Patient Education for innovative technology in shoulder arthroplasty: does knowledge improve outcomes?

Abstract

Background

As technologies such as three-dimensional pre-operative planning, navigation, and augmented or mixed reality become integral to total shoulder arthroplasty (TSA), their influence on patient perception and satisfaction remains unclear. While patient education has been shown to improve understanding and acceptance of innovation in hip and knee arthroplasty, comparable findings in shoulder surgery are limited. Previous work by this author group demonstrated that pre-operative education improves patient confidence and perception of both their surgeon and intervention. This study evaluated whether these improved perceptions about surgical technology via pre-operative education independently impacted clinical outcomes (patient-reported outcome measures (PROMs), range of motion [ROM]) following primary TSA.

Methods

We conducted a prospective cohort study of 154 patients undergoing primary TSA by a single surgeon between 2021 and 2024. Patients were assigned to an intervention group (video group, VG; n = 80) or a control group (no video group, NVG; n = 74). The intervention group viewed a 3-min surgeon-narrated video describing innovative technologies used in shoulder arthroplasty surgery. Pre- and post-video surveys assessed understanding, perceptions, and confidence in the surgeon. Clinical outcomes, including ROM and PROMs (American Shoulder and Elbow Surgeons, Subjective Shoulder Value, Penn), were collected at 6 weeks, 3, 6, and 12 months. Differences between groups were analyzed using t-tests, Mann–Whitney U tests, and Fisher exact tests, with paired tests for within-group changes.

Results

A total of 154 patients (mean age 69 ± 9 years; 45% women) were included. Baseline demographics and pre-operative function were comparable between groups. Baseline characteristics were comparable between groups. The educational video significantly increased confidence in the surgeon (95.5%-97.6%, P= .034) and improved expectations for better results (P= .003), fewer complications (P< .001), less pain (P= .001), and faster recovery (P< .001). However, there were no significant differences in post-operative ROM or PROMs between groups at any time point (all P> .05).

Conclusion

Pre-operative education about surgical technology enhances patient confidence and optimism but does not independently influence functional recovery or satisfaction after TSA. While previously established that educational interventions improve patient experience, they do not independently alter clinical outcomes. Incorporating structured, interactive education may further strengthen patient engagement as technology becomes increasingly central to shoulder arthroplasty.

Technology has become a cornerstone of modern shoulder arthroplasty. Innovations such as three-dimensional pre-operative planning, computer-assisted navigation, and mixed or augmented reality have been shown to enhance surgical precision, standardize implant placement, and improve the management of complex glenoid deformities.^5,9,11,14,23 As multiple studies have demonstrated improved accuracy and clinical benefits, the incorporation of these tools in total shoulder arthroplasty (TSA) has rapidly transitioned from innovation to routine practice.^22,24

However, while surgeon adoption continues to rise, patient understanding of these technologies remains limited. Most patients are unaware that advanced planning and navigation systems are utilized during their procedure or how they contribute to safety and surgical success. In contrast, literature from hip and knee arthroplasty has shown that pre-operative education about robotics and navigation can improve trust, align expectations, and increase acceptance of newer technologies.^1,6,20 However, similar investigations within shoulder arthroplasty are scarce.

Despite generally positive perceptions of navigation, augmented reality, and robotics, early studies show persistent concerns about surgeon experience and safety.¹⁵ Educational initiatives have the potential to bridge gaps and shape perceptions, but whether these improvements translate into measurable differences in satisfaction, confidence, or post-operative outcomes remains unclear. As patient-reported outcomes (PROs) become central to value-based care, clarifying the role of pre-operative education in shaping patient experience and perceived success has become increasingly important.^16,21 Previous work by this author group demonstrated that pre-operative patient education regarding surgical technology improved patient confidence, expectations of outcomes, and perception of their surgeon.¹⁹

The purpose of this study was to serve as a continuation of the authors' previous work regarding the effects of pre-operative patient education on perceptions of technology in shoulder surgery. Specifically, we sought to evaluate whether improved psychological preparedness through education about advanced technologies used in shoulder arthroplasty translates into measurable differences in patient confidence, satisfaction, and post-operative functional outcomes. We hypothesized that educational interventions would improve patient confidence in their surgeon but would not significantly alter PROs or recovery trajectories.

Methods

Study design

This prospective cohort study compared patients who received a pre-operative educational video about the surgical plan (video group, VG) with those who received standard counseling alone (no video group, NVG). The study was conducted at a single academic institution from 2021 to 2024 and received institutional review board approval. Patients were assigned to either the VG or NVG based on the availability of the educational intervention during clinic visits. Patients were consecutively enrolled, and the cohorts demonstrated comparable baseline demographics and pre-operative characteristics. This study builds upon previously published work¹⁹ by the same author group. Given the potential for conceptual and/or dataset overlap, the methodology was designed to ensure that the current analysis addresses distinct research questions and includes updated or expanded data. Any overlapping elements are explicitly acknowledged and cited to maintain complete transparency.

Patient selection

Adult patients (≥18 years) scheduled to undergo primary reverse TSA by a single fellowship-trained shoulder surgeon were consecutively enrolled. Indications included rotator cuff arthropathy and massive rotator cuff tear, primary glenohumeral osteoarthritis, and a smaller subset of post-traumatic conditions. Eligibility criteria included primary TSA, and all patients underwent pre-operative planning with Blueprint (Stryker) or comparable three-dimensional pre-operative planning software. Patients undergoing revision arthroplasty or who were non-English speaking were excluded.

Educational video intervention

Patients in the VG viewed a 3-min surgeon-narrated video outlining the steps of shoulder arthroplasty and the role of pre-operative planning and intraoperative technologies in optimizing accuracy and outcomes. Only VG patients completed a pre- and post-video survey during their pre-operative clinic visit. The 32-item questionnaire collected demographic information (age, sex, race/ethnicity, income, education, marital status, and insurance type), overall health status, and health literacy. Additional items assessed baseline familiarity with surgical innovations, perceived benefits, confidence in the surgeon, and satisfaction with the operative plan. Post-video questions reassessed confidence, satisfaction, and expectations regarding pain, recovery, and complication rates.

Outcome measures and follow-up

All patients were followed for a minimum of 12 months post-operatively. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and the Penn Shoulder Score. Patient-reported outcome measures (PROMs) and range of motion (ROM) for both VG and NVG were recorded at 6 weeks, 3 months, 6 months, and 12 months post-operatively.

Statistical analysis

Descriptive statistics summarized patient demographics and outcomes. Normality was assessed with the Shapiro–Wilk test. Between-group comparisons used independent t-tests or Mann–Whitney U tests for continuous variables and Fisher exact tests for categorical variables. Within-group changes were evaluated with paired tests. A P value <.05 was considered significant. Patients with missing data at a given interval were excluded from that analysis. All analyses were performed using Stata 13 (StataCorp, College Station, TX).

A power analysis, adapted from the methodology reported in a similar prior study evaluating a pre-operative educational video in shoulder arthroplasty by Fasulo et al,⁷ was completed to estimate the appropriate sample size for this study. This analysis indicated that 25 subjects per group were required to achieve greater than 80% power at α = 0.05; therefore, enrollment of approximately 30 patients per group was considered appropriate. The final cohort included 154 patients, exceeding this threshold.

Results

Demographics

A total of 154 patients were included, with 80 in the VG and 74 in the NVG. Baseline demographics were similar between cohorts (Table I). Mean age was comparable (VG: 69.4 ± 8.5 years; NVG: 69.3 ± 10.0 years; P= .97), as were gender distribution (45:35 vs. 38:36; P= .40) and body mass index (28.3 ± 5.1 vs. 27.8 ± 6.7; P= .57). The number of comorbidities did not differ significantly between groups (2.5 ± 1.7 vs. 2.8 ± 2.6; P= .62).

Table I.

Patient demographics (video group vs. no video group).

Characteristic	Video group (n = 80)	No video group (n = 74)	P value
Age (mean ± SD)	69.4 ± 8.5	69.3 ± 10.0	.971
Gender (M:F)	45:35	38:36	.404
BMI (mean ± SD)	28.3 ± 5.1	27.8 ± 6.7	.570
Number of comorbidities	2.5 ± 1.7	2.8 ± 2.6	.620

SD, standard deviation; BMI, body mass index; M, male; F, female.

Patient demographic characteristics of both cohorts are presented as mean ± SD for continuous variables and counts for categorical variables. P values were obtained using independent-samples t-tests for continuous variables and chi-square tests for categorical variables. Statistically significant values (P< .05) are denoted with an asterisk.

Pre-operative characteristics

Baseline ROM and PROs were similar between groups (Table II). Median forward flexion was 110° (interquartile range: 90-160) in the VG and 130° (80-160) in the NVG (P= .58). Abduction was 90° (70-160) vs. 105° (70-160) (P= .51), and external rotation was 30° (10-45) vs. 30° (20-40) (P= .88). Pre-operative PROs were also comparable, including ASES (38 vs. 38; P= .57), Penn Shoulder Score (31 vs. 29; P= .95), and SSV (20 vs. 33; P= .14). Within the VG, 34.1% reported adopting new technologies early, 56.3% were unfamiliar with advanced technologies in shoulder arthroplasty, and 81.4% correctly identified pre-operative planning as the use of imaging to model their anatomy.

Table II.

Pre operative clinical characteristics by group.

Characteristics	Video group (median (IQR))	No video group (median (IQR))	P value
Forward flexion	110 (90-160)	130 (80-160)	.58
Abduction	90 (70-160)	105 (70-160)	.51
External rotation	30 (10-45)	30 (20-40)	.88
ASES	38 (27-53)	38 (23-50)	.57
Penn Score	31 (21-40)	29 (19-46)	.95
SSV	20 (20-40)	33 (20-50)	.14

IQR, interquartile range; ASES, American Shoulder and Elbow Surgeons; SSV, Subjective Shoulder Value.

Pre-operative functional range of motion and patient-reported outcome scores are reported as median with (IQR. P values were calculated using nonparametric tests (Mann–Whitney U) for continuous variables.

Statistically significant values (P< .05) are denoted with an asterisk.

Impact of technology and effect of the educational video

Within the VG, 60.9% reported greater confidence in surgeons who use innovative technologies, and 56.3% viewed advanced pre-operative planning as a marker of superior surgical skill. However, only 41.3% indicated they would prefer a lower-volume surgeon using such technologies over a higher-volume surgeon using traditional methods.

Baseline confidence in the treating surgeon was high (95.5%) and increased further after viewing the video (97.6%, P= .034). Satisfaction with knowing that their surgeon used advanced tools was similarly high pre-video (94.6%) and remained stable post-video (96.8%, P= .086). The video significantly improved expectations regarding outcomes: the proportion anticipating “better overall results” increased from 67.8% to 86.3% (P= .003), “fewer complications” from 41.4% to 64.2% (P< .001), “less post-operative pain” from 31.0% to 51.9% (P= .001), and “faster recovery” from 29.9% to 51.9% (P< .001). Conversely, the percentage who believed technology would have little effect decreased from 14.4% to 8.6% (P= .08).

Post-operative outcomes

Overall, both groups demonstrated improvement in ROM and PROMs at all post-operative time points. At 6 weeks, the mean gain in forward flexion was 11.5° ± 6.2 in the NVG and 4.3° ± 7.9 in the VG, the mean gain in abduction was 15.6° ± 9.2 in the NVG and 3.4° ± 8.7 in the VG, and the mean gain in external rotation was −1.8° ± 3.7 in the NVG and 2.0° ± 3.3 in the VG. Although improvements in forward flexion, abduction, and functional scores were observed in both groups, there were no statistically significant differences seen between groups (forward flexion (P= .48), abduction (P= .35), and external rotation (P= .45). In addition, patient satisfaction, Penn Score, and ASES scores were not significantly different between groups (P= .81, P= .29, and P= .30, respectively).

At the 3-month follow-up, the NVG demonstrated greater improvement in external rotation (mean change: 21.0° vs. 7.6°, P= .014; median: 45° vs. 30°, P= .004); however, there were no differences seen in forward flexion and abduction between groups (P= .42 and P= .34, respectively). In addition, the NVG showed a greater increase in ASES score (mean delta: 36.9 vs. 21.3, P= .036). By 6 months, both groups achieved substantial and comparable functional gains. Median forward flexion reached 160° in both groups (P= .89), abduction reached 160° in both groups (P= .34), and external rotation improved to 40° (NVG) and 50° (VG), with no significant difference (P= .28). Final PROs, including satisfaction, Penn Score, and ASES score, were also similar between groups (all P= .42, P= .77, and P= .38, respectively).

When comparing overall improvement from baseline to 6 months post-operatively, both groups showed similar improvements across PROMs. The change in SSV was 48.2 ± 7.1 in the VG and 41.8 ± 5.3 in the NVG (P= .47), the change in ASES score was 33.0 ± 4.7 vs. 35.4 ± 4.6 (P= .72), and improvement in Penn Score was 37.9 ± 4.8 vs. 34.9 ± 4.4 (P= .65), respectively. None of these changes were statistically significant. ROM gains over the same period were also comparable. Forward flexion improved by 33.9° ± 6.5° in the VG and 33.1° ± 6.7° in the NVG (P= .93), abduction improved by 44.6° ± 7.1° vs. 34.8° ± 8.9° (P= .39), and external rotation improved by 19.3° ± 3.4° vs. 14.3° ± 4.3° (P= .36) (Table III).

Table III.

Change in pre-operative to 6-month post-operative patient-reported outcomes and range of motion.

Outcome	Video group (n = 80)	No video group (n = 74)	P value
Δ SSV	48.2 ± 7.1	41.8 ± 5.3	.47
Δ ASES	33.0 ± 4.7	35.4 ± 4.6	.72
Δ Penn Shoulder Score	37.9 ± 4.8	34.9 ± 4.4	.65
Δ Forward flexion °	33.9 ± 6.5	33.1 ± 6.7	.93
Δ Abduction °	44.6 ± 7.1	34.8 ± 8.9	.39
Δ External rotation °	19.3 ± 3.4	14.3 ± 4.3	.36

SSV, Subjective Shoulder Value; ASES, American Shoulder and Elbow Surgeons.

Discussion

This study examined whether pre-operative education on the use of innovative technology in shoulder arthroplasty independently influenced patients' clinical outcomes. As established by this author group's previous work,¹⁹ the intervention successfully increased patient confidence in their surgeon and elevated expectations for improved results, suggesting that educational content can enhance reassurance and perceived preparedness for surgery. However, these improvements in confidence did not translate into superior functional recovery or higher post-operative satisfaction. Although PROs remain similar between groups, the increase in confidence highlights a clear role for pre-operative education in enhancing the overall patient experience. By properly educating the patient on the technology being used, the surgeon fostered trust and reduced anxiety prior to surgery. However, this study demonstrated that the initial increase in confidence and reassurance are not reflected over time in outcome measures such as ROM and PROMs.

These findings are consistent with previous literature in other domains of orthopedics demonstrating that pre-operative education improves patient preparedness, reduces anxiety, and increases satisfaction with care, even when objective outcomes remain unchanged. In hip and knee arthroplasty, decision aids and educational materials have consistently improved patient engagement and expectation alignment without producing consistent differences in PROMs.^2,8,10,12,18 McDonald et al¹⁷ conducted a Cochrane review reporting modest improvements in pain, function, and psychological outcomes after educational interventions, while Longo et al²² emphasized gains in discharge readiness and satisfaction. Our results extend these observations to shoulder arthroplasty, an area in which the effect of pre-operative technology-focused education has been minimally studied, and demonstrate that although education strengthens patient confidence, it does not directly affect functional recovery.

The lack of measurable improvement in outcomes despite enhanced patient perceptions suggests that education about surgical technology alone is unlikely to independently alter recovery or long-term satisfaction. This study builds upon our previous work¹⁹ that investigated how patient perceptions were affected by intervention via pre-operative education about surgical technology. Our previous study demonstrated that this intervention improved patient perception of and confidence in their surgeon while also increasing their expectations of the surgical procedure itself. While one might expect this enhanced perspective to translate to greater subjective PROs following surgery, perhaps due to greater willingness to follow rehabilitation protocols because of increased surgeon confidence, this was not found to be true. While not directly reflected by patient outcomes, such education appears to have an important role in strengthening psychological readiness by increasing patient trust and reducing pre-operative anxiety, 2 important factors in enhancing the overall surgical experience. These elements, though less quantifiable, remain critical components of patient-centered care. Similar results have been reported in the hip and knee literature regarding robotic or computer-assisted arthroplasty, where greater patient enthusiasm for technology has not consistently correlated with better objective outcomes.^3,13

Emerging data suggests that video education, while useful, may not be the most effective standalone format. In TSA, Fasulo et al⁷ demonstrated that a pre-operative educational video improved patient satisfaction and perceived knowledge but did not significantly improve objective understanding compared with standard consultation. Similarly, in total knee arthroplasty, Wasim et al²⁶ reported that adding an educational video to routine counseling improved pre-operative knowledge and satisfaction but did not produce measurable differences in downstream clinical outcomes. A systematic review by Aydin et al⁴ found that pre-operative patient education had a significant improvement on pre-operative anxiety but had no effect on post-operative outcomes. In contrast, more structured and interactive educational formats appear to confer greater tangible clinical benefits. Sisak et al²⁵ found that participation in a pre-operative education class before total knee arthroplasty reduced hospital length of stay, particularly for patients at high risk for extended stays. Notably, Camillieri et al⁸ found that virtual joint classes were at a minimum noninferior to in-person sessions with respect to post-operative outcomes and satisfaction, suggesting that interactivity and structured engagement. Taken together, these findings imply that while video-based education can enhance preparedness and satisfaction, interactive, structured education (live, in-person, or virtual) may more consistently improve clinical outcomes such as length of stay and discharge disposition. Future studies should directly compare video-only, live, and hybrid approaches to investigate whether alternate means of patient education translate into direct effects on patient outcomes.

The present study investigating patient outcomes following pre-operative education prior to shoulder arthroplasty, when combined with our previous work focused on patient perceptions following the same intervention. While educational interventions may improve patient confidence and preparedness, the present findings suggest that these perception-based improvements do not independently translate into measurable differences in post-operative functional recovery, highlighting the importance of distinguishing psychological benefit from clinical efficacy when evaluating technology-focused patient education strategies. Although the educational video increased patient optimism regarding recovery speed and post-operative pain relief, these elevated expectations did not correspond with measurable differences in outcomes. This mismatch highlights a well-recognized challenge in surgical care—unmet expectations can undermine patient satisfaction even when objective measures show meaningful clinical improvement. Future educational interventions should strive to balance enthusiasm for technological innovation with clear, realistic guidance on recovery trajectories. Incorporating personalized or interactive elements may further strengthen these interventions by addressing patient individual priorities, concerns, and baseline understanding. Future studies may investigate whether patient-specific pre-operative education, using not only video means but other more intensive approaches, translate into tangible differences in patient outcomes that are congruent with their enhanced expectations and perception of their surgery.

Limitations

This study has several limitations. While this was a single-surgeon study, uniformity in surgical technique, implant selection, perioperative protocols, and data collection was ensured, it may limit the generalizability of our results to other settings. The educational intervention consisted of a single brief video designed to reflect a practical and reproducible tool; therefore, results from the study may not be extrapolated to other types or formats of patient education tools regarding the use of technology in shoulder surgery. In addition, the authors did not survey the NVG for baseline confidence. Thus, while the VG demonstrated an increase in patient confidence, no definitive comparison could be made between cohorts. Finally, unmeasured factors such as patient motivation, social support, complications, or rehabilitation adherence may have influenced outcomes. These variables are unlikely to differ substantially between groups and were mitigated through standardized post-operative protocols.

Conclusion

Pre-operative education about surgical technology enhances patient confidence and optimism but does not independently influence functional recovery or satisfaction after rTSA. While previously established that educational interventions improve patient experience, they do not independently alter clinical outcomes. Incorporating structured, interactive education may further strengthen patient engagement as technology becomes increasingly central to shoulder arthroplasty.

Disclaimers:

Funding: This study was supported by a research grant received from Stryker.

Conflicts of interest: Vani J. Sabesan, MD reports consulting relationships with Stryker, DePuy Synthes, and restored. In addition, Stryker provided funding for this study. Her immediate family and affiliated research foundations have no additional relevant disclosures. Given his role as Associate Editor, Vani Sabesan had no involvement in the peer-review of this article and has no access to information regarding its peer-review. Full responsibility for the editorial process for this article was delegated to J. Michael Wiater.

Sina Ramtin reports relationship with Elseviers.

Any additional authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.