Courtesy: Ms. Ruth Delaney, MB BCh, MMedSc, FFSEM, FRCS
Founder, Dublin Shoulder Institute
Consultant Orthopaedic Surgeon, Shoulder Surgery Specialist, Associate Professor
Introduction to Mixed Reality
What Is Mixed Reality?
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Mixed reality is a technology that blends the real physical world with digitally generated content.
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It allows surgeons to interact with virtual objects while remaining aware of the real environment.
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The concept was first described in 1994 by Paul Milgram, who placed mixed reality along a continuum between the real world and fully virtual environments.
Reality–Virtuality Continuum
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Real world
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Augmented reality
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Mixed reality
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Virtual reality
Key Mixed Reality Devices Used in Surgery
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Microsoft HoloLens
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Introduced in 2017
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Head-mounted mixed reality device used for surgical visualization, navigation, and training
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Magic Leap
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Advanced spatial computing headset
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Enables three-dimensional holographic visualization and interaction
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Market Growth and Relevance
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The global augmented reality and virtual reality market is projected to grow by approximately three hundred and fifty percent.
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Market value is expected to increase from two point seven billion United States dollars to nearly ten billion United States dollars over the next five years.
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This rapid growth highlights increasing adoption in healthcare and surgical practice.
How Mixed Reality Works in Surgery
Head-Mounted Display Technology
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Sterile, hands-free holographic visualization within the operating room
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Interaction through:
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Voice commands
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Hand and gesture controls
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Three-Dimensional Planning and Navigation
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Integration of preoperative imaging such as:
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Computed tomography scans
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Magnetic resonance imaging scans
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Real-time intraoperative guidance with holographic overlays
Why Mixed Reality in Upper Extremity Surgery?
Challenges in Upper Extremity Procedures
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Highly complex anatomy involving:
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Nerves
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Blood vessels
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Small and irregular bones
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Requirement for extreme precision in procedures such as:
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Glenoid component placement
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Corrective osteotomies
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Mixed Reality Solutions
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Enhanced three-dimensional anatomical visualization
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Real-time intraoperative adjustments based on patient-specific anatomy
Preoperative Applications
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Three-dimensional fracture mapping:
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Scapula fractures
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Humerus fractures
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Virtual implant sizing and positioning
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Surgical rehearsal and simulation prior to entering the operating room
Intraoperative Applications
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Live navigation for critical steps such as:
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Glenoid guide pin placement
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Holographic surgical guides:
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Kirschner wire trajectory visualization
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Remote collaboration:
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Real-time expert input during surgery
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General Benefits of Mixed Reality in Orthopaedic Trauma
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Provides intuitive real-time feedback to improve:
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Implant positioning accuracy
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Surgical efficiency
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Clinical studies demonstrate:
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Reduced operative time
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Decreased radiation exposure
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Improved accuracy in procedures such as:
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Superior pubic ramus Kirschner wire placement
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Dynamic hip screw insertion
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Trauma Applications
Proximal Humerus Fractures
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Clinical challenge:
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Complex fracture patterns
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Mixed reality solution:
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Virtual fracture reduction planning
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Guidance for percutaneous pin placement
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Elbow Stabilization Using an Internal Joint Stabilizer
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Clinical challenge:
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Accurate drilling along the transepicondylar axis
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Mixed reality solution:
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Holographic alignment of the anatomical axis
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Osteotomy Applications
Cubitus Varus Deformity Correction
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Clinical challenge:
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High complication rates
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Mixed reality solution:
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Virtual wedge planning
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Real-time intraoperative adjustment
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Arthroplasty Applications
Reverse Shoulder Arthroplasty
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Clinical challenge:
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Malpositioning of the glenoid component
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Mixed reality solution:
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Three-dimensional preoperative planning
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Live intraoperative navigation
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Arthroscopy Applications
Rotator Cuff Repair
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Clinical challenge:
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Optimal portal placement
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Mixed reality solution:
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Virtual humerus rotation to improve footprint access
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Glenoid Reconstruction for Shoulder Instability
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Clinical challenge:
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Significant bone loss
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Mixed reality solution:
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Holographic shaping of distal tibia allograft
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Acromioclavicular Joint Injury Repair
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Clinical challenge:
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Coracoid drilling accuracy with conventional techniques ranges from sixty-two to eighty-four percent
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Mixed reality advantages:
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Improved spatial awareness
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Virtual drill guides replicating ideal clavicle-to-coracoid trajectory
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Holographic measurements for precise positioning
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Virtual screens displaying fluoroscopy and arthroscopic views
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Oncology Applications
Tumor Resection
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Clinical challenge:
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Tumor proximity to nerves and blood vessels
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Mixed reality solution:
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Three-dimensional tumor visualization
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Mapping of adjacent neurovascular structures
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Remote Collaboration and Surgical Training
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Live surgical streaming for expert guidance during procedures
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Resident and fellow training through immersive virtual simulations
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Enhanced understanding of complex anatomy without patient risk
Benefits of Mixed Reality in Surgery
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Increased precision, with reported accuracy within approximately one millimeter
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Reduced radiation exposure due to decreased fluoroscopy use
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Faster procedures, with time reductions of up to twenty percent
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Improved surgical education and training outcomes
Challenges and Limitations
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High initial costs for hardware and software
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Learning curve for surgeons and operating room staff
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Potential technical issues during surgery
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Increased preoperative planning time
Future Directions
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Integration of artificial intelligence for automated planning and decision support
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Development of smaller, lighter, and more affordable devices
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Wider adoption across operating rooms and surgical specialties
Conclusion
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Mixed reality represents a major advancement in upper extremity surgery.
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It significantly improves surgical precision, efficiency, and collaboration.
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Ongoing research is required to establish long-term outcomes and cost-effectiveness.
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With continued technological evolution, mixed reality is likely to become an integral part of modern orthopaedic practice.
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