Markerless Augmented Reality Registration for Surgical Guidance: A Multi-Anatomy Clinical Accuracy Study
Abstract
Purpose: In this paper, we develop and clinically evaluate a depth-only, markerless augmented reality (AR) registration pipeline on a head-mounted display, and assess accuracy across small or low-curvature anatomies in real-life operative settings. Methods: On HoloLens 2, we align Articulated HAnd Tracking (AHAT) depth to Computed Tomography (CT)-derived skin meshes via (i) depth-bias correction, (ii) brief human-in-the-loop initialization, (iii) global and local registration. We validated the surface-tracing error metric by comparing "skin-to-bone" relative distances to CT ground truth on leg and foot models, using an AR-tracked tool. We then performed seven intraoperative target trials (feet x2, ear x3, leg x2) during the initial stage of fibula free-flap harvest and mandibular reconstruction surgery, and collected 500+ data per trial. Results: Preclinical validation showed tight agreement between AR-traced and CT distances (leg: median |Delta d| 0.78 mm, RMSE 0.97 mm; feet: 0.80 mm, 1.20 mm). Clinically, per-point error had a median of 3.9 mm. Median errors by anatomy were 3.2 mm (feet), 4.3 mm (ear), and 5.3 mm (lower leg), with 5 mm coverage 92-95%, 84-90%, and 72-86%, respectively. Feet vs. lower leg differed significantly (Delta median ~1.1 mm; p < 0.001). Conclusion: A depth-only, markerless AR pipeline on HMDs achieved ~3-4 mm median error across feet, ear, and lower leg in live surgical settings without fiducials, approaching typical clinical error thresholds for moderate-risk tasks. Human-guided initialization plus global-to-local registration enabled accurate alignment on small or low-curvature targets, improving the clinical readiness of markerless AR guidance.
Keywords
Cite
@article{arxiv.2511.02086,
title = {Markerless Augmented Reality Registration for Surgical Guidance: A Multi-Anatomy Clinical Accuracy Study},
author = {Yue Yang and Fabian Necker and Christoph Leuze and Michelle Chen and Andrey Finegersh and Jake Lee and Vasu Divi and Bruce Daniel and Brian Hargreaves and Jie Ying Wu and Fred M Baik},
journal= {arXiv preprint arXiv:2511.02086},
year = {2025}
}