Navigating the future: A comprehensive review of technology in shoulder arthroplasty

Abstract

The volume of shoulder arthroplasty (SA) procedures has increased significantly in recent years, outpacing the growth of hip and knee arthroplasty. As a relatively young area in orthopedics, shoulder arthroplasty offers many opportunities for innovation, often borrowing from established practices in other subspecialties. Degenerative shoulder pathology presents unique challenges that can be difficult to adequately address with conventional reconstructive methods alone. Currently, three-dimensional preoperative planning is the most widely utilized technology in shoulder arthroplasty. Implementation of patient-specific instrumentation is increasing, primarily for patients with severe deformity. Computer-assisted navigation, widely used in hip and knee reconstruction, is gaining traction. These technologies have demonstrated increased accuracy and precision in correcting glenoid deformity and implant positioning, which are known to influence the long-term performance of SA. However, studies specifically evaluating the long-term clinical benefits of these innovations are lacking. In the near future, the application of robotic and immersive technologies like augmented reality for SA demonstrates promise for enhancing the surgeon's ability to address glenoid deformity intraoperatively. These advancements provide exciting opportunities to transform the field of shoulder arthroplasty, yet they must be critically evaluated for their cost and impact to outcomes clinical cohorts with long-term follow-up.

Level of evidence

Level V; Narrative Review.

1. Introduction

The demand for shoulder arthroplasty is rapidly increasing, with the volume of procedures projected to rise by as much as 235 % by 2025 according to the Poisson model.¹ As the United States population ages and life expectancy increases, current projections estimate that this growth will be sustained and eventually outpace that of total hip arthroplasty (THA) and total knee arthroplasty (TKA).¹ As a relatively young area in the field of orthopedics, opportunities for innovation in shoulder arthroplasty are exciting and drawing on established practices in adult hip and knee reconstruction, may be applied to address the unique challenges of shoulder reconstruction).

One of the challenges of shoulder arthroplasty is the procedure is known to have a steep learning curve. Shoulder arthroplasty performed by low-volume surgeons (defined as performing less than 30 arthroplasties per year) is associated with worse outcomes, including lower patient function, higher complication rates, longer patient length-of-stay, and increased costs.² Yet, when compared to hip and knee arthroplasty, shoulder arthroplasty is more commonly performed by low-volume surgeons.^3,4

Additionally, degenerative glenohumeral morphology is highly complex and varies significantly across the population.^5,6 Plain radiographs performed with proper technique can provide a reliable global assessment of glenoid erosion and humeral head subluxation,^7,8 but measurements of glenoid version on plain radiographs are highly influenced by scapular rotation in the sagittal plane.⁹ Computed tomography (CT) imaging is less influenced by scapular rotation and is favored for more accurate measurements of glenoid parameters. However, measurements of glenoid version and inclination differ if obtained from uncorrected 2-dimensional (2D) CT images, 2D CT images corrected to the plane of the scapula, or automated 3D CT reconstructions.10, 11, 12

Exposure and instrumentation of the glenoid is known to be challenging.¹³ This is especially difficult in cases where significant retroversion or bone loss is present.¹⁴ The importance of proper glenoid implant positioning especially in these complex cases with deformity, is critical for successful outcomes for both anatomic and reverse TSA.15, 16, 17, 18, 19, 20, 22, 23 Standard instrumentation and utilization of either plain radiographs or 2D CT images is associated with inaccuracies in glenoid implant placement, particularly for more severe glenoid deformities.²¹

These challenges have fueled the development of new technologies in shoulder arthroplasty to address the lack of 3D evaluation of pathology, the difficulty in exposure and orientation intraoperatively, and the importance of correction of deformity and optimal implant placement on outcomes. The goal of this review is to provide a summary of the new technology such as, 3D preoperative planning software, intraoperative navigation, and patient-specific instrumentation, that has arisen in SA, focusing on the accuracy and precision along impact on outcomes.

1.1. Current technology – where we stand

1.1.1. Preoperative planning software

Preoperative planning software is one of the most widely utilized technological advances for SA. Due to the limitations of plain radiographs in accurately characterizing the morphology of the arthritic glenoid – particularly retroversion and bone loss – it is now common practice to obtain a CT scans preoperatively.⁹ In order to be compatible with 3D planning software programs, typically the following criteria must be met: imaging window must include the entire scapula, maximum cut thickness must be 0.6 mm, and maximum slice increment must be 0.6 mm.²⁴ These software programs convert raw CT voxels into humeral and scapular point clouds, forming a digital foundation from which various measurements can be obtained and virtual implants can be placed.²⁵ Most implant companies now offer some form of 3D planning software (Table 1).

Table 1.

Overview of 3D preoperative planning systems for shoulder arthroplasty.

Company	System	Planning Method	Description
Enovis	Match Point System	Manual	A comprehensive 3D planning software that uses CT scans to create patient-specific preoperative plans. Patient-specific instrumentation can be customized based on the preoperative plan.
Zimmer-Biomet	Signature ONE Surgical Planning	Semi-Automated	Facilitates both automated and manual planning methods. Patient-specific guides and instruments are produced based on 3D preoperative plans to aid in guide pin placement, reaming depth, baseplate impacting, and baseplate screw guide.
Stryker	Blueprint	Automated	A 3D planning software using an automated best-fit sphere approach. Designed for preoperative planning that supports patient-specific instruments, enhancing surgical outcomes in shoulder arthroplasty. Blueprint was originally created by Tornier and eventually acquired by Stryker.
DePuy Synthes	Materialise TRUMATCH Personalized Solutions Shoulder System	Semi-Automated	A versatile 3D planning tool for complex cases, offering both automated and manual methods for creating detailed preoperative plans. Intended to be used as a surgical instrument to assist in the intra-operative positioning of glenoid components used with anatomic and reverse shoulder arthroplasty by referencing anatomic landmarks of the shoulder that are identifiable on pre-operative CT- imaging scans.
Arthrex	Virtual Implant Positioning (VIP) System and OrthoVis	Manual	A web-based 3D planning system where patient data and CT scan images can be easily uploaded without the need for software downloads. The system enables surgeons to position implant components with the aid of planning software and guidance instrumentation during shoulder arthroplasty.
Medacta	MyShoulder and NextAR	Semi-Automated	Customizable 3D preoperative planning software focusing on patient-specific implant placement and surgeon input on glenoid position. Utilizes a software application, a compact single-use tracking system, and augmented reality glasses.
Exactech	Equinoxe	Semi-Automated	A 3D planning software that supports preoperative planning in shoulder surgeries, enabling detailed and patient-specific implant positioning. Planning can be done with ExactechGPS navigation system, no patient specific instrumentation.
Smith + Nephew	ATLASPLAN	Semi-Automated	Developed in partnership with Materialise NV, this system enables pre-operative case planning for total shoulder arthroplasty with a user-friendly, web-based interface accessible from any device. It features a quick turnaround time from image upload to planning and offers an optional 3D-printed glenoid guide with a patented coracoid clip.

Legend: CT = computed tomography. Systems are categorized by their planning methods (manual, semi-automated, automated) and include descriptions of their capabilities for preoperative planning, patient-specific instrumentation, and intraoperative guidance.

Using preoperative planning software provides two major advantages. First, it corrects for the plane of the scapula and glenoid by including the entire scapula, affording a more comprehensive understanding of glenoid deformity. It also facilitates selection of different implants to match the patient's stature, bony morphology, and potential soft tissue pathology. The preoperative planning software has increased agreement regarding glenoid classification and surgical plans among surgeons of all experience levels, and particularly among low-volume surgeons.²⁶ Additionally, application of these preoperative planning programs positively influences implant decision making, including nuanced decisions between standard and specialized augmented or custom options (Fig. 1).27, 28, 29, 30, 31, 32, 33 However, the benefits of these programs are not limited to the preoperative planning stage – they have demonstrated value for improving the technical execution of SA as well. Application of 3D planning software improves the accuracy of free-hand glenoid guide pin placement, decreases variance among surgeons, and decreases the risk of inadvertent glenoid vault perforation.34, 35, 36 Furthermore, these programs improve restoration of native version and inclination, even in the settings of glenoid bone loss.³⁷ Preoperative planning also helps predict intraoperative implant size fairly accurately which can help guide resources and potential limit instrumentation needed.²⁷ Lastly, preoperative planning software improves the overall accuracy of final implant position.^21,35, 36, 37

Fig. 1.

Preoperative 3D planning software for shoulder arthroplasty. The figure demonstrates the use of 3D preoperative planning systems to assess and optimize implant positioning for shoulder arthroplasty.

Despite these benefits, preoperative planning software is not without limitations. First, it must be noted that there are variations in the methods of deformity assessment between commercially available software systems. The two primary methods are the best-fit sphere (automated; Blueprint) and friedman's line and landmark (manual; Enovis, DePuy, Stryker, Arthrex).^12,38,39 The freidman's line method most closely resembles how surgeons manually take measurements, while the best-fit sphere uses a complete 3D reconstruction of the humerus for fully automated measurements.¹² At present, neither method has demonstrated superiority in replicating the true anatomy,⁴⁰ however, the automated method eliminates interobserver and intra-observer discrepancies, which may enhance consistency and improve accuracy in preoperative planning for shoulder arthroplasty.¹² Equally noteworthy is the fact that the accuracy of these three-dimensional assessments declines in the setting of severe deformity.^32,37 This should be kept in mind by the surgeon and can prompt software or should prompt surgeons to further scrutinize preoperative plans, consider manually planning these cases and verify with intraoperative findings.^37,41 Third, while evidence indicates that these programs can aid in determining humeral implant sizing with reasonable accuracy,³² predicting final implant choice within one size, they have not consistently demonstrated reliability in accurately recreating proximal humeral anatomy, especially when a free hand cut is involved.^31,42,43 Finally, contemporary goals for glenoid reconstruction are largely based on historical thresholds determined from two-dimensional measurements. Currently, there is a paucity of high-quality data regarding how these thresholds influence patient outcomes and implant survival.²⁵ Measurements of version and inclination may differ by as much as 5° – 15° between traditional 2D methods and current 3D methods,⁴⁴ as preoperative planning software systems tend to overestimate retroversion, inclination, and posterior humeral head subluxation.⁴⁰ The shoulder arthroplasty literature would benefit from establishing more uniform guidelines for glenoid and proximal humeral reconstruction that take into account recent advances and widespread implementation of this technology.

1.1.2. Patient-specific instrumentation

Patient-specific instrumentation (PSI) was originally developed to improve the accuracy of total knee arthroplasty by using custom guides and cutting blocks based on patient anatomy.45, 46 These concepts were more recently applied to SA, with several implant manufacturers now offering PSI options (Table 2). Development of PSI for SA has focused primarily on facilitating glenoid instrumentation, with limited data available to support its use for humeral instrumentation.⁴⁷ Glenoid PSI guides contain multiple peripheral projections which seat on specific landmarks along the glenoid rim, precisely orienting a central wire from which all glenoid instrumentation is based.⁴⁸ The proposed advantage of PSI is that it may further enhance the improved accuracy obtained through 3D preoperative planning. This technology decreases outliers, has demonstrated efficacy in cases involving severe bone loss or deformity, and facilitates alternative or minimally invasive approaches.^21,34,35,37,49, 50, 51 However, in the setting of mild to moderate glenoid deformity, PSI may only provide incremental improvements with unclear clinical benefit.^14,50,52, 53, 54, 55 Changes in version and inclination correction of 4° or less and improvements in guide pin placement of 1 mm or less may not offer sufficient advantages to justify the cost and additional time needed to manufacture these guides, which are the primary limitations of this technology.^50,56 Direct costs are estimated at approximately $500- $2500, which when combined with other indirect costs and the timeframe for production, make this technology less appealing to surgeons, payers, and patients alike.^57,58 Two types of PSI are available: single-use disposable guides and adjustable reusable guides, both of which have demonstrated similar efficacy.²¹ Although there is variability in how these guides are made and designed there has not been any comparitive study looking at the accurac, variability, or optimal PSI guide construction. A reusable guide may provide a more cost effective option with immediate availability based on the preoperative plan, but is implant vendor specific, based on availability, and can be more difficult to use than single-use monobloc guides. Future advances in 3D printing may increase access to single-use guides by allowing faster, lower cost production.58, 59, 60

Table 2.

Implant companies offering patient-specific instrumentation for shoulder arthroplasty.

Proprietary Name	Company	Guidance Technology	Features
ExactechGPS	Exactech	Computer-assisted navigation surgery	3-D planning software; glenoid navigation for TSA; intraoperative modification of plan permissible.
Blueprint	Stryker	PSI (single use)	3-D planning software with templating for TSA; 3-D bone model provided.
Match Point	Enovis	PSI (single use)	PSI guide aims at the glenoid edge with optional 3-D bone modeling for aTSA and rTSA; reusable guide available.
Signature ONE Surgical Planning	Zimmer-Biomet	PSI (single use)	3-D planning software with templating; PSI guide for glenoid placement, glenoid face targeting.
Virtual Implant Positioning System (VIP)	Arthrex	PSI (reusable)	3-D planning system for implant positioning; 3-D bone model of glenoid; reusable PSI guide available.
Materialise TruMatch	DePuy-Synthes	PSI (single use)	3-D bone model of the glenoid; PSI guide for aTSA and rTSA with coracoid pinning options.
MyShoulder	Medacta	PSI (single use)	3-D planning software with patient-specific solutions; PSI guide tailored for optimal glenoid placement and positioning for aTSA and rTSA.
Smart SPACE	Lima	PSI (single use)	Advanced 3-D planning software for aTSA and rTSA; patient-specific instrumentation with a focus on precision and reproducibility in glenoid implant positioning.

Legend: aTSA = anatomic total shoulder arthroplasty; rTSA = reverse total shoulder arthroplasty; PSI = patient-specific instrumentation; 3-D = three-dimensional. Table adapted from Virk et al.⁶¹.

1.2. Computer-assisted navigation

Computer-assisted navigation (CAN) was initially introduced to improve safe instrumentation in spine surgery. Subsequent adaptations led to its application to hip and knee arthroplasty procedures, and more recently to SA. These systems consist of a computer station with a monitor, a camera, an infrared sensor, and a series of trackers. Two or three trackers are commonly used for shoulder arthroplasty procedures – one affixed to the coracoid process, one connected to a free-moving probe for anatomic referencing, and a third that can be attached to key instruments such as the glenoid reamer.²⁴ Information from the first two trackers is collated with the 3D model of the glenoid generated from the preoperative CT scan to create an accurate 3-dimensional representation of the patient's anatomy and position in space. This is then used to provide real-time guidance of instrumentation based on the surgeon's preoperative plan.

Computer-assisted navigation offers several potential advantages for the execution of TSA procedures. It has been shown to blunt the typically steep learning curve associated with glenoid component positioning.⁶² This is due in part to an enhanced ability to understand and effectively interact with each patient's unique scapular morphology, with decreased reliance on the limited landmarks available in typical open shoulder approaches.⁶³ Computer-assisted navigation may also offer improvements in glenoid instrumentation beyond that of PSI by providing real-time feedback during reaming, screw placement, and implant placement.⁶⁴ Furthermore, CAN has been shown to improve accuracy and precision while decreasing variability in version correction,63, 64, 65, 66, 67, 68 guide pin placement, baseplate screw placement,^65,69, 70, 71 and final implant position.^68,70,72

However, CAN is not without limitations. Setting up the necessary equipment can increase operative time by 9.5 %–23 %, although this additional time typically decreases after approximately 8 cases once the surgeon has familiarized themselves with the technology.^63,73,74 Technical difficulties are unfortunately common, with the rate of aborted cases due to technical failures ranging from 2.7 % to 60 %.⁶³ Additionally, coracoid fractures can occur due to tracker placement. The reported 5.5 % incidence of this difficult-to-manage complication may be unacceptably high for many surgeons.⁷³ Finally, access to this technology is a significant barrier. Computer-assisted navigation systems require a significant initial investment, both in terms of the direct costs of the system itself as well as the indirect cost of increased operative time.^73,75 Some of these costs have been managed by the implant manufacturers and have increased access to this technology. Two systems are currently available for use in SA ExactechGPS (Exactech; Gainesville, FL) system and Nextar (Medacta).⁷⁴

1.3. Robotics

Robotics, defined as a reprogrammable, multifunction manipulator designed to move material and devices through various programmed motions for the performance of specific tasks, robotics has a wide spectrum of applications in orthopaedics.⁷⁶ Categorically, these systems exhibit varying degrees of autonomy, ranging from passive (surgeon-supervised) to semi-active to fully active (autonomous).⁷⁷ The choice of implants in robotics can be closed, with pre-selected implants and potential contractual obligations, or open, allowing greater implant flexibility but less specificity. The reference frame may also vary – these systems can be image-based, collating preoperative advanced imaging with real-time tracking of patient anatomy, or imageless, relying solely on intraoperative data points (Table 3).

Table 3.

List of commercially available robotic systems for arthroplasty.

Name	Company	Autonomy	Implant	Imaging	Procedures
ROSA	Zimmer-Biomet; Warsaw, IN	passive/semi-active	semi-open	CT	Total knee, hip, and shoulder arthroplasty
MAKO	Stryker; Fort Lauderdale, FL	semi-active	closed	CT	Total knee, and total hip arthroplasty
ROBODOC/TCAT	Think Surgical, Inc.; Fremont, CA	active	open	CT	Total knee and hip arthroplasty
Navio	Blue Belt Technologies; Plymouth, MN	semi-active	semi-open	Imageless	Total knee arthroplasty

Legend: CT = computed tomography. The table summarizes robotic systems currently available for arthroplasty, including their autonomy levels, implant options, imaging requirements, and applicable procedures.

Across industries, the introduction of robotics has consistently improved accuracy, precision and efficiency (Fig. 2).⁷⁶ In orthopedic surgery, however, most studies comparing robotic systems to conventional instrumentation for THA and TKA have found no clinical differences.78, 79, 80, 81 A notable exception is robotic-assisted unicompartmental knee arthroplasty, which has demonstrated improved clinical outcomes and implant survivorship compared to standard manual techniques.⁷⁷ Robotics has also been applied to spine surgery for pedicle screw placement, although current data does not clearly indicate benefit for accuracy or clinical outcomes.⁸²

Fig. 2.

MAKO robotic system. The MAKO robotic system interface demonstrating real-time navigation for knee implant positioning.

Robotics in shoulder arthroplasty is in its early stages. Preclinical descriptions of robotic systems designed for shoulder arthroplasty show promise, offering a more compact design that fits the constrained working space of the shoulder.⁸³ The first of its kind, Zimmer Biomet's Robotic Surgical Assistant (ROSA) for shoulder arthroplasty offers a semi-active platform that integrates preoperative CT-based imaging with real-time intraoperative tracking, optimizing implant positioning with greater accuracy. This closed-loop system reduces the need for extensive bony instrumentation and improves outcomes, particularly in cases with severe deformity.⁸⁴ Initial data on this system has shown precision with bone resection, accuracy in kinematic alignment, and lower revision rates in the early postoperative period. However, long-term outcomes and survivorship are still under evaluation.

However, future integration of robotics for SA will not be without challenges. Hurdles to widespread implementation include increased direct cost, disruption of surgical workflows, prolonged surgical time, and additional procedural complexity prior to overcoming the learning curve.^76,77

1.4. Emerging technology – What's around the corner

1.4.1. Immersive technology

In parallel with robotics, immersive technologies, such as Virtual Reality (VR) and Augmented Reality (AR), have emerged to improve surgical accuracy and patient outcomes following shoulder arthroplasty.85, 86, 87, 88 VR utilizes a head-mounted display to immerse users in a completely digital environment, while AR superimposes digital images onto the user's field of view in real-time.⁸⁹ These technologies share three essential components: a position-tracking system, a display system (headsets for VR and AR), and system control software that merges data from the tracking system with virtual images to create real-time integration as the user interacts with either the virtual environment (VR) or with virtual images superimposed on the surrounding environment (AR) (Fig. 3, Fig. 4).⁸⁹ AR may also combine several types of sensors such as infrared lasers, high-definition cameras, accelerometers, and microphones with an integrated computer.⁹⁰

Fig. 3.

PrecisionOS interface in shouldersurgery: The figure depicts a virtual reality simulated surgical environment.

Fig. 4.

Augmented Reality in the Operating Room. The figure demonstrates the use of augmented reality technology during shoulder arthroplasty.

Surgical training modules utilizing VR have predominantly focused on arthroscopy, with limited modules dedicated to shoulder arthroplasty.⁸⁵ These modules have demonstrated significant improvements in technical skills, efficiency, and knowledge acquisition^85,91 – all with zero risk of patient harm. Additional benefits include flexibility in training schedules and potential for collaboration across geopolitical boundaries. While robust data with larger cohorts is lacking and current access and cost constraints hinder widespread application, this technology will likely play a central role in the future of surgical education.⁹²

Immersive technology currently has applications both in the preoperative and intraoperative phases of SA. VR software allows surgeons to perform preoperative planning in an immersive VR environment, rehearse surgical procedures with their team, and even educate patients about their diagnosis and management. Promising data have been reported with the use of AR in various orthopedic procedures, including percutaneous sacroiliac screw placement,⁹³ percutaneous pelvic K-wire placement,⁹⁴ placement of distal interlock screws for intramedullary nails,^95,96 pelvic and long-bone tumor resection,^97,98 periacetabular osteotomy,⁹⁹ acetabular cup placement in total hip arthroplasty,^100,101 tibial bone cut and alignment in total knee arthroplasty,^102,103 and pedicle screw placement.104, 105, 106 For SA specifically, preclinical data indicates that the central guidewire can be placed within 5° of the planned trajectory^87,107,108 whereas standard instrumentation has a mean error of 7.1° in version and 8.5° in inclination.¹⁴ Early reports on the implantation of RSA using AR have shown proper implant placement without delays or complications.¹⁰⁹

This technology offers numerous potential benefits, including improved accuracy and precision, reduced radiation exposure, real-time access to patient information, and remote interaction during surgery.^89,109 However, there are a number of challenges as well with this technology, including technical issues with the devices themselves, real time coordination with the preoperative software, additional time requirements, user comfort and cognitive load, battery life, system latency, perception concerns, and cost barriers remain to be addressed (Table 4).110, 111, 112

Table 4.

Comparison of Headsets for Augmented, Virtual, and Mixed Reality (Adapted from Tepper et al.90).

	Google Glass	Occulus Rift	Microsoft HoloLens
Technology Type	Augmented Reality	Virtual Reality	Mixed Reality
Wearability	Eyeglasses-style	Adjustable headband	Adjustable headband
Battery Life	∼1 hour of continuous use	Wired power	2–3 hours of use
HIPAA Compliance	Yes (limited to third-party apps)	N/A	Not off the shelf compliant
No-touch operation	Touchpad (right arm) and voice control	No	Gestures and voice commands
True Heads-Up Display	Yes	N/A	Yes

Footnote:The HoloLens was in active use at the time of manuscript preparation; however, its discontinuation has been announced and is anticipated in the near future.

1.4.2. Artificial intelligence

Artificial intelligence (AI) encompasses the development of deep learning algorithms that can be "trained" to categorize or predict specific outputs by processing inputs and establishing intricate relationships between "predictor variables" and outcomes.¹¹³ This capability to analyze extensive datasets through AI-based strategies holds the potential to transform clinical and surgical decision-making by offering safer and more informed options for patients.

Numerous studies have demonstrated benefits associated with early clinical applications of AI to TSA. These range from predicting risk profiles and patient outcomes to aiding image assessment and implant decisions.114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124 It has been demonstrated that in 78 % of cases, AI's surgical recommendation for the optimal arthroplasty type (aTSA vs. rTSA) aligned with that of expert surgeons.¹²⁵ This early evidence suggests that AI holds promise for providing automated suggestions for implant choices based on iterative learning from decisions made by experts.

However, barriers to widespread application of AI remain, including privacy concerns, data ownership, and external validation. These must be addressed in order to fully leverage the potential of AI in clinical practice. In a recent systematic review of 48 articles, Gupta et al.¹²⁶ examined the application of AI models in shoulder surgery, evaluating both model performance and validation. The pooled data suggested that AI model performance is modest and external validity remains to be demonstrated. This evidence suggests that larger prospective trials are needed prior to the adoption of AI for clinical use.

2. Conclusion

The continuous evolution of surgical technologies presents a multitude of opportunities to improve the precision and accuracy of TSA, particularly for assessment and instrumentation of glenoid. However, the current body of evidence primarily involves smaller, heterogeneous samples taken largely from pre-clinical or time-zero evaluations. A recent meta-analysis suggests that the introduction of novel technologies to TSA over the past two decades has not yielded significant improvements in short to mid-term functional outcomes.¹²⁷ While these findings must be considered carefully, the impacts of innovation may take time to materialise and the absence of inferior outcomes with disruptive technologies can be cautiously considered a positive indicator. In evaluating these advancements, the ultimate criterion lies in determining the overall value to the patient, which necessitates a careful consideration of the cost relative to any additional benefit it confers.

The integration of current and emerging technologies in shoulder arthroplasty holds significant potential. Yet, the effective realization of this potential demands rigorous evaluations with long-term follow-up. Future prospective randomized trials comparing new technology against conventional techniques with extended clinical follow-up and homogenous populations will be essential for providing a nuanced understanding of the benefits, limitations, and overall value of these technologies.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.