A short history of computers in orthopaedics

‘Computer’ originally referred to a person who made calculations, often with the assistance of a mechanical device. Among the devices used in this numerical manipulation were the abacus (invented between 1000 BCE to 500 BCE), the Antikythera mechanism (created about 100 BCE to calculate the position of the sun and moon), and the slide rule (invented in the 1600s). Punch cards, a 19th century invention, were first used to control textile looms; they were later used in computer programming, at least until the advent of magnetic disk storage in the 1970s.

The origins of the modern computer go back to the 1940s and employed vacuum tubes. Eventually, the tubes were replaced by transistorized components. By the 1970s, integrated circuits and microprocessors enabled the development of smaller, cheaper, and faster computers. Today, computers are commonplace and computer technology is used in almost every electronic device.

Computers in medicine
The first article in a medical journal that referenced use of a computer appeared in 1958.¹ By 1961, several authors described using computers as diagnostic aids or in patient care management.^2,3 But within a few years after computers were introduced to the medical care setting, physicians felt threatened by the technology, as evidenced by a 1963 article titled “Doctors and fear of the computer: Will the computer make the doctor obsolete?”⁴

The first journal articles to discuss use of computers in surgical specialties appeared in 1971. Initially, computers were used for surgical recordkeeping and note taking.⁵ A discussion on using computers intraoperatively to assist the surgeon first appeared in the neurosurgical literature in 1986.^6,7

Computers in orthopaedics
Soon after the adoption of computers in mainstream business technology, and long before most of today’s orthopaedic residents were born, Fabry and Dickerson discussed the use of digital computer records in orthopaedic surgery practice in 1970 and 1972.^8,9 Not many practices or institutions followed the call to digitize orthopaedic records, which Schurman promoted again in 1985.¹⁰

Some orthopaedic surgeons, however, recognized that computers could be used in other ways, apart from simple clerical or recordkeeping duties. These pioneers applied the computer’s ability to capture and organize massive amounts of data to assist in describing, categorizing, and diagnosing orthopaedic conditions. In 1979, Tracy et al described using computers to diagnose gait disorders.¹¹

By the early 1980s, computers and the computed tomography (CT) scanner had become more commonplace. Surgeons were quick to use improved imaging technology to their advantage. Barmeir et al described using CT to plan complicated total hip arthroplasty.¹² In 1989, Mulier et al described the intraoperative use of a computer to create a custom femoral prosthesis for a total hip replacement.¹³

During the past 30 years, ortho-paedists have made great strides in using computers to support patient care. Many have adopted computer management systems for patient records, and a growing number of physicians use digital radiography in their hospitals as well as their offices.

The current debate on using computers in orthopaedics has moved from these simple applications to the computer’s role in assisting intraoperative decision making. Recently, authors in the orthopaedic literature have described using computers as real-time intraoperative adjuncts, particularly in procedures such as minimally invasive total hip and total knee replacements, insertion of intramedullary locking screws, placement of cannulated hip screws, fixation of intertrochanteric femur fractures, placement of iliosacral screws, pelvic fracture fixation, placement of anterior cruciate ligament tunnels and O-arm fluoroscopy.^14-18 Indeed, computer use in the operating room has become so common that some surgeons promote their surgical technique to the public as ‘computer-assisted’ orthopaedic surgery (CAOS).¹⁹

Additionally, some surgeon educators have begun to use computers as virtual reality tools for educating future orthopaedic surgeons and residents.²⁰ This is an area of immense possibility to improve surgeon training and intraoperative skills in a cost-effective and reproducible fashion.

Future of computers in orthopaedics
Computers have changed the business landscape dramatically during the past 30 years. They are making inroads into medical care as well, albeit more slowly in the surgical specialties. Orthopaedic surgeons must recognize that computer technology is here to stay and offers them many potentially significant advantages.

The role of computers in the operating room will certainly increase as research to define its most appropriate applications continues. Many orthopaedic procedures may benefit from the use of computers due to their need for high precision in placing hardware and aligning limbs and components, and the precise geometric nature of bony cuts. As more advanced imaging and referencing technologies become available, surgeons interested in the computer revolution will investigate the computer’s utility in improving surgical technique and outcomes for patients.

The Washington Health Policy Fellows include Aaron Covey, MD; Samir Mehta, MD; Sharat K. Kusuma, MD; Alok D. Sharan, MD; James W. Genuario, MD; Ryan M. Nunley, MD; Anil Ranawat, MD; John Flint, MD; and Alex Jahangir, MD. References for the studies cited in this article can be found online at www.aaos.org/now.

Did you know

• Nearly 16,000 (approximately 3 percent) of the 523,000 total knee replacement procedures performed in the United States in 2006 used computer-assisted navigation.
• The orthopaedic community began discussing the use of computers for medical records and patient care in the 1970s; more than 30 years later, many offices still have not made the transition.
• We are just beginning to explore the potential for computers to improve surgical skills and technique in virtual reality scenarios.
• We have yet to fully define the most effective ways to use computers to improve patient care and surgical outcomes.

References

1. Sekel JP, Jegier W, Johnson AL: Automatic electronic computer for the estimation of arterial concentration of Evans blue dye. Am Heart J 1958;55:485-503.
2. Caceres CA, Rikli AE: The digital computer as an aid in the diagnosis of cardiovascular disease. Trans N Y Acad Sci 1961;23:240-245.
3. Lipkin M, Engle RL, Davis BJ, et al: Digital computer as aid to differential diagnosis: Use in hematologic diseases. Arch Intern Med 1961;108:56-72.
4. Lamport H: Doctors and fear of the computer: Will the computer make the doctor obsolete? Conn Med 1963;27:599-601.
5. Abrams ME: Computers with regard to surgical records and notes. Br J Surg 1971;58:783-784.
6. Kall BA, Kelly PJ, Goerss SJ: The computer as a stereotactic surgical instrument. Neurol Res 1986;8:201-208.
7. Kelly PJ, Kall BA, Goerss S, Earnest F 4th:Computer-assisted stereotaxic laser resection of intra-axial brain neoplasms. J Neurosurg 1986;64:427-439.
8. Fabry G. Use of computers in medicine with special emphasis on its use in the orthopaedic clinic. Acta Orthop Belg 1970;36:255-271.
9. Dickerson RC: Digital computer records in orthopaedic surgery. Clin Orthop Relat Res 1972;83:163-169.
10. Schurman DJ: Computerization of orthopaedic medical records. Instr Course Lect 1985;34:469-474.
11. Tracy KB, Montague EC, Gabriel RP, Kent BE: Computer-assisted diagnosis of orthopedic gait disorders. Phys Ther 1979;59:268-277.
12. Barmeir E, Dubowitz B, Roffman M: Computed tomography in the assessment and planning of complicated total hip replacement. Acta Orthop Scand 1982;53:597-604.
13. Mulier JC, Mulier M, Brady LP, et al: A new system to produce intraoperatively custom femoral prosthesis from measurements taken during the surgical procedure. Clin Orthop Relat Res 1989;(249):97-112.
14. Walde HJ, Walde TA: Minimally invasive orthopedic surgery: First results in navigated total hip arthroplasty. Orthopedics 2006;29(10 Suppl):S139-141. Erratum in: Orthopedics 2007;30:327.
15. Malek S, Phillips R, Mohsen A, Viant W, Bielby M, Sherman K: Computer assisted orthopaedic surgical system for insertion of distal locking screws in intra-medullary nails: A valid and reliable navigation system. Int J Med Robot 2005;1:34-44.
16. Hamelinck HK, Haagmans M, Snoeren MM, Biert J, van Vugt AB, Frolke JP: Safety of computer-assisted surgery for cannulated hip screws. Clin Orthop Relat Res 2007;455:241-245.
17. Chong KW, Wong MK, Rikhraj IS, Howe TS: The use of computer navigation in performing minimally invasive surgery for intertrochanteric hip fractures: The experience in Singapore. Injury 2006;37:755-762.
18. Gebhard FT, Kraus MD, Schneider E, Liener UC, Kinzl L, Arand M. Does computer-assisted spine surgery reduce intraoperative radiation doses? Spine 2006 1;31:2024-2027; discussion 2028.
19. Callaghan JJ, Warth LC, Liu SS, Hozack WJ, Klein GR: Internet promotion of MIS and CAOS in TKA by Knee Society members. Clin Orthop Relat Res 2006;452:97-101.
20. Mohan M, Proctor A: Virtual reality—a ‘play station’ of the future: A review of virtual reality and orthopaedics. Acta Orthop Belg 2006;72:659-663.