Informed Consent for Robotic-Assisted Reverse Shoulder Arthroplasty

As awareness of robotic-assisted arthroplasty grows among patients and the broader public, some may be under the impression that the robot is “in charge” of the procedure1. We recently witnessed those assumptions with the introduction of robotic assistance in reverse shoulder arthroplasty (RSA) at our institutions. Some patients seem to picture the robot performing the operation on its own, while others assume that anything labeled “robotic” is destined to deliver better outcomes. That misunderstanding clearly matters because it shapes the expectations that patients bring into surgery. Surgeons owe their patients a clear definition of what the word “robot” means in orthopaedic surgery, and, just as importantly, a clear definition of what robots currently do not do. It is also worth pointing out that patients rarely hear about robotic surgery for the first time in a neutral setting. Hospital advertising, device branding, and other narratives around robotic surgery can prime expectations of robotic autonomy and guaranteed superiority even before the surgeon walks into the room to discuss surgical options. This makes the office conversation even more important, as our encounters with patients provide an opportunity to reframe the procedure with information that is accurate, grounded, and clinically honest. We write this article as early adopters of robotic-assisted RSA, having performed enough cases to appreciate both its potential advantages and the hidden additional work for the surgeon and the operating room team. With experience, the workflow smooths out and the time pressure eases, but the challenge regarding consent remains. Informed consent is more than a legal formality: it protects patient autonomy by providing information so that patients understand what surgeons are recommending and why, and it aligns expectations so that recovery is not shaped by assumptions that were never meant to be created. One practical way to frame this conversation is to focus on a small number of core elements that should be covered during informed consent for robotic-assisted RSA—namely, surgeon agency, patient benefit, workflow implications, and contingency planning. First, robotic assistance can help execute the preoperative plan, but it does not replace the judgment of the surgeon. Patients should end the visit with an understanding of who is making the surgical decisions. The most important sentence for a surgeon to say in a consent conversation regarding robotic-assisted surgery may simply be “I perform the operation.” The robot does not decide what implants to use, where to place them, or how to adapt to limitations related to exposure or other unexpected challenges. In other words, the robot represents an enabling technology that is used by the surgeon. What seems obvious to surgeons may not be so obvious to patients, and that is where misunderstandings begin. Surgeons should present a balanced discussion of the benefits of this technology, describing the rationale for its use without turning it into an overpromise. It is fair to share with patients that robotics improves the accuracy and precision of implant positioning while explaining that greater accuracy and precision do not automatically translate into better pain relief, function, or implant longevity. Outcomes are shaped by many factors outside the reach of the robot, such as baseline health and comorbidities, the severity of the underlying pathology, rehabilitation, and the psychosocial context that shapes recovery. That psychosocial context includes the expectations that patients carry into surgery. Expectations can influence satisfaction, trust, and how patients interpret discomfort, progress, and recovery. In the specific case of robotic-assisted RSA, exaggerated expectations may lead patients to view the technology as a guarantee of a smoother recovery or a superior result, which can amplify disappointment when the postoperative course is more prolonged than anticipated. The potential value of robotic assistance may be more compelling in anatomically complex cases in which preoperative planning and execution fidelity may matter most, such as in substantial glenoid deformity or bone loss, whereas the incremental advantage may be less apparent in more routine cases. The absence of medium and long-term comparative data should also shape this discussion. In practical terms, this means that surgeons should avoid implying that improved execution of a preoperative plan has already been shown to translate into superior implant longevity, fewer revisions, or better-sustained patient-reported outcomes compared with conventional RSA. After discussing surgeon agency and the potential benefits of robotic assistance, it is also important to share with the patient the modified workflow associated with robotic-assisted surgery. Robotic cases add steps, and those steps have consequences that patients may care about, such as increased time under anesthesia and operating room time. More broadly, the disadvantages of this technology include added setup and verification requirements, a learning curve during adoption, and greater workflow complexity for the surgeon and the operating room team. Patients probably do not need to know the mechanics of registration and robotic execution, but they deserve to know that robotics requires additional setup and verification, which may lengthen the duration of the procedure, particularly when performed by a surgeon with less experience with this technology. Recent data suggest that robotic-assisted RSA may achieve operative time neutrality after an initial learning period of approximately 23 cases, although no single case number should be interpreted as a universal definition of competency2. Finally, surgeons should normalize contingency and explicitly state that safety comes first. Workflow conversions are rare, but they happen, and they should be framed as a prudent decision to preserve safety and efficiency when the robotic workflow cannot be completed. Patients should know that if the system cannot be used safely or efficiently during the case, the surgeon will switch to standard instrumentation and complete the shoulder replacement. Stating these facts up front reinforces trust and the core principle of the entire conversation, which is that the surgeon, not the robot, makes real-time decisions in the operating room. We believe that these core elements of consent can be covered efficiently in the office by standardizing what matters and steering clear of hype. Although framed around robotic-assisted RSA, these principles of consent will likely apply across shoulder arthroplasty as robotic technologies evolve. The following is a practical example of plain-language consent wording: “For your shoulder replacement, I could use robotic assistance for part of the operation. I would still be the one performing the surgery, and the robot does not operate on its own. The robot is a tool that helps me execute your preoperative plan and may improve consistency in implant positioning, but it does not guarantee a better result for you, and the long-term benefits remain unknown. Using the robot adds extra setup and verification steps and can add time in the operating room. If the system cannot be used safely or efficiently during the case, I will switch to standard instruments and will still complete your shoulder replacement in a safe and efficient manner. We routinely obtain a preoperative computed tomography scan to plan your shoulder replacement, whether or not a robot is used; when using robotic assistance, computed tomography is also needed to create and execute the plan. The overall goals of surgery and your rehabilitation plan would remain the same.” Robotic assistance in shoulder arthroplasty can help us execute a surgical plan more consistently but can also inflate expectations. Clear communication about the roles of the surgeon and the robot, the realistic benefits, and the contingency plans helps patients understand what they are consenting to. As robotics becomes widely available in shoulder arthroplasty, the quality of these conversations will increasingly shape how patients understand the technology, and, ultimately, how much value it delivers.