There have been some publications in the past eighteen months that have attracted attention: the FDA De Novo clearance for the stemmed Tornier pyrocarbon humeral head [1], the Hatzidakis IDE multicenter study [2], the McBride AOANJRR comparison of pyrocarbon humeral resurfacing against best-in-class anatomic total shoulder arthroplasty (aTSA) [3], the Griswold 5-year U.S. radiographic study with prospective Walch typing [4], and the Hoy PyroTITAN single-surgeon prospective cohort with disease-specific PROMs and Walch typing on every patient [5]. Together with the Boileau group’s HA-PYC survival and risk-factor analysis [6] and the Barret/Boileau 10-year interposition cohort [7], the evidence base is now sufficient to make some statements about these implants. With the help of Claude AI and Open Evidence I’ve tried to put together what we can glean from the literature.
Disclosure: I have not used a pyrocarbon implant in my 50+ years of practice (no first-hand experience). I have no relationship with any orthopaedic company. While I try to refrain from using proprietary names in my posts, I have done so here to clarify which implant is under discussion. My summary may contain errors and I would welcome corrections and comments. You may wish to compare this information to that in the prior post regarding the ream and run.
At least three different implant configurations
It seems that three distinct configurations of “pyrocarbon shoulder arthroplasty” have entered clinical practice:
• Pyrocarbon humeral resurfacing (PHR) / PyroTITAN: a stemless pyrocarbon resurfacing cap stabilized by a short central post seated on the prepared humeral head. The resurfacing cap is intended to solve two of the problems of the classic hemiarthroplasty technique: there is no metal collar/disc beneath the head that can oversize the construct, and there is no humeral stem that can malposition the bearing surface in height, version or inclination. The trade-off is the intrinsic risk of implant fracture— a failure mode identified during early device development that prompted design refinement and proof-testing after product re-release, and subject to a 2013 Therapeutic Goods Administration hazard alert [8]. This is the implant in the McBride 2022 [9], McBride 2026 [3], and Hoy 2026 [5] papers — the AOANJRR “PHR” label and the commercial “PyroTITAN” name refer to the same device class, which has undergone several design iterations under three sponsors (Ascension, Integra/LMT Surgical, Smith+Nephew). The implant is not FDA-cleared in the United States.
• Stemmed pyrocarbon hemiarthroplasty (HA-PYC / PyCHA). A conventional press-fit humeral stem (e.g. the Aequalis Ascend Flex) carrying a pyrocarbon head mounted on a metal Morse-taper tray. Humeral head excision and metaphyseal broaching are identical to other stemmed hemiarthroplasties; only the bearing surface differs. This construct retains the two technique vulnerabilities that resurfacing eliminates: the 1.5–2 mm metal disc beneath the pyrocarbon head effectively oversizes the construct (unless the surgeon systematically downsizes), and stem positioning errors in height, version or inclination can compound the oversizing. This is the implant in the European literature (Boileau, Cointat, Garret, Kleim, Ranieri) [6,10–13], the New Zealand registry [14], the Griswold U.S. five-year study [4], and the U.S. IDE study published in JBJS in April 2026 [2]. It is also the only configuration FDA-cleared in the U.S., via De Novo DEN220012 in late 2022 [1].
• Pyrocarbon interposition (PISA / InSpyre). A pyrocarbon spheroid with no humeral fixation. Largely supplanted by the stemmed head construct, but the Barret/Boileau 10-year PISA cohort [7] remains the only true long-term human data on any pyrocarbon shoulder implant.
The distinction matters for several reasons. First, the metaphyseal-preservation contention — that PHR may protect the rotator cuff blood supply because the arcuate artery is not violated [3] — applies to PHR/PyroTITAN and does not transfer to stemmed HA-PYC, where the head is excised. Second, the European mid-term PROM data (Constant, ASES, SSV, return-to-work, return-to-sport) come predominantly from stemmed HA-PYC series [6,10–13]. The Australian registry papers (McBride 2022, McBride 2026) report PHR survivorship without PROMs [3,9]. The Hoy 2026 paper is the only mid-term study with disease-specific PROMs (WOOS) and prospective Walch typing on every patient in the PHR/PyroTITAN configuration [5]. Third, the radiographic erosion data come from different measurement methods that are not directly comparable. Hoy reported mean medial glenoid erosion of 2.0 mm at 3 years following PHR (glenoid–medial spinoglenoid notch distance on Grashey radiographs) [5]; Griswold reported 2.9 mm at 2 years and 4.0 mm at 5+ years following stemmed HA-PYC (center-of-rotation to acromion–glenoid reference, with magnification correction) [4]. The absolute numbers cannot be compared across the two studies, but both constructs show most erosion in the first 1–2 years and substantial slowing thereafter [5,13]. Fourth, the FDA-cleared U.S. indication applies only to the stemmed construct and excludes inflammatory arthritis and total shoulder arthroplasty configurations [1] — a label restriction that would, for example, exclude the 4.2% inflammatory-arthritis cases in the Hoy PHR cohort [5]. Fifth, the implant-fracture history is specific to the PHR/PyroTITAN construct and is documented even in the contemporary design — Hoy reported one spontaneous fracture in 119 shoulders at 3 years (0.8%) [5], and the AOANJRR has tracked fracture-related revisions through three design iterations [3,9].
To summarize, the resurfacing-vs-stemmed decision can be thought of as a deliberate trade between two different failure modes. The stemmed construct carries a design-mediated, technique-modifiable failure mode: oversizing from the metal disc, plus stem malposition in height, version or inclination. Both drive nonanatomic reconstruction. Boileau and colleagues reported nonanatomic humeral reconstruction with oversizing of the pyrocarbon head in 24% of cases even in expert hands, and this single technical error was associated with roughly a 19-fold increase in revision risk (25% revision rate in the oversized subgroup vs. ~1.3% in the anatomic subgroup) and a 3.46-fold odds of progressive glenoid erosion (95% CI 1.13–10.55, P = .0295) [6]. The AOANJRR registry analyses align with this: the main reasons for revision in pyrocarbon HA were ongoing pain and implant fracture, in contrast to metal HA, where revisions were mostly for glenoid erosion [3,9,15]. The resurfacing construct eliminates the disc and the stem — and with them the oversizing and malposition problems — but introduces an implant-mediated failure mode: pyrocarbon head fracture, which the AOANJRR PHR cohort has tracked through three design iterations and which Hoy still observed in 0.8% of his contemporary series [5]. Both failure modes may be partly modifiable: the stemmed problem has been addressed by systematic downsizing — a surgeon-borne correction for a geometric perturbation introduced by the design itself; the resurfacing problem has been addressed by progressive design refinement and proof-testing improvements [5,8]. The jury is still out.
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References
1. U.S. Food and Drug Administration. De Novo classification request for Tornier Pyrocarbon Humeral Head. DEN220012. Silver Spring (MD): Center for Devices and Radiological Health; 2022. https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN220012.pdf
2. Hatzidakis AM, Garrigues GE, Mauter LA, de Gast A, Venegoni MR, Yang Y, Johnston PS. Clinical Outcomes of Pyrocarbon Hemiarthroplasty: A Short-Term, Multicenter Study. J Bone Joint Surg Am. 2026;108(8):572–583. doi:10.2106/JBJS.25.00054.
3. McBride A, Hurley R, Gill D, Du P, Duke P, Taylor F, Hoy G, Page R, Ross M. Outcomes of pyrolytic carbon humeral resurfacing hemiarthroplasty compared to best-in-class total shoulder arthroplasty in young patients with osteoarthritis: analysis from the Australian Orthopaedic Association National Joint Replacement Registry. J Shoulder Elbow Surg. 2026;35(5):1209–1218. doi:10.1016/j.jse.2025.09.007.
4. Griswold BG, Berger JM, Davis BP, Mauter L, Boyd M, Schuette HB, Johnston PS, Sears BW, Hatzidakis AM. Five-Year Radiographic and Clinical Outcomes of Pyrocarbon Hemiarthroplasty for Glenohumeral Arthritis and Osteonecrosis. J Bone Joint Surg Am. 2025;107(24):2751–2762. doi:10.2106/JBJS.25.00163.
5. Hoy G, Burrows K, McBride A, Ross M, Davis K, Warby S. PyroTITAN Pyrocarbon Shoulder Hemiarthroplasty: Clinical and Radiographic Outcomes with Medium-Term Follow-up. J Bone Joint Surg Am. Epub 2026 May 13. doi:10.2106/JBJS.25.00779.
6. Boileau P, Cointat C, Raynier JL, Schippers P, Ranieri R. Pyrocarbon hemiarthroplasty for the treatment of shoulder osteoarthritis in young, active patients: survival and risk factors for revision. J Shoulder Elbow Surg. 2026;35(2):421–437. doi:10.1016/j.jse.2025.06.021.
7. Barret H, Garret J, Favard L, Bonnevialle N, Collin P, Gauci MO, Boileau P. Long-term (minimum 10 years) survival and outcomes of pyrocarbon interposition shoulder arthroplasty. J Shoulder Elbow Surg. 2025;34(3):739–749. doi:10.1016/j.jse.2024.05.040.
8. Therapeutic Goods Administration. PyroTitan humeral resurfacing arthroplasty – hazard alert. Canberra, Australia: Australian Government Department of Health; 2013.
9. McBride AP, Ross M, Hoy G, Duke P, Page R, Peng Y, Taylor F. Mid-term outcomes of pyrolytic carbon humeral resurfacing hemiarthroplasty compared with metal humeral resurfacing and metal stemmed hemiarthroplasty for osteoarthritis in young patients: analysis from the Australian Orthopaedic Association National Joint Replacement Registry. J Shoulder Elbow Surg. 2022;31(4):755–762. doi:10.1016/j.jse.2021.08.017.
10. Cointat C, Raynier JL, Vasseur H, Lareyre F, Raffort J, Gauci MO, Boileau P. Short-term outcomes and survival of pyrocarbon hemiarthroplasty in the young arthritic shoulder. J Shoulder Elbow Surg. 2022;31(1):113–122. doi:10.1016/j.jse.2021.06.002.
11. Garret J, Cuinet T, Ducharne L, ReSurg, Godèneche A. Pyrocarbon humeral heads for hemishoulder arthroplasty grant satisfactory clinical scores with minimal glenoid erosion at 5–9 years of follow-up. J Shoulder Elbow Surg. 2024;33(2):328–334. doi:10.1016/j.jse.2023.06.021.
12. Kleim BD, Zolotar A, Hinz M, Nadjar R, Siebenlist S, Brunner UH. Pyrocarbon hemiprostheses show little glenoid erosion and good clinical function at 5.5 years of follow-up. J Shoulder Elbow Surg. 2024;33(1):55–64. doi:10.1016/j.jse.2023.05.027.
13. Ranieri R, Cointat C, Lacouture-Suarez JD, Boileau P. B2 and B3 glenoid osteoarthritis: outcomes of corrective and concentric (C2) reaming of the glenoid combined with pyrocarbon hemiarthroplasty. J Shoulder Elbow Surg. 2025;34(3):726–738. doi:10.1016/j.jse.2024.06.028.
14. Gao R, Viswanath A, Frampton CM, Poon PC. Short-term outcomes following 159 stemmed pyrolytic carbon shoulder hemiarthroplasties and how they compare with conventional hemiarthroplasties and total shoulder arthroplasties in patients younger than 60 years with osteoarthritis: results from the New Zealand National Joint Registry. J Shoulder Elbow Surg. 2023;32(8):1594–1600. doi:10.1016/j.jse.2023.01.020.
15. Khoriati AA, McBride AP, Ross M, Duke P, Hoy G, Page R, Holder C, Taylor F. Survivorship of shoulder arthroplasty in young patients with osteoarthritis: an analysis of the Australian Orthopaedic Association National Joint Replacement Registry. J Shoulder Elbow Surg. 2023;32(10):2105–2114.
