Title of the article: AI in orthopedics: Saudi surgeons’ familiarity and perspectives

Authors

Abstract

Aim The growing interest in artificial intelligence (AI) in various medical specialties has led to increased investment in its use for diagnosis, treatment, and improved prognosis. Recent studies have shown that orthopedic surgeons worldwide are optimistic about the potential of AI to improve patient outcomes and diagnostic accuracy. Our aims are to investigate the potential application of AI for diagnosis and treatment purposes among orthopedic surgeons in Saudi Arabia. Additionally, this study aimed to gain valuable insights into the knowledge, perceptions, and concerns of orthopedic surgeons toward AI in the field of orthopedic surgery.
Materials and Methods A cross-sectional, questionnaire-based study was conducted in Saudi Arabia from September 2023 to January 2024. A prevalidated questionnaire was distributed in Arabic and English to orthopedic surgeons to assess AI familiarity, subjective interpretations, and concerns.
Results Our study included 300 orthopedic surgeons, of whom 81% were male and 54% were aged 25–29, which aligns with the younger, male-dominant trend in orthopedics. Only 13% had a complete understanding of AI, but 19.3% planned to learn more. Concerns about AI included clear responsibility (31% complete concern) and cognitive dissonance (39.7% moderate concern). While 14.7% advocated for a complete transformation based on AI, 22.7% supported AI inclusion in training. Significant gender differences exist in AI awareness and usefulness perceptions.
Discussion Our study highlighted a knowledge gap in AI understanding among orthopedic surgeons in Saudi Arabia. However, there is a willingness to learn and embrace AI, with notable gender differences in awareness and perceptions.

Keywords

Introduction

Artificial Intelligence (AI) is progressively transforming medical practice by improving diagnostic accuracy, personalizing treatment plans, and enhancing administrative workflows [1, 2]. In surgical fields, AI’s impact is particularly significant, enabling advancements in robotic-assisted procedures, real-time decision-making, and predictive analytics [3]. For instance, AI-powered tools analyze patient data to predict complications, guide surgical planning, and optimize outcomes, thereby reducing human error and improving recovery rates [4]. Additionally, AI enhances the interpretation of medical imaging, enabling surgeons to identify anomalies and plan interventions with greater precision [5]. These advancements are revolutionizing not only surgical procedures but also the broader landscape of healthcare delivery, fostering innovation and improving patient care [1]. In the field of orthopedic surgery, AI has shown remarkable potential to enhance precision, streamline workflows, and improve patient outcomes [6]. By leveraging advanced algorithms, AI analyzes patient-specific imaging data to develop personalized surgical plans, ensuring the correct placement and alignment of implants during joint replacement surgeries [7]. AI-guided robotic systems enable minimally invasive procedures with greater accuracy, reducing recovery time and minimizing complications. Such applications have gained significant attention among orthopedic surgeons for their potential to revolutionize diagnostic and therapeutic approaches in this specialty [8]. However, the integration of AI in orthopedic surgery is not without challenges. Concerns include the high cost of AI technologies, the need for specialized training, and ethical and legal issues related to decision-making accountability [9, 10]. Additionally, many orthopedic surgeons express apprehension about over-reliance on AI, fearing it could diminish clinical judgment and hands-on surgical skills. These challenges highlight the necessity of addressing technical, ethical, and educational barriers to maximize AI’s benefits in orthopedic surgery [10–12]. Globally, studies have begun to explore orthopedic surgeons’ perspectives on AI. For instance, a survey in Türkiye revealed that while many surgeons are familiar with AI, a significant gap remains between awareness and implementation [13]. Similarly, research from European countries indicates mixed attitudes, with most aspiring surgeons viewing AI as an assistive tool rather than a job threat [11]. Despite these insights, there is limited research examining the attitudes and expectations of orthopedic surgeons in Saudi Arabia, a context where healthcare is rapidly evolving alongside technological advancements.
This study aims to investigate the potential applications of AI in diagnosis and treatment from the perspective of orthopedic surgeons in Saudi Arabia. It seeks to understand their knowledge, perceptions, and concerns, providing valuable insights to guide the successful integration of AI technologies in orthopedic practices within the country.

Materials and Methods

Study Design
A cross-sectional study involving five major regions was undertaken from September 2023 to January 2024 in Saudi Arabia. This study utilized a pre-validated questionnaire to investigate the potential application of AI for diagnosis and treatment purposes among orthopedic surgeons in Saudi Arabia. Furthermore, this study aimed to gain valuable insights into orthopedic surgeons’ perspectives on AI in the field of orthopedic surgery.
Study Population and Sample Size
The study’s required sample size was calculated to be 250 participants based on the methodology proposed by Richard Geiger, with a confidence interval of 95% and a margin of error of 5%. The sample size of this study included participants who fulfilled the inclusion and exclusion criteria. The inclusion criteria were as follows: Saudi and non-Saudi orthopedic surgeons who have worked in Saudi Arabia, either as residents, specialists, or consultants for more than one year. We excluded any Saudi and non-Saudi orthopedic surgeons who had worked in Saudi Arabia for less than a year.
The Questionnaires
The Google Form questionnaire included in this study was driven by research conducted in Türkiye. The Dokuz Eylül University Noninterventional Clinical Research Ethics Board approved the questionnaire with protocol number 2021/16-01 on May 27, 2021 [13]. This study utilized the same questionnaire in two languages: Arabic, the native language of Saudi Arabia, and English, the global language. The questionnaire was distributed in the hospital via email and social media platforms like WhatsApp. The questionnaire has six sections. The first section includes demographic information (gender, age, current degree, description of the current institution, description of the residency training institution, and finally, years of experience in orthopedic surgery). The second section of the questionnaire evaluated the level of awareness of AI. The third section of the questionnaire was used to evaluate the orthopedic surgeon’s level of consideration for the use of AI to manage their patients. The fourth section assessed concerns about AI in multiple situations. The fifth section evaluated the orthopedic surgeon’s idea of the extent of usefulness of AI in different orthopedic subspecialties, and the last section evaluated the orthopedic surgeon’s idea of how AI is needed in classifying fractures in different regions. The participants were provided with clear explanations of the study’s purpose. The publication process did not necessitate the disclosure of personal information, and all the data were confidential and utilized only for scientific research. Additionally, we obtained written informed consent from each participant electronically at the beginning of the questionnaire, ensuring their voluntary and optional participation in this research.
Statistical Analysis
A comprehensive statistical analysis was conducted on the dataset, encompassing both descriptive and inferential methodologies. First, a descriptive analysis is conducted to summarize the demographic characteristics of the participants, which include age, sex, and other features. This provides an overview of the study population. Subsequently, inferential analyses such as the Mann-Whitney and Kruskal-Wallis tests are employed to examine the score differences between different variables. Statistical significance is established at a p value of 0.05 or lower and a 95% confidence interval. P values equal to 0.05 warrant further investigations with longitudinal studies to establish causal associations. All the statistical analyses were executed via IBM SPSS software, version 29.0.0.
Ethical Approval
This study was approved by the Ethics Committee of King Faisal University (Date: 2023-06-06, No: ETHICS949).

Results

Demographics
Our study included 300 Orthopedic Surgeons, the majority were males (81%) in the age group of 25-29 years (54%). Most of them were residents (67%), primarily trained in community hospitals (in Orthopedic surgery (62.7%) (Table 1).
AI Awareness and Use
13% have a complete understanding of the AI concept, whereas 19.3% plan to learn more about AI in the coming years. In daily clinical practice, 7.7% use AI to a complete extent. Opinions regarding the AI's potential for rapid diagnosis are divided, with 15.7% believing that it will be better. Concerns about future unemployment due to AI are expressed by 9.3%. In particular, 14.7% advocated for a complete transformation of orthopedic activities based on AI. Additionally, 22.7% support AI inclusion in the specialty training curriculum (Figure 1).
Perceived Applications
15.3% of the surgeons acknowledge that AI can be used to a complete extent in diagnosis, whereas 21% endorse its complete use in radiological evaluations. 17.7% of the respondents recognize that the application of AI can accomplish surgical planning for their cases. Regarding the prediction of disease course, 21% believe AI has a role, while 19.3% think it can assess treatment success. The literature review garners the highest percentage of complete endorsements, at 29.3%.
Concerns and Barriers
When we question orthopedic surgeons’ perceptions and concerns about incorporating AI into daily clinical practice, the most prominent worry was the potential lack of clear responsibility in the event of AI-related errors, with 31% of respondents expressing complete concern. Other considerable apprehensions included cognitive dissonance (39.7% reporting moderate concern), difficulty adapting AI to real clinical scenarios (29% moderate concern), the perceived lack of patient sensitivity in AI-driven care (30.3% moderate concern), and unease about AI becoming a central decision-maker in clinical workflows (31.3% moderate concern). These findings highlight that while surgeons recognize AI’s potential, there remain substantial reservations about its practical and ethical implications (Figure 2). The highest proportion of orthopedic surgeons believe that AIs can be used in the reconstruction of limbs and joint replacement (Figure 3).
Fracture Evaluation
Our study revealed that orthopedic surgeons express varying levels of acceptance regarding the usefulness of AI in evaluating different fracture types. 30.3% believed that the role of AI in evaluating wrist fractures was "enough." In contrast, the lowest confidence was reported for pelvic fractures (46.7%), which also had the most significant proportion of “slight” or “never” responses (38%). For other fracture types, such as those of the vertebrae, humerus, and ulna, a moderate proportion of the AI utility rates were "moderate," ranging from 29.3% to 33.7%. These responses suggest a moderate to sufficient level of acceptance of the AI's usefulness in assessing various types of fractures, with wrist fractures receiving the highest endorsement.
Subgroup Analysis
The results showed significant differences in AI awareness scores among surgeons. Gender differences exist, with females having higher awareness scores than males (p < 0.001). Although age, title, residency training institute, and years of experience did not yield significant differences in overall awareness, surgeons with 15–19 years of experience reported higher awareness of AI applications in treatment (p = 0.013). Gender differences were also evident in awareness of AI use in daily clinical practice (p = 0.022), where females again scored higher. Notably, surgeons working in private-sector hospitals reported the highest scores for AI usage in daily practice (p = 0.021). Similarly, females rated AI as more useful across different orthopedic sub-branches (p = 0.048) and in evaluating fracture types (p < 0.001). Board-certified specialists gave higher ratings for AI in fracture evaluation, with additional variation observed by residency training and the current working institute (Table 2, 3).

Discussion

This study highlights a growing but still limited awareness and utilization of AI among orthopedic surgeons in Saudi Arabia. Although only 13% report a complete understanding of AI concepts, there is clear interest in future adoption, with nearly one-fifth expressing intent to learn more. Globally, orthopedic surgeons view AI favorably, expecting improved patient outcomes and diagnostic accuracy. Our study revealed that 81% of the participants were male and that 54% were aged 25-29, which aligns with a younger, male-dominant trend in Orthopedics [14, 15]. In daily clinical practice, 7.7% of the surgeons reported using AI to a complete extent. This finding is in line with the gradual integration of AI into healthcare, with early adopters paving the way for broader adoption [16]. Interestingly, opinions on the AI's potential for acute diagnosis were divided, with 15.7% believing that it would be better. This uncertainty could be attributed to concerns about AI accuracy and the need for further validation in clinical settings [17].
Concerns about future unemployment due to AI were expressed by 9.3% of the participants. This apprehension has been echoed in previous literature, with discussions concerning AI's role in augmenting rather than replacing healthcare professionals [18]. The idea of AI complementing surgical skills rather than replacing surgeons is an important point to address in future educational initiatives. Notably, 14.7% of surgeons advocate for a complete transformation of orthopedic activities on the basis of AI. This indicates a willingness to embrace AI-driven changes in practice, which aligns with the concept of "surgical innovation ecosystems" proposed by S Mitra et al. (2020), where technology and innovation are integrated into surgical practice [19]. Moreover, 22.7% of the participants supported the inclusion of AI in the specialty training curriculum. This finding underscores the importance of updating medical education to equip future surgeons with AI skills [20]. We think integrating AI education into medical curricula can prepare the next generation of orthopedic surgeons to harness the benefits of AI effectively. Overall, 21% of the orthopedic surgeons' perceptions of AI applications in treatment endorsed the complete use of AI in radiological evaluations, highlighting the potential of AI to increase diagnostic accuracy in imaging [21]. There were significant gender-based differences in awareness scores, with females scoring higher in terms of AI usage in treatment steps. These findings suggest that female orthopedic surgeons may have a more optimistic view of the potential applications of AI in clinical practice. Additionally, surgeons with 15–19 years of experience were the most aware of AI usage in treatment steps. This could be attributed to their exposure to evolving technologies throughout their careers, making them more receptive to AI innovations.
Our findings reveal the concerns and perceptions of orthopedic surgeons regarding AI in daily medical practice. The foremost concern is the lack of clear responsibility in AI error cases (31% expressing complete concern), emphasizing the need for legal and ethical frameworks [22]. Cognitive dissonance (39.7% moderate concern) may reflect the challenge of trusting AI recommendations. Concerns about adapting to real clinical practices (29% moderate concern) highlight the importance of user-friendly AI interfaces. The perception of AI as insensitive (30.3% moderate concern) underscores the need for patient- centric AI. Additionally, making AI a primary decision-maker (31.3% moderate concern) suggests a cautious approach to the role of AI in clinical decisions.
There were significant gender differences in awareness of AI use in daily medical practice scores, with females rating AI higher than males. This distinction may reflect variations in exposure to AI technologies or differences in perceptions. Surgeons with less than 5 years of experience in orthopedic surgery also scored higher regarding AI usage in daily medical practice, possibly because of their exposure to more recent technological advancements during their training.
Various orthopedic surgeons' views on the potential use of AI in various sub-branches of orthopedics. The varying degrees of acceptance reflect the complexity of AI adoption across different specialties within orthopedics. Joint replacement, foot & ankle, and hand surgery & microsurgery were areas where AI's potential was viewed as "enough" or "moderate" by the majority. This aligns with the notion that AI can increase surgical precision, improve outcomes in specific areas, and predict complications [23].
Various orthopedic surgeons' opinions on the usefulness of AI in evaluating fracture types indicate a moderate to sufficient level of acceptance for the usefulness of AI in assessing various types of fractures. Wrist fractures received the highest endorsement, with 30.3% considering AI's role as "enough." These findings suggest that AI may play a significant role in streamlining the diagnosis and management of common fractures [24].
Various significant gender-based differences in perceptions regarding the usefulness of AI in evaluating fracture types exist. Females rated the AI higher in this respect. Surgeons with the title "Board Certified Specialist" also rated AI as more useful than consultants did. These findings suggest that experienced specialists may recognize the potential of AI in fracture evaluation.

Limitations

Our survey is limited by some limitations from our perspective. Due to the study's cross-sectional design, it was impossible to establish a clear association between the factors being studied. Although there were three hundred participants, the sample size was somewhat small, and the response rate was skewed toward a specific group, the community governmental hospital, and it cannot represent the opinions of private-sector surgeons or university institutions. However, it included a variable level between consultants and board-certified vs. residents, which showed how experience affects attitudes.
Furthermore, despite a high response rate, the potential for response bias cannot be entirely ruled out. Finally, this survey was collected around January 2024, which may have influenced views since then, since AI technology evolves quickly.

Conclusion

Our study provides valuable insights into orthopedic surgeons' attitudes toward and expectations of AI. While there is a need for increased AI education and awareness, the willingness to learn and adopt AI is evident. Persistent ethical and practical concerns — including accountability for AI-related errors, and challenges in clinical integration — continue to temper enthusiasm. Subgroup analysis indicates that gender, institutional setting, and professional experience significantly influence attitudes, with female surgeons showing greater receptiveness to AI adoption. These findings highlight the importance of targeted educational and institutional initiatives to enhance AI literacy and build confidence in AI as a supportive tool rather than a replacement for clinical judgment. Future research and initiatives should focus on integrating AI education into medical curricula and exploring the potential of AI in specific sub-branches of orthopedics.

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