Smartphone applications have become ubiquitous in various industries in this country. Medicine is no exception. A recent study has stated the prevalence of smartphone or tablet use by physicians to be nearly 87%, including 80% over the age of 55 yr.1 Within the field of orthopaedics, smartphone usage in trainees has increased from 61% in 2010 to 100% in 2014 and attending use increased from 52% in 2010 to 100% during the same period.2 With such a high prevalence of smartphones, the development and use of smartphone applications has become a rapidly evolving field. This new technological era changes both the patient-surgeon relationship and interaction3 as well as how clinical data are acquired, analyzed, applied, and disseminated.
In terms of market share, the two dominant platforms for applications are Apple’s iOS (Apple Inc, Cupertino, CA) and Google’s Android (Alphabet, Mountain View, CA).4 An increasing number of smartphone applications have become available to the public, specifically designed for orthopaedic surgeons. These applications function as clinical and educational tools, as well as for recreational purposes.
Between August 2010 and August 2014, orthopaedic trainees increased their use of smartphone apps in the clinical setting from 60% to 84%. In this period, attending physician use increased from 41% to 61%.5 Still to this day, the use of applications for the purposes of clinical evaluation, decision-making, and treatment guidance has been limited in the field despite a majority of orthopaedic providers owning a smartphone. The purpose of this study was to conduct a systematic review of the literature and a descriptive analysis of the apps within the field of orthopaedics.
MATERIALS AND METHODS
In both the iOS and Android platforms, simple searches were performed to evaluate the search results that were obtained. Key words search queries used were: “orthopedic,” “orthopedics,” “orthopaedic,” and “orthopaedics.” Applications catered toward specific events and programs were excluded. In addition, general medical applications that were not specific to the orthopaedic discipline also were excluded.
In total across both the Apple app store and the Google Play store, 146 unique applications were found. Of these applications reviewed, 78 were unique to the Apple app store, 29 were unique to the Android Google Play store, and 39 were found in both stores. The applications that were found were then categorized and analyzed (Table 1).
A literature search was conducted using Medline and Embase. Search terms included the text word queries “smartphone,” “phone,” “cellphone,” “iphone,” “ipad,” or “android.” This yielded 17,430 Medline articles and 35,166 Embase articles. The search was limited to papers in the English language that included the text word queries “orthopedic,” orthopedics,” “orthopaedic,” and “orthopaedics.” This limited the number of articles to 101 and 627, respectively, with 51 duplicates. The abstracts from the articles of the refined search were obtained and assessed for relevance to the study at hand. Articles were reviewed to isolate those concentrating on the use of smartphone applications within the field of orthopaedics. After reviewing the abstracts, 34 articles were identified, and their full texts were obtained for analysis (Table 2).
The applications that were found during our initial comprehensive search were divided into three main categories: reference and information, clinical tools, and games. Reference and information type applications totaled 110 (75%), while 25 (17%) were related clinical tools, and 11 (8%) were classified as gaming and entertainment-related (Figure 1).
Reference and Information
The reference and information category was subcategorized into orthopaedic journal applications, anatomy, presurgical patient education, and general references (Figure 2). Many orthopaedic journal apps provide the user with the ability to create online accounts and to subscribe to specific peer-reviewed journals on their smartphone. Such applications are often journal-specific, resulting in the user having to subscribe to them individually. Those in the presurgical patient education category provide patient information about relevant procedures, as well as information on how to triage and avoid injuries based upon lifestyle changes. Many apps also contain self-guided physical therapy information, providing users with ailment-specific stretching and strengthening exercises and advice on reducing the risk of injury. The general references subcategory was the largest, disseminating information and news updates with variable relevance to the orthopaedic field to a broad and unspecified audience.
The clinical tools category was subdivided into angular measurements, coding apps, image processing, guidelines to aid diagnosis, and medical diagram drawing apps (Figure 3). Apps designed to aid in diagnosis and angle measurements accounted for 68% of the apps in this category. Image processing apps allow for a mobile and convenient method of image review. Medical diagram drawing apps act as useful tools in patient education during consults. Such applications allow for a clinician to access and modify visual aids as needed during patient counseling. Coding apps increase the availability and ease of access to diagnostic and procedural codes. This may, in certain circumstances, drastically streamline the office work flow by allowing instantaneous access to information.
Multiple studies have shown that smartphone applications are reliable and efficient tools in terms of the measurement of Cobb angles. Several studies demonstrated that smartphone Cobb angle applications are an equivalent measurement tool to the manual protractor.6–8 With digital applications, measurement times are approximately 15% less than using traditional methods.6 Langensiepen et al.9 came to the conclusion that digital Cobb angle measurements showed high degrees of reliability and tended to be slightly better when compared to manual methods. Smartphone-aided measurements for axial trunk rotation10,11 and scoliotic rib humps have shown excellent reliability in the spine literature.12,13 In a systematic review by Prowse et al.14 apical trunk rotation (ATR) was accurately and reproducibly measured in the transverse plane using a relatively inexpensive model. However, it was noted that these measuring devices only exist for measurement in the transverse plane despite the three-dimensional characteristics of scoliosis and that further research is necessary to assess postural asymmetry in all anatomic planes. Smartphone applications may offer clinical utility in the quantification of standing lumbar lordosis.15
Smartphone app-guided measurements of knee flexion angles offer a higher degree of precision and accuracy than more conventional measurement techniques.16 Ockendon and Gilbert17 reported such results in terms of intraobserver reliability in the clinical setting. In a study performed by Hoshino et al.18 on the digital quantification of the pivot shift test, anterior cruciate ligament (ACL) deficient patients were tested under anesthesia using skin markers attached to various bony landmarks. The recorded movie was processed by the iPad application to measure the lateral translation of the knee joint. Despite technical corrections needed to improve the image data sampling, the potential of the iPad to quantify the pivot shift test was effectively demonstrated. Ferretti et al.19 concluded that the SmartJoint application may provide an effective method of characterizing anterior tibial translation in ACL-deficient knees. The SmartJoint app used in this study was comparable and highly correlated with measurements obtained from the KT1000 measuring device.19 Werner et al.20 reported on the quantification of shoulder range of motion in both healthy and postoperative cohorts. They reported excellent agreement with a goniometer-based gold standard and a smartphone clinometer. Chan et al.21 similarly utilized a mobile computing touch-screen system to capture subjective and objective outcome data for assessment of patients with rotator cuff tears. Such a system provided good inter- and intra-rater reliability while measuring shoulder flexion and external rotation.21
Walter et al.22 reported that applications targeted at measuring angular deformities have the capability of reliably measuring hallux valgus angles (HVA) and intermetatarsal angles. However, it was found that measurements of the distal metatarsal articular angle were more challenging and led to less reliable results. In studies by Ege et al.23 and Meng et al.24 similar results were obtained in terms of measurement of HVAs. Additionally, time reported in taking smartphone measurements was reportedly decreased in comparison to traditional methods.23,24
Smartphones also have been used in the quantification of level walking. Furrer et al.25 showed that smartphone applications can be used to measure vertical center of mass displacement and step duration during level walking. Nishiguchi et al.26 arrived at a similar conclusion using a smartphone and a tri-axial accelerometer that was secured over the L3 spinous process.26 In another study, Yamada et al.27 focused upon the quantification of gait in rheumatoid arthritis patients and age-matched individuals. Patients in the study walked 20 m at their preferred speed, and trunk acceleration was measured using a smartphone.27 The authors concluded that gait parameters recorded using a smartphone represent an acceptable assessment tool for gait in patients with rheumatoid arthritis.
In the rehabilitation setting, Gupta et al.28 found that incorporation of inertial sensors in commonly used braces were simple, economical, and could provide additional monitoring tools for rehabilitation progression. They also added that additional features such as electrodiagnostic based biofeedback, transcutaneous electrical nerve stimulation (TENS), and heat therapy would make such a device comprehensive in all aspects of rehabilitation.
In addition to the multitude of data gathering tools made available by the increasing numbers of available orthopaedic smartphone applications, certain apps have been developed to assist in intraoperative decision making. Peters et al.29 developed a system using the accelerometer and camera function of a smartphone to assist in acetabular cup orientation in total hip arthroplasty. A level indicator application and protractor application were used intraoperatively in a prospective study of 50 cases, showing good results with all cups being placed within a narrow range in the safe zone. They found less than 5% difference between the preoperative, intraoperative, and postoperative acetabular inclinations.
Novel smartphone applications also have been introduced that are capable of assessing rotational deformity for purposes of rotational osteotomy. Comparing visual estimation, osteotomy templates, and contemporary smartphone measurement to CT, it was found that using a smartphone app was significantly more accurate and consistent than both visual estimation and osteotomy templates.30
Hawi et al.31 performed a cadaveric study in which 12 femora were measured for anteversion using a smartphone gyroscope as well as with a conventional navigated technique. CT was used to measure femoral anteversion before a rotational deformity was created via a mid-diaphyseal osteotomy. The app generated acceptable results and could contribute to the improvement of results of femoral nailing, but further clinical testing was necessary before implementation.
Smartphone applications also may serve as appropriate therapy interventions to address deficits often occurring with common hand injuries. Algar et al.32 found that for individuals with trapeziometacarpal arthrosis, gaming can encourage radial abduction range of motion and neuromuscular control required for joint stability.
With the increasing complexity of methods of communications in the hospital setting, smartphones have become increasingly common in the workplace and may contribute to increased efficiency and accuracy during handovers. In a study by Khanna,33 residents reported swifter and more efficient handovers after introduction of a smartphone based communication tool. Giordano et al.34 found an excellent interobserver and intraobserver agreement in the imaging assessment of tibial plateau fractures sent via WhatsApp Messenger. The authors proposed the systematic use of the application to facilitate faster documentation and obtaining the opinion of an experienced consultant when not on call.
Mobile computing tools are also revolutionizing the manner in which information is disseminated. The Orthogeriatrics app developed by AO Trauma provided a method of education to help improve patient care, with content input by experienced faculty and app improvements made based on user feedback.35 Varcadipane et al.36 found that iPad use among orthopaedic surgery residents may improve access to educational resources. This may in turn lead to more time studying in general and improvement in orthopaedic intraining examination (OITE) scores. Most large orthopaedic device companies have created apps for surgeons that include video guides, tutorials, product brochures, and technique guides. Examples include Acumed, Braun, DePuy, Smith and Nephew, Stryker, and Synthes.37 However, it may be noted that the majority of apps designed to propagate information have no named medical professional involvement and lack peer review, raising concerns over content and evidence-base.38,39
Use of smartphone applications in orthopaedic surgery has surged in recent years. Popat et al.40 reported a total of 13 articles published on smartphones in orthopaedic surgery between 2010 and 2013. Franko41 reported that 80 orthopaedic apps in the iTunes store were available for the iPad in 2011. The most requested categories of apps were textbooks and references, techniques and guides, OITE and board review, and billing and coding.42 Key features associated with successful applications were noted to be low cost, a user-friendly interface, and overall simplicity.43
Smartphones have become ubiquitous across the field of medicine as rapid advancements in technology have allowed for their expansion as tools with capabilities far beyond that of basic communication. Their uses in digital imaging as well as messaging have been well documented and have been in common use since the advent of the high resolution digital camera. This study investigated the capabilities of such sophisticated machines past their basic capabilities allowed by advancements in hardware. Orthopaedic applications have combined the raw computing power of these devices with their imaging capabilities to create novel tools capable of performing complex analyses. Many of these apps have shown increased efficiency and portability when compared to traditional methods.
Smartphones and their applications have gained widespread use in the orthopaedic clinical setting and have been shown to be a reliable tool for angle and range of motion analysis. The utility of smartphone applications for angular and range of motion measurements has been applied to both upper and lower extremities, and the spine. They have also been used as tools to capture patient outcome data. More recent literature has also emerged demonstrating the utility of smartphone applications in complex data collection and analysis related to ligamentous stability as well as gait analysis. As smartphone applications and their utility continue to expand, they have also gained entrance into the operating theater as well as the rehabilitation setting, serving as adjuvant tools for potentially improving patient care and outcomes.
Smartphone applications are also expanding into the role of intra-hospital communication. Although the use of cellular devices for accelerated communication and image sharing pre-dates both smartphones and smartphone applications, the use of applications for handoffs and for remote diagnosis and evaluation is well documented. Potential concerns arise with regard to patient privacy and sensitive healthcare information. Apps used for communication are not necessarily designed to maintain a level of security necessary to handle information in a manner compliant with HIPAA regulations. In addition, much of the information available via educational smartphone applications continues to be relatively unregulated. Most large orthopaedic device companies have created apps designed for surgeon education.37 However, the majority of apps had no named medical professional involvement, raising concerns over their content and evidence-base, especially if such information is used directly to guide patient management.38,39
Telehealth, which has been defined as a collection of telecommunication technologies used for enhancing health care, public health, and health education is an emerging field within medicine. It encompasses a broad variety of technologies including live video, data storage and transmission, remote patient monitoring, and mobile health. As with all mobile transmission devices, concerns arise with regard to patient privacy and sensitive healthcare information. Apps used for communication are not necessarily designed to maintain the level of security necessary to handle information in a manner compliant privacy regulations. Jurisdiction over mobile health applications has been divided over multiple federal agencies: the Food and Drug Administration governs devices intended to store, convert, transmit, or convert data, the Federal Trade Commission protects consumers from unfair or deceptive acts and practices, and the Federal Communications Commission governs mobile health from a communications perspective. Given its recent emergence into the healthcare field, mobile health policies governing the use of these technologies are continually being shaped.
Our study reaffirms the role of smartphone applications in and beyond their role as adjunct devices designed for use in communication and education. They have shown promise within a multitude of subspecialties across the field of orthopaedics. Applications ranging in capabilities from angular management to preoperative templating and quantification of gait have already been developed and analyzed in the literature. As more advanced applications are developed, it is likely that smartphones will gain an ever greater presence both the operative room and clinic settings.
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