Mixed reality improves agreement on surgical approach selection and patient positioning in tibial plateau fracture planning compared to CT, 3DCT and 3D printing

PURPOSE: Tibial plateau fractures require precise preoperative planning, particularly regarding treatment concept, patient positioning, and surgical approach. Mixed reality (MR) may enhance three-dimensional understanding of fracture morphology beyond conventional imaging and physical 3D models. This study investigated whether MR improves agreement on key preoperative planning decisions compared to computed tomography (CT), 3D computed tomography (3DCT), and 3D-printed fracture models. METHODS: Twelve orthopaedic trauma surgeons (6 junior, 6 senior) evaluated 22 surgically treated tibial plateau fractures (AO/OTA type B or C). Each case was assessed in four steps using (1) CT, (2) 3DCT reconstructions, (3) physical 3D-printed models, and (4) MR visualization using Microsoft Hololens 2. Raters selected (i) treatment concept, (ii) patient positioning, and (iii) surgical approach. Interobserver agreement was analysed using Fleiss' kappa (κ) and percentage match (PM). RESULTS: Mixed Reality (MR) yielded the highest interobserver agreement for both surgical approach (PM 32%, κ = 0.30) and patient positioning (PM 57%, κ = 0.35), particularly among junior surgeons (approach PM 39%, κ = 0.28; positioning PM 57%, κ = 0.39). Compared to CT, 3DCT, and 3D printing, MR demonstrated consistent improvements, while agreement on treatment concepts remained high across all modalities (PM > 82%). CONCLUSION: Mixed Reality (MR) improved interobserver agreement in preoperative planning for tibial plateau fractures, particularly for surgical approach selection and patient positioning. These effects were most pronounced among less experienced raters, highlighting MR's role as a cognitive support tool and a promising instrument in surgical education. Compared to conventional imaging and 3D printing, MR provided dynamic interaction and greater planning flexibility. While further clinical validation is required, these findings support MR as a valuable adjunct in orthopaedic trauma planning. LEVEL OF EVIDENCE: Level II.