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 severe rotator cuff damage, studies and data suggest the surgery is a viable option for wheelchair users. Just nine years ago, there was still a dearth of studies on how it would perform under the extreme demands of wheelchair use. 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-and-socket structure is reversed to achieve greater stability. The metal ball-and-socket is fixed to the body, and the prosthetic ball-and-socket 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 has had good results with the 12 he has performed for wheelchair users. He considers RTSA “the greatest advance in shoulder surgery ever,” providing a simpler and more forgiving surgery than standard replacement surgery and producing good outcomes for the general population.

Issues

Thirty-two years as an L2-3 paramedic left Dave Cornelson with both shoulders “shattered,” with bone on bone and shredded tendons on both sides. Unable to sleep because of the pain, Cornelson, 71, had a full dislocation of his left shoulder in early 2020 and his right shoulder 11 months later. The left shoulder has since been dislocated twice. He says he didn’t get good physical therapy guidance upon discharge and may have set back recovery when a large dog he was walking pulled on the leash. “I feel 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 his right shoulder with the RTSA is doing great, with no issues. He’s pain-free, can do transfers on his own, and pushes a manual chair. He also has normal range of motion forward and overhead, but can barely reach behind his waist.

When asked about potential RTSA issues, Connor says dislocation is the primary concern after RTSA. While less than 5% of able-bodied 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 to shift and transfer weight 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 a knowledgeable physical therapist to build strength 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, which had him keep his shoulder in a sling for eight weeks before beginning range-of-motion exercises and gentle physical therapy. “I waited about six months before I was cleared for unlimited movement,” he says. “Six months after the first total reversal, I was playing tennis, holding my racket in my right hand.” [the shoulder that was replaced] hand and pushing my manual chair.” He still pushes a manual chair and drives a ramped van, but he transfers to a six-position transfer seat for driving and uses a slide board for transfers.

“When I perform a total reverse shoulder operation on a wheelchair user, I go over all the aspects of rehabilitation with them: ‘Do you have a Hoyer lift? Do you have a trapeze that you can pull with instead of pushing on the bed?’” Connor says. He has his patients get everything ready before surgery so they can practice using the equipment and learn to avoid placing the affected arm behind them while pushing, which could put them at risk for dislocation or screw breakage and lead to catastrophic failure.

(Un)screwed

Allen Rucker, 78, a veteran columnist for New Mobility, in his 28th year as a T10 paramedic due to transverse myelitis, opted for RTSA in May 2022 when the pain in his left shoulder increased and he was in pain all the time. Imaging showed that his tendons were torn. His recovery went well, until he felt sharp, intense pain that wouldn’t go away nine months after surgery. Imaging revealed that the screws holding the implant in place had broken, a rare complication of the procedure.

“Some estimates indicate that wheelchair users exert approximately 500% greater force on their shoulders than 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 ball implant that was custom-3D printed using medical imaging of his own body. While most RTSA surgeries use a prosthetic ball 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 inversion and had me lift heavy weights at first, and it’s probably partly my fault for doing too much — too many transfers, etc. — too soon,” Rucker says. As of this writing, Rucker is five months post-surgery and reports that he’s at home, improving and carefully recovering.

Failure to review or bone on bone

Connor says the entire healing and rehabilitation process for an RTSA takes about six to eight months. He notes that even when the shoulder is healed, it won’t be the same as a normal shoulder. “I don’t perform a total reverse shoulder operation on a patient unless their shoulder is really bad and they 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.