Technological Innovations in Shoulder Replacement: Current Concepts and the Future of Robotics in Total Shoulder Arthroplasty.

Abstract

Total shoulder arthroplasty (TSA) has been rapidly evolving over the last several decades, with innovative technological strategies being investigated and developed in order to achieve optimal component precision, joint alignment and stability, preserve implant longevity, and improve patient outcomes. Future advancements such as robotic-assisted surgeries, augmented reality, artificial intelligence, patient-specific instrumentation (PSI) and other peri/preoperative planning tools will continue to revolutionize TSA. Robotic-assisted arthroplasty is a novel and increasingly popular alternative to the conventional arthroplasty procedure in the hip and knee but has not yet been investigated in the shoulder. Therefore, the purpose of this study was to conduct a narrative review of the literature on the evolution and projected trends of technological advances and robotic assistance in total shoulder arthroplasty. A narrative synthesis method was employed for this review, rather than a meta-analysis or systematic review of the literature. This decision was based on two primary factors: (1) the lack of eligible, peer-reviewed studies with high quality level of evidence available for review on robotic-assisted shoulder arthroplasty, and (2) a narrative review allows for a broader scope of content analysis, including a comprehensive review of all technological advances-including robotics-within the field of TSA. A general literature search was performed using PubMed, Embase, and Cochrane Library databases. These databases were queried by two independent reviewers from database inception through November 11, 2022, for all articles investigating the role of robotics and technology-assistance in total shoulder arthroplasty. Inclusion criteria included studies describing "shoulder arthroplasty" and "robotics". After exclusion criteria were applied, four studies on robotic-assisted TSA were described in the review. Given the novelty of this technology and limited data on robotics in TSA, these studies consisted of a literature review, non-validated experimental biomechanical studies in sawbones models, and preclinical proof-of-concept cadaveric studies using prototype robotic technology primarily in conjunction with patient specific instrumentation (PSI). The remaining studies described the technological advancements in TSA, including PSI, computer-assisted navigation (CAS), artificial intelligence, machine learning, and virtual/augmented/mixed reality. Although not yet commercially available, robotic-assisted TSA confers the theoretical advantages of precise humeral head cuts for restoration of proximal humerus anatomy (RPHA), more accurate glenoid preparation, and improved soft-tissue assessment in limited early studies. The evidence for the use of robotics in THA and TKA demonstrates improved component accuracy, more precise radiographic measurements, and improved early/mid-term patient-reported and functional outcomes. While no such data currently exists for shoulder arthroplasty given that the technology has not yet been commercialized, the lessons learned from robotic hip and knee surgery in conjunction with its rapid adoption suggests robotic-assisted TSA is on the horizon of innovation. By achieving a better understanding of the past, present and future innovations in TSA through this narrative review, orthopedic surgeons can be better prepared for future applications.