Artificial intelligence in orthopaedics: A scoping review

Simon J. Federer; Gareth G. Jones

doi:10.1371/journal.pone.0260471

Peer Review History

Original SubmissionMay 19, 2021
8 Jul 2021 Decision Letter - Georg Osterhoff, Editor PONE-D-21-16475 Artificial intelligence in orthopaedics: a scoping review PLOS ONE Dear Dr. Federer, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Aug 22 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Georg Osterhoff, M.D. Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Introduction: There should be a concrete example of implementation of AI based decision support or image classification/segmentation to exemplary show the scope of new developments in this field. Additionally, the ethical and data privacy aspect of saving and processing patient data in big quantities should be addressed. Material and methods: It is unfortunate that the review stops at 2019, since the quantity of new papers covering this area of interest hast evolved since then. This should be discussed later. The exclusion criteria seem very specific and the decision for exclusion should be explained concretely. I.e. exclusion rehabilitation and prosthetics can be applied in clinical application. Results: Short and focused on the few results given. It would be interesting to correlate the year of publication and geographical location of the papers, maybe a graph could be added to emphasize this. Discussion: A clear differentiation between classic algorithms and machine learning or artificial intelligence based self-learning systems needs to be implemented, since this is topic to controversial discussion, since we lack clear definitions to the term “artificial intelligence”. Overlapping research fields: In conclusion this presents us with the opportunity to promote interdisciplinary research, an opportunity which thus far is underdeveloped, especially because specialist knowledge from data science is needed to progress in the field of machine learning and AI in the general field of medicine. Conclusion: Ethical considerations and data privacy, especially with “big data”, as needed for development of AI and ML (machine learning) need to be discussed. Line 207: “AI in clinical practice is embryoic” -> well put, but the research in this paper is not able to support this thesis well enough and it seems like an overdramatization. Other wording should be considered. The conclusion given make general suggestions, that whilst very interessting, cannot be supported by a scoping review, with the few data end points extracted from the 222 papers included. More careful evaluation of results and more focused discussion and conclusion should be considered Reviewer #2: Dear authors, thank you very much for this very interesting, timely manuscript. The present manuscript is well-written and aims to give an overview on this very relevant topic. Unfortunately, it is hard for me to identify the general concept throughout the paper. The structure should be revised and the sections “results”, “discussion” as well as “conclusion” should be extensively revised, focusing on the actual meaning of these sections. Furthermore, referencing must be optimized in order to support your statements. Thus, I am afraid that this paper should not be published in its present state and needs extensive revision. Below you will find some specific comments. Specific comments: Introduction: Since the European General Data Protection Regulation, medical registries are struggling to gather data and therefore, there is actually a decrease of registry data in most of the European countries. Please take that into account and adjust to it. Literature search Was there full agreement on the studies selected between both authors? Please add whether there was full agreement or if there was agreement negotiated. In table 2 you mention search-terms for MEDLINE but did not report literature search in medline for this section. Please adjust. Please describe whether you have only searched for articles in English or any other language. Discussion Generally, I would prefer better structuring of the discussion. I would not put sub-headings and the discussion should be related to the results presented. Unfortunately, in my opinion, a clear concept of this paper is lacking. You are mentioning that research of AI in orthopaedics is at an early stage. How can you support this? Is there more research in other medical fields? In my opinion, parts of the discussion should be rather pointed out in the results section (e.g. line 141-149). Please adjust this to the whole manuscript (strictly describing results versus discussion of these findings). Overlapping research fields: this sub-section seems a bit out of place. Unfortunately, I cannot identify the central idea behind this. Please discuss the arising data protection problems in regards of registry data. Please add references to support your statements (e.g. line 159-161). Conclusion In my opinion, your conclusion is more a discussion than a straight conclusion. Please adjust this and identify actual discussion of findings, compared to a straight conclusion based on your manuscript. Furthermore, I think you should point out the relevance of your findings more extensively. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** Dr. med. David Baur Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. 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Revision 1
17 Aug 2021 Author Response Dear Editor and Reviewers, Thank you for your time reviewing and commenting on our submission. Please see the table below detailing where specific comments have been addressed in the revised manuscript. Introduction • There should be a concrete example of implementation of AI based decision support or image classification/segmentation to exemplary show the scope of new developments in this field. First paragraph of introduction Line 42 • Additionally, the ethical and data privacy aspect of saving and processing patient data in big quantities should be addressed. 2nd paragraph of introduction Line 52 • Since the European General Data Protection Regulation, medical registries are struggling to gather data and therefore, there is actually a decrease of registry data in most of the European countries. Please take that into account and adjust to it. 2nd paragraph of introduction Line 52 Methods • It is unfortunate that the review stops at 2019, since the quantity of new papers covering this area of interest hast evolved since then. This should be discussed later. Mentioned in discussion. Line 357 • The exclusion criteria seem very specific and the decision for exclusion should be explained concretely. I.e. exclusion rehabilitation and prosthetics can be applied in clinical application. Line 95 • Was there full agreement on the studies selected between both authors? Please add whether there was full agreement or if there was agreement negotiated Line 100 • In table 2 you mention search-terms for MEDLINE but did not report literature search in medline for this section. Please adjust. Line 79 • Please describe whether you have only searched for articles in English or any other language. Line 78 and 90 Results • Short and focused on the few results given. It would be interesting to correlate the year of publication and geographical location of the papers, maybe a graph could be added to emphasize this. Stacked bar chart as updated figure 3 Discussion • A clear differentiation between classic algorithms and machine learning or artificial intelligence based self-learning systems needs to be implemented, since this is topic to controversial discussion, since we lack clear definitions to the term “artificial intelligence”. First paragraph of results. Line 120 • Overlapping research fields: In conclusion this presents us with the opportunity to promote interdisciplinary research, an opportunity which thus far is underdeveloped, especially because specialist knowledge from data science is needed to progress in the field of machine learning and AI in the general field of medicine. Added to discussion. Line 236. • Generally, I would prefer better structuring of the discussion. I would not put sub-headings and the discussion should be related to the results presented. Unfortunately, in my opinion, a clear concept of this paper is lacking. Acknowledged. Headings removed. Restructured. • You are mentioning that research of AI in orthopaedics is at an early stage. How can you support this? Is there more research in other medical fields? Line 186. • In my opinion, parts of the discussion should be rather pointed out in the results section (e.g. line 141-149). Please adjust this to the whole manuscript (strictly describing results versus discussion of these findings). Results & discussion restructured • Overlapping research fields: this sub-section seems a bit out of place. Unfortunately, I cannot identify the central idea behind this. Acknowledged. Results & discussion restructured • Please discuss the arising data protection problems in regards of registry data. Discussed in introduction and again in line 319-322. • Please add references to support your statements (e.g. line 159-161) References added. Now lines 192-195. Conclusion • Ethical considerations and data privacy, especially with “big data”, as needed for development of AI and ML (machine learning) need to be discussed. Line 207: “AI in clinical practice is embryoic” -> well put, but the research in this paper is not able to support this thesis well enough and it seems like an overdramatization. Other wording should be considered. Ethical considerations added. Lines 319-322. Conclusion amended. • The conclusion given make general suggestions, that whilst very interessting, cannot be supported by a scoping review, with the few data end points extracted from the 222 papers included. More careful evaluation of results and more focused discussion and conclusion should be considered Conclusion amended to be more focused. • In my opinion, your conclusion is more a discussion than a straight conclusion. Please adjust this and identify actual discussion of findings, compared to a straight conclusion based on your manuscript. Furthermore, I think you should point out the relevance of your findings more extensively. Conclusion amended. We hope you find our revised manuscript suitable for publication and look forward to hearing from you in due course. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0260471.r002
1 Oct 2021 Decision Letter - Georg Osterhoff, Editor PONE-D-21-16475R1Artificial intelligence in orthopaedics: a scoping reviewPLOS ONE Dear Dr. Federer, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Nov 15 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Georg Osterhoff, M.D. Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: I thank the authors for adressing the comments made in the last review. With small adjustments the paper should be eligble to be published. Introduction: Added examples and insight into the collection of data and the potential for those registries complements the overall picture well. Literature search and eligible studies No further comments. Results: Lines 118-122: Since the The term classical algorithms should not be used in this way. It is to unspecific, rather use: machine learning tequniques, since VMs, random forests can be classified as such. Furthermore ANN artifical neural networs and CNN convolutional neural networks should not be separated in these two groups. ANN is a very unspecific terminology as well and can and does in many papers include CNNs. This should be adressed. i.e. Of the artificial networks XX implemented convolution layers... etc. No further comments. Discussion: Line 286-287: Eventough I agree that terminology is very herterogenic when it comes to AI, the term Artificial intelligence is not clearly defined, therefore is not suted as an umbrella term for keyword searches. The problem I see is the broadness of this term, which would generate an unclear and broad term for researchers. Conclusion: No comments. Reviewer #2: Dear authors, thank you very much for this revision. Thanking you for the amendments. Publication should be considered now. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0260471.r003
Revision 2
11 Oct 2021 Author Response Dear Editor and Reviewers, Thank you for your time reviewing and commenting on our submission. The further comments and suggestions have been noted, and we have amended our submission accordingly. Lines 118-122 have been updated with the appropriate terminology. Lines 245-248 have been amended to suggest “Machine learning” as a more suitable umbrella term. We hope you find our revised manuscript suitable for publication and look forward to hearing from you in due course. Yours sincerely, Simon Federer Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0260471.r004
11 Nov 2021 Decision Letter - Thippa Reddy Gadekallu, Editor Artificial intelligence in orthopaedics: a scoping review PONE-D-21-16475R2 Dear Dr. Federer, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Thippa Reddy Gadekallu Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Abstract No further comments. Introduction No further comments. Methods No further comments Results No further comments Discussion Comment was included. No further comments. Conclusion Short and on point. No further comments. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No https://doi.org/10.1371/journal.pone.0260471.r005
Formally Accepted
15 Nov 2021 Acceptance Letter - Thippa Reddy Gadekallu, Editor PONE-D-21-16475R2 Artificial intelligence in orthopaedics: a scoping review Dear Dr. Federer: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Thippa Reddy Gadekallu Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0260471.r006

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