Mixed Reality spatial computing for preoperative surgical planning in orthopedic oncology: review of 72 cases and evolution of clinical implementation

Aim: Planning orthopedic tumor surgery requires substantial cognitive effort to interpret 3D plans derived from 2D preoperative images and translate them into the patients’ actual anatomy. Mixed Reality (MR) 3D holograms overlaid on patients may help surgeons visualize surgical steps more intuitively before making skin incisions. This study evaluated the use of MR for preoperative assessment in 72 patients with primary or revision orthopedic oncology conditions, as well as the technical issues encountered during clinical implementation, between July 2021 and November 2025. Methods: 3D Slicer or MIMICS software was used to generate tumor models and support surgical planning. A proprietary MR platform (versions 1 and 2) was developed to integrate patients’ medical images and 3D models into digital asset bundles, which were then downloaded to the MR headset in the operating room via the hospital’s Wi-Fi network. The surgeon examined each patient preoperatively using the conventional 2D method first, and then applied the MR 3D hologram method. Results: A Likert-scale questionnaire showed that the MR 3D hologram group outperformed the 2D group across all aspects of spatial awareness of the patient’s pathoanatomy and was viewed as a more effective tool for preoperative planning. Regarding NASA-TLX scores, the overall cognitive workload during preoperative assessment was lower in the MR 3D hologram group. Since December 2024, generating cinematic-rendered 3D models with the upgraded MR software platform (version 2) has taken an average of 61 minutes (49–156). Engineer intervention was needed in 4 of 36 cases (11.1%). All cases were wirelessly accessible and completed an MR assessment. The average time to perform hologram-to-patient registration for the last 26 cases was 2.3 minutes (0.95–5.17). Conclusions: Our results suggest that MR technology could enhance surgeons’ 3D spatial awareness in various orthopedic tumor surgeries and reduce cognitive load during the translation of surgical plans.