Artificial intelligence in knee arthroplasty: current concept of the available clinical applications

Surgical site soft tissue thickness as a predictor of complications following arthroplasty

Appreciation of soft-tissue thickness (STT) at surgical sites is an increasingly recognized aspect of arthroplasty procedures as it may potentially impacting postoperative outcomes. Recent research has focused on the predictive value of preoperative STT measurements for complications following various forms of arthroplasty, particularly infections, across procedures such as total knee, hip, shoulder, and ankle replacements. Several studies have indicated that increased STT is associated with a higher risk of complications, including infection and wound healing issues. The assessment of STT before surgery could play a crucial role in identifying patients at a higher risk of complications and may be instrumental in guiding preoperative planning to optimize outcomes in arthroplasty procedures. Standardized measurement techniques and further research are essential to enhance the reliability and clinical utility of STT assessment for arthroplasty surgery.

Preoperative, intraoperative, and postoperative concepts to prevent infection for unicompartmental knee arthroplasty

Periprosthetic joint infection (PJI) is a complication that occurs in less than 1% of patients after unicompartmental knee arthroplasty (UKA). Though infrequent, it may potentially lead to revision while placing a significant financial burden on the healthcare system. Preoperative, intra-operative, and postoperative strategies should be implemented to minimize the risk of PJI. Patient optimization prior to surgery can help to identify patients at risk for PJI and also maximize the health of the patient prior to surgery. Intraoperative and postoperative strategies can also mitigate the risk of postoperative infection. This article will summarize the evidence for preoperative, intra-operative, and postoperative strategies to prevent PJI in UKA. This will include topics on malnutrition and obesity, Staphylococcus aureus, smoking, human immunodeficiency virus, rheumatoid arthritis, as well as skin preparation, laminar air flow, preoperative antibiotic administration antimicrobial incision drapes, pulsatile lavage, vancomycin powder, wound closure method, thromboprophylactic agents, and closed incisional negative pressure wound therapy dressings.

Evaluating Knee Recovery Beyond Patient Reports: A Comparative Study of Smart Implantable Device-Derived Gait Metrics Versus Patient-Reported Outcome Measures in Total Knee Arthroplasty

BACKGROUND

Total Knee Arthroplasty (TKA) is frequently performed for advanced osteoarthritis, with patient-reported outcome measures (PROMs) traditionally reporting on efficacy. These subjective evaluations, although useful, may inaccurately reflect post-TKA activity levels. With technological advancements, smart implantable devices (SIDs) offer objective, real-time gait metrics, potentially providing a more accurate postoperative recovery assessment. This study compares these objective metrics with PROMs to evaluate TKA success more effectively.

METHODS

We conducted a retrospective cohort study with 88 participants undergoing TKA using a SID. Eligible patients were aged 18 years or older and had advanced osteoarthritis. We excluded those who had bilateral TKAs, joint infections, or neuromuscular disease. The SID system collected daily gait metrics, including step count, distance traveled, walking speed, stride length, cadence, and functional knee range of motion. The PROMs, including Knee Injury and Osteoarthritis Outcome Score-Joint Replacement, Veterans Rand 12 Physical Component Summary, and Veterans Rand 12 Mental Component Summary, were analyzed against SID gait metrics. Among the 88 patients, 80 provided continuous data over 12 weeks.

RESULTS

All gait metrics, except stride length, significantly increased at the 12-week point (P < .05). The PROMs also significantly improved postoperatively (P < .05). Initial low positive correlations between 12-week PROMs and SID metrics decreased after adjusting for demographic variables, leaving only weak correlations between the Veterans Rand 12 Physical Component Summary and Knee Injury and Osteoarthritis Outcome Score-Joint Replacement with functional knee range of motion (r = 0.389, P = .002; r = 0.311, P = .014, respectively), and Veterans Rand 12 Mental Component Summary with step count (r = 0.406, P = .001) and distance traveled (r = 0.376, P = .003).

CONCLUSIONS

This study indicates that both PROMs and SID gait metrics show significant improvements post-TKA, though they correlate weakly with each other, suggesting a possible discrepancy between perceived recovery and actual functional improvement. The SID gait metrics might provide a valuable addition to traditional PROMs by offering an objective representation of physical capabilities unaffected by patient compliance or subjective perceptions of recovery. Further research is needed to validate these findings in larger populations and to explore whether integrating SID metrics can enhance long-term functional outcomes.

AI in Surgery: Navigating Trends and Managerial Implications Through Bibliometric and Text Mining Odyssey

Background: This research employs bibliometric and text-mining analysis to explore artificial intelligence (AI) advancements within surgical procedures. The growing significance of AI in healthcare underscores the need for healthcare managers to prioritize investments in this technology. Purpose: To assess the increasing impact of AI on surgical practices through a comprehensive analysis of scientific literature, providing insights that can guide managerial decision-making in adopting AI solutions.Research Design: The study analyzes over 6000 scientific articles published since 1990 to evaluate trends and contributions in the field, informing managers about the current landscape of AI in surgery.Study Sample: The research focuses on publications from various influential publishers across North America, Northern Asia, and Eastern & Western Europe, highlighting key markets for AI implementation in surgical settings.Data Collection and Analysis: A bibliometric approach was utilized to identify key contributors and influential journals. At the same time, text-mining techniques highlighted significant keywords related to AI in surgery, aiding managers in recognizing essential areas for further exploration and investment.Results: The year 2022 marked a significant upsurge in publications, indicating widespread AI integration in healthcare. The U.S. emerged as the foremost contributor, followed by China, the UK, Germany, Italy, the Netherlands, and India. Key journals, such as Annals of Surgery and Spine Journal, play a crucial role in disseminating research findings, serving as valuable resources for managers seeking to stay informed.Conclusions: The findings underscore AI's pivotal role in enhancing diagnostic precision, predicting treatment outcomes, and improving operational efficiency in surgical practices. This progress represents a significant milestone in modern medical science, paving the way for intelligent healthcare solutions and further advancements in the field. Healthcare managers should leverage these insights to foster innovation and improve patient care standards.

Advancements and Strategies in Robotic Planning for Knee Arthroplasty in Patients with Minor Deformities

Knee arthroplasty, commonly performed to treat osteoarthritis, necessitates precise surgical techniques for optimal outcomes. The introduction of systems such as the Persona Knee System (Zimmer Biomet, Warsaw, IN, USA) has revolutionized knee arthroplasty, promising enhanced precision and better patient outcomes. This study investigates the application of robotic planning specifically in knee prosthetic surgeries, with a focus on Persona Knee System prostheses. We conducted a retrospective analysis of 300 patients who underwent knee arthroplasty using the Persona Knee System between January 2020 and November 2023, including demographic data, surgical parameters, and preoperative imaging. Robotic planning was employed to simulate surgical procedures. The planning process integrated preoperative imaging data from a specific program adopted for conducting digital preoperative planning, and statistical analyses were conducted to assess correlations between patient characteristics and surgical outcomes. Out of 300 patients, 85% presented with minor deformities, validating the feasibility of robotic planning. Robotic planning demonstrated precise prediction of optimal arthroplasty sizes and alignment, closely aligning with preoperative imaging data. This study highlights the potential benefits of robotic planning in knee arthroplasty surgeries, particularly in cases with minor deformities. By leveraging preoperative imaging data and integrating advanced robotic technologies, surgeons can improve precision and efficacy in knee arthroplasty. Moreover, robotic technology allows for a reduced level of constraint in the intraoperative choice between Posterior-Stabilized and Constrained Posterior-Stabilized liners compared with an imageless navigated procedure.

Artificial intelligence in planned orthopaedic care

The integration of artificial intelligence (AI) into orthopaedic care has gained considerable interest in recent years, evidenced by the growing body of literature boasting wide-ranging applications across the perioperative setting. This includes automated diagnostic imaging, clinical decision-making tools, optimisation of implant design, robotic surgery, and remote patient monitoring. Collectively, these advances propose to enhance patient care and improve system efficiency. Musculoskeletal pathologies represent the most significant contributor to global disability, with roughly 1.71 billion people afflicted, leading to an increasing volume of patients awaiting planned orthopaedic surgeries. This has exerted a considerable strain on healthcare systems globally, compounded by both the COVID-19 pandemic and the effects of an ageing population. Subsequently, patients face prolonged waiting times for surgery, with further deterioration and potentially poorer outcomes as a result. Furthermore, incorporating AI technologies into clinical practice could provide a means of addressing current and future service demands. This review aims to present a clear overview of AI applications across preoperative, intraoperative, and postoperative stages to elucidate its potential to transform planned orthopaedic care.

Clinical validation of a deep learning-based approach for preoperative decision-making in implant size for total knee arthroplasty

BACKGROUND

Orthopedic surgeons use manual measurements, acetate templating, and dedicated software to determine the appropriate implant size for total knee arthroplasty (TKA). This study aimed to use deep learning (DL) to assist in deciding the femoral and tibial implant sizes without manual manipulation and to evaluate the clinical validity of the DL decision by comparing it with conventional manual procedures.

METHODS

Two types of DL were used to detect the femoral and tibial regions using the You Only Look Once algorithm model and to determine the implant size from the detected regions using convolutional neural network. An experienced surgeon predicted the implant size for 234 patient cases using manual procedures, and the DL model also predicted the implant sizes for the same cases.

RESULTS

The exact accuracies of the surgeon's template were 61.54% and 68.38% for predicting femoral and tibial implant sizes, respectively. Meanwhile, the proposed DL model reported exact accuracies of 89.32% and 90.60% for femoral and tibial implant sizes, respectively. The accuracy ± 1 levels of the surgeon and proposed DL model were 97.44% and 97.86%, respectively, for the femoral implant size and 98.72% for both the surgeon and proposed DL model for the tibial implant size.

CONCLUSION

The observed differences and higher agreement levels achieved by the proposed DL model demonstrate its potential as a valuable tool in preoperative decision-making for TKA. By providing accurate predictions of implant size, the proposed DL model has the potential to optimize implant selection, leading to improved surgical outcomes.

Biomechanical analysis of ligament modelling techniques in TKA knees during laxity tests using a virtual joint motion simulator

Total knee arthroplasty (TKA) is an end-stage treatment for knee osteoarthritis that relieves pain and loss of mobility, but patient satisfaction and revision rates require improvement. One cause for TKA revision is joint instability, which may be due to improper ligament balancing. A better understanding of the relationship between prosthesis design, alignment, and ligament engagement is necessary to improve component designs and surgical techniques to achieve better outcomes. We investigated the biomechanical effects of ligament model complexity and ligament wrapping during laxity tests using a virtual joint motion simulator. There was little difference in kinematics due to ligament complexity or ligament wrapping.

Emerging Innovations in Preoperative Planning and Motion Analysis in Orthopedic Surgery

In recent years, preoperative planning has undergone significant advancements, with a dual focus: improving the accuracy of implant placement and enhancing the prediction of functional outcomes. These breakthroughs have been made possible through the development of advanced processing methods for 3D preoperative images. These methods not only offer novel visualization techniques but can also be seamlessly integrated into computer-aided design models. Additionally, the refinement of motion capture systems has played a pivotal role in this progress. These "markerless" systems are more straightforward to implement and facilitate easier data analysis. Simultaneously, the emergence of machine learning algorithms, utilizing artificial intelligence, has enabled the amalgamation of anatomical and functional data, leading to highly personalized preoperative plans for patients. The shift in preoperative planning from 2D towards 3D, from static to dynamic, is closely linked to technological advances, which will be described in this instructional review. Finally, the concept of 4D planning, encompassing periarticular soft tissues, will be introduced as a forward-looking development in the field of orthopedic surgery.

Successful Knee Replacement in a Patient With a History of Multiple Knee Surgeries: A Case Report

This case report describes the successful total knee arthroplasty (TKA) in a 58-year-old female with a prior history of multiple knee surgeries. The patient had three prior surgical procedures. The first surgery of the patient was a partial knee replacement, the second surgery the patient underwent was an arthroscopic meniscectomy, and the third surgery was a high tibial osteotomy (HTO) that left her with an extensive amount of scar tissue and a change in physical structure. When scar tissue develops over or close to a joint, the surrounding tissues are pulled inward by this shrinking or contraction. A joint may experience restricted movement as a result of this tightness. Stretchy and excessively flexible joints are common in people with Ehlers-Danlos syndrome. This may become an issue if you need sutures for a wound because the skin is frequently not strong enough to support them. The patient already undergone three surgeries prior but still showed signs of severe pain, swelling, and stiffness in the knee which made the patient suffer more during rest position and also made it sometimes so difficult that it affected everyday tasks. In this situation when the patient consulted the doctors, the patient was suggested to undergo TKA. TKA is the method of orthopedic surgical technique that is most consistently successful and highly effective. Patients with end-stage degenerative knee osteoarthritis might expect reliable results from this surgery. The case demonstrates the preoperative planning, surgical methods, and postoperative care needed to successfully treat a complicated patient profile. Hospital protocols were followed, and the patient's surgery was done with proper care and hygiene.

Predictive Tool Use and Willingness for Surgery in Patients With Knee Osteoarthritis: A Randomized Clinical Trial

Importance

Despite the increasing number of tools available to predict the outcomes of total knee arthroplasty (TKA), the effect of these predictive tools on patient decision-making remains uncertain.

Objective

To assess the effect of an online predictive tool on patient-reported willingness to undergo TKA.

Design, Setting, and Participants

This parallel, double-masked, 2-arm randomized clinical trial compared predictive tool use with treatment as usual (TAU). The study was conducted between June 30, 2022, and July 31, 2023. Participants were followed up for 6 months after enrollment. Participants were recruited from a major Australian private health insurance company and from the surgical waiting list for publicly funded TKA at a tertiary hospital. Eligible participants had unilateral knee osteoarthritis, were contemplating TKA, and had previously tried nonsurgical interventions, such as lifestyle modifications, physiotherapy, and pain medications.

Intervention

The intervention group was provided access to an online predictive tool at the beginning of the study. This tool offered information regarding the likelihood of improvement in quality of life if patients chose to undergo TKA. The predictions were based on the patient's age, sex, and baseline symptoms. Conversely, the control group received TAU without access to the predictive tool.

Main Outcomes and Measures

The primary outcome measure was the reduction in participants' willingness to undergo surgery at 6 months after tool use as measured by binomial logistic regression. Secondary outcome measures included participant treatment preference and the quality of their decision-making process as measured by the Knee Decision Quality Instrument.

Results

Of 211 randomized participants (mean [SD] age, 65.8 [8.3] years; 118 female [55.9%]), 105 were allocated to the predictive tool group and 106 to the TAU group. After adjusting for baseline differences in willingness for surgery, the predictive tool did not significantly reduce the primary outcome of willingness for surgery at 6 months (adjusted odds ratio, 0.85; 95% CI, 0.42-1.71; P = .64).

Conclusions and Relevance

Despite the absence of treatment effect on willingness for TKA, predictive tools might still enhance health outcomes of patients with knee osteoarthritis. Additional research is needed to optimize the design and implementation of predictive tools, address limitations, and fully understand their effect on the decision-making process in TKA.

Trial Registration

ANZCTR.org.au Identifier: ACTRN12622000072718.

The Rise of Artificial Intelligence: Implications in Orthopedic Surgery

Artificial intelligence (AI) is slowly making its way into all domains and medicine is no exception. AI is already proving to be a promising tool in the health-care field. With respect to orthopedics, AI is already under use in diagnostics as in fracture and tumor detection, predictive algorithms to predict the mortality risk and duration of hospital stay or complications such as implant loosening and in real-time assessment of post-operative rehabilitation. AI could also be of use in surgical training, utilizing technologies such as virtual reality and augmented reality. However, clinicians should also be aware of the limitations of AI as validation is necessary to avoid errors. This article aims to provide a description of AI and its subfields, its current applications in orthopedics, the limitations, and its future prospects.

Artifical intelligence use in orthopedics: an ethical point of view

Artificial intelligence (AI) is increasingly being utilized in orthopedics practice. Ethical concerns have arisen alongside marked improvements and widespread utilization of AI. Patient privacy, consent, data protection, cybersecurity, data safety and monitoring, bias, and accountability are some of the ethical concerns.

Artificial intelligence in orthopaedic surgery

The use of artificial intelligence (AI) is rapidly growing across many domains, of which the medical field is no exception. AI is an umbrella term defining the practical application of algorithms to generate useful output, without the need of human cognition. Owing to the expanding volume of patient information collected, known as 'big data', AI is showing promise as a useful tool in healthcare research and across all aspects of patient care pathways. Practical applications in orthopaedic surgery include: diagnostics, such as fracture recognition and tumour detection; predictive models of clinical and patient-reported outcome measures, such as calculating mortality rates and length of hospital stay; and real-time rehabilitation monitoring and surgical training. However, clinicians should remain cognizant of AI's limitations, as the development of robust reporting and validation frameworks is of paramount importance to prevent avoidable errors and biases. The aim of this review article is to provide a comprehensive understanding of AI and its subfields, as well as to delineate its existing clinical applications in trauma and orthopaedic surgery. Furthermore, this narrative review expands upon the limitations of AI and future direction.

A role for artificial intelligence applications inside and outside of the operating theatre: a review of contemporary use associated with total knee arthroplasty

BACKGROUND

Artificial intelligence (AI) has become involved in many aspects of everyday life, from voice-activated virtual assistants built into smartphones to global online search engines. Similarly, many areas of modern medicine have found ways to incorporate such technologies into mainstream practice. Despite the enthusiasm, robust evidence to support the utility of AI in contemporary total knee arthroplasty (TKA) remains limited. The purpose of this review was to provide an up-to-date summary of the use of AI in TKA and to explore its current and future value.

METHODS

Initially, a structured systematic review of the literature was carried out, following PRISMA search principles, with the aim of summarising the understanding of the field and identifying clinical and knowledge gaps.

RESULTS

A limited body of published work exists in this area. Much of the available literature is of poor methodological quality and many published studies could be best described as "demonstration of concepts" rather than "proof of concepts". There exists almost no independent validation of reported findings away from designer/host sites, and the extrapolation of key results to general orthopaedic sites is limited.

CONCLUSION

While AI has certainly shown value in a small number of specific TKA-associated applications, the majority to date have focused on risk, cost and outcome prediction, rather than surgical care, per se. Extensive future work is needed to demonstrate external validity and reliability in non-designer settings. Well-performed studies are warranted to ensure that the scientific evidence base supporting the use of AI in knee arthroplasty matches the global hype.

Application of machine learning in the prevention of periprosthetic joint infection following total knee arthroplasty: a systematic review

BACKGROUND

Machine learning is a promising and powerful technology with increasing use in orthopedics. Periprosthetic joint infection following total knee arthroplasty results in increased morbidity and mortality. This systematic review investigated the use of machine learning in preventing periprosthetic joint infection.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed was searched in November 2022. All studies that investigated the clinical applications of machine learning in the prevention of periprosthetic joint infection following total knee arthroplasty were included. Non-English studies, studies with no full text available, studies focusing on non-clinical applications of machine learning, reviews and meta-analyses were excluded. For each included study, its characteristics, machine learning applications, algorithms, statistical performances, strengths and limitations were summarized. Limitations of the current machine learning applications and the studies, including their 'black box' nature, overfitting, the requirement of a large dataset, the lack of external validation, and their retrospective nature were identified.

RESULTS

Eleven studies were included in the final analysis. Machine learning applications in the prevention of periprosthetic joint infection were divided into four categories: prediction, diagnosis, antibiotic application and prognosis.

CONCLUSION

Machine learning may be a favorable alternative to manual methods in the prevention of periprosthetic joint infection following total knee arthroplasty. It aids in preoperative health optimization, preoperative surgical planning, the early diagnosis of infection, the early application of suitable antibiotics, and the prediction of clinical outcomes. Future research is warranted to resolve the current limitations and bring machine learning into clinical settings.

Integration of Square Fiducial Markers in Patient-Specific Instrumentation and Their Applicability in Knee Surgery

Computer technologies play a crucial role in orthopaedic surgery and are essential in personalising different treatments. Recent advances allow the usage of augmented reality (AR) for many orthopaedic procedures, which include different types of knee surgery. AR assigns the interaction between virtual environments and the physical world, allowing both to intermingle (AR superimposes information on real objects in real-time) through an optical device and allows personalising different processes for each patient. This article aims to describe the integration of fiducial markers in planning knee surgeries and to perform a narrative description of the latest publications on AR applications in knee surgery. Augmented reality-assisted knee surgery is an emerging set of techniques that can increase accuracy, efficiency, and safety and decrease the radiation exposure (in some surgical procedures, such as osteotomies) of other conventional methods. Initial clinical experience with AR projection based on ArUco-type artificial marker sensors has shown promising results and received positive operator feedback. Once initial clinical safety and efficacy have been demonstrated, the continued experience should be studied to validate this technology and generate further innovation in this rapidly evolving field.

Improving Resource Utilization for Arthroplasty Care by Leveraging Machine Learning and Optimization: A Systematic Review

Background

There is a growing demand for total joint arthroplasty (TJA) surgery. The applications of machine learning (ML), mathematical optimization, and computer simulation have the potential to improve efficiency of TJA care delivery through outcome prediction and surgical scheduling optimization, easing the burden on health-care systems. The purpose of this study was to evaluate strategies using advances in analytics and computational modeling that may improve planning and the overall efficiency of TJA care.

Methods

A systematic review including MEDLINE, Embase, and IEEE Xplore databases was completed from inception to October 3, 2022, for identification of studies generating ML models for TJA length of stay, duration of surgery, and hospital readmission prediction. A scoping review of optimization strategies in elective surgical scheduling was also conducted.

Results

Twenty studies were included for evaluating ML predictions and 17 in the scoping review of scheduling optimization. Among studies generating linear or logistic control models alongside ML models, only 1 found a control model to outperform its ML counterpart. Furthermore, neural networks performed superior to or at the same level as conventional ML models in all but 1 study. Implementation of mathematical and simulation strategies improved the optimization efficiency when compared to traditional scheduling methods at the operational level.

Conclusions

High-performing predictive ML-based models have been developed for TJA, as have mathematical strategies for elective surgical scheduling optimization. By leveraging artificial intelligence for outcome prediction and surgical optimization, there exist greater opportunities for improved resource utilization and cost-savings in TJA than when using traditional modeling and scheduling methods.

Segmentation of polyps based on pyramid vision transformers and residual block for real-time endoscopy imaging

Polyp segmentation is an important task in early identification of colon polyps for prevention of colorectal cancer. Numerous methods of machine learning have been utilized in an attempt to solve this task with varying levels of success. A successful polyp segmentation method which is both accurate and fast could make a huge impact on colonoscopy exams, aiding in real-time detection, as well as enabling faster and cheaper offline analysis. Thus, recent studies have worked to produce networks that are more accurate and faster than the previous generation of networks (e.g., NanoNet). Here, we propose ResPVT architecture for polyp segmentation. This platform uses transformers as a backbone and far surpasses all previous networks not only in accuracy but also with a much higher frame rate which may drastically reduce costs in both real time and offline analysis and enable the widespread application of this technology.