The impact of visualization paradigms on the detectability of spatial misalignment in mixed reality surgical guidance

Wenhao Gu, Alejandro Martin-Gomez, Sue Min Cho, Greg Osgood, Bert Bracke, Chad Josewski, Jonathan Knopf, Mathias Unberath

Research output: Contribution to journalArticlepeer-review


Purpose:: Mixed reality (MR) for image-guided surgery may enable unobtrusive solutions for precision surgery. To display preoperative treatment plans at the correct physical position, it is essential to spatially align it with the patient intra-operatively. Accurate alignment is safety critical because it will guide treatment, but cannot always be achieved for varied reasons. Effective visualization mechanisms that reveal misalignment are crucial to prevent adverse surgical outcomes to ensure safe execution. Methods:: We test the effectiveness of three MR visualization paradigms in revealing spatial misalignment: wireframe, silhouette, and heatmap, which encodes residual registration error. We conduct a user study among 12 participants and use an anthropomorphic phantom mimicking total shoulder arthroplasty. Participants wearing Microsoft HoloLens 2 are presented with 36 randomly ordered spatial (mis)alignments of a virtual glenoid model overlaid on the phantom, each rendered using one of the three methods. Users choose whether to accept or reject the spatial alignment at every trial. Upon completion, participants report their perceived difficulty while using the visualization paradigms. Results:: Across all visualization paradigms, the ability of participants to reliably judge the accuracy of spatial alignment was moderate (58.33%).The three visualization paradigms showed comparable performance. However, the heatmap-based visualization resulted in significantly better detectability than random chance (p= 0.007). Despite heatmap enabling the most accurate decisions according to our measurements, wireframe was the most liked paradigm (50 %), followed by silhouette (41.7 %) and heatmap (8.3 %). Conclusion:: Our findings suggest that conventional mixed reality visualization paradigms are not sufficiently effective in enabling users to differentiate between accurate and inaccurate spatial alignment of virtual content to the environment.

Original languageEnglish (US)
Pages (from-to)921-927
Number of pages7
JournalInternational Journal of Computer Assisted Radiology and Surgery
Issue number5
StatePublished - May 2022


  • Image-guided surgery
  • Mixed reality
  • Perception
  • Registration

ASJC Scopus subject areas

  • Surgery
  • Biomedical Engineering
  • Radiology Nuclear Medicine and imaging
  • Computer Vision and Pattern Recognition
  • Computer Science Applications
  • Health Informatics
  • Computer Graphics and Computer-Aided Design


Dive into the research topics of 'The impact of visualization paradigms on the detectability of spatial misalignment in mixed reality surgical guidance'. Together they form a unique fingerprint.

Cite this