Evaluation of commercial AI algorithms for the detection of fractures, effusions, and dislocations on real-world clinical data: A prospective registry study

Abstract

PURPOSE: To prospectively evaluate and directly compare the performance of three commercial AI algorithms (Gleamer, AZmed, and Radiobotics) for detecting fractures, dislocations, and joint effusions across multiple anatomical regions in real-world adult clinical radiography. MATERIAL AND METHODS: In this single-center, prospective technical performance evaluation study, we assessed these algorithms on radiographs from adult patients (n = 1037; 2926 radiographs; 22 anatomical regions) at the Technical University of Munich (January-March 2025). Radiologists' reports served as the reference standard, with CT adjudication when available. Sensitivity, specificity, accuracy, and AUC were calculated; AUCs were compared using Bonferroni-corrected DeLong tests. RESULTS: Fractures were identified in 29.60 % of patients; 13.69 % had acute fractures and 6.65 % had multiple fractures. For all fractures, Gleamer (AUC 83.95 %, sensitivity 75.57 %, specificity 92.33 %) and AZmed (AUC 84.88 %, sensitivity 79.48 %, specificity 90.27 %) outperformed Radiobotics (AUC 77.24 %, sensitivity 60.91 %, specificity 93.56 %). For acute fractures, AUCs were comparable (range: 84.81-87.78 %). For multiple fractures, performance was limited (AUCs 64.17-73.40 %). AZmed had higher AUC for dislocation (61.85 % vs. 54.48 % for Gleamer), while Gleamer and Radiobotics outperformed AZmed for effusion (AUC 69.59 % and 73.63 % vs. 57.99 %). No algorithm exceeded 91 % accuracy for acute fractures. CONCLUSION: In this real-world, single-center study, commercial AI algorithms showed moderate to high performance for straightforward fracture detection but limited accuracy for complex scenarios such as multiple fractures and dislocations. IMPLICATIONS FOR PRACTICE: Current tools should be used as adjuncts rather than replacements for radiologists and reporting radiographers. Multicenter validation and more diverse training data are necessary to improve generalizability and robustness.

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