The metaverse in orthopaedics: Virtual, augmented and mixed reality for advancing surgical training, arthroscopy, arthroplasty and rehabilitation

Abstract

Purpose: The metaverse and extended reality (XR), which includes augmented reality (AR), virtual reality (VR) and mixed reality (MR), are transforming orthopaedic surgery by enhancing training, procedural accuracy and rehabilitation. However, a literature review of these new virtual tools is lacking. The purpose of this narrative review is to summarise available evidence about the metaverse and discuss current and future clinical applications.

Methods: A narrative review of the current literature was performed for studies evaluating XR tools and their respective clinical and educational utility. Studies from all orthopaedic subspecialties were eligible for inclusion. The XR tools evaluated in each study were categorised according to the reality spectrum and future research or clinical applications were discussed.

Results: XR is a technological spectrum that includes AR, VR and MR to create immersive and interactive surgical training environments. VR-based simulators may improve surgical education by allowing trainees to refine their skills in a risk-free setting. AR may enhance intraoperative guidance and has been studied within orthopaedics to improve implant positioning accuracy and reduce complications in procedures including arthroscopy and total joint arthroplasty. In rehabilitation, AR and VR have been implemented to facilitate patient engagement and adherence, promoting functional recovery through gamified therapy and remote telerehabilitation.

Conclusions: There has been a paradigm shift in orthopaedic care in which digital tools are integrated with patient care to optimise patient outcomes. However, challenges to the widespread implementation of promising XR technology include high costs, steep learning curves and limited clinical validation. Ethical concerns, including data security and patient privacy, further complicate its use in clinical settings. Future research must focus on cost-effectiveness, standardisation and improving accessibility to ensure seamless integration into clinical practice.

Level of evidence: Level V.

Keywords: augmented reality; education, medical, graduate; orthopedic procedures; rehabilitation; virtual reality.

Figure 1

illustrates the reality spectrum from a fully virtual to real environment. Mixed reality bridges virtual and augmented reality using devices such as head‐mounted displays, whereas simulators are examples of virtual reality (VR) and smart glasses examples of augmented reality (AR).

Figure 2

Example of anatomy education using three‐dimensional (3D) anatomical models and 3D‐scanned cadaveric dissections. Dissection Master XR (Medicalholodeck, Zurich, Switzerland).

Figure 3

Example virtual reality (VR) education modules for orthopaedic trauma surgery. (a). Fracture reduction tool in a calcaneal fracture model. (b). Plate‐screw application in a pelvis fracture model. SharpSurgeon (Non Nocere GmbH, Berlin, Germany).

Figure 4

Minimal invasive hallux valgus surgery education module. (a) Preoperative deformity evaluation on a complete foot model. (b) Deformity evaluation on bone model of the same patient. (c) Postoperative view of corrected deformity after osteotomy and screw fixation. SharpSurgeon (Non Nocere GmbH, Berlin, Germany).

Figure 5

Example of using virtual reality to practice use of surgical instruments and implants. (a) Rongeur application in spine surgery. (b) Screw application using a screw‐driver. SharpSurgeon (Non Nocere GmbH, Berlin, Germany).

Figure 6

Real‐time virtual reality collaborative session on the surgical treatment of Lisfranc injuries, enabling educators and trainees from around the world to participate. Medical Imaging XR (Medicalholodeck, Zurich, Switzerland).