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What Are the Applications and Limitations of Artificial Intelligence for Fracture Detection and Classification in Orthopaedic Trauma Imaging? A Systematic Review

Langerhuizen, David W. G. MD; Janssen, Stein J. MD, PhD; Mallee, Wouter H. MD; van den Bekerom, Michel P.J. MD, PhD; Ring, David MD, PhD; Kerkhoffs, Gino M. M. J. MD, PhD; Jaarsma, Ruurd L. MD, PhD, FRACS; Doornberg, Job N. MD, PhD

Clinical Orthopaedics and Related Research: November 2019 - Volume 477 - Issue 11 - p 2482-2491
doi: 10.1097/CORR.0000000000000848

Background Artificial-intelligence algorithms derive rules and patterns from large amounts of data to calculate the probabilities of various outcomes using new sets of similar data. In medicine, artificial intelligence (AI) has been applied primarily to image-recognition diagnostic tasks and evaluating the probabilities of particular outcomes after treatment. However, the performance and limitations of AI in the automated detection and classification of fractures has not been examined comprehensively.

Question/purposes In this systematic review, we asked (1) What is the proportion of correctly detected or classified fractures and the area under the receiving operating characteristic (AUC) curve of AI fracture detection and classification models? (2) What is the performance of AI in this setting compared with the performance of human examiners?

Methods The PubMed, Embase, and Cochrane databases were systematically searched from the start of each respective database until September 6, 2018, using terms related to “fracture”, “artificial intelligence”, and “detection, prediction, or evaluation.” Of 1221 identified studies, we retained 10 studies: eight studies involved fracture detection (ankle, hand, hip, spine, wrist, and ulna), one addressed fracture classification (diaphyseal femur), and one addressed both fracture detection and classification (proximal humerus). We registered the review before data collection (PROSPERO: CRD42018110167) and used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). We reported the range of the accuracy and AUC for the performance of the predicted fracture detection and/or classification task. An AUC of 1.0 would indicate perfect prediction, whereas 0.5 would indicate a prediction is no better than a flip-of-a-coin. We conducted quality assessment using a seven-item checklist based on a modified methodologic index for nonrandomized studies instrument (MINORS).

Results For fracture detection, the AUC in five studies reflected near perfect prediction (range, 0.95-1.0), and the accuracy in seven studies ranged from 83% to 98%. For fracture classification, the AUC was 0.94 in one study, and the accuracy in two studies ranged from 77% to 90%. In two studies AI outperformed human examiners for detecting and classifying hip and proximal humerus fractures, and one study showed equivalent performance for detecting wrist, hand and ankle fractures.

Conclusions Preliminary experience with fracture detection and classification using AI shows promising performance. AI may enhance processing and communicating probabilistic tasks in medicine, including orthopaedic surgery. At present, inadequate reference standard assignments to train and test AI is the biggest hurdle before integration into clinical workflow. The next step will be to apply AI to more challenging diagnostic and therapeutic scenarios when there is absence of certitude. Future studies should also seek to address legal regulation and better determine feasibility of implementation in clinical practice.

Level of Evidence Level II, diagnostic study.

D. W. G. Langerhuizen, R. L. Jaarsma, J. N. Doornberg, Flinders University, Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Adelaide, Australia

S. J. Janssen, Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands

W. H. Mallee, G. M. M. J. Kerkhoffs, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centre, Amsterdam, the Netherlands

M. P. J. van den Bekerom, Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands

D. Ring, Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX, USA

D. W. G. Langerhuizen, Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Bedford Park, Level 5, Room 5A 153, Bedford Park 5042 South Australia, Email:

One of the authors (DWGL) certifies that he received an amount less than USD 10,000 from the Michael van Vloten Foundation (Rotterdam, the Netherlands), an amount less than USD 10,000 from the Anna Foundation (Oegstgeest, the Netherlands), and an amount less than USD 10,000 from the Traumaplatform Foundation (Amsterdam, the Netherlands). One of the authors (DR) certifies that he received payments in an amount of less than USD 10,000 in royalties from Skeletal Dynamics (Miami, FL, USA) and payments in an amount of less than USD 10,000 in personal fees from Wright Medical (Memphis, TN, USA), personal fees as Deputy Editor for Clinical Orthopaedics and Related Research®, personal fees from universities and hospitals, and personal fees from lawyers outside the submitted work. One of the authors (JND) certifies that he has received an unrestricted Postdoc Research Grant from the Marti-Keuning-Eckhardt Foundation.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his institution waived approval for the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

This study was performed at Flinders Medical Centre, Adelaide, Australia and the Amsterdam University Medical Centre, Amsterdam, the Netherlands.

© 2019 by the Association of Bone and Joint Surgeons
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