The Brave New World of Arthroplasty Needs Both ‘Deep Learning’ and ‘Deep Listening’

Deep learning will easily take the crown for ‘word of the decade’ given the exuberant enthusiasm around artificial Intelligence and newer technologies. Automations, AI and Robotics seem to be influencing almost all facets of our current life. As arthroplasty stands at a crossroad straddling the new technology-driven world and the old gold standard conventional world, it is important that we set aside our preconceived notions for this issue on ‘Technology in Arthroplasty’ and view this new world with a fresh pair of eyes.

We must also take lessons from history as we stand on the verge of another renaissance driven by AI and deep learning algorithms. A valuable lesson being any learning and in particular ‘Deep Learning’ needs ‘Deep listening’. While orthopaedics was first mentioned in 1741 in a treatise written by Nicolas Andre, a medicine professor from Paris, Arthroplasty as a speciality had no one father and instead grew with the concerted efforts of many legendary figures who did not fear to experiment and improvise. In the field of arthroplasty, Moore and Bohlman are credited with being the users of the first modern endoprosthesis. [1] Thompson improvised the same into short-stem metal and then long-stem metal devices [2]. These devices developed by Thompson and Moore functioned so well that they are used with minor modification until very recently [3]. Knee replacement started with resection arthroplasty, interposition arthroplasty and then moved into an era of modern joint replacement with the advent of polycentric knee designs by Gunston [4] While the instrumentation was poor and the knee did not mimic the original knee kinematics, yet the design proved to be a milestone in the field of Knee arthroplasty. Arthroplasty as a specialty continues to flourish with an exponential increase in numbers.

In this ‘Technological Renaissance’ three key developments are happening—we are getting software that can process data faster and accurately than humans, we are getting machines that can execute tasks better than humans, and we are getting humans that are trusting machines more than surgeons [5]. Together these three are fundamentally changing ways of art, science and commerce. With better execution, the acclaimed art of surgery is being overtaken by robots; With accurate and faster analysis AI is triumphing over experience and with us, humans trusting technology more than fellow humans—hospitals are acquiring gadgets to ensure that commerce does not suffer. So clearly the bell tolls for the olden golden era of arthroplasty surgeons!

Having said that, this is also an opportunity to create the future that we want. It's human nature to be selective and interpretive. As surgeons we have been hard-wired to process information through filters and biases accumulated over the years. Even the most respected journals and most astute clinicians are susceptible to eminence bias. Technology will shatter the traditional way we process the information and the key will be deep listening. While gen next tech wizards are focussed on deep learning algorithms, the key to success lies in deep listening. It is here that the human touch, the wisdom and the experience will be a game changer. Focus areas and contentious subjects where technique and technology will likely hold hands to be the vehicle of the future are:

Robotic Wars in Arthroplasty

Unlike Navigation, Robotics have started dominating operating rooms on an unprecedented scale. The pace of adoption in countries like India has stunned seasoned industry leaders. All major companies have invested substantially in being a part of this revolution. One of the key reasons behind this adoption is the current generation of arthroplasty surgeons who have grown up using technological gadgets thus shortening the learning curve to 7 cases [6]. Software’s ability to create accurate 3D Models allowing precise positioning, securing desired alignment and balance has the current generation hooked. An argument that was constantly used against navigation was that the purported benefits did not yield any clinical improvement. The same applies to robotics too and whether or not benefits from Robotic yield clinical improvement in the long run needs to be seen. Regardless, the fact remains that adoption will continue to grow as it is driven also by the pressure from patients who have been made to believe that any technological advance especially automation is for good and that precise execution across all spectrums is best achieved through machines. As man and machine join hands to improve outcomes, a battle rages between manufacturers of these machines with each one suggesting that their product is better, and to buttress these arguments newer features with dubious significance are added to augment sales. As experienced arthroplasty surgeons will vouch, while current technology enables great execution, the thought process and decision-making are the critical pieces for a good outcome and still remains in the surgeon’s domain.

The Technique Conundrum and the Era of Personalised Medicine

While Technological strides are undoubtedly influencing the way we do our arthroplasty, some fundamental disagreements still remain. There are varied thoughts on the type of alignment that is best for a particular knee. We have covered a lot of ground in the past 5 decades with mechanical alignment, anatomical alignment, kinematic alignment, restricted kinematic alignment and moved into this new era of personalised or what we prefer to call “The Intelligent Alignment” (Fig. 1). Similarly, the debates on patellar resurfacing, cruciate retaining, most appropriate exposure and use of cement continue to still dominate many discourses in the arthroplasty fraternity. Experienced surgeons know and the technology is now clearly showing that the era of one size fits all and my way or highway is slowly yielding to an era where the solutions are being customised to the anatomy, pathology and the need of the patient. Towards this end, the data both real-time and the one analysed retrospectively is likely to be the torch bearer. We truly await when most debates will be settled objectively with the right evidence and not eminence.

Fig. 1.

The era of Intelligent Alignment based not only on surgeon’s preference but data collected pre and intraoperatively

Availability, Accessibility and Affordability

The newer developments come at a cost and as surgeons, we are often placed in a terrible quandary, while were expected to give our best to our patients, we are also expected to help operate a successful business and contain costs. Working within budget constraints and within tight guidelines and framework may cloud our judgements on the appropriate use of technology. As a community, we must give a thought and put our hands together with industry so as to ensure that the fruits of rapid development percolate to those who need and will benefit from it the most—patients and surgeons included!

AI and Big Data Revolution

As we keep searching for better answers, we cannot rest on our past laurels and must be armed with better tools. With AI and enhanced computational Prowess, everyone has a chance to be a genius. AI can validate our treatment programs—both surgical and non-surgical and evaluate whether they indeed do improve the desired outcome. Mere radiologically excellent outcomes will not serve and that we must adopt the principle of improving patient function as our new paradigm. PROMS and registry data are invaluable and so are culture-specific surveys and data emanating from all across the globe [7] The world of joint replacement as we know it will not last forever. We must be cognisant of the problems and barriers to success in the past and turn a new page in our newfound relationship with data.

Learning and Teaching

To know is information, to apply is action, to Realise is wisdom and to experience is transformation. The experts of yesterday may not be experts of tomorrow. It is thus important that we learn and teach with open minds. Technology has levelled the field ensuring that Boston, Botswana and Bombay together have common access to educational resources. As we continue to herald a paradigm shift, newer teaching tools such as Augmented reality (AR), Virtual Reality and Simulators will play a big role in mentoring our young individuals who will perhaps be immensely more dependent on technological upgrades than we were ever exposed to.

Conclusion

We all have a choice today—Choice to see history being made and become a part of this creation. The enthusiasm for newer techniques and technologies need to be pared and paired with what is much needed and much lacking—“the deep listening”. What makes our specialty strong will and should make us all strong. What we do in this decade of technological renaissance will set the stage for the future and for most of us this future is now. We must not just stand around as before we realize, the future will be past and we will be left just standing! To create this future we must continue to learn deeply and for that, we must first listen deeply. Listen to the past, listen to our teachers, listen to our patients, Listen to our next generation but most importantly listen to the real data!

Declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with human or animal subjects performed by the any of the authors.