In the context of the current digital transformation of the health care system and before the background of the Covid-19 pandemic with reduced personal contacts, telemedicine is becoming more and more important, also in orthopedics (5, 7, 8). Because a complete restructuring of existing processes is necessary in some areas, telemedicine may even be seen as a disruptive technology (9).
The presented case-control study examined the benefits of an OTC among patients and doctors in the setting of orthopedic follow-up examinations. In particular, the technical feasibility, the doctor's assessment of usefulness and possible obstacles and challenges were analyzed. In addition, the study results of OTC and LC were compared in for each patient in order to make a statement about the quality of OTC and thus draw conclusions about the future use of OTC within the field of orthopedics.
One of the noteworthy results of the study was the positive evaluation of the OTC experience by patients and doctors. A clearly positive attitude towards recommending OTC to other patients or doctors was ascertainable, and at the same time the atmosphere during OTC was subjectively perceived as pleasant. Therefore, a previously described negative effect on the doctor-patient relation by mere online consultations, without personal interaction, could not be confirmed (14). It could be proven that orthopedic patients were satisfied with the performance of OTC within their treatment (16). One reason for a positive evaluation of OTC could be the familiar surroundings, indicated as an advantage by the patients, which is confirmed by the existing literature (17). But also, the potential elimination of long travel and waiting times helped made the patients evaluate the OTC positively. This is consistent with study results from other authors (9, 10, 18).
In the presented study, the OTC was mainly used for surgical aftercare. For this purpose, online consultations have already proven to be practicable in the literature (19, 20). Still, it must be stated that not all patients apply for online consultation only, and that online consultations should only accompany examinations in person (9). As a result, the OTC could help to focus the LC more on already well pre-diagnosed cases and those, who have started therapy – to the benefit of all involved.
In most of the cases the OTC ran without technical problems. However, in about one third of the conducted OTC challenges were still noticeable, which is comparable to findings in other studies (23, 24). In the course of this study, low bandwidth in rural areas in Germany were found as impairing for well-working consultations, which has already been described for other regions worldwide (19, 24). These problems require major attention, as they may lower the acceptance of telemedicine and the willingness to use it in the future (25). A strong and stable internet connection should thus be regarded as crucial and essential (19).
In addition to the good acceptance and the objective benefits of the technology, the study also demonstrated the comparatively good quality of the physician-patient consultation by comparing the findings of LC and OTC. Different studies have suggested that physical examination of patients with musculoskeletal diseases by telemedicine is very limited (26–28). However, the examination quality of medical history and inspection were nearly equivalent in this study. Similar results could also be demonstrated for the other sections of a physical examination, such as palpation and active range of motion. It has already been demonstrated that the examination of hip, knee, shoulder, and elbow joint, is well feasible using telemedicine. The examination quality could be increased by handing out a checklist to the patients in advance with preparatory information for the telemedicine consultation (22). Although in the presented study OTC have demonstrated limitations in terms of functional tests of a joint with classic examination methods, it seems that with the help of modifications to those functional tests and the use of assistive devices, it is possible to make reliable statements about this important component of the examination (21, 22). Most importantly, analyzing the established procedures in for each case individually, showed that the OTC recommendations for further treatment were similar to the live consultation recommendations in 96% of the cases. It therefore can be that decisions on further procedures can be made solely using OTC.
Additionally, in this study, we analyzed the distance from patients’ residences to our clinic, the different forms of transportation, and the consumed time for LC that would have otherwise been spent for work commitments. We found that very long travel distances often had to be covered by the patients themselves. The fact that travelling and waiting times in the outpatient clinic were eliminated when using OTC, suggests that patients were committed for a much shorter period of time and thus would have been partly available to the employer (9, 10). Furthermore, patients that are in pain are not affected by the journey to the clinic or by any painful experience that may result from travelling. In addition to the patients themselves, other people were also involved (e.g., accompanying drivers). Next to this, almost 50 percent of the patients needed to drop out of work for at least half a day, unless they were already on sick leave. These factors indicate a significant strain on human and financial resources, which could be reduced by implementing OTC (11, 12, 29).
The study has some limitations. Firstly, the direct comparison of the OTC with a live study cannot guarantee the objectivity of double-blind, randomized, controlled studies. Secondly, it must be critically noted that there was no time recording of the duration of the online and live investigation, which would have provided an important additional measure of effectiveness when compared to each other. Finally, the number of selected patient cases is not large and comprehensive enough to make a statement for all orthopedic disease entities. The voluntary nature of participation could also have led to a biased selection. Participants who were already interested in digital topics might have been more willing to participate in studies on this topic. In the future, more patients should be included with a wider range of age and a more balanced gender distribution.