Translate this page into:
Surgeon perspectives on a virtual reality platform for preoperative planning in complex bone sarcomas
, Justin B. Castonguaya, Noe Treviñoa, Mohammed Munima, Sarah C. Teppera, Rex Haydonb, Terrance D. Peabodyc, Alan Blanka, Matthew W. Colmana,
⁎Corresponding author: Matthew W. Colman. colman.reserach@rushortho.com
-
Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Treatment of primary bone and soft tissue sarcomas typically includes complete surgical resection with or without adjunctive modalities. Despite best efforts, for the most challenging clinical scenarios such as axial or pelvic sarcoma, five-year survival rates are reported to be between 27 and 40 %. Since quality of resection is a key determinant of oncologic outcomes, it is critical to preoperatively plan the surgical approach to improve resection accuracy, ensure sufficient surgical margins, and reduce the risk of local or metastatic recurrence. The computer conversion of 2-dimensional (2D) computerized tomography (CT) and magnetic resonance imaging (MRI) to a three-dimensional (3D) virtual reality (VR) avatar image may allow improved preoperative estimation of tumor size, location, adjacent anatomy, and spatial understanding of the tumor without relying on surgeon experience, memory, and imagination. The purpose of this study is to investigate the utility of a virtual reality platform in preoperative planning and surgical approach in a retrospective cohort of pelvic bone sarcoma cases.
The histopathology database at our institution was queried for all historical cases of bone and soft tissue sarcoma with surgical resection failure, defined as positive gross or microscopic margins. Four cases of pelvic bone sarcoma were chosen for retrospective review by fellowship-trained orthopedic tumor specialists. For each case, participants first studied conventional 2D preoperative CT images and answered a questionnaire pertaining to objective case parameters. Participants then interacted with case-specific 3D models while wearing a VR headset and answered the same questionnaire. The VR ‘avatar’ was created with custom-developed software. After using both modalities, participants completed a Likert-scale survey aiming to evaluate the VR technology's subjective impact on understanding tumor environment, surgical plan confidence, and its ability to improve communication with colleagues and patients. Four attending orthopedic oncologists, one orthopedic oncology fellow, and one senior orthopedic oncology resident participated in the study.
Four cases of failed resection were evaluated by a group of both attending surgeons and a group of trainees composed of both residents and fellows. Tumor borders were clearly delineated in 0 % and 66.6 % cases when evaluating with conventional 2D imaging and VR, respectively. Participants changed adjacent structure involvement grade 22.2 % of the time after assessing involvement grade on the VR technology, with adjacent ligamentous structure grading changed most frequently in 55.5 % of cases. Users reported they would change the surgical approach or margins 44.4 % of the time after reviewing with VR technology. Initial 6 plane resection plans were changed in every user case. Subjective responses indicated that surgeons expressed more confidence in their approach, confidence with obtaining negative margins, and provided more detail regarding structures to be resected in specific planes.
Pelvic tumors present unique surgical challenges due to complex 3D anatomy, the proximity of vital structures, consistency of the tumor, and the need to alter patient position during resection procedures. Using examples of failed pelvic bone sarcoma resections, our study found that VR imaging increased understanding of the tumor environment, characteristics, and ability to communicate with patients and colleagues.
Keywords
Virtual reality
Sarcoma
Resection
Orthopaedic oncology
1 Introduction
Orthopedic oncology comprises clinical and surgical treatment of patients diagnosed with tumors in bone and soft tissues. The treatment for these tumors may include complete surgical resection and adjunctive external radiation or systemic therapy. The subset of pelvic tumors increases difficulty of resections due to the proximity of vital structures and challenging anatomy. When examining pelvic osteosarcomas literature reports that overall survival to range between 20 % and 47 %, which is worse than patients suffering from osteosarcomas of the extremities.1–5 Recurrence rates for osteosarcomas of the pelvis have been reported as high as 35 %.6 This stems from increased difficulty in obtaining negative margins due to the increased anatomical complexity.7 Taking into consideration the significant relationship between surgical margins and recurrence rates the overall worse prognosis of pelvic tumor patients is not unexpected.8 Therefore, it is critical to preoperatively plan the surgical approach to improve resection accuracy, ensure sufficient surgical margins, and reduce the risk of local or metastatic recurrence. While current preoperative imaging tools, such as computerized tomography (CT) and magnetic resonance imaging (MRI) allow for estimation of tumor size, location, and adjacent anatomy, the surgeon must still rely on experience, memory, and personal imagination to “reconstruct” the tumor extent and develop an intraoperative plan. A study in pelvic tumor resection accuracy found that even with experienced surgeons, the probability of obtaining a 1 cm surgical margin in simulated pelvis models is only 52 %.9 As an alternative, the conversion of two-dimensional imaging to a three-dimensional (3D) patient-specific avatar may allow for improved spatial understanding of the tumor and its environment before embarking upon the surgical procedure.
In recent years, novel virtual reality (VR) tools have been introduced into various surgical contexts to overcome limitations and improve outcomes. Virtual reality technologies are being explored for preoperative planning in certain surgical subspecialties such as cardiothoracic surgery.10 In regards to oncologic procedures, potential benefits of VR include the ability to visualize tumors and adjacent structures in 3D, to manipulate the image and gain insight from different angles, and to immerse oneself “within” the anatomy. VR has gained popularity for tumor resection planning in general surgery and neurosurgery cases with encouraging results.11,12 In orthopedics, applications of virtual reality technologies largely revolves around resident education.13,14 Spine surgery has successfully incorporated VR in the form of Augmented Reality (AR), whereby a precise optical see-through head-mounted display worn by the surgeon projects virtual images onto the surgical field.15 Although certain subspecialities within orthopedics have begun to study and or incorporate VR technology, there is a paucity of literature discussing VR applications within orthopedic oncology.
In addition to potentially improved outcomes, there are significant theoretical benefits in terms of surgeon communication, education, and research. Nevertheless, the clinical utility of these technologies in orthopedic oncology is largely unexplored. VR offers surgeons an immersive preoperative visualization of three-dimensional medical images processed from CT and/or MRI scans with goals of improving the surgeon's spatial perception of patient anatomy and intuitively enhancing preparation for complex tumor resection cases. The purpose of this study is to investigate the utility of a VR platform in preoperative planning and surgical approach in a retrospective cohort of pelvic bone sarcoma surgical cases and describe surgeon perceptions of the novel technology. We hypothesize that preoperative visualization with VR technology may increase the surgeon's understanding of anatomy and pathology, thereby influencing operating planning and potentially affecting surgical outcomes.
2 Methods
2.1 Subject selection
Four attending orthopedic oncologists, one orthopedic oncology fellow, and one senior orthopedic oncology resident (PGY-4) participated in the study.
2.2 Patient selection
The histopathology database at our institution was queried for all historical cases of bone and soft tissue sarcoma with surgical resection failure, defined as positive gross or microscopic margins in the setting of wide resection intent. The search yielded 175 cases between the years 1995 and 2021, comprising both extremity and pelvic tumors. From these, 4 cases of complex pelvic bone sarcoma were chosen for retrospective review by a fellowship-trained orthopedic tumor specialist (Table 1). Patient records were retrospectively reviewed for operative parameters, histopathological findings, surgical outcomes, and complications (see Table 2).Case 1A grade 2 chondrosarcoma located within the ilium, extending into surrounding periosteal tissue, and present focally at the inferior margin of the ilium. The surgical plan undertaken was an en bloc resection with neurovascular dissection.Case 2An osteosarcoma in the left sacrum. The surgical plan undertaken involved an excision with left-sided en bloc hemisacrectomy, posterior laminectomy from L4-S2, resection of the left ilium, followed by sacral reconstruction using femoral allograft. This was followed by left-sided S1-S4 nerve root resection. The patient then underwent posterior spinal fusion with instrumentation from L3 to pelvis. A femoral ring intervertebral graft was applied from L5-S1 followed by posterior iliac crest bone graft.Case 3Metastatic colon carcinoma to the right ilium. The surgical plan utilized wide resection of the right iliac wing with metastatectomy.Case 4A grade 2 de-differentiated liposarcoma. The surgical plan undertaken was a radical resection of the left pelvis sarcoma requiring extensive arteriovenous exposure. This was followed by en bloc excision of the ilium.
| Case | Gender/Age | Diagnosis | Tumor Location | Resected Specimen via Pathology Report |
| 1 | F | Chondrosarcoma (Grade 2) | Left ileum | 95 × 35 × 29 mm |
| 2 | F | Chondroblastic osteosarcoma | Left hemisacrum & ileum | 119 × 82 × 92 mm |
| 3 | M | Oligometastatic colon carcinoma | Right pelvis | 82 × 48 × 14 mm |
| 4 | M | Dedifferentiated liposarcoma | Pelvis | 190 × 119 × 60 mm |
| Case | Average surgeon estimated Tumor Volume based on Pre-Op CT Imaging | Average Tumor Volume from VR | Percent Variance |
| 1 | 387.90 cm3 | 378.4 cm3 | −2.0 % |
| 2 | 381.51 cm3 | 487.6 cm3 | 27.8 % |
| 3 | 434.67 cm3 | 475.6 cm3 | 9.42 % |
| 4 | 315.75 cm3 | 393.0 cm3 | 24.4 % |
2.3 Virtual reality visualization
AVATAR MEDICAL Software V1 (Paris, France) is a virtual reality imaging solution, which creates lossless 3D reconstructions from raw DICOM data. Based on ray casting techniques AVATAR leverages the data within DICOM to create a stereoscopic non-segmented representation that allows the end user to navigate and interact with the data in a streamlined experience. The user can determine the visualization angle, magnification, or make different kinds of measurements.
2.4 VR solution performance
For each case, study participants were provided with the anatomical location, pathologic diagnosis and surgical plan undertaken before evaluating any imaging. Thereafter, the orthopedic surgeon first studied conventional two-dimensional (2D) preoperative CT scans and answered a questionnaire pertaining to objective case parameters including tumor dimensions, tumor volume, surgical plan, adjacent structure involvement, specific structures resected in six planes (anterior, superior, posterior, inferior, medial, and lateral), and whether tumor borders are clearly delineated. The orthopedic surgeon then visualized 3D images in the virtual reality solution and answered the same questionnaire.
Specifically, participants answered whether tumor borders were clearly delineated. Participants then graded adjacent structures and the degree of tumor involvement on a scale of 1–4, 1 being minimal and 4 being a high degree of involvement. Individual grading was collected for the following structures: bone, cartilage, muscles/tendons, ligaments, neurovascular and lymphatic structures. Surgeons then answered whether they would deviate from the surgical plan provided at the beginning of the case. Study participants were then asked to indicate the specific structures they would resect in six planes and margins appropriate for surgical resection.
The study participants were then instructed to visualize the three-dimensional reconstruction made with AVATAR MEDICAL Software V1 through a virtual reality headset and answer the same questionnaire mentioned above. The VR solution is equipped with tumor dimension and volume measuring tools that participants used to estimate the tumor size. These objective parameters aimed to quantify surgeon perception of tumor dimensions, understanding of local anatomy, planned surgical approach, and desired surgical margins.
After visualizing the tumor through both modalities, participants completed a Likert-scale questionnaire comparing the virtual reality solution with conventional CT imaging. Six items were developed by our research team to evaluate the performance of the virtual reality solution for surgical understanding, user friendliness, ease of clinical collaboration, and patient communication. Responses were recorded on a scale of 1–5 (Strongly Disagree – Strongly Agree). One item was a dichotomous question evaluating whether the virtual reality solution changed their surgical margin or approach plan.
2.5 Data analyses
Surveys included quantitative feedback with a Likert scale and qualitative, open answer responses. Quantitative metrics were analyzed with descriptive statistics and qualitative responses were used to better understand the participants' experience with the virtual reality solution.
2.6 Statistical analyses
For Likert-scale items, the internal consistency of the scale was assessed with Cronbach's Alpha coefficients. Cronbach's Alpha measures how closely related a set of test items are as a group.
3 Results
Four cases of failed resection were evaluated by study participants. According to the evaluators, tumor borders were clearly delineated 0 % of the time when evaluating with conventional 2D CT scans. When visualizing the tumor in virtual reality, surgeons reported tumor borders were improved and clearly delineated 66.6 % of the time. On average, participants changed adjacent structure involvement grade 22.2 % of the time after assessing involvement grade on the VR technology, with adjacent ligamentous structure grading changed most frequently in 55.5 % of cases. Attending surgeons changed adjacent structure involvement grade 14.3 % of the time and the trainee group changed adjacent structure involvement 32.1 % of the time following virtual reality usage after an initial CT scan evaluation (Table 3). The complete rates of adjacent structure grade change following VR usage are represented in Table 3. When evaluating for specific structures resected in six planes (anterior, posterior, superior, inferior, medial and lateral), we found that for every case at least one change to the six-plane resection plan was made following use of VR technology. More specifically, when all the initial resection planes are viewed as a collective group the participants changed or gave more detail to 66.67 % of said planes following VR usage. The resection plans were further stratified by training level. Analysis showed that for attending level surgeons 40 % of the initial plane resection plans were modified following VR usage. Trainee data indicated that 50 % of the initial surgical planes viewed as a total group were altered (see Table 4) (see Fig. 1).
| Structure (All Cases) | Bone | Cartilage | Muscles/tendons | Ligaments | Vascular | Neural | Lymphatic |
| 0 % | 22.20 % | 22.20 % | 55.50 % | 22.90 % | 22.90 % | 11.10 % | |
| Any structure involvement grading change by case | 1 | 2 | 3 | 4 | |||
| 21.40 % | 28.50 % | 14.20 % | 14.20 % | ||||
| Percent grading change by training level | Attending | Trainee | |||||
| 14.30 % | 32.10 % |
| Case | 1 | 2 | 3 | 4 |
| 75 % | 50 % | 66.6 % | 50 % | |
| Training Level, all cases | Attending | Trainee | ||
| 50 % | 40 % | |||
The Likert-scale response items aimed to evaluate the VR technology's subjective impact on understanding tumor environment, tumor volume and dimensions, surgical plan confidence, and its ability to improve communication with colleagues (residents, faculty, interprofessional collaboration, etc.) and patients when compared with 2D imaging. The mode for individual items is as shown on Fig. 2. The mode was 4 (Agree) for all Likert-scale items except when assessing for confidence about the surgical plan. The mode for this item was 5 (Strongly Agree). The Cronbach's Alpha (0.813, >0.7 is acceptable) showed internal consistency for the questionnaire suggesting reliability in assessing surgeon experience after using the VR solution.
Surgeons answered “Yes” in 44.44 % of cases to the item evaluating whether the VR solution changed the surgical margin or approach plan, they answered “No” for the remaining cases. Many of the “Yes” responses were for Case 1, which was a grade 2 chondrosarcoma in the ilium, extending into surrounding periosteal tissue, and present focally at the inferior margin of the ilium. The patient was treated with an en bloc resection with neurovascular dissection. The total mass resected was 12 × 10 × 9 cm portion of the left iliac wing and sacrum with surrounding soft tissue, including fibroadipose and skeletal tissue. In many cases where surgeon's selected “No,” they did provide additional comments that indicated an improved understanding of tumor dimension or anatomical relationships and thus more confidence with the case. For example, in case 4 a surgeon indicated “better understanding of vessel relationship to tumor.” Further anecdotal feedback was obtained. For case 2, an osteosarcoma in the left sacrum, an orthopedic oncology fellow mentioned being able to visualize the tumor more clearly in VR than in 2D thus allowing them to be more confident in their plan to resect up to L4. This physician specifically mentioned being better able to appreciate the subtle abnormality and tumor volume in VR. Another surgeon noted it was difficult to know the extent of sacroiliac joint and paraspinal muscle involvement on 2D imaging for case 2.
When evaluating for user experience, free response answers for the subjective questionnaires included an attending level surgeon mentioning they were “able to appreciate a lot more disease anteriorly” and another surgeon noted VR was “helpful and better idea as to position of the nerve” for case 2. One surgeon said the virtual reality solution “would have helped me decide to resect all of the sacroiliac joint” in case 1.
4 Discussion
Using examples of failed pelvic bone sarcoma resections, our study aimed to evaluate the utility of a virtual reality solution on preoperative planning and overall case understanding. This is the first report to describe preoperative planning with a head mounted display-based VR solution prior to pelvic bone sarcoma resection. Our study identified several advantages of the VR solution compared to conventional imaging for preoperative planning. The VR solution provides an immersive environment that allows cropping and scrolling of the image at any angle or level and thus facilitates a detailed understanding of the tumor and its proximity to nearby structures. Data suggests that the VR experience increased surgeon understanding of tumor environment, characteristics, and ability to communicate with patients and colleagues. This is exemplified by 66.6 % of responses following AVATAR usage indicating clearly delineated tumor margins. Our study showed that in 44.4 % of cases users would have altered the surgical approach or changed margins. Furthermore, in all cases, at least one of the six planes of resection would have been changed by users. Lastly, adjacent structure grading was altered in 22.2 % of cases. Thus, even if the approach was not changed, some aspect of the procedure was impacted by the improved spatial understanding provided by the 3D headsets. Surgeons at both training levels were able to grasp and navigate the technology with relative ease after a brief explanation on its functionality and were able to extrapolate a more detailed view of the tumor and its boundaries. Subjective measures across 5 categories were overwhelmingly positive. The subjective data from our study suggests orthopedic surgeons found visualizing the tumor in virtual reality to be beneficial in their preoperative process, understanding, and in communicating complex information to colleagues and patients (Fig. 2). This shows an overall favorable user experience with the AVATAR 3D technology.
An idea of the potential clinical outcome benefit of successful VR adoption within orthopaedic oncology can be gained by looking at navigation adoption in the literature. Both navigation and VR provide increased knowledge of the surrounding anatomy, whether that be through enhanced visual models or enhanced control of surgical approach and resection. In a 3-year minimum follow-up of patients who underwent resections of pelvic osteosarcomas utilizing navigation technology, Cho et al. reports a survival rate of 80 %.16 In contrast, Ozaki et al. reports the overall five-year survival of patients with pelvic osteosarcoma to be 27 %.17 Although further study is needed within navigation to solidify its impact on clinical outcomes, parallels of these early studies can be drawn to provide an expectation of VR's benefits. A search of the literature did provide one clinical instance of VR within orthopaedic oncology in the form of Mixed Reality (MR). An en-bloc spondylectomy of L1 chordoma was performed under the guidance of holographic 2D CT images with favorable results.18 However, current exploration of VR application in orthopaedic oncology is primarily limited to in-vitro models. A study by Cho et al. examined the use of an Augmented Reality (AR) navigation system for bone tumor resections utilizing pig femur models compared to conventional resection planning. The model outputs a virtual bar that indicates the longitudinal relationship data between the articular surfaces of the bone, the tumor margins, and the tumor itself. The accuracy of resection was examined by comparing the surgical margin with pre-operative planning. Ultimately, the mean margin resection errors of the AR group were found to be significantly less than that of the conventional group.19 This does suggest that the improved visual interpretation of tumor extension provided by VR could lead to improved clinical outcomes and does support further study of the AVATAR visualizing system.
Research on the application of VR within pelvic resections can best be described as nascent. Given the impact VR can have on improved margins, it is imperative this gap is addressed, and further study is undertaken. A systematic review by He et al. determined that for pelvic osteosarcoma inadequate margin was associated with significantly higher risk of local recurrence compared to adequate margins, stressing the importance of clean margins.20 Cho et al. reported on the impact AR made on pelvic osteosarcoma resection utilizing pig models comparing resection errors between an AR group and a conventional group. Interestingly, the mean resection error of simulated pelvic osteosarcoma in the AR group was 1.59 mm compared to a resection error of 4.55 mm in the conventional resection error, resulting in a statistically significant difference.21 These results stress the potential benefit of appropriate application of VR technology within orthopaedic oncology to improve outcomes and encourage continued evaluation of current technologies such as AVATAR. Improved visualization and spatial understanding of tumors is crucial to improving the outcomes. Further study is needed to evaluate the clinical impact of prospectively utilizing a virtual reality solution to aid in preoperative planning and communication. The extent to which VR technology can lead not only to a change in the surgical strategy, but also to a change in surgical complication rates or patient outcomes can only be answered by further study.
5 Limitations
A larger and prospective sample size is needed to further elucidate the impact of virtual reality on surgical planning and clinical outcomes. It is also important to highlight that users were provided detailed operative descriptions and outcomes of the chosen cases for analysis, there may have been some degree of bias being introduced that impacted answers to questions asking if surgical approaches and or margins were to be changed. Therefore, prospective evaluation of the use of this VR technology before and possibly during actual cases will provide additional data on its utility.
CRediT authorship contribution statement
Rajko S. Vucicevic: Formal analysis, Investigation, Data curation, Writing – original draft. Justin B. Castonguay: Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization. Noe Treviño: Formal analysis, Investigation, Writing – original draft. Mohammed Munim: Investigation, Data curation. Sarah C. Tepper: Writing – review & editing, Visualization. Rex Haydon: Methodology, Writing – review & editing, Supervision. Terrance D. Peabody: Conceptualization, Methodology. Alan Blank: Conceptualization, Methodology, Software, Validation, Writing – review & editing, Supervision, Project administration. Matthew W. Colman: Conceptualization, Methodology, Software, Validation, Resources, Writing – review & editing, Supervision, Project administration.
Ethical statement
This study is IRB exempt because of the use of an institutional deidentified sample database.
Guardian/patient consent form
Not applicable to this study. No patient personal data was stated in the manuscript. No clinical images were included in this study's manuscript submission.
Disclosures
There are no financial disclosures or conflicts of interest to report. There was no funding received for the completion of this stud.
Sentence summary
Examining surgeon perspectives on the implementation of virtual reality to enhance preoperative planning in bone sarcoma resections.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
References
- Primary treatment of pelvic osteosarcoma: report of five cases. Cancer. 1992;69(5):1137-1145.
- [Google Scholar]
- Osteosarcoma of the pelvis. A clinical and histopathological study of twenty-five patients. J Bone Joint Surg. 1992;74(3):321-330.
- [Google Scholar]
- Osteosarcoma of the pelvis : oncologic results of 40 patients. Clin Orthop Relat Res. 1998;348(348):196-207.
- [Google Scholar]
- Osteosarcoma of the pelvis: outcome analysis of surgical treatment. Clin Orthop Relat Res. 2009;467(2):510-518.
- [Google Scholar]
- CORR® tumor board: is the width of a surgical margin associated with the outcome of disease in patients with peripheral chondrosarcoma of the pelvis? A multicenter study. Clin Orthop Relat Res. 2019;477(11):2429-2431.
- [Google Scholar]
- Retroperitoneal soft-tissue sarcoma: analysis of 500 patients treated and followed at a single institution. Ann Surg. 1998;228(3):355-365.
- [Google Scholar]
- Surgical inaccuracy of tumor resection and reconstruction within the pelvis: an experimental study. Acta Orthop. 2008;79(5):695-702.
- [Google Scholar]
- Virtual reality three-dimensional echocardiographic imaging for planning surgical atrioventricular valve repair. JTCVS Tech. 2021;7:269-277.
- [Google Scholar]
- Augmented reality visualization in brain lesions: a prospective randomized controlled evaluation of its potential and current limitations in navigated microneurosurgery. Acta Neurochir. 2022;164(1):3-14.
- [Google Scholar]
- Virtual reality in neurosurgery: beyond neurosurgical planning. Int J Environ Res Publ Health. 2022;19(3):1719.
- [Google Scholar]
- Bone drilling haptic interaction for orthopedic surgical simulator. Comput Biol Med. 2007;37(12):1709-1718.
- [Google Scholar]
- Shoulder arthroscopy simulator performance correlates with resident and shoulder arthroscopy experience. J Bone Joint Surg. 2012;94(21)
- [Google Scholar]
- Current innovation in virtual and augmented reality in spine surgery. Ann Transl Med. 2021;9(1):94.
- [Google Scholar]
- The outcomes of navigation-assisted bone tumour surgery: minimum three-year follow-up. J Bone Joint Surg British. 2012;94(10):1414-1420.
- [Google Scholar]
- Osteosarcoma of the pelvis: experience of the cooperative osteosarcoma study group. J Clin Oncol. 2003;21(2)
- [Google Scholar]
- Augmented reality–mediated stereotactic navigation for execution of en bloc lumbar spondylectomy osteotomies. J Neurosurg Spine. 2021;34(5):700-705.
- [Google Scholar]
- Augmented reality in bone tumour resection: an experimental study. Bone Joint Res. 2017;6(3):137-143.
- [Google Scholar]
- Effects of resection margins on local recurrence of osteosarcoma in extremity and pelvis: systematic review and meta-analysis. Int J Surg. 2016;36(Pt A):283-292.
- [Google Scholar]
- Can Augmented Reality Be Helpful in Pelvic Bone Cancer Surgery? an in Vitro Study. 2018
- [Google Scholar]