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. Only nine years ago, there was still a dearth of studies on how it would hold up 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 the many wheelchair users who turned to RTSA — the acronym for the surgery’s official name, “reverse total shoulder arthoplasty” — after having tried everything else. Leavitt, 75, a T4 para for 55 years, is famous for playing in the U.S. Open National Wheelchair Tennis Championships for a record 25 years straight. He has also racked up eight rotator cuff surgeries — four tendon repairs on the right, two tendon repairs on the left, and an RTSA on each side — not a record, but enough to make him an expert. “I’d have a rotator cuff repair and it would last two to three years and then would retear, 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 “great.”

“Knowing what I know now, instead of going through tendon repair, I would do the total reverse — the rehab and recovery is faster” he says. “Unless it is an acute tear, which I would still have fixed, as it seems it is easier for surgeons to fix a fresh tear.”

In an RTSA, the ball and socket structure is reversed for greater stability. The metal ball is attached to the body, and the prosthetic socket is attached on the end of the arm by a metal stem. This eliminates the need for the damaged tendons to power and move the arm, shifting the burden to the deltoid muscle that covers the shoulder.

In 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 done for wheelchair users. He calls RTSA “the single biggest advancement in shoulder surgery ever,” as it provides an easier and more-forgiving surgery than standard replacement surgery and yields good results for the general population.

Problems

Thirty-two years as a L2-3 para left both of Dave Cornelson’s shoulders “shot,” with bone on bone and shredded tendons on both sides. Unable to sleep due to pain, Cornelson, 71, had a total reverse on his left shoulder in early 2020 and on his right shoulder 11 months later. Since then the left shoulder has dislocated twice. He says he did not receive good PT guidance on discharge and may have set the recovery back when a large dog he was walking yanked on the leash. “It feels like there is something loose. I still need to see my doctor to see what is going on,” he says. On the other hand, Cornelson says his right shoulder with the RTSA is doing great, with no problems. He is pain-free, able to do transfers on his own, and pushes a manual chair. He also has normal range of motion in front and overhead, but can barely reach behind his waist.

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

“A real key to success is working with a knowledgeable physical therapist for strengthening and also teaching you the do’s and don’ts,” says Connor.

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

“When I do a total reverse shoulder with a wheelchair user, I go over every aspect of rehab with them: ‘Do you have a Hoyer lift? Do you have a trapeze where you can pull instead of push in bed?’” says Connor. He has his patients get everything in place before surgery so they can practice using the equipment and learning to avoid placing the affected arm behind them while pushing, which would risk dislocation or breaking screws for a catastrophic failure.

(Un)Screwed

Longtime New Mobility columnist Allen Rucker, 78, in his 28th year as a T10 para due to transverse myelitis, opted for RTSA in May 2022 when the pain in his left shoulder increased to hurting all the time. Images showed his tendons shredded. His recovery went well, until he felt a sharp, intense pain that wouldn’t go away after nine months post-surgery. The images revealed that the screws holding the implant had broken, a rare complication of the procedure.

“Some estimates state that wheelchair users put around 500% higher forces on a shoulder than the average ambulatory person [does],” says Connor, adding that the key to successful recovery is to refrain from doing transfers or other movements that will stress the screws before bone can grow into the porous part of the implant. This takes about four months, but once complete, becomes like hardened cement around rebar.

Twelve months after the failure, Rucker underwent a revision surgery with a ball implant that was custom 3D-printed using medical images from 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 can opt for a 3D-printed alternative. “It is likely my shoulder failed because the person that was guiding my PT probably didn’t know much about total reverse and had me lifting big weights early on, and it’s probably partially my fault for doing too much, too many transfers, etc., too early,” Rucker says. As of this writing, Rucker is five months post-surgery and reports he is home, doing well and carefully rehabbing.

Failure in Revision or Bone on Bone

Connor says the total healing and rehab process on an RTSA takes around six to eight months. He emphasizes that even when the shoulder is healed, it’s not going to be the same as a normal shoulder. “I don’t do a total reverse shoulder in a patient unless their shoulder is really bad and you can’t tolerate it anymore,” he says.

In terms of how long an RTSA will last with a wheelchair user, Connor says that is the big question. “The reasonable guess for RTSA is that about 1% per year will need to be revised. So that means that 10 years after that joint is put in, you have a 90% chance that it is doing fine. And at 15 years you have an 85% chance that it will be doing fine,” he says.

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