Augmented reality (AR) devices with head mounted displays (HMDs) facilitate the direct superimposition of 3D preoperative imaging data onto the patient during surgery. To use an HMD-AR device as a stand-alone surgical navigation system, the device should be able to locate the patient and surgical instruments, align preoperative imaging data with the patient, and visualize navigation data in real time during surgery. Whereas some of the technologies required for this are known, integration in such devices is cumbersome and requires specific knowledge and expertise, hampering scientific progress in this field. This work therefore aims to present and evaluate an integrated HMD-based AR surgical navigation framework that is adaptable to diverse surgical applications. The framework tracks 2D patterns as reference markers attached to the patient and surgical instruments. It allows for the calibration of surgical tools using pivot and reference-based calibration techniques. It enables image-to-patient registration using point-based matching and manual positioning. The integrated functionalities of the framework are evaluated on two HMD devices, the HoloLens 2 and Magic Leap 2, with two surgical use cases being evaluated in a phantom setup: AR-guided needle insertion and rib fracture localization. The framework was able to achieve a mean tooltip calibration accuracy of 1 mm, a registration accuracy of 3 mm, and a targeting accuracy below 5 mm on the two surgical use cases. The framework presents an easy-to-use configurable tool for HMD-based AR surgical navigation, which can be extended and adapted to many surgical applications. The framework is publicly available at https://github.com/abdullahthabit/SurgNavAR.

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