Accuracy and safety of acetabular cup placement in total hip arthroplasty using mixed-reality navigation: A prospective trial

Joseph P. Costello; Samantha G. Mosle; Hannah Mosher; Aneesh V. Samineni; Gilberto O. Lobaton; Michele R. D'Apuzzo; Victor H. Hernandez

doi:10.1016/j.jor.2026.02.010

View/Download PDF

Buy Reprints

PDF

Translate this page into:

75 (); 262-267

doi:

10.1016/j.jor.2026.02.010

Accuracy and safety of acetabular cup placement in total hip arthroplasty using mixed-reality navigation: A prospective trial

Joseph P. Costello^a, Samantha G. Mosle^b, Hannah Mosher^c, Aneesh V. Samineni^d, Gilberto O. Lobaton^d, Michele R. D'Apuzzo^d, Victor H. Hernandez^d,

a Atrium Health-Carolinas Medical Center, Atrium Health Musculoskeletal Institute, 1000 Blythe Blvd, Charlotte, NC, 28203, USA

b University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA, 98195, USA

c University of Miami Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL, 33136, USA

d Department of Orthopedics, University of Miami Miller School of Medicine, 1321 NW 14th St. Suite 306, Miami, FL, 33125, USA

⁎Corresponding author: Victor H. Hernandez. vhh1@miami.edu

Received: 2026-1-19, Accepted: 2026-2-2, Published: 2026-2-3

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Safe and accurate placement of the acetabular component is critical in total hip arthroplasty (THA). Fluoroscopy helps with cup positioning in the direct anterior approach (DAA) but increases radiation exposure. Augmented and mixed-reality (MR) systems may improve precision while decreasing reliance on fluoroscopy. This study assessed the accuracy, safety, and impact on radiation exposure of MR navigation in anterior and posterior THA.

From July 2023 to May 2024 at a single tertiary level institution, 33 patients underwent unilateral THA with MR by either the anterior (16) or posterior (17) approach. Operative time, patient demographics, pre-operative plan and post-operative positioning measures (center of rotation, leg length discrepancy, anteversion, and inclination) were compared between cohorts.

There were no demographic differences between cohorts, though operative time was significantly longer in the anterior group (106.30 vs 94.12 min, p < 0.001). Evidence of a learning curve was observed in the anterior cohort, with significantly higher radiation dose (187.40 vs 119.30 uGym², p = 0.03) and reference air kerma (4.17 vs 2.60 mGy, p = 0.02) in the initial 20% of cases. While cup placement accuracy was comparable between groups for center of rotation, leg length discrepancy, and anteversion, inclination differed significantly (2.88 vs −6.71°, p = 0.0003). Within-group analyses showed significant deviations from the preoperative plan for all measured variables in both cohorts. Despite this, all patients met clinical thresholds for LLD (<18 mm) and anteversion (15° ± 10°), with 100% of anterior and 88.2% of posterior cases within the target inclination range (40° ± 10°), and 72.7% achieving a center of rotation within ≤5 mm of the plan.

MR-navigated THA can safely produce accurate acetabular cup placement in both anterior and posterior total hip arthroplasty, validating safe use in THA. The observed learning curve suggests MR reduces reliance on fluoroscopy while enhancing surgical precision.

Keywords

Mixed reality

Total hip arthroplasty

Acetabular cup placement

Surgical navigation

Radiation exposure

Learning curve

Show Related Articles from PubMed

1 Introduction

Accurate placement of acetabular components in total hip arthroplasty (THA) is essential to prevent complications such as hip dislocation, uneven load distribution, polyethylene liner deterioration, component migration or loosening, poor functional outcomes, and the need for revision surgery ^1–4. Prior studies have identified several key differences in cup placement between the direct anterior approach (DAA) and posterior approach (PA). Specifically, DAA has been associated with lower average cup anteversion, reduced variance in average cup abduction angle, and more accurate cup placement overall compared to PA ^5–7.

Traditionally, the DAA utilizes fluoroscopy to confirm the accuracy of cup placement. Although fluoroscopy offers valuable intraoperative guidance, its use imparts disadvantages, including increased intraoperative time and radiation exposure, operating room clutter, and a heightened risk of infection ^8–11. Advanced technologies that overlay computer-generated perceptual information onto the user's environment offer a potential alternative by providing indirect visualization of the acetabulum without the need for fluoroscopy, while potentially increasing the placement accuracy of acetabular components.

Virtual reality (VR), augmented reality (AR), and mixed reality (MR) are related technologies that differ primarily in how they interact with the real environment. VR typically involves the use of a headset that completely blocks out the physical world, immersing the user in a fully virtual environment. In contrast, AR overlays digital elements onto the real world, allowing users to simultaneously see both. MR combines elements of both VR and AR by integrating virtual objects in the real-world view in a more spatially aware and interactive way, enabling users to engage and manipulate digital content as if it were part of the physical environment.¹²^,¹³

Compared to AR technology, MR-navigation is considered especially advantageous for intraoperative use, as it offers a real-time 3D visualization of the operative field, including relevant anatomical structures and orientation, adjacent neurovascular elements, surgical instruments, and implant templates.¹⁴ Mixed reality (MR) technology addresses many of the limitations of augmented reality (AR) by delivering a more intuitive and interactive interface, with strong potential to additionally enhance orthopaedic training.¹⁵^,¹⁶ Through spatial mapping that anchors virtual objects to real-world markers, MR provides a more accurate sense of depth and spatial orientation, helping users better interpret complex 3D anatomy and instrument positioning. The seamless integration of real-world information into the virtual environment creates an interactive feedback loop between the user, the physical world, and digital elements, thereby enhancing the realism of the experience. Additionally, MR enables users to interact with virtual elements using natural inputs such as gestures, gaze, or voice—closely mimicking real-world interactions. In summary, MR offers a distinct advantage by rapidly integrating environmental data and enabling seamless immersion between users, their surroundings, and virtual models.¹³

Given the potential of MR technology in THA, the purpose of this study was to determine 1) if there is a learning curve with use of MR-navigation in the DAA, 2) if using MR can deliver accurate cup placement based on pre-operative templating, and 3) if there is a difference in accuracy of cup placement with MR between anterior and posterior approaches. We predict that the integration of MR technology into THA will produce accurate acetabular cup placement in both anterior and posterior total hip arthroplasty, while reducing reliance on fluoroscopy.

2 Materials & methods

2.1

2.1 Patients

Between July 2023 and May 2024 at a single tertiary-level institution, adult patients undergoing elective primary THA for osteoarthritis were prospectively screened for eligibility and inclusion. Exclusion criteria included pregnancy, incarcerated patients, post-traumatic disease, developmental dysplasia of the hip, and acetabular protrusio or other deformity. A total of 41 patients were prospectively screened for eligibility, and 33 met the inclusion criteria. Data was subsequently collected retrospectively by chart review. Eight patients were later excluded due to inadequate postoperative imaging, such as poor quality or lack of a standing image, and concurrent spine pathology resulting in lower extremity contracture. To enhance intra-rater reliability, all DAA THA were performed by one surgeon (V.H.) and all PA THA by another (M.D.).

The HipInsight Mixed Reality Navigation System (Zimmer Biomet, Warsaw, IN, USA) was utilized for preoperative planning and intraoperative guidance for all procedures. The MR guidance system used preoperative computed tomography (CT) scans to generate 3D digital templates of the pelvis and femur, enabling preoperative planning of the acetabular component size and orientation to achieve target anteversion and inclination angles within 3 degrees of accuracy. The goal of the advanced imaging and patient-specific planning was to determine the optimal “safe zone” for acetabular cup placement via template parameters to optimize leg length and offset change, stem (size, position, anteversion), cup (size, position, orientation), and screw positioning (Fig. 1). This study implemented the Lewinnek safe zone as defined by a target range of 40° ± 10° for inclination and 15° ± 10° for anteversion.¹⁷ Conventional radiographs were obtained pre- and post-operatively for all patients.

Example of preoperative template generated by HipInsight (Zimmer Biomet, Warsaw, IN, USA).

2.2

2.2 Surgical technique

The HipInsight MR Navigation System was used in all cases and provided real-time holographic overlays of the patient's anatomy, instruments, and implants (Fig. 2). This “x-ray vision” feature enabled surgeons to visualize and adjust the acetabular cup placement dynamically to keep alignment similar to the preoperative plan. After standard surgical approach, the augmented reality registration array was placed onto the pelvis allowing the Microsoft HoloLens 2 (Microsoft Corporation, Redmond, Washington, United States) headset to automatically register utilizing data from the pre-operative CT scan and begin real-time tracking capabilities. Following the template overlay, which is used for alignment of the acetabular component by monitoring its position relative to the patient's anatomy, the acetabulum was reamed to the final intended size and acetabular component was placed according to the preoperative plan. Once the final polyethylene liner was placed, the pelvic array was removed. Following femoral component placement, the leg length, offset, and fit within the femoral canal were confirmed with fluoroscopy only in the DAA group.

Intraoperative applications of HipInsight navigation technology.

2.3

2.3 Data analysis

The learning curve for use of MR in DAA was determined by comparing the length of surgery and intraoperative radiation dose between the first and last 20% of procedures performed. The length of surgery was compared for all patients, whereas radiation dose was only evaluated across DAA patients as fluoroscopy was not used in PA patients. The accuracy of cup placement was determined by calculating the difference between the preoperative plan and final implant measured postoperatively for the following variables: center of rotation (CoR), leg length discrepancy (LLD), radiographic anteversion (RA), and radiographic inclination (RI) – obtained using TraumaCad templating software (BrainLab Inc, Westchester, IL) (Fig. 3). This method has been previously evaluated for accuracy and intra-observer and inter-observer reliability.¹⁸^,¹⁹ Operative time and demographics including age, sex, body mass index (BMI), and laterality were collected. Unpaired t-tests and Fisher's exact tests were utilized for statistical comparisons, with P < 0.05 considered significant. IRB approval was obtained for this study.

Schematic of TraumaCad postoperative measurements assessing acetabular component positioning.

3 Results

A total of 33 patients were included in this preliminary study (16 DAA, 17 PA). There were no differences in age, sex, BMI, or laterality between the anterior and posterior cohorts (Table 1). Operative time was significantly longer in the anterior cohort compared to the posterior cohort (106.30 vs 94.12 min, p < 0.001).

Table 1 Patient and procedure characteristics between groups.

	Overall, N = 33	Anterior, N = 16	Posterior, N = 17	P Value
No. Males (%)	18 (54.5)	8 (50)	10 (58.8)	0.73
No. Females (%)	15 (45.5)	8 (50)	7 (41.2)	0.73
Age in Years, Mean ± Std	59.96 ± 11.36	61.66 ± 10.35	58.36 ± 12.32	0.41
Average Body Mass Index kg/m², Mean ± Std	28.86 ± 5.60	27.97 ± 5.57	29.69 ± 5.65	0.39
No. Right Laterality (%)	16 (48.5)	7 (43.7)	9 (52.9)	0.73
No. Left Laterality (%)	17 (51.5)	9 (56.3)	8 (47.1)	0.73
Average Operative Time in Minutes, Mean ± Std	94.12 ± 21.45	106.30 ± 20.81	82.71 ± 15.12	0.0008

The first outcome of interest was assessing the presence, if any, of a learning curve using MR navigation in the DAA cohort. Examination of intraoperative radiation from fluoroscopy revealed the initial 20% of procedures had significantly higher average intraoperative radiation dose (187.40 vs 119.30 μGy m²) p = 0.03) and reference air kerma (4.17 vs 2.60 mGy, p = 0.02) compared to the final 20% of cases (Table 2). However, average radiation time in minutes did not differ significantly.

Table 2 Fluoroscopic learning curve in the direct anterior total hip arthroplasty group.

	Initial 20% of Procedures	Final 20% of Procedures	P Value
Average Radiation Time in Minutes, Mean ± Std	0.33 ± 0.06	0.27 ± 0.06	0.23
Average Dose Area Produced μGy·m²., Mean ± Std	187.40 ± 33.64	119.30 ± 7.92	0.03
Average Reference Air Kerma mGy, Mean ± Std	4.17 ± 0.72	2.60 ± 0.17	0.02

The second outcome assessed the accuracy of cup placement in relation to the preoperative plan by comparing individual implant variables, as measured by the difference of final implant postoperatively and the preoperative plan. For both the DAA and PA cohorts, there was no significant difference regarding CoR, LLD, or RA. However, RI differed significantly, with the anterior group showing a mean deviation of 2.88° versus −6.71° in the posterior group (p = 0.0003) (Table 3).

Table 3 Difference between final implant measured postoperatively and preoperative planning for direct anterior and posterior total hip arthroplasty groups.

	Overall	Anterior group	Posterior group	P Value
Average Difference in Center of Rotation in mm, Mean ± Std	3.67 ± 4.07	3.88 ± 3.93	3.4758 ± 4.30	0.78
Average Difference in Leg Length Discrepancy in mm, Mean ± Std	6.49 ± 6.82	4.94 ± 7.78	7.94 ± 5.62	0.21
Average Difference in Degrees of Anteversion, Mean ± Std	−4.82 ± 4.73	−5.63 ± 3.58	−4.06 ± 5.61	0.35
Average Difference in Degrees of Inclination, Mean ± Std	−2.06 ± 8.02	2.88 ± 4.75	−6.71 ± 8.09	0.0003

Further within-group analysis revealed that in the anterior cohort, the preoperative plan differed significantly from postoperative measurements for CoR (12.19 vs 16.06 mm, p = 0.005), LLD (−1.81 vs 4.88 mm, p = 0.0001), RA (20.81 vs 15.19°, p < 0.0001), and RI (43.13 vs 46.00°, p = 0.03) (Table 4). Similarly, in the posterior cohort, significant differences were observed between planned and actual values for CoR (13.88 vs 17.35 mm, p = 0.02), LLD (−6.12 vs 1.82 mm, p = 0.0004), RA (21.35 vs 17.29°, p = 0.006), and RI (43.35 vs 36.65°, p = 0.0013).

Table 4 Comparison of Average Preoperative Plan vs Postoperative Measurements for Direct Anterior and Posterior Groups.

	Anterior group			Posterior group
	Preoperative	Postoperative	P Value	Preoperative	Postoperative	P Value
Average Center of Rotation in mm, Mean ± Std	12.19 ± 3.19	16.06 ± 4.01	0.005	13.88 ± 4.21	17.35 ± 4.00	0.02
Average Leg Length Discrepancy in mm, Mean ± Std	−1.81 ± 3.02	4.88 ± 5.16	0.0001	−6.12 ± 6.74	1.82 ± 4.73	0.0004
Average Degrees of Anteversion, Mean ± Std	20.81 ± 1.33	15.19 ± 3.82	<0.0001	21.35 ± 0.86	17.29 ± 5.61	0.006
Average Degrees of Inclination, Mean ± Std	43.13 ± 0.62	46.00 ± 4.98	0.03	43.35 ± 0.49	36.65 ± 7.86	0.0013

All patients in this study had a postoperative LLD within the preferred threshold (<18 mm) and were within the target RA range (15° ± 10°). For RI, 100% (16/16) of anterior and 88.2% (15/17) of posterior patients fell within the acceptable range (40° ± 10°). Across both approaches, a total of 72.7% (24/33) of patients maintained a CoR within ≤5 mm of the planned position. Comparison between aggregate data across all patients demonstrated the average preoperative plans and postoperative measures were significant for CoR, LLD, and RA (p < 0.001), but not for RI (p = 0.15) (Table 5).

Table 5 Preoperative vs Postoperative Outcomes.

	Preoperative	Postoperative	P Value
Average Center of Rotation in mm, Mean ± Std	13.06 ± 3.79	16.73 ± 4.00	0.0003
Average Leg Length Discrepancy in mm, Mean ± Std	−4.03 ± 5.63	3.30 ± 5.11	<0.0001
Average Degrees of Anteversion, Mean ± Std	21.09 ± 1.13	16.27 ± 4.87	<0.0001
Average Degrees of Inclination, Mean ± Std	43.24 ± 0.56	41.18 ± 8.06	0.15

There was one complication in the anterior cohort as a patient returned to the Emergency Department on postoperative day 8 with minor wound drainage, which resolved without surgical intervention.

4 Discussion

This preliminary study included 33 patients evaluating the role of MR navigation in THA and demonstrated three key findings. First a learning curve was observed in the DAA cohort, as indicated by significantly reduced radiation exposure over the case series. Second, MR navigation achieved accurate acetabular cup positioning in both anterior and posterior approaches, validating the safe use of the technology. Third, although deviations from the preoperative plan were noted for all measured parameters, these differences generally remained within clinical acceptable thresholds. Importantly, only one minor complication occurred, which resolved without surgical intervention.

4.1

4.1 Learning curve and radiation exposure

Our data showed a significant decrease in fluoroscopic dose and reference air kerma in later anterior cases, indicating a learning effect with MR use. This supports the potential of MR navigation to reduce dependence on fluoroscopy as surgeons become more familiar with the system. Previous studies of augmented reality (AR) navigation also reported decreased fluoroscopic exposure and more consistent cup placement with increased experience.⁹^,¹⁷^,²⁰^,²¹ Given the cumulative radiation exposure to orthopaedic surgeons and operating room staff, MR systems may provide an important occupational health benefit by reducing exposure during anterior THA.

4.2

4.2 Accuracy of acetabular cup placement

MR navigation enabled precise acetabular cup placement, with 100% of DAA and 88.2% of posterior approach (PA) cases achieving inclination within Lewinnek's safe zone, and all patients achieving anteversion within targeted thresholds. Although deviations from preoperative planning were statistically significant for the center of rotation (CoR), leg length discrepancy (LLD), anteversion, and inclination, most still fell within clinically acceptable ranges. A notable trend was seen in radiographic inclination (RI): anterior cases slightly overestimated RI, while posterior cases underestimated it. These differences might be related to patient positioning during surgery compared to postoperative radiographic evaluation, especially due to variations in pelvic tilt or roll.

4.3

4.3 Accuracy of acetabular cup placement

Accurate cup placement is closely linked to a lower risk of dislocation, revision, and poor functional outcomes^1–4^,²⁰. Our findings indicate that MR navigation can consistently achieve safe acetabular positioning across different approaches, supporting its role as a valuable clinical tool in THA. In addition to accuracy, MR technology offers intraoperative visualization of anatomy and implant orientation, which may improve safety near neurovascular structures and streamline the surgeon's workflow. Moreover, MR has shown promise as an educational resource, enhancing spatial understanding and surgical simulation in orthopaedic training.¹⁵^,¹⁶

4.4

4.4 Limitations and future directions

This study has several limitations. The sample size was modest, with procedures performed by only two surgeons at a single institution, limiting generalizability. Postoperative accuracy was evaluated using two-dimensional radiographs, which may introduce errors due to pelvic rotation, projection differences, or metal artifacts. Additionally, integrating MR headsets into the sterile environment could create logistical challenges in broader clinical practice. Future research should involve larger, multi-center cohorts with three-dimensional imaging techniques and longer follow-up periods to confirm these findings.

5 Conclusion

In summary, MR navigation in THA is a feasible and promising tool that allows for safe, accurate placement of the acetabular cup in both anterior and posterior approaches. The learning curve seen in the anterior group, marked by reduced radiation exposure over time, shows the potential for MR to lessen reliance on fluoroscopy. Although small deviations from preoperative plans were common, most stayed within safe zones, supporting MR-navigation as an effective way to improve precision, safety, and surgeon workflow. Larger, multi-center studies are needed to evaluate the long-term clinical effects, optimize workflow integration, and determine the wider applicability of MR technology in total hip arthroplasty. By decreasing dependence on fluoroscopy and enabling consistent implant positioning within safe zones, MR shows promise as a technology to boost surgical accuracy, safety, and training in total hip arthroplasty.

Ethical statement

Institutional Review Board approval was obtained for this study.

Author contributions: CRediT author statement for authors is as follows

Joseph P. Costello2nd: Conceptualization, Methodology, Formal analysis, Writing - Original Draft. Samantha G. Mosle: Conceptualization, Methodology, Investigation, Data Curation, Writing - Original Draft, Writing - Review & Editing, Visualization. Hannah Mosher: Investigation, Writing - Original Draft. Aneesh V. Samineni: Writing - Review & Editing, Supervision. Gilberto O. Lobaton: Writing - Review & Editing. Michele R. D'Apuzzo1: Writing - Review & Editing, Funding acquisition. Victor H. Hernandez1: Writing - Review & Editing, Supervision, Funding acquisition.

1. Predominant or surgeons who have contributed patients.

Funding

This work was supported by HipInsight Mixed Reality Navigation System (Zimmer Biomet, Warsaw, IN, USA).

References

Agarwal S., Eckhard L., Walter W.L., et al . The use of computer navigation in total hip arthroplasty is associated with a reduced rate of revision for dislocation: a study of 6,912 navigated THA procedures from the Australian orthopaedic association national joint replacement registry. J Bone Joint Surg Am. Oct 20 2021;103(20):1900-1905.
[Google Scholar]
Bohl D.D., Nolte M.T., Ong K., Lau E., Calkins T.E., Della Valle C.J., . Computer-assisted navigation is associated with reductions in the rates of dislocation and acetabular component revision following primary total hip arthroplasty. J Bone Joint Surg Am. Feb 6 2019;101(3):250-256.
[Google Scholar]
Davis E.T., McKinney K.D., Kamali A., Kuljaca S., Pagkalos J., . Reduced risk of revision with computer-guided versus non-computer-guided THA: an analysis of manufacturer-specific data from the national joint registry of England, Wales, Northern Ireland and the Isle of Man. JB JS Open Access. Jul-Sep 2021;6(3)
[Google Scholar]
Goyal P., Lau A., Naudie D.D., Teeter M.G., Lanting B.A., Howard J.L., . Effect of acetabular component positioning on functional outcomes in primary total hip arthroplasty. J Arthroplast. Mar 2017;32(3):843-848.
[Google Scholar]
Hamilton W.G., Parks N.L., Huynh C., . Comparison of cup alignment, jump distance, and complications in consecutive series of anterior approach and posterior approach total hip arthroplasty. J Arthroplast. Nov 2015;30(11):1959-1962.
[Google Scholar]
Hu F., Shang X., Zhang X., Chen M., . Direct anterior approach in lateral position achieves superior cup orientation in total hip arthroplasty: a radiological comparative study of two consecutive series. Int Orthop. Mar 2020;44(3):453-459.
[Google Scholar]
Kruse C., Rosenlund S., Broeng L., Overgaard S., . Radiographic cup position following posterior and lateral approach to total hip arthroplasty. An explorative randomized controlled trial. PLoS One. 2018;13(1)
[Google Scholar]
Keenen T.L., Demirel S., Gheen A., Casabarro B., Fleishman D., . Intraoperative fluoroscopy radiation using OEC 9900 elite C-arm: risk and method for decreasing exposure. Health Phys. May 1 2023;124(5):380-390.
[Google Scholar]
Alexander C., Loeb A.E., Fotouhi J., Navab N., Armand M., Khanuja H.S., . Augmented reality for acetabular component placement in direct anterior total hip arthroplasty. J Arthroplast. Jun 2020;35(6):1636-1641.e3.
[Google Scholar]
Hoffler C.E., Ilyas A.M., . Fluoroscopic radiation exposure: are we protecting ourselves adequately? J Bone Joint Surg Am. May 6 2015;97(9):721-725.
[Google Scholar]
Chou L.B., Johnson B., Shapiro L.M., et al . Increased prevalence of breast and all-cause cancer in female orthopaedic surgeons. J Am Acad Orthop Surg Glob Res Rev. May 1 2022;6(5)
[Google Scholar]
Lei P.F., Su S.L., Kong L.Y., Wang C.G., Zhong D., Hu Y.H., . Mixed reality combined with three-dimensional printing technology in total hip arthroplasty: an updated review with a preliminary case presentation. Orthop Surg. Oct 2019;11(5):914-920.
[Google Scholar]
Su S., Lei P., Wang C., Gao F., Zhong D., Hu Y., . Mixed reality technology in total knee arthroplasty: an updated review with a preliminary case report. Front Surg. 2022;9
[Google Scholar]
Wu X., Liu R., Yu J., et al . Mixed reality technology-assisted orthopedics surgery navigation. Surg Innov. Jun 2018;25(3):304-305.
[Google Scholar]
Su S., Wang R., Zhou R., Chen Z., Zhou F., . The effectiveness of virtual reality, augmented reality, and mixed reality training in total hip arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res. 2023/02/19 2023;18(1):121.
[Google Scholar]
Kaplan A.D., Cruit J., Endsley M., Beers S.M., Sawyer B.D., Hancock P.A., . The effects of virtual reality, augmented reality, and mixed reality as training enhancement methods: a meta-analysis. Hum Factors. Jun 2021;63(4):706-726.
[Google Scholar]
Lewinnek G.E., Lewis J.L., Tarr R., Compere C.L., Zimmerman J.R., . Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. Mar 1978;60(2):217-220.
[Google Scholar]
Kumar P.G., Kirmani S.J., Humberg H., Kavarthapu V., Li P., . Reproducibility and accuracy of templating uncemented THA with digital radiographic and digital TraumaCad templating software. Orthopedics. Nov 2009;32(11):815.
[Google Scholar]
Steinberg E.L., Shasha N., Menahem A., Dekel S., . Preoperative planning of total hip replacement using the TraumaCad™ system. Arch Orthop Trauma Surg. Dec 2010;130(12):1429-1432.
[Google Scholar]
Ong C.B., Chiu Y.F., Premkumar A., Gonzalez Della Valle A., . Use of a novel imageless navigation system reduced fluoroscopy exposure and improved acetabular positioning in anterior approach total hip arthroplasty: a case-control study. Arch Orthop Trauma Surg. May 2023;143(5):2739-2745.
[Google Scholar]
Tsukada S., Ogawa H., Hirasawa N., Nishino M., Aoyama H., Kurosaka K., . Augmented Reality- vs accelerometer-based portable navigation system to improve the accuracy of acetabular cup placement during total hip arthroplasty in the lateral decubitus position. J Arthroplast. Mar 2022;37(3):488-494.
[Google Scholar]

Show Sections

[1] Agarwal S., Eckhard L., Walter W.L., et al . The use of computer navigation in total hip arthroplasty is associated with a reduced rate of revision for dislocation: a study of 6,912 navigated THA procedures from the Australian orthopaedic association national joint replacement registry. J Bone Joint Surg Am. Oct 20 2021;103(20):1900-1905.
[Google Scholar]

[2] Bohl D.D., Nolte M.T., Ong K., Lau E., Calkins T.E., Della Valle C.J., . Computer-assisted navigation is associated with reductions in the rates of dislocation and acetabular component revision following primary total hip arthroplasty. J Bone Joint Surg Am. Feb 6 2019;101(3):250-256.
[Google Scholar]

[3] Davis E.T., McKinney K.D., Kamali A., Kuljaca S., Pagkalos J., . Reduced risk of revision with computer-guided versus non-computer-guided THA: an analysis of manufacturer-specific data from the national joint registry of England, Wales, Northern Ireland and the Isle of Man. JB JS Open Access. Jul-Sep 2021;6(3)
[Google Scholar]

[4] Goyal P., Lau A., Naudie D.D., Teeter M.G., Lanting B.A., Howard J.L., . Effect of acetabular component positioning on functional outcomes in primary total hip arthroplasty. J Arthroplast. Mar 2017;32(3):843-848.
[Google Scholar]

[5] Hamilton W.G., Parks N.L., Huynh C., . Comparison of cup alignment, jump distance, and complications in consecutive series of anterior approach and posterior approach total hip arthroplasty. J Arthroplast. Nov 2015;30(11):1959-1962.
[Google Scholar]

[6] Hu F., Shang X., Zhang X., Chen M., . Direct anterior approach in lateral position achieves superior cup orientation in total hip arthroplasty: a radiological comparative study of two consecutive series. Int Orthop. Mar 2020;44(3):453-459.
[Google Scholar]

[7] Kruse C., Rosenlund S., Broeng L., Overgaard S., . Radiographic cup position following posterior and lateral approach to total hip arthroplasty. An explorative randomized controlled trial. PLoS One. 2018;13(1)
[Google Scholar]

[8] Keenen T.L., Demirel S., Gheen A., Casabarro B., Fleishman D., . Intraoperative fluoroscopy radiation using OEC 9900 elite C-arm: risk and method for decreasing exposure. Health Phys. May 1 2023;124(5):380-390.
[Google Scholar]

[9] Alexander C., Loeb A.E., Fotouhi J., Navab N., Armand M., Khanuja H.S., . Augmented reality for acetabular component placement in direct anterior total hip arthroplasty. J Arthroplast. Jun 2020;35(6):1636-1641.e3.
[Google Scholar]

[10] Hoffler C.E., Ilyas A.M., . Fluoroscopic radiation exposure: are we protecting ourselves adequately? J Bone Joint Surg Am. May 6 2015;97(9):721-725.
[Google Scholar]

[11] Chou L.B., Johnson B., Shapiro L.M., et al . Increased prevalence of breast and all-cause cancer in female orthopaedic surgeons. J Am Acad Orthop Surg Glob Res Rev. May 1 2022;6(5)
[Google Scholar]

[12] Lei P.F., Su S.L., Kong L.Y., Wang C.G., Zhong D., Hu Y.H., . Mixed reality combined with three-dimensional printing technology in total hip arthroplasty: an updated review with a preliminary case presentation. Orthop Surg. Oct 2019;11(5):914-920.
[Google Scholar]

[13] Su S., Lei P., Wang C., Gao F., Zhong D., Hu Y., . Mixed reality technology in total knee arthroplasty: an updated review with a preliminary case report. Front Surg. 2022;9
[Google Scholar]

[14] Wu X., Liu R., Yu J., et al . Mixed reality technology-assisted orthopedics surgery navigation. Surg Innov. Jun 2018;25(3):304-305.
[Google Scholar]

[15] Su S., Wang R., Zhou R., Chen Z., Zhou F., . The effectiveness of virtual reality, augmented reality, and mixed reality training in total hip arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res. 2023/02/19 2023;18(1):121.
[Google Scholar]

[16] Kaplan A.D., Cruit J., Endsley M., Beers S.M., Sawyer B.D., Hancock P.A., . The effects of virtual reality, augmented reality, and mixed reality as training enhancement methods: a meta-analysis. Hum Factors. Jun 2021;63(4):706-726.
[Google Scholar]

[17] Lewinnek G.E., Lewis J.L., Tarr R., Compere C.L., Zimmerman J.R., . Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. Mar 1978;60(2):217-220.
[Google Scholar]

[18] Kumar P.G., Kirmani S.J., Humberg H., Kavarthapu V., Li P., . Reproducibility and accuracy of templating uncemented THA with digital radiographic and digital TraumaCad templating software. Orthopedics. Nov 2009;32(11):815.
[Google Scholar]

[19] Steinberg E.L., Shasha N., Menahem A., Dekel S., . Preoperative planning of total hip replacement using the TraumaCad™ system. Arch Orthop Trauma Surg. Dec 2010;130(12):1429-1432.
[Google Scholar]

[20] Ong C.B., Chiu Y.F., Premkumar A., Gonzalez Della Valle A., . Use of a novel imageless navigation system reduced fluoroscopy exposure and improved acetabular positioning in anterior approach total hip arthroplasty: a case-control study. Arch Orthop Trauma Surg. May 2023;143(5):2739-2745.
[Google Scholar]

[21] Tsukada S., Ogawa H., Hirasawa N., Nishino M., Aoyama H., Kurosaka K., . Augmented Reality- vs accelerometer-based portable navigation system to improve the accuracy of acetabular cup placement during total hip arthroplasty in the lateral decubitus position. J Arthroplast. Mar 2022;37(3):488-494.
[Google Scholar]

Accuracy and safety of acetabular cup placement in total hip arthroplasty using mixed-reality navigation: A prospective trial

Abstract