Q. I’m 62, in my 40th year as a T4 complete para, and my active life has taken its toll on my shoulders, especially my left one. An MRI shows severe cartilage wear, and the ball and socket are bone on bone, which causes excruciating pain from something as simple as brushing my teeth. It’s so bad I can’t sleep. My orthopedist recommends a procedure called a reverse total shoulder replacement. I’ve only found two small studies on shoulder replacement in wheelchair users, and neither addressed functional outcome. If I have the surgery, what is the recovery time? After rehab, will I be able to transfer on my own? Will I be able to push a manual chair?
— Debbie

A. Debbie, you are not alone in looking for information in this area — of the little information out there, much is outdated. For answers I turned to Dr. Edward McFarland, professor and director of shoulder and elbow surgery at the Johns Hopkins School of Medicine. In March 2015, Johns Hopkins submitted a study on shoulder replacement surgery on six wheelchair users ranging in age from 44 to 81 years, with follow-ups from one to three years.

A standard total shoulder replacement — known as total shoulder arthroplasty — consists of cutting off the ball located on the end of the humerus (upper arm bone) and replacing it with a metal ball attached to a stem that fits into the humerus. The socket, located in the scapula (shoulder blade) is replaced with a plastic socket held in place with a special cement.

McFarland explains that traditional TSA is a challenge in wheelchair users because they often have damage in the rotator cuff — muscles and tendons that surround the shoulder — and a TSA relies on the rotator cuff to hold the ball socket in place. Rotator cuff damage can lead to unsupported areas that allow the TSA to fail in two ways — it can dislocate or the damaged rotator cuff can put uneven stress on the plastic socket, which can cause it to loosen.

According to McFarland, a reverse shoulder replacement (approved by the FDA in 2004, also called a reverse total shoulder arthroplasty), “has been a godsend for wheelchair users because it can address rotator cuff damage.” In a RTSA the ball and socket structure is reversed for greater stability. The ball is attached to the scapula, instead of the humerus, via screws, and an area of porous material that bone grows and bonds with, and the socket fits on the end of the humerus via a metal stem (see above image).

The downside of RTSA is it requires a longer recovery because the bone needs to grow into the prosthesis and there is no long-term data on how they perform. In the Johns Hopkins study, all six wheelchair users had RTSAs with significant decrease in pain and no medical complications, and all were able to do their own transfers and push a manual chair.

Dr. Benjamin DuBois, shoulder surgery specialist at Grossmont Orthopaedic Medical Group in San Diego, Calif., has done about 650 shoulder replacements in his career, five on wheelchair users. His outcomes are on par with McFarland’s. Both surgeons say if the rotator cuff is in good condition, a standard TSA works well, but with rotator cuff damage, an RTSA is in order.

Both surgeons agree that shoulder replacement surgery in a wheelchair user is a serious endeavor to be considered only when all other options have failed. “When a wheelchair user comes into my office, it is because there is something terribly wrong with their shoulder,” says DuBois. “I tell them if they are still able to function, it is best to wait. If the pain gets to the point they can’t sleep at night, I discuss the risks and the rehab process — the key is understanding this. Then I say ‘I can fix this as long as you understand the risks.’” McFarland and DuBois both emphasize the importance of finding a specialist who performs 50 or more surgeries a year and/or comes highly recommended. The procedure takes two or three hours.

Within a couple of days of surgery the arm can be used for non-weight bearing tasks like typing on a keyboard. For a standard TSA, no weight bearing is allowed for six to eight weeks. Using a power chair and staying at a care facility, typically a nursing home that provides transfers to bathing and bowel care, is recommended. McFarland says that for an RTSA, the recovery period until transfers are allowed is three months. You should not move your arm behind the plane of your body — as in putting on a jacket — for six months. Both surgeons agree that once initial healing has taken place, self-transfers and pushing a manual chair can start at a pace dictated by how long it takes to regain strength in atrophied arm and shoulder muscles.

In both doctors’ experience, after recovery and rehab, wheelchair users with a shoulder replacement are able to do their own transfers and push a manual chair. However, both recommend using a power chair because shoulder replacements aren’t designed for the constant wear of pushing a manual chair — they are mechanical, so they will eventually wear out. This is where power assist units like a SmartDrive or, for higher level injuries, a Spinergy ZX-1, can be shoulder savers, enabling a person to stay in a manual chair and reduce wear on a shoulder replacement (see resources).

Tim Davis, 66, a Vietnam veteran, became a double above-the-knee amputee in 1968. Although Davis has huge shoulder muscles and healthy rotator cuffs, 40 years of wheelchair sports wore out his shoulder cartilage. “My right shoulder got so painful that I couldn’t lift my hand up to wash my hair,” he says.

In 2007 Davis had a total shoulder replacement, but after two years he still couldn’t reach up to shave. His VA doc sent him to Ann Arbor, Mich., where Dr. Bruce Miller X-rayed the shoulder and said the stem and ball was put in crooked and didn’t match up with the socket. “Dr. Miller re-did the shoulder, and now the arm works great,” says Davis. Although he did transfers within eight weeks, he says it took three and a half years to get to 100 percent, which for Davis means full range of motion, pushing his manual chair and extreme strength.

Two years ago Davis had a total shoulder replacement on his left shoulder done by Dr. Matthew Snyder at Fort Wayne Orthopedics in Fort Wayne, Ind. “My left shoulder has great strength, but I still don’t have total range of motion — I can’t reach straight above my head yet, but I know that’s coming,” he says.

Jan Brown (pseudonym), 64, in her 43rd year as a T5 para, had shoulder pain off and on for 20 years. It initially responded well to physical therapy and rest, but over the past five years the pain became relentless. X-rays showed both shoulders were severely arthritic and the rotator cuffs were shredded due to lack of joint space.

In mid-April 2015 Brown had a reverse shoulder replacement on her left shoulder at St. Agnes Medical Center in Fresno, Calif., by a surgeon who has been doing the procedure for 10 years. “Now, three months after surgery, I’m pleased with the results,” she says. “The main plus of the surgery is a huge decrease in pain.” She is home and able to do her own transfers and push her manual chair for short periods of time around the house, but uses a power chair most of the time. Now pain in her right shoulder is causing her to consider having it replaced later this year.

Resources

• SmartDrive, 800/637-2980; max-mobility.com
• Spinergy ZX-1, 760/496-2121; www.spinergy.com/catalog/zx1_power_add_on.php