on the use of TXA focusing on the toxicity on chondrocytes and the articular cartilage that may or may not be provoked by the topical use of TXA.

Comparison of the clinical accuracy of cervical （C2-C7） pedicle screw insertion assisted by fluoroscopy, computed tomography-based navigation, and intraoperative three-dimensional C-arm navigation

Background The complicated anatomy of the cervical spine and the variation among pedicles reduces the accuracy and increases the risk of neurovascular complications associated with screw implantation in this region. In this study, we compared the accuracy of cervical （C2-C7） pedicle screw fixation assisted by X-ray fluoroscopy, computed tomography （CT）-based navigation, or intraoperative three-dimensional （3D） C-arm navigation.Methods This prospective cohort study was performed in 82 consecutive patients who underwent cervical pedicle screw fixation. The accuracy of screw insertion was assessed by postoperative CT scan with 3D reconstruction. The accuracy of screw insertion was assessed as： excellent （screw completely within pedicle）; acceptable （≤ 1 mm screw outside pedicle cortex）; poor （〉1 mm screw outside pedicle cortex）.Results A total of 145 screws were inserted in 24 patients who underwent C-arm fluoroscopy. Of these, 96 screws （66.2%） were excellent, 37 （25.5%） were acceptable, and 12 （8.3%） were poor. One hundred and fifty-nine screws were inserted in 29 patients in the CT-based navigation group. Among these, 141 （88.7%） were excellent, 14 （8.8%） were acceptable, and 4 （2.5%） were poor. A total of 140 screws were inserted in 29 patients in the intraoperative 3D C-arm navigation group, of which 127 （90.7%） were excellent, and 13 （9.3%） were acceptable. No severe or permanent neurovascular complications associated with screw insertion were observed in any patient.Conclusione CT-based and intraoperative 3D C-arm navigation were similarly accurate, and were both significantly more accurate than C-arm fluoroscopy for guiding cervical pedicle screw fixation. They were able to accurately guide the angle and depth of screw placement using visual 3D images. These two techniques are therefore preferable for high-risk cervical pedicle screw fixation. The ease and convenience of intraoperative 3D C-arm navigation suggests that it may replace virtual-fluoroscopy and CT-based navigation systems in future clinical applications.

Computer-assisted auto-frame navigation system for distal locking of tibial intramedullary nails: a preliminary report on clinical application

Objective： To evaluate the clinical feasibility and effect of the computer-assisted auto-frame navigation system for distal locking of tibial intramedullary nails. Methods： The hardware components of the system included a PC computer with a monitor, auto mechanical stereotactical locating cubic frame, foot holder and localization operative apparatus. Special navigation software can be used for registration of X-ray fluoroscopic images and real-time controlling navigation of tools. Twenty-one cases of dose tibial and fibular fractures were treated with dosed intramedullary nailing, 6 of which involved in middle third, 12 in middle and lower third, 3 in lower third. C-arm alignment and registration time, fluoroscopic time and drilling time involved in the locking procedure were recorded. The size of unreamed or reamed tibial nails ranged from 8/300-11/330. Results： All distal holes except 1 were locked successfully. In 9 of 41 locked holes （21.95 % ）, the drill bit touched the canal of locking hole without damage of the nail and clinical consequences. The fluoroscopy time per pair of screws was 2.23 s± 0.31s. Conclusions： The computer-assisted auto-frame navigation system for distal locking is well designed, easy to operate and do not need additional instrmnents during the procedure. The developed system enables the physician to precisely navigate surgical instruments throughout the anatomy using just a few computer-calibrated radiographic images. The total time of x-ray exposure per procedure can be significantly reduced.