Augmented and Virtual Reality for Preoperative Trauma Planning, Focusing on Orbital Reconstructions: A Systematic Review

Augmented Reality Navigation in Craniomaxillofacial/Head and Neck Surgery

Objective

This study aims to (1) develop an augmented reality (AR) navigation platform for craniomaxillofacial (CMF) and head and neck surgery; (2) apply it to a range of surgical cases; and (3) evaluate the advantages, disadvantages, and clinical opportunities for AR navigation.

Study Design

A multi-center retrospective case series.

Setting

Four tertiary care academic centers.

Methods

A novel AR navigation platform was collaboratively developed with Xironetic and deployed intraoperatively using only a head-mounted display (Microsoft HoloLens 2). Virtual surgical plans were generated from computed tomography/magnetic resonance imaging data and uploaded onto the AR platform. A reference array was mounted to the patient, and the virtual plan was registered to the patient intraoperatively. A retrospective review of all AR-navigated CMF cases since September 2023 was performed.

Results

Thirty-three cases were reviewed and classified as either trauma, orthognathic, tumor, or craniofacial. The AR platform had several advantages over traditional navigation including real-time 3D visualization of the surgical plan, identification of critical structures, and real-time tracking. Furthermore, this case series presents the first-known examples of (1) AR instrument tracking for midface osteotomies, (2) AR tracking of the zygomaticomaxillary complex during fracture reduction, (3) mandibular tracking in orthognathic surgery, (4) AR fibula cutting guides for mandibular reconstruction, and (5) integration of real-time infrared visualization in an AR headset for vasculature identification.

Conclusion

While still a developing technology, AR navigation provides several advantages over traditional navigation for CMF and head and neck surgery, including heads up, interactive 3D visualization of the surgical plan, identification of critical anatomy, and real-time tracking.

Augmented reality for perforator mapping: A systematic review and meta-analysis

BACKGROUND

Augmented reality (AR) is increasingly used to aid perioperative navigation of patient anatomy, improve intraoperative accuracy and reduce operating times. This review compares outcomes relating to AR versus conventional imaging for perforator mapping in flap reconstruction.

METHODS

A systematic search was performed, suitable articles reviewed, and data extracted by 2 independent reviewers, with conflicts resolved by consensus. Meta-analysis was conducted to evaluate AR versus Doppler on outcomes including distance between imaged perforators and intraoperative findings, number of perforators identified, perforator localisation time, total operating time, and postoperative complications.

RESULTS

Of 1005 articles retrieved, 14 were eligible for meta-analysis. Intraoperative use of AR was associated with a significantly shorter distance between identified perforators and intraoperative findings (SMD = -1.88; 95% CI -3.69 to -0.08; P = 0.04) and identification of more perforators than conventional Doppler (SMD = 0.12; 95% CI 0.01 to 0.23; P = 0.04). AR decreased time taken for perforator localisation (SMD = -2.53; 95% CI -5.14 to 0.08; P = 0.06) and significantly reduced total operating time (SMD = -16.34; 95% CI -21.72 to -10.95; P< 0.00001). There was no significant difference between the 2 groups in the number of postoperative complications (SMD = 1.12; 95% CI 0.46 to 2.74; P = 0.80).

CONCLUSIONS

The results suggest that AR technologies offer increased intraoperative accuracy of perforator identification and reduced time to perforator identification and total operating times compared to conventional imaging. Further high-quality studies with larger sample sizes are required to definitively confirm the benefits to support their widespread uptake and use.

In house 3-D printed surgical guide for frontal sinus osteotomy in traumatology: A technical note

Frontal sinus surgery and particularly frontal sinus osteotomy represent historically a procedure demanding precision and careful planning. Achieving optimal results while minimizing complications requires meticulous preoperative planning and execution. Cutting guides are crucial tools in surgical procedures, particularly in complex osteotomies like could be those involving the frontal sinus. The aim of the study is to show the worflow for the in-house custom made cutting guide for secure and accurated frontal sinus approach. Given the simplicity, efficacy, rapidity, and safety of the procedure, the workflow for programming the cutting guide can be considered valid for all surgical procedures that contemplate performing an osteotomy on the anterior wall of the frontal sinus, such as trauma pathology, inflammatory naso-sinus pathology, benign or malignant neoplastic pathology, and craniofacial malformation pathology.

Validation of mixed reality in planning orbital reconstruction with patient-specific implants

This study aims to evaluate and compare the usability and performance of mixed reality (MR) technology versus conventional methods for preoperative planning of patient-specific reconstruction plates for orbital fractures. A crossover study design was used to compare MR technology with conventional three-dimensional (3D) printing approaches in the planning of maxillofacial traumatology treatments. The primary focus was on user-friendliness and the accuracy of patient-specific reconstruction planning. Secondary outcomes included investigating time differences between the two approaches and evaluating the potential effects on the learning curve. Participants were asked to complete questionnaires assessing various aspects, such as visualization, interaction, segmentation, treatment planning, and evaluation. Objective endpoints were evaluated blindly, while subjective endpoints were analyzed through a double-blind process. The total workflow time for MR technology was significantly shorter compared to the conventional method. Moreover, treatment planning using MR was significantly more accurate (p = .028), with participants reporting a higher mean global satisfaction score compared to the conventional group (80.6% vs. 72.5%). This study sheds light on the potential benefits of employing MR technology in maxillofacial orbital reconstruction. This preoperative method allows for faster and more precise design of patient-specific implants for orbital reconstruction, potentially leading to improved long-term cost-effectiveness.

Augmented Reality for extremity hemorrhage training: a usability study

Introduction

Limb massive hemorrhage is the first cause of potentially preventable death in trauma. Its prompt and proper management is crucial to increase the survival rate. To handle a massive hemorrhage, it is important to train people without medical background, who might be the first responders in an emergency. Among the possible ways to train lay rescuers, healthcare simulation allows to practice in a safe and controlled environment. In particular, immersive technologies such as Virtual Reality (VR) and Augmented Reality (AR) give the possibility to provide real time feedback and present a realistic and engaging scenario, even though they often lack personalization.

Methods

This work aims to overcome the above-mentioned limitation, by presenting the design, development and usability test of an AR application to train non-experienced users on the use of antihemorrhagic devices. The application combines a Microsoft Hololens2 headset, with an AR application developed in Unity Game Engine. It includes a training scenario with a multimodal interactive system made of visual and audio cues, that would adapt to user's learning pace and feedback preference.

Results

Usability tests on 20 subjects demonstrated that the system is well tolerated in terms of discomfort and workload. Also, the system has been high rated for usability, user experience, immersion and sense of presence.

Discussion

These preliminary results suggest that the combination of AR with multimodal cues can be a promising tool to improve hemorrhage management training, particularly for unexperienced users. In the future, the proposed application might increase the number of people who know how to use an anti-hemorrhagic device.

Digital Twins Use in Plastic Surgery: A Systematic Review

Background/Objectives: Digital twin technology, initially developed for engineering and manufacturing, has entered healthcare. In plastic surgery, digital twins (DTs) have the potential to enhance surgical precision, personalise treatment plans, and improve patient outcomes. This systematic review aims to explore the current use of DTs in plastic surgery and evaluate their effectiveness, challenges, and future potential. Methods: A systematic review was conducted by searching PubMed, Scopus, Web of Science, and Embase databases from their infinity to October 2024. The search included terms related to digital twins and plastic surgery. Studies were included if they focused on applying DTs in reconstructive or cosmetic plastic surgery. Data extraction focused on study characteristics, technological aspects, outcomes, and limitations. Results: After 110 studies were selected for screening, 9 studies met the inclusion criteria, covering various areas of plastic surgery, such as breast reconstruction, craniofacial surgery, and microsurgery. DTs were primarily used in preoperative planning and intraoperative guidance, with reported improvements in surgical precision, complication rates, and patient satisfaction. However, challenges such as high costs, technical complexity, and the need for advanced imaging and computational tools were frequently noted. Limited research exists on using DTs in postoperative care and real-time monitoring. Conclusions: This systematic review highlights the potential of digital twins to revolutionise plastic surgery by providing personalised and precise surgical approaches. However, barriers such as cost, complexity, and ethical concerns must be addressed. Future research should focus on validating clinical outcomes through large-scale studies and developing soft tissue modelling and real-time monitoring capabilities.

Acceptance and use of extended reality in surgical training: an umbrella review

BACKGROUND

Extended reality (XR) technologies which include virtual, augmented, and mixed reality have significant potential in surgical training, because they can help to eliminate the limitations of traditional methods. This umbrella review aimed to investigate factors that influence the acceptance and use of XR in surgical training using the unified theory of acceptance and use of technology (UTAUT) model.

METHODS

An umbrella review was conducted in 2024 by searching various databases until the end of 2023. Studies were selected based on the predefined eligibility criteria and analyzed using the components of the UTAUT model. The quality and risk of bias of the selected studies were assessed, and the findings were reported descriptively.

RESULTS

A total of 44 articles were included in this study. In most studies, XR technologies were used for surgical training of orthopedics, neurology, and laparoscopy. Based on the UTAUT model, the findings indicated that XR technologies improved surgical skills and procedural accuracy while simultaneously reducing risks and operating room time (performance expectancy). In terms of effort expectancy, user-friendly systems were accessible for the trainees with various levels of expertise. From a social influence standpoint, XR technologies enhanced learning by providing positive feedback from experienced surgeons during surgical training. In addition, facilitating conditions emphasized the importance of resource availability and addressing technical and financial limitations to maximize the effectiveness of XR technologies in surgical training.

CONCLUSIONS

XR technologies significantly improve surgical training by increasing skills and procedural accuracy. Although adoption is facilitated by designing user-friendly interfaces and positive social influences, financial and resource challenges must be overcome, too. The successful integration of XR into surgical training necessitates careful curriculum design and resource allocation. Future research should focus on overcoming these barriers, so that XR can fully realize its potential in surgical training.

Technological Advancements in Augmented, Mixed, and Virtual Reality Technologies for Surgery: A Systematic Review

Recent advancements in artificial intelligence (AI) have shown significant potential in the medical field, although many applications are still in the research phase. This paper provides a comprehensive review of advancements in augmented reality (AR), mixed reality (MR), and virtual reality (VR) for surgical applications from 2019 to 2024 to accelerate the transition of AI from the research to the clinical phase. This paper also provides an overview of proposed databases for further use in extended reality (XR), which includes AR, MR, and VR, as well as a summary of typical research applications involving XR in surgical practices. Additionally, this paper concludes by discussing challenges and proposed solutions for the application of XR in the medical field. Although the areas of focus and specific implementations vary among AR, MR, and VR, current trends in XR focus mainly on reducing workload and minimizing surgical errors through navigation, training, and machine learning-based visualization. Through analyzing these trends, AR and MR have greater advantages for intraoperative surgical functions, whereas VR is limited to preoperative training and surgical preparation. VR faces additional limitations, and its use has been reduced in research since the first applications of XR, which likely suggests the same will happen with further development. Nonetheless, with increased access to technology and the ability to overcome the black box problem, XR's applications in medical fields and surgery will increase to guarantee further accuracy and precision while reducing risk and workload.

A stepwise approach to chainsaw kickback injury of the nasoorbital complex: a case-based meta-narrative review

PURPOSE

This article outlines the management of a rare and severe nasoorbital injury resulting from a chainsaw kickback accident in a 60-year-old male. A meta-narrative review of English, French, and German literature indexed in PubMed, Embase, and the Cochrane Library up to January 8, 2024, accompanies the case report.

METHODS

This was a case report combined with a comprehensive review based on the 2011 Oxford Centre for Evidence-Based Medicine's highest and most recent level of evidence (LoE) and highest recommendation grade (RG). Rigorous selection criteria were applied.

RESULTS

The patient had an open nasal fracture, complex lacerations, and avulsion of the left eyelid, lateral orbital wall and lateral rectus muscle. Staged surgical interventions comprised repositioning and fixation of the fractured nose, buccal mucosal grafting for nasal mucosa and conjunctiva repair, titanium mesh and polydioxanone sheet for lateral orbital wall reconstruction, and subsequent muscle and eyelid repair. The second intervention 3 months postsurgery addressed lateral ectropion, nasal dorsal hump, and nasolacrimal system issues. Despite the rarity of such injuries, evidence-based discussions were conducted.

CONCLUSIONS

Complex nasoorbital trauma resulting from chainsaw kickback necessitates a meticulous, staged surgical approach. The inside-out technique proved effective in addressing various challenges. This article concludes with evidence-based recommendations, highlighting the importance of adapting established principles to unique nature of these injuries.

Exploring Augmented Reality Integration in Diagnostic Imaging: Myth or Reality?

This study delves into the transformative potential of integrating augmented reality (AR) within imaging technologies, shedding light on this evolving landscape. Through a comprehensive narrative review, this research uncovers a wealth of literature exploring the intersection between AR and medical imaging, highlighting its growing prominence in healthcare. AR's integration offers a host of potential opportunities to enhance surgical precision, bolster patient engagement, and customize medical interventions. Moreover, when combined with technologies like virtual reality (VR), artificial intelligence (AI), and robotics, AR opens up new avenues for innovation in clinical practice, education, and training. However, amidst these promising prospects lie numerous unanswered questions and areas ripe for exploration. This study emphasizes the need for rigorous research to elucidate the clinical efficacy of AR-integrated interventions, optimize surgical workflows, and address technological challenges. As the healthcare landscape continues to evolve, sustained research efforts are crucial to fully realizing AR's transformative impact in medical imaging. Systematic reviews on AR in healthcare also overlook regulatory and developmental factors, particularly in regard to medical devices. These include compliance with standards, safety regulations, risk management, clinical validation, and developmental processes. Addressing these aspects will provide a comprehensive understanding of the challenges and opportunities in integrating AR into clinical settings, informing stakeholders about crucial regulatory and developmental considerations for successful implementation. Moreover, navigating the regulatory approval process requires substantial financial resources and expertise, presenting barriers to entry for smaller innovators. Collaboration across disciplines and concerted efforts to overcome barriers will be essential in navigating this frontier and harnessing the potential of AR to revolutionize healthcare delivery.

Comparison of virtual reality and computed tomography in the preoperative planning of complex tibial plateau fractures

INTRODUCTION

Preoperative planning is a critical step in the success of any complex surgery. The pur-pose of this study is to evaluate the advantage of VR glasses in surgical planning of complex tibial plateau fractures compared to CT planning.

MATERIALS AND METHODS

Five orthopedic surgeons performed preoperative planning for 30 fractures using either conventional CT slices or VR visualization with a VR headset. Planning was performed in a randomized order with a 3-month interval between planning sessions. A standardized questionnaire assessed planned operative time, planning time, fracture classification and understanding, and surgeons' subjective confidence in surgical planning.

RESULTS

The mean planned operative time of 156 (SD 47) minutes was significantly lower (p < 0.001) in the VR group than in the CT group (172 min; SD 44). The mean planning time in the VR group was 3.48 min (SD 2.4), 17% longer than in the CT group (2.98 min, SD 1.9; p = 0.027). Relevant parameters influencing planning time were surgeon experience (-0.61 min) and estimated complexity of fracture treatment (+ 0.65 min).

CONCLUSION

The use of virtual reality for surgical planning of complex tibial plateau fractures resulted in significantly shorter planned operative time, while planning time was longer compared to CT planning. After VR planning, more surgeons felt (very) well prepared for surgery.

Accuracy of surgical navigation for patient-specific reconstructions of orbital fractures: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to review the recent literature on the technical accuracy of surgical navigation for patient-specific reconstruction of orbital fractures using a patient-specific implant, and to compare surgical navigation with conventional techniques.

MATERIALS AND METHODS

A systematic literature search was conducted in PubMed (Medline), Embase, Web of Science, and Cochrane (Core Collection) databases on May 16, 2023. Literature comparing surgical navigation with a conventional method using postoperative three-dimensional computed tomography imaging was collected. Only articles that studied at least one of the following outcomes were included: technical accuracy (angular accuracy, linear accuracy, volumetric accuracy, and degree of enophthalmos), preoperative and perioperative times, need for revision, complications, and total cost of the intervention. MINORS criteria were used to evaluate the quality of the articles.

RESULTS

After screening 3733 articles, 696 patients from 27 studies were included. A meta-analysis was conducted to evaluate volumetric accuracy and revision rates. Meta-analysis proved a significant better volumetric accuracy (0.93 cm3 ± 0.47 cm3) when surgical navigation was used compared with conventional surgery (2.17 cm3 ± 1.35 cm3). No meta-analysis of linear accuracy, angular accuracy, or enophthalmos was possible due to methodological heterogeneity. Surgical navigation had a revision rate of 4.9%, which was significantly lower than that of the conventional surgery (17%). Costs were increased when surgical navigation was used.

CONCLUSION

Studies with higher MINORS scores demonstrated enhanced volumetric precision compared with traditional approaches. Surgical navigation has proven effective in reducing revision rates compared to conventional approaches, despite increased costs.

Surgical treatment of orbital tumors in a single center: Analysis and results

BACKGROUND

Orbital tumors, arising within the bony orbit and its contents, present diverse challenges due to their varied origins and complex anatomical context. These tumors, classified as primary, secondary, or metastatic, are further subdivided into intraconal and extraconal based on their relationship with the muscle cone. This classification significantly influences surgical approach and management. This study highlights surgical experiences with orbital tumors, underscoring the importance of tailored surgical approaches based on the lesion's site and its proximity to the optic nerve.

METHODS

This retrospective study at the National Institute of Cancer's Head and Neck Department (2005-2014) analyzed 29 patients with orbital tumors treated with surgery, radiotherapy, chemotherapy, or combinations of them. Patient demographics, tumor characteristics, and treatment responses were evaluated using computed tomography (CT), magnetic resonance imaging, and positron emission tomography-CT imaging. Malignant tumors often required orbital exenteration and reconstruction, highlighting the study's commitment to advancing orbital tumor treatment.

RESULTS

29 patients (18 females and 11 males, age 18-88 years, mean 53.5 years) with orbital tumors exhibited symptoms such as decreased vision and exophthalmos. Tumors included primary lesions like choroidal melanoma and secondary types like epidermoid carcinoma. Treatments varied, involving a multidisciplinary team for surgical approaches like exenteration, with follow-up from 1 to 9 years. Radiotherapy and chemotherapy were used for specific cases.

CONCLUSION

Our study underscores the need for a multidisciplinary approach in treating orbital tumors, involving various surgical specialists and advanced technologies like neuronavigation for tailored treatment. The integration of surgery with radiotherapy and chemotherapy highlights the effectiveness of multidimensional treatment strategies.