Introduction
An innovative, patient-specific, hip implant was developed for canine patients suffering from developmental hip dysplasia. In a first cohort study, the post-operative positions of the implants deviated with an average of 5 mm when compared to the pre-operatively planned positions. A novel augmented reality (AR) based intra-operative navigation method (Holoma) was proposed to decrease implant positioning errors to a maximum of 3 mm. Holoma provides ArUco marker-based, mixed reality surgical navigation on the Hololens 2. The goal of this study was to quantify the error associated with each technical component in Holoma, to determine its navigational accuracies.

Methods
Holoma’s technical errors were quantified in a laboratory setting within a surgical operation room. The accuracy of ArUco marker localization and the amount of jittering (falsely detected marker movement) were tested by performing stationary and dynamic experiments. The precision of three image-to-patient registration methods (marker pose, point-to-point, point cloud) was determined by calculating the euclidean distance between multiple registration attempts. Lastly, implant navigation accuracy was quantified by positioning an implant on a precisely predetermined position and recording Holoma’s navigation instructions.

Results
Holoma’s ArUco marker localization accuracy had a median error of -0.97 mm (min; max: -2.04; -0.27) with a marker-to-camera distance of 60 cm, and median jittering was 0.65 mm (min; max: 0; 2.07). Median image-to-patient registration precision was 2.20 mm (min; max: 0.39; 6.00), 3.52 mm (0.21; 6.92), and 3.79 mm (0.55; 8.83), for marker pose, point-to-point, and point cloud registration, respectively. Lastly, implant navigation instructions showed median errors of 2 mm (min; max: 0; 7), 3 mm (0; 7), and 4 mm (0; 9) after marker pose, point-to-point, and point cloud registration, respectively.

Discussion and conclusion
The experiments suggest an accumulation of technical errors in Holoma’s navigation application. The accuracy and precision of the navigation software were determined to be inadequate to decrease patient specific hip implant placement errors, at the time of investigating. Future improvements within Holoma will determine its feasibility for accurate implant navigation. Other navigation techniques should be considered in the search for optimal implant positioning guidance.