A normal shoulder works like a ball in a shallow socket. The ball is the head of the humerus, the arm bone. The socket is the glenoid, a surface on the shoulder blade. The tendons of the rotator cuff keep the ball centred while the deltoid lifts the arm. If the cuff disappears, the ball rides upwards, jams under the acromion, and the arm no longer lifts, even when the deltoid itself is perfectly strong.
A reverse shoulder replacement turns that arrangement around. A metal half sphere is fixed to the shoulder blade, where the socket used to be, and a cup is fitted on top of the humerus. The ball therefore ends up on the shoulder blade side and the socket on the arm side, and that swap moves the centre of rotation inwards and downwards, which lengthens the lever arm of the deltoid. The deltoid then lifts the arm on its own, without any help from the missing tendons.
This principle was developed in France, in Dijon, by Professor Paul Grammont in the 1980s, and it transformed the management of so called pseudo paralytic shoulders. Implants have evolved a great deal since, but the logic is unchanged.
An anatomic shoulder replacement reproduces your own anatomy: a ball on the humerus, a cup on the glenoid. It restores natural mechanics and gives excellent rotation, but it needs a working rotator cuff to hold the head centred. It is therefore reserved for so called centred arthritis, when the tendons are still there.
A reverse shoulder arthroplasty asks nothing of the tendons. It is far more forgiving on that point, it relieves pain very well, and it reliably restores forward elevation of the arm. In exchange, external rotation, the movement that takes your hand away from your body with the elbow at your side, recovers less well, especially if the teres minor is destroyed too. The choice between the two is made on the state of your cuff on the CT scan and the MRI, not on your age alone. I explain that choice in detail on the page devoted to the anatomic shoulder replacement.
I offer a reverse total shoulder replacement in five situations.
Eccentric arthritis, also called cuff tear arthropathy. The joint is worn out and the tendons have gone, so the head has migrated up under the acromion. This is the historical indication and by far the most common one.
A massive, irreparable rotator cuff tear without established arthritis, in a patient who can no longer lift the arm above the horizontal despite preserved strength. This is what we call a pseudo paralytic shoulder.
Complex fractures of the upper end of the humerus in older patients, when there are too many fragments, or the bone is too fragile, for proper healing after fixation.
Revision of an anatomic shoulder replacement whose cuff has torn afterwards, or of an implant that has become painful and unstable.
Certain sequelae of a fracture that healed badly, and certain joint destructions caused by rheumatoid arthritis.
The average age of my patients undergoing a reverse shoulder replacement is above sixty five, but there is no cut off age. A younger patient whose cuff is irreversibly destroyed can benefit from it, knowing that a revision will probably be needed later in life. We discuss that together before deciding.
Before surgery I plan the implant on a three dimensional CT scan. That lets me choose the size of the implants, the orientation of the half sphere and the exact position of the screws, taking into account the wear pattern of your own joint. At the Clinique Victor Hugo I also have mixed reality, which overlays that plan onto the surgical field during the operation.
The operation is done under general anaesthesia, almost always combined with a nerve block that numbs the shoulder and the arm for the first few hours. That block is why many patients feel almost nothing on the day itself.
I reach the joint through a vertical incision of about eight centimetres at the front of the shoulder, between the deltoid and the pectoralis major, in a natural interval between two muscles. I detach no muscle, and that is what changes everything for the recovery. The worn humeral head is removed, the half sphere is fixed to the shoulder blade with a baseplate and screws, and the cup and the stem are seated in the humerus. The operation takes forty five minutes to one hour. I perform around one hundred and fifty of them a year.
The operation is done as a day case or with a single night in hospital. You go home with no sling and no immobilisation, with a prescription for painkillers and a written rehabilitation protocol.
It is the question I am asked most often, and the answer is usually reassuring.
For the first two or three days, the pain is the pain of bone surgery. It is covered by the block and then by painkillers, and it stays manageable for the great majority of patients. Regular icing helps.
For the first two weeks, the discomfort is mainly mechanical: the arm feels heavy and the nights are uncomfortable. Sleeping propped up in a semi seated position, supported by cushions, changes everything during that period. The arm is not immobilised, and you use it straight away for simple everyday tasks.
Between the third and the sixth week, background pain drops clearly. Night pain, the pain that used to wake you before surgery, is often the first to go, and that is the change patients remember most.
After that, pain on exertion or at the end of the day often persists for two to three months, while the muscles get used to working again. Pain that increases instead of settling, a fever, redness or any discharge is not a normal part of recovery and should prompt you to call me straight away.
There is no sling and no immobilisation after the operation. That follows directly from the technique: since I detach no muscle, there is nothing to protect while a tendon heals. You use your arm from the very next day to dress, eat and wash yourself.
Rehabilitation after a reverse shoulder replacement is simpler than after a rotator cuff repair, because there is no sutured tendon to protect. It remains essential.
From the day you go home you start gentle self directed exercises, several times a day, with the arm relaxed, with no weight and no forcing. Physiotherapy begins within the week following surgery, with passive and then assisted active mobilisation.
Active work begins very early: lifting the arm on your own, reaching for an object on a shelf, taking up everyday gestures again. The rhythm is three physiotherapy sessions a week, for a rehabilitation that lasts three to four months in total.
Forward elevation of the arm usually comes back between the third and the sixth month. The final result, in strength as well as in range, is judged between six months and one year. External rotation improves more slowly and does not always return to the range you had before the disease, which I always make clear before surgery.
For the first six weeks, three movements are to be avoided, because they expose the implant to a risk of dislocation.
Putting your hand behind your back, to reach a back pocket, pull up a zip or fasten a garment. What causes trouble is the combination of hand behind the back, elbow tucked in and arm pulled backwards, more than the gesture in isolation.
Pushing up on the operated arm to get out of an armchair, a bed or a car seat.
Carrying, pulling or pushing anything with that arm, including a heavy door or a shopping trolley.
Beyond that period, the restrictions come down to common sense precautions that stay with you for the life of the implant. Avoid repeatedly carrying loads of more than five kilos with the operated arm, violent pulling and pushing, contact sports and falls, which remain the leading cause of late complications. The five kilo limit is not a six week rule, it applies for as long as you have the prosthesis. A stable step stool is better than stretching at arm's length for something out of reach.
No surgery is without risk and I would rather name those risks plainly.
Dislocation of the implant is the classic complication of reverse shoulder replacements. In my own series it stands at zero for primary implantations. When it does occur, most often after a fall, it requires the joint to be put back in place, and sometimes a revision.
Infection is the most feared complication. It affects around one per cent of cases in my series and it is prevented by a strict protocol. It is why you should keep an eye on the wound and report anything unusual to me, a fever, redness or any discharge.
Scapular notching is wear of the lower edge of the shoulder blade caused by contact with the implant. It is often visible on follow up X rays without bothering the patient, and modern implants limit it.
A stress fracture of the acromion or of the scapular spine shows itself as pain that comes back after several weeks of improvement. If that happens, tell me: we take a check X ray, and treatment is most often non surgical, based on rest and on a slower resumption of rehabilitation.
Temporary injury to a nerve, in particular the axillary nerve, shows itself as a numb patch over the point of the shoulder and usually recovers alone.
Loosening of the implants, finally, is a late complication.
These risks exist, they remain uncommon, and I go through them one by one with you before we set a date.
The most consistent benefit is that the pain goes, night pain in particular. The second is that forward elevation comes back, which lets you comb your hair, reach an object in a cupboard, drive and wash yourself unaided. Those gestures define the result, far more than degrees measured with a goniometer.
As for how long the implant lasts, follow up now goes beyond ten years. National registries and published series track these implants over time and the results are encouraging. I am wary of percentages taken out of context: longevity depends on your age, on the quality of your bone, on your activity and on how well the precautions are respected. What I can tell you is a comparison: the question of revision surgery comes up far less often in a patient operated on after the age of seventy than in a patient operated on at fifty.
A yearly X ray for the first few years, then at wider intervals, lets us follow the implants and pick up silent wear in time.
Driving restarts immediately. Since there is no immobilisation, nothing stops you holding the wheel with both hands as soon as the pain allows. Simply start with a short trip in daylight.
Sleeping after shoulder replacement is the hard part of the first month. A semi seated position, a cushion under the elbow on the operated side and a pillow behind your back are usually enough.
For dressing, choose loose clothes that button at the front, and always put the sleeve on the operated side first. A loose tee shirt or a buttoned shirt makes the first month far simpler than a narrow necked jumper.
As for work, going back depends entirely on your job. Since there is no immobilisation, a desk job is resumed much sooner than after tendon surgery, whereas heavy work means waiting until rehabilitation is finished. We set that date together in consultation, based on the movements you actually make.
As for sport, breaststroke swimming, cycling, walking and hiking are open to you from the third month. Golf is possible for many patients around the sixth month. Overhead racket sports, contact sports, climbing and weight training with heavy loads are not sensible with a reverse shoulder replacement.
Gardening and light DIY come back gradually, within the five kilo limit.
Many of my patients do not live in France, and the pathway is organised so that the trip to Paris stays short and predictable. It starts with a teleconsultation in English, in which you describe what your shoulder stops you doing. You send me your X rays, your CT scan and your MRI beforehand, in their original digital format rather than as photographs of a screen, because the planning is done on those images. If something is missing or too old, I tell you what to obtain locally before travelling.
If surgery is the right answer, you receive a written quotation before you travel, covering the surgical fees, the anaesthetic and the hospital stay, and my team coordinates the whole stay in English. I operate at the Hopital Americain de Paris and at the Clinique Victor Hugo, both used to international patients, and you should plan to stay in Paris beyond the hospital stay itself so that I can see you after surgery, check the wound and start your rehabilitation properly before you fly home. Once you are home, follow up continues remotely by video, with a physiotherapist near you working to my written protocol. The practical side of the pathway is set out on the consultation page.
These journeys are typical situations, built from cases common in my practice. They do not retell the story of any identifiable patient.
A woman of seventy three has had a painful right shoulder at night for two years and can no longer lift the arm above the horizontal. The CT scan shows eccentric arthritis with a destroyed cuff. Reverse shoulder replacement, one night in hospital, no sling. At six weeks she sleeps without pain. At four months she reaches her plates in the top cupboard again. At one year she has gone back to walking and gardening and no longer thinks about her shoulder.
A man of sixty eight, a retired craftsman, falls on his left shoulder. The fracture of the upper end of the humerus has four fragments in fragile bone, and a reverse shoulder replacement is fitted straight away. Recovery after a fracture is slower than after arthritis: it takes him six months to lift the arm comfortably and his external rotation stays limited, but he has his full independence back and no longer takes painkillers.
Your own care pathway is described step by step, from the first consultation to the last review, on the dedicated care pathway page.
For the first six weeks, avoid putting your hand behind your back, pushing up on the operated arm to stand, and carrying or pulling anything with that arm. After that, the lasting reverse shoulder replacement restrictions are repeatedly lifting more than five kilos, contact sports and anything that exposes you to a fall, and those ones apply for the life of the implant.
Sharp post operative pain lasts a few days and then settles gradually. Between three and six weeks, background pain has clearly dropped and night pain is often the first to disappear. Pain on exertion or at the end of the day may persist for two to three months, while the muscles readapt.
Follow up on these implants now goes beyond ten years. National registries and published series track them over time and the results are encouraging. Real longevity depends on your age, on the quality of your bone and on your activity. In practice, the question of revision surgery comes up far less often in a patient operated on after the age of seventy than in a patient operated on at fifty.
Forward elevation of the arm comes back reliably, usually between the third and the sixth month, and lets you comb your hair and reach an object above your head. External rotation improves more slowly and sometimes stays limited, especially if the teres minor was already destroyed before surgery.
Plan for three physiotherapy sessions a week, for a rehabilitation that lasts three to four months in total, preceded by daily self directed exercises from the day you go home. The final result is judged between six months and one year.
Driving restarts immediately, because there is no immobilisation. Nothing stops you holding the wheel with both hands as soon as the pain allows. Simply begin with a short trip in daylight.
Because an anatomic shoulder replacement needs a working rotator cuff to keep the humeral head centred. When the tendons are destroyed and irreparable, only a reverse shoulder replacement lets the deltoid lift the arm without them. The choice is made on the state of your cuff on the CT scan and the MRI.
Sport after reverse shoulder replacement is a matter of choosing the right ones. Walking, hiking, cycling and breaststroke swimming are open to you from the third month, golf often around the sixth. Contact sports, overhead racket sports and weight training with heavy loads are not advised.
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