Abstract
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Accurate component placement in shoulder arthroplasty is crucial for avoiding complications, achieving superior biomechanical performance and optimizing functional outcomes.
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Shoulder and elbow surgeons have explored various methods to improve surgical understanding and precise execution including preoperative planning with 3D computed tomography (CT), patient-specific instrumentation (PSI), intraoperative navigation, and mixed reality (MR).
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3D preoperative planning facilitated by CT scans and advanced software, enhances surgical precision, influences decision-making for implant types and approaches, reduces errors in guide pin placement, and contributes to cost-effectiveness.
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Navigation demonstrates benefits in reducing malpositioning, optimizing baseplate stability, improving humeral cut, and potentially conserving bone stock, although challenges such as varied operating times and costs warrant further investigation.
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The personalized patient care and enhanced operational efficiency associated with PSI are not only attractive for achieving desired component positions but also hold promise for improved outcomes in complex cases involving glenoid bone loss.
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Augmented reality (AR) and virtual reality (VR) technologies play a pivotal role in reshaping shoulder arthroplasty. They offer benefits in preoperative planning, intraoperative guidance, and interactive surgery. Studies demonstrate their effectiveness in AR-guided guidewire placement, providing real-time surgical advice during reverse total shoulder arthroplasty (RTSA). Additionally, these technologies show promise in orthopedic training, delivering superior realism and accelerating learning compared to conventional methods.
Introduction
The development of RTSA by Grammont in 1985 marked a significant milestone in orthopedic surgery (1). Since its inception, the application of RTSA has seen a remarkable global surge owing to its expanding indications, which now encompass glenohumeral osteoarthritis, cuff tear arthropathy, proximal humeral fractures, and even as an applicable revision option (2). In spite of the promising mid to long-term outcomes on patient satisfaction, a considerable number of complications persist (3, 4). While both anatomic total shoulder arthroplasty (aTSA) and RTSA have shown excellent long-term survival rates, complications still arise (5). Some of the most frequent complications are scapular notching, instability, and glenoid loosening which are often linked to the inappropriate positioning of the glenoid component (3, 5, 6). Accurate component placement has been identified as a crucial factor in avoiding such complications, achieving superior biomechanical performance, and optimizing functional outcomes, which underlines the importance of precise implant positioning to minimize the risk of adverse events (7).
Although the optimal placements for the components continue to be debated, consensus suggests that glenoid positioning with over 10– 15 degrees of retroversion and superior inclination can lead to detrimental effects such as loosening and instability (8, 9, 10). The challenge lies in the restricted intraoperative visibility of the scapula, compounded by the complexities of dealing with glenoid bone loss (11). To achieve precision, meticulous 3D planning with specialized software is necessary (12). In this context, shoulder and elbow surgeons have explored various methods to enhance surgical understanding, preoperative planning, and precise execution. Noteworthy advances include preoperative planning with 3D CT, use of intraoperative navigation, PSI, AR, and MR (13). With the aid of these advanced technologies, surgeons achieve enhanced visualization and guidance during procedures for precise component positioning. By integrating these innovative tools, surgeons can gain inestimable insights into preoperative deformities, plan component placements accurately, and may achieve improved surgical outcomes. Consequently, PSI has the potential to reduce complications and could improve patient outcomes in shoulder arthroplasty (14). In the meantime, applications of extended reality options (AR, VR, MR) could have potential in transforming shoulder arthroplasty.
The aim of this review is to evaluate the effectiveness and impact of integrating 3D planning, navigation, PSI, AR, and MR technologies in shoulder arthroplasty for achieving precise implant positioning and to assess their potential benefits in reducing complications and enhancing patient outcomes.
3D preoperative planning and evaluation
Preoperative planning and implant templating, which have been effectively used in other orthopedic procedures including knee and hip arthroplasty, have drawn a lot of attention in the context of shoulder arthroplasty (15). Traditionally, preoperative planning involves, first, standard shoulder radiographs, such as anteroposterior (AP) view, scapular Y, and axillary (16). These radiographs demonstrate the patient's glenoid version, bone loss, inclination, head migration, and stage of the cuff arthropathy (17). However, the limitations of 2D imaging are evident when accurately depicting glenoid deformities and available bone stock, thereby necessitating the integration of 3D CT (18).
Three-dimensional CT scans of the shoulder empower surgeons with precise analyses of the bony architecture, enabling them to determine the patient's baseline glenoid and provide insights into glenoid wear patterns, version, and inclination (18). For instance, in cases with advanced Walch A2, B2, C type glenoids, the incorporation of CT imaging alongside radiographs can significantly impact the preoperative decision-making process, influencing the choice of shoulder arthroplasty type and the approach to address glenoid wear, such as reaming, bone grafting, or augmented glenoids (19). The reliability of glenoid inclination 2D measurements is influenced by the viewing angle on plain radiographs, making it necessary to utilize 3D imaging for accurate and dependable measurements (17). Werner et al. demonstrated that calculations with 3D preoperative planning software improve glenoid positioning accuracy and significantly impact decision-making in comparison to less accurate assessments for glenoid version and inclination using reformatted 2D CT scans (20). Moreover, two-dimensional radiographic measurements of glenoid inclination have inaccuracies and underestimate the true 3D value by about 5° compared to gold standard 3D measurements (21). Ianotti et al. introduced a novel surgical method that involved using 3D preoperative planning software to create patient-specific surgical models for guiding the placement of a glenoid guide pin during aTSA. (22) The results showed that the use of 3D preoperative planning software significantly improved the accuracy of the guide pin (Fig. 1) positioning, with a notable reduction in version, inclination, and location errors (22). In their cadaveric study, Walch et al. observed a mean error of 2.39° in the 3D orientation of the guide pin. The entry point position error averaged 1.05 mm, and the inclination angle error was 1.42°. The version angle showed an average error of 1.64°(23).
3D preoperative glenoid guide pin planning with MyShoulder software (Medacta International, Castel San Pietro, Switzerland).
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0200
Another potential benefit of preoperative 3D planning is reducing costs and optimizing implant management (24). In a multicenter study involving 200 patients (100 TSA and 100 RSA), revealing a high concordance rate (85% for TSA, 90% for RSA) between planned implant selection and actual intraoperative implant use, with minimal mismatches (24). In addition, a recent study has also demonstrated that pre-operative 3D templating for aTSA demonstrates remarkable accuracy in predicting both glenoid and humeral component sizes, with 99% of glenoid sizes falling within one size of the template (25). Poltaretskyi et al.'s computerized statistical shape model (SSM) with 3D reconstructions through CT scans streamlines surgical planning, reducing estimation requirements during implantation (26). With the help of this method, surgeons can efficiently assess all necessary 3D geometric parameters prior to surgery, streamlining the prosthesis size and implant selection (26).
Despite illustrated potential benefits of preoperative 3D planning, surgeons should always question data from automated software. A recent study aimed to assess the impact of a software update on measurements of glenoid inclination, version, and humeral head subluxation performed by the automated 3D planning program Blueprint (Stryker) (27). The hypothesis was that the software update would significantly alter these measurements. The results revealed a statistically significant difference in mean glenoid inclination values between Blueprint 2018 and Blueprint 2020, indicating that a software update can indeed affect this parameter (27). While variations between two software versions were also observed for glenoid version and humeral head subluxation, they were not statistically significant. Therefore, surgeons are advised to critically evaluate data obtained through automated software to make informed decisions. Despite having access to 3D planning, they may prefer visual estimation (eyeballing) over relying solely on accurate measurements when positioning the implants during surgery. This highlights the need to carefully consider and combine both automated tools and visual assessments for a well-rounded approach to making surgical decisions (27).
Intraoperative navigation
Intraoperative navigation has gained widespread acceptance in orthopedic surgery, especially in hip and knee arthroplasty (28). Recently, it has been demonstrated that intraoperative navigation can enhance the precise positioning of components, thereby reducing the incidence of malpositioning by providing the ability to detect glenoid reaming depth, optimize baseplate screw trajectory, and offer real-time feedback during the procedure (29, 30). Comparable advantages can be achieved concerning the precision of the glenoid positioning, stability of the baseplate, and humeral cut (31).
Glenoid component positioning
The precision of glenoid component positioning is significantly optimized through the application of intraoperative navigation. A prospective, randomized study involved two groups with or without navigation (n = 10 each). Glenoid version was measured preoperatively and at 6 weeks postoperatively. Retroversion change was significantly improved (3.7° ± 6.3°) compared to the non-navigation group (10.9° ± 6.8°, P = 0.021) (32). Recently, Larose et. al. reported their results on 16 723 TSA performed worldwide with the navigation system (30). In 98% of cases (16,368), the navigation procedure was completed without abandoning its use during surgery. Minimal deviations were observed in the execution of the preoperative plan for version (0.6° ± 1.96°), inclination (0.2° ± 2.04°), and the starting point on the glenoid face (1.90 mm ± 1.2 mm). There were nine reported cases of coracoid fractures (0.05%) (30). The use of navigation resulted in over twice the incidence of augmented glenoid components (45.5% vs 19.2%), markedly decreasing variability in postoperative version (33). Furthermore, navigation significantly elevated the proportion of components aligned in ‘neutral’ for inclination and version, with more than 70% of cases achieving glenoid implantation within 5° of the surgical plan.
Baseplate stability
One critical aspect of navigation is the dynamic real-time feedback it offers for achieving the ideal trajectory and screw length during glenoid baseplate fixation (34, 35). Ensuring the accurate trajectory of baseplate screws is essential to minimize complications and increase screw purchase, reducing micromotion and aseptic loosening (5, 36). Hones et al. analyzed 200 RSAs (100 with computer navigation and 100 without), the study found that computer navigation led to a reduction in the number of screws used (3.4 vs 4.1) and an increase in the average screw length (35.0 mm vs 32.6 mm) (34). A significant majority (61%) of computer navigation cases used three screws compared to only 1% in cases without navigation (34). Longer screws (≥30 mm) were more frequently used with computer navigation (34). The use of fewer, longer screws may conserve bone stock, minimize stress on the glenoid, and reduce operative time (34). Another study compared 51 patients with computer navigation and preoperative templating with 63 without and revealed that the navigated group used longer screws, had a greater composite screw length, and used fewer screws overall (35). There was also a higher frequency of using only two screws in the navigated group (35).
Humeral component positioning
While most of the literature focused on navigation's impact on glenoid positioning, a few studies explored its application for the humeral component. Cavanagh et al. compared patient-specific guides and navigation in executing planned humeral head osteotomy during shoulder arthroplasty. Utilizing 3D models from CT scans, two groups underwent osteotomies. Results showed no significant differences in cut height and version. However, navigation demonstrated less neck-shaft angle error than patient-specific guides, and for osteoarthritic cases, navigation had less version error (36).
Operative time and costs
Nonetheless, there are various limitations, including extended surgical duration, high costs, issues with intraoperative navigation, and a lack of convenient portability (12, 35, 37). The steps for the preparation of the navigation increase the operation time significantly. In the study by Kircher et al., the group that utilized navigation encountered significantly longer operating times when compared to the non-navigation group (169.5 ± 15.2 vs 138 ± 18.4 min) (32, 38). Sprowls et al. also reported significantly longer operating times (98.6 ± 19.5 min vs 85.8 ± 18.7 min) (32, 35, 38). On the other hand, Wang et al. reported shorter surgical time (77.3 ± 11.8 min vs 78.5 ± 18.1 min), and Venne et al. found 23.5% less intraoperative time with navigation (39, 40). Various factors must be taken into account, such as learning curves, surgeon adaptation to the system, and time required for setting up additional devices in the operating room (41). Further research is required to determine whether navigation offers superior benefits over PSI.
Patient-specific instrumentation
A promising alternative option is PSI, eliminating the shortcomings of computer-assisted techniques (42). Surgeons use software planning to define the glenoid baseplate axis and patient-specific surgical guides along with a glenoid vault replica to precise its intraoperative placement (43). The surgical technique remains consistent, with minimal additional exposure. Noteworthy, reusable PSI is available, potentially offering a cost-effective and time-efficient alternative to single-use instruments in the long term (44). Kwak et al. assessed the effectiveness of PSI compared to conventional methods (45). The PSI group (n = 19) showed significantly smaller differences between planned and postoperative measurements for screw length, angle, and baseplate rotation compared to the conventional group (n = 20) (45). PSI also reduced the risk of neurovascular injury in the spinoglenoid notch (45). In another study involving 35 RSA cases, the use of PSI guides demonstrated a mean difference below 2.5° between planned and postoperative measures and reduced risk of errors (46). Similarly, Marcoin et al. analyzed 36 arthroplasties, highlighted the impact of PSI in significantly minimizing variability in glenoid inclination (47). Verborgt et al. investigated 32 RTSAs, showed that PSI facilitates accurate execution (Fig. 2) of preoperative 3D plans, with deviations in baseplate version, inclination, and entry point falling within clinically acceptable ranges (48). Walch et al. investigated a novel approach for precise glenoid component placement by patient-specific templates generated through preoperative surgical planning and 3D modeling, the method demonstrated a mean error of 2.39° in 3D orientation, 1.05 mm in entry point position, 1.42° in inclination angle, and 1.64° in version angle (23). Hwang et al. investigated the impact of PSI on short-term outcomes. Patients were divided into two groups: standard manufactured guides (SG) and PSI for glenoid guide pin placement. Both groups showed similar improvements in patient-reported outcomes. While the SG group demonstrated better improvements in certain range of motion measures, the PSI group exhibited greater abduction and external rotation strength (49). Additionally, the use of PSI is notably beneficial in cases with glenoid bone loss. Sadeghi et al. evaluated the effectiveness of PSI in guiding pin placement accuracy for glenoid components, especially in cases of glenoid bone deformity (50). Postoperative CT scans demonstrated high accuracy with PSI, particularly in type C defected glenoid and non-arthritic glenoid (50).
Intraoperative images illustrating the use of four PSI guides for planning glenoid component implantation. Adapted from Verborgt et al. (48). With permission from Elsevier.
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0200
There are various PSI and preoperative planning software available. In a study involving 173 patients with end-stage glenohumeral arthritis, the accuracy of glenoid implant placement in primary TSA was evaluated using different types of instrumentation and 3D CT preoperative planning. Patients were grouped based on intraoperative guide pin placement methods. The study showed no significant differences in the accuracy of glenoid implant placement among the three major treatment groups: standard instrumentation, single-use PSI, and reusable PSI.
While most studies evaluated glenoid placement, Rojas et al. compared humeral osteotomy outcomes using PSI and standard cutting guides (SCG). After 3D planning with preosteotomy CT scans, PSI showed less deviation in humeral retrotorsion and height compared to SCG. The deviations in inclination were similar between the two groups. SCG had significantly greater deviations in retrotorsion and height, leading to more outliers, particularly in retrotorsion (>10°) (51).
Despite the multiple benefits of PSI, there may be potential complications associated with its use. Navarro et al. evaluated the impact of CT scans and PSI in their retrospective cohort study. Analyzing data from 8117 procedures, no reduction in the risk of aseptic revision was observed with the use of these technologies. Patients with CT scans showed a lower likelihood of 90-day emergency department visits but a higher likelihood of venous thromboembolic events (52).
Moreover, preoperative planning consumes more time, relying on external technical support, limits its applicability to elective surgeries, and renders it unsuitable for urgent cases like fractures. For these reasons, Darwood et al. introduced a novel intraoperative robotics platform designed for efficient and cost-effective patient-specific guides in shoulder arthroplasty. Tested in a cadaveric trial, the platform includes a tableside robot with a 3D optical scanner and a sterile robotic drill. The process involves creating molds of the joint surface, scanning, and registering them with preoperative plans. The platform achieved average angular accuracies of 1.9° version, 1.2° inclination, and positional accuracy of 1.1 mm, which suggests comparable accuracy to existing technologies (53).
While the personalized patient care and enhanced operational efficiency associated with PSI are attractive for achieving desired component positions, the efficiency gains observed in other procedures may not necessarily translate to shoulder arthroplasty (44). Evaluating the added cost of PSI manufacturing against potential clinical benefits is crucial.
VR, AR and MR in shoulder arthroplasty
In the context of shoulder arthroplasty, a comprehensive understanding of augmented, virtual, and mixed realities becomes crucial, as these technologies are ready to revolutionize various aspects of the field, from preoperative planning to postoperative rehabilitation (54). Milgram and Kishino (1994) were pioneers in this field, proposing the concept of ‘augmented reality’ in their seminal work (55). VR immerses users in a computer-generated, entirely synthetic environment using technologies like head-mounted displays (HMD) and motion tracking (56). It replaces the real world with a digitally created environment, offering a high level of immersion. AR, on the other hand, enhances the real world by overlaying computer-generated content onto the user's view, typically through devices like smartphones or smart glasses. It provides additional information or context about the physical surroundings (57). MR combines elements of both AR and VR (55). In MR, virtual objects are integrated into the real world in a way that they coexist and interact with physical surroundings (55, 57). MR often employs transparent or semi-transparent headsets to blend digital content with the real environment (58). Currently, applications of VR in surgery are primarily focused on preoperative planning, patient education, and practical training for surgical techniques to enhance residents' skills (59). Notably, both AR and MR are being used during the operative procedure itself (59).
As AR and VR are still in the early steps of clinical application, there are only a few studies illustrating the clinical impact of these technologies. In a study by Kriechling et al., the feasibility, reliability, and accuracy of AR through HMD in guiding guidewire placement for RTSA baseplate positioning were investigated (60). Twelve cadaver shoulders were CT scanned and 3D planned for RTSA baseplate positioning (60). Utilizing Microsoft HoloLens, an AR hologram was superimposed during surgery to guide the central guidewire to the planned entry point and trajectory (60). Postoperatively, CT scans revealed a mean deviation of 3.5 mm for the entry point and 3.8° for the trajectory (60). Schlueter-Brust et al. conducted a feasibility study using a single CT scan of an osteoarthritic right shoulder with the Blueprint CT protocol. They explored AR guidance via Microsoft HoloLens 2 (61). Postoperative measurements revealed a 3 mm discrepancy in the glenoid entry point and a mean angulation error of 5° (61). A similar study explored the use of AR technology via HMD working on ten human scapulae with 3D-printed models based on CT data (62). Guidewire placement for the glenoid baseplate was planned using dedicated software, and a hologram of the planned trajectory was projected onto the cadaveric shoulder models (62). Optical tracking facilitated registration, and after navigated guidewire placement, CT imaging was used to analyze the deviation from the planned trajectory and entry point (62). The results suggest that AR holds promise for highly precise execution of 3D preoperative planning in RTSA, with mean deviations of 2.7° for the trajectory and 2.3 mm for the entry point (62). A recent study by Sanchez-Sotelo et al. showed that the difference between planned and executed values for the navigated entry point on the glenoid was 1.7 ± 0.8 mm, with deviations of 1.2 ± 0.6 mm in the superior-inferior direction and 0.9 ± 0.8 mm in the anterior–posterior direction. The maximum deviation from the entry point for all 13 analyzed specimens was 3.1 mm (63).
There are few clinical studies investigating intraoperative applications of AR and MR. Rojas et al. investigated the accuracy of glenoid component placement in RTSA using the navigated AR NextAR (Medacta International) system through an HMD (64). Six human cadavers underwent preoperative planning with CT scans, and the navigated AR system-guided intraoperative glenoid component placement (Fig. 3) (64). The deviations between planned and postoperative values were minimal: 1.0° for inclination, 1.8° for retroversion, 1.1 mm for entry point, 0.7 mm for depth, and 1.7° for rotation (64). Similarly, the comparison between intra- and postoperative values showed low deviation: 0.9° for inclination, 1.2° for retroversion, 0.6 mm for depth, and 0.3° for rotation (64). The study concluded that the use of the navigated AR system through an HMD in RSA resulted in highly accurate glenoid component placement with minimal deviations between planned and postoperative parameters (64).
(A) The infrared (IR) disposable sensors, comprising a tracker and a camera, are employed by the tracking system (TS) to dynamically monitor the instrument's position relative to anatomical structures in real time. (B) Information from the TS is transmitted to the control unit (CU) through Bluetooth, where it is seamlessly integrated with the planning data. (C) Via Bluetooth, the head-mounted display receives data from the CU. The visualization of surgical actions overlaid on the surgical field enables the surgeon to maintain concentration on the patient. (D) Intraoperative clinical application of navigated AR system; NextAR (Medacta Medacta International, Castel San Pietro, Switzerland) Note: Adapted from Rojas JT, Jost B, Zipeto C, Budassi P, Zumstein MA. Glenoid component placement in reverse shoulder arthroplasty assisted with augmented reality through a head-mounted display leads to low deviation between planned and postoperative parameters. J Shoulder Elbow Surg. 2023. With permission from Elsevier.
Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0200
AR and VR have unique advantages in interactive surgery (65). In a study spanning 13 surgeries across 13 countries, Gregory et al. utilized the HoloLens2 directly on the patient, projecting the preoperative plan onto the unregistered glenoid for RTSA (65). Simultaneously, the HoloLens2 connected to a video conference involving four surgeons in different countries for real-time advice and HMD adjustments (65). Despite not measuring specific glenoid component positions, the authors reported satisfactory placement within a 90-minute surgical duration (65). Surgeons expressed high satisfaction levels (52.9% very satisfied, 47.1% satisfied) and a resounding intent (94.1%) to integrate MR into future clinical practice (65). Of note, 82.4% of surgeons found the remote assist functionality, enhancing intraoperative communication, to be the most valuable feature (65). This underscores the collaborative potential of MR technology, suggesting the need for further exploration and development beyond 3D holographic viewing (65).
This technology provides a projected view for broader observation and offers constant feedback on surgical decisions, potentially enhancing surgical security by enabling direct visualization of the patient's anatomy. In a study published by Berhouet, they approximated a patient's original glenoid anatomy and projected it onto the surgical field using Epson Moverio BT-200 smart glasses (12, 66). This technique aimed to aid the surgeon in placing glenoid components accurately by providing a better understanding of the patient's premorbid anatomy, which could be useful in a revision setting (66). In their technical note, Gregory et. al. performed RTSA with a Walch A2-type glenoid using HoloLens technology (67). Despite the absence of calibration between the HoloLens and the navigation system, the MR headset allowed manual dragging of holograms (67). The surgeon manually positioned a holographic 3D reconstruction of the scapula, aligning the visible part of the scapula with the corresponding holographic segment (67). This innovative approach enabled the surgeon to visualize the posterior part of the scapula in holographic mode. Through simple gestures in front of the headset, the surgeon efficiently scaled and manipulated the 3D reconstruction in approximately 3 minutes (67). The CT scan scapula reconstruction was seamlessly superimposed onto the visible bone, ensuring no significant lengthening of the operating time or adverse events (67).
VR and MR in surgical training
VR training has shown a proven ability to enhance resident performance in specific surgical skills. Furthermore, there is substantial evidence supporting the effectiveness of VR (68). Lohre et al.’s multicenter, blinded, randomized controlled trial aimed to assess the validity and efficacy of VR training in orthopedic resident education, focusing on glenoid exposure on fresh-frozen cadavers (68). The study involved 19 senior orthopedic residents and seven consultant shoulder arthroplasty surgeons (68). Immersive VR demonstrated greater realism and superiority in teaching glenoid exposure compared to traditional learning (68). The immersive VR group, completing the learning activity and knowledge tests faster, showed a 570% reduction in learning time (68). This study group also significantly outperformed traditional learning in glenoid exposure completion time and Objective Structured Assessment of Technical Skills (OSATS) instrument handling scores (68). Another study compared computer-assisted virtual surgical technology and 3D printing technology for preoperative planning in proximal humeral fractures (69). Patients were divided into conventional, virtual surgical, and 3D printing groups (69). Both virtual surgical and 3D printing methods showed excellent sensitivity, specificity, and accuracy for fracture characteristics (69). The virtual surgical group exhibited higher correlations for neck-shaft angle and humeral head height compared to the 3D printing group (69). Virtual surgical and 3D printing methods resulted in shorter operative time, less blood loss, and fewer fluoroscopic images than the conventional method (69). Both virtual surgical and 3D printing groups demonstrated better functional outcomes than the conventional group (69). However, the virtual surgical method proved more convenient and efficient, showing improved correlation with preoperative planning (69). Additionally, emerging evidence suggests the potential utility of mixed reality MR in training applications (70). Erickson et al. investigated the impact of MR training on glenoid guidewire placement, comparing it to freehand (FH) placement. Thirty B2 glenoid models were used, with MR-trained residents exhibiting significantly improved starting point accuracy (1.49 mm vs 2.52 mm) and reduced version deviation (5.3° vs 11.69°) compared to FH. Inclination differences showed no significant distinction (7.11° vs 8.4°) (70). With developments in the future, these technologies may have significant roles in orthopedic training.
Limitations and future directions
Despite the advantages, 3D planning in shoulder arthroplasty has limitations. Its accuracy heavily relies on preoperative imaging quality, and unexpected intraoperative anatomical variations may compromise the precision of the planned procedure (18, 27). Additionally, the learning curve for surgeons adopting 3D planning may influence its widespread adoption (18, 20).
Navigation systems offer real-time guidance but come with their set of limitations. The accuracy is contingent on the correct registration of anatomical landmarks, and intraoperative factors, such as soft tissue interference, may affect tracking (35, 37, 41). High costs, potential malfunctions, and extended learning curves for surgeons are additional challenges associated with navigation systems (41).
PSI offers customization for each patient but is not without limitations. Its effectiveness depends on the accuracy of preoperative imaging and the manufacturing process (44). Surgeons must consider potential delays in receiving postoperative data, and unforeseen intraoperative challenges may necessitate adjustments that PSI cannot accommodate(44).
In the context of MR technology, limitations include the accessibility and costs of MR headsets, potential risks such as coracoid fractures in combined MR-navigation strategies, and the primary design of MR wearables initially intended for entertainment (12, 65). Advantages and disadvantages of technologies are summarized in Table 1.
Advantages and disadvantages of new technologies in shoulder arthroplasty.
| Technology | Advantages | Disadvantages |
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| Navigation |
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| PSI |
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| AR-MR |
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Conclusion
Optimizing patient outcomes in shoulder arthroplasty requires precise component placement. 3D CT for preoperative evaluation is now commonly used for better understanding patient anatomy. Studies on intraoperative assistive devices such as navigation, PSI, and MR technology demonstrate promise, hinting at a potential future of advancements in shoulder arthroplasty. Further studies are needed to fully explore their roles and benefits in improving surgical outcomes.
ICMJE Conflict of Interest Statement
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding Statement
This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.
Author contribution statement
All authors contributed to the study conception and design. The first draft of the manuscript was written by UCK and AP; DA reviewed and edited the manuscript before submission.
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