The Latest in Shoulder Surgery: Reverse Total Shoulder Replacement for Wheelchair Users

More than two decades after the FDA approved reverse total shoulder replacement as an option for people with severely damaged rotator cuffs, studies and data suggest the surgery is a viable option for wheelchair users. Just nine years ago, studies on how it would hold up to the extreme demands of wheelchair use were still lacking. Since then, at least three studies have shown good results in pain relief and movement for wheelchair users.

Wayne Leavitt is one of many wheelchair users who turned to RTSA (an acronym for the surgery’s official name, “reverse total shoulder arthroplasty”) after trying everything else. Leavitt, 75, a T4 paralyzed for 55 years, is famous for having played in the U.S. Open National Wheelchair Tennis Championships for a record 25 consecutive years. He has also racked up eight rotator cuff surgeries (four tendon repairs on the right side, two tendon repairs on the left, and one RTSA on each side) — not a record, but enough to make him an expert. “I would have a rotator cuff repair and it would last two or three years and then it would tear again, but in a different place or a different tendon,” he says. His most recent surgery on each side was an RTSA, and he says the results were “excellent.”

“Knowing what I know now, instead of having the tendon operated on, I would do the opposite: rehabilitation and recovery are quicker,” he says. “Unless it is an acute tear, which I would still repair, as surgeons seem to find it easier to repair a fresh tear.”

In an RTSA, the ball joint structure is inverted for greater stability. The metal ball joint is attached to the body and the prosthetic ball joint is attached to the end of the arm using a metal stem. This eliminates the need for damaged tendons to propel and move the arm, shifting the load to the deltoid muscle that covers the shoulder.

At his North Carolina practice, Dr. Patrick Connor performs about 150 RTSAs a year. He says he’s had good results with the 12 he’s done for wheelchair users. He calls RTSA “the greatest advancement in shoulder surgery ever made,” as it provides an easier and more forgiving surgery than standard replacement surgery and produces good outcomes for the general population.

Issues

Thirty-two years like L2-3 left both of Dave Cornelson’s shoulders “shot,” with bone on bone and shattered tendons on both sides. Unable to sleep due to pain, Cornelson, 71, suffered a complete setback to his left shoulder in early 2020 and his right shoulder 11 months later. Since then, his left shoulder has been dislocated twice. He says he did not receive good guidance from the physical therapist upon discharge and that he may have delayed recovery when a large dog he was walking pulled on the leash. “It feels like there’s something loose. I still need to see my doctor to see what’s going on,” he says. On the other hand, Cornelson says that his right shoulder with the RTSA is very good, without problems. He feels no pain, he can perform transfers on his own and pushes a manual chair. He also has a normal range of motion in front of and above his head, but can barely reach behind the waist.

When asked about potential RTSA issues, Connor says dislocation is the primary concern after RTSA. While less than 5% of nondisabled people have dislocation issues, the unnatural stresses of wheelchair life put wheelchair users at greater risk. An RTSA is very strong and adapted for pulling, but pushing a wheelchair and pushing the body up for weight shifts and transfers put extreme stresses on any shoulder, whether surgically repaired or not, so any subtle imperfections in the placement of an RTSA on a wheelchair user will be amplified.

“A real key to success is working with an expert physical therapist to strengthen you and also teach you the do’s and don’ts,” says Connor.

Leavitt attributes part of the success of his two RTSAs to his surgeon’s conservative approach in having Leavitt keep his shoulder in a sling for eight weeks before starting range of motion and gentle physical therapy. “I waited about six months before I was cleared to have unlimited motion,” he says. “Six months after the first total setback, I was playing tennis, holding my racket in my right hand. [the shoulder that was replaced] “I’m pushing my manual chair by hand.” He still pushes a manual chair and drives a van with a ramp, but he transfers to a six-position transfer seat for driving and uses a slide board for transfers.

“When I do a total reverse shoulder with a wheelchair user, I go over all aspects of rehab with them: ‘Do you have a Hoyer lift? Do you have a trapezius that you can pull on instead of pushing on the bed?’” Connor says. He has his patients set everything in place before surgery so they can practice using the equipment and learn to avoid placing the affected arm behind them while pushing, which would risk dislocating or breaking screws in a catastrophic failure.

(un)screwed

Longtime New Mobility columnist Allen Rucker, 78, in his 28th year as a T10 due to transverse myelitis, opted for RTSA in May 2022 when pain in his left shoulder increased until it hurt all the time. The images showed his shattered tendons. His recovery went well, until he felt sharp and intense pain that did not disappear nine months after surgery. The images revealed that the screws holding the implant had broken, a rare complication of the procedure.

“Some estimates indicate that wheelchair users exert approximately 500% greater force on the shoulder than that of the average ambulatory person. [does]“The key to a successful recovery is to refrain from transfers or other movements that stress the screws before the bone has a chance to grow into the porous part of the implant,” says Connor, adding that the key to a successful recovery is to refrain from transfers or other movements that stress the screws before the bone has a chance to grow into the porous part of the implant. This takes about four months, but once completed, it becomes like hardened cement around the reinforcing bar.

Twelve months after the failure, Rucker underwent revision surgery with a 3D-printed ball implant using medical imaging of his own body. While most RTSA surgeries use a ball prosthesis that comes in different sizes, when the joint is bone-on-bone or if a previous RTSA has failed, surgeons may opt for a 3D-printed alternative. “My shoulder likely failed because the person guiding my physical therapist probably didn’t know much about full reverse and had me lift heavy weights early on, and it’s probably partly my fault for doing too many, too many transfers, etc., too soon,” Rucker says. At the time of this writing, Rucker is five months post-surgery and reports that he’s home, doing well, and carefully rehabbing.

Failure to review or bone on bone

Connor says the entire healing and rehabilitation process in an RTSA takes between six and eight months. He emphasizes that even when the shoulder is healed, it will not be the same as a normal shoulder. “I don’t do a full inverted shoulder on a patient unless her shoulder is really bad and you can’t tolerate it anymore,” he says.

As for how long an RTSA will last with a wheelchair user, Connor says that’s the big question. “The reasonable estimate for RTSA is that about 1% per year will need to be revised. That means 10 years after that joint is put in, there’s a 90% chance it’s going to be okay. And at 15 years there’s an 85% chance it’s going to be okay,” he says.