In this post we take a bit of a deeper dive into the clinical information available regarding pyrocarbon humeral arthroplasty - looking at evidence from the Australian and New Zealand registries alongside the currently available reports on specific cohorts.
Please note that this is a "best effort" attempt to put together what's out there. If the reader finds any of this to be in error, please do let me know.
Newspaper-style, the post starts with a summary
and then presents data that may support the points presented in the summary.
1. There is no single “pyrocarbon shoulder” — there are at least three. Resurfacing (PyroTITAN, not FDA-cleared in the U.S.), the U.S. FDA-cleared stemmed pyrocarbon hemiarthroplasty, and the European stemmed hemiarthroplasty with systematic head-downsizing. Each uses different implants or different techniques; a finding for one may not transfer to another, and pooling them is a common error in this literature.
2. Registries present data on revision rate, not function. McBride 2026, the AOANJRR 2025 special clinical assessment, and the New Zealand registry agree that pyrocarbon is revised about as often as a good anatomic TSA. However revision is a surrogate endpoint: the observation that a patient's implant was not revised does not necessarily mean that the patient had good shoulder comfort and function (we know this from reverse total shoulders where patients living with poor postoperative comfort and function often do not have revision surgery). What matters most to the patient and to us is the degree to which the arthroplasty improved the patient's quality of life.
3. The currently available data often do not relate to implants and techniques currently in use. Most series are based heavily on approaches no longer in play today.
4. Where patient-reported outcomes exist, they show - like just about every other type of shoulder arthroplasty - clinically significant improvement over the preoperative state that lasts 5–10 years. Appropriately controlled studies that compare clinical outcomes for pyrocarbon humeral arthroplasty to other surgical options for managing glenohumeral arthritis are, however, uncommon.
5. The one head-to-head functional comparison still favors total over hemiarthroplasty early on. In the New Zealand registry, anatomic TSA surpassed pyrocarbon hemi on the Oxford score at both 6 months and 5 years. Notably, the functional advantage of total over hemi is not eliminated by changing the use of pyrocarbon bearing surface.
6. Royalties or research funding from pyrocarbon implant manufacturers are disclosed in many of the cohort series. That does not invalidate the data, but it is recognized that industrial support can affect study design, data analysis and conclusions.
7. The bearing surface is not the most important aspect of the reconstruction. As is the case for all other types of shoulder arthroplasty, the outcome of pyrocarbon arthroplasty is critically dependent on patient selection, component size, component positioning, glenoid management, soft tissue balancing, and rehabilitation.
Future clinical research will hopefully define the indications, the appropriate implants, the surgical technique, and the clinical outcomes for pyrocarbon humeral arthroplasty.
Now for the details
Two Australian Orthopaedic Association (AOANJRR) analyses: two different pyrocarbon devices. Both draw on the AOA registry, but they study different pyrocarbon configurations. Both presen revision/survivorship endpoints with no patient-reported outcomes.
1. McBride presents the pyrocarbon humeral hemi-resurfacing (PHR/PyroTITAN — a resurfacing cap, no head excision, the Australian research-restricted device that is not FDA-cleared for use in the U.S.), comparing PHR in patients <65 versus the five lowest-CPR (cumulative percent revision) aTSA combinations.
2. The AOA Annual Report also presents data on a hemi stemmed pyrocarbon implant. That stemmed configuration is basically the same as the U.S.-cleared device and the European (Boileau) stemmed construct.
To complement these registry studies, cohort reports concern the three pyrocarbon devices in current use: (1) resurfacing (PHR/PyroTITAN); (2) the U.S. stemmed hemiarthroplasty (FDA-cleared Tornier/Stryker); and (3) the Boileau/European stemmed hemiarthroplasty. Devices 2 and 3 share the same hardware (Aequalis Ascend Flex stem + pyrocarbon head) but have separate literature, study designs, and technique: the Boileau approach systematically downsized the component.
In the table above, each cell carries a generation/technique caveat: the long-term numbers may not describe the devices and techniques commonly used today.
AOANJRR 2025
The AOANJRR 2025 “hemi stemmed anatomic — pyrocarbon head” class does not differentiate U.S. vs Boileau technique. This Annual Report compares four shoulder arthroplasty classes in patients under 60 with OA, restricted to prostheses still implanted in 2024 (the “modern prostheses” filter), with data to 31 December 2024.
Note that the confidence intervals for all four classes overlap. Adjusted for age and sex, no comparison to the pyrocarbon hemi reached significance. The executive summary states it plainly: “a hemi stemmed anatomic with a pyrocarbon head was not different to traditional total shoulder replacement options in this age group.” The report contains no patient reported outcome data.
New Zealand National Joint Registry
Gao and colleagues reported the 159 stemmed pyrocarbon hemiarthroplasties (PyCHAs (Tornier Flex stem, pyrocarbon head) against 1,280 conventional metal HAs and 4,285 aTSAs. Importantly, average follow-up was shorter for PyCHA (3.3 yr vs 12.7 and 8.3). With this caveat, PyCHA retention (96.9%) was comparable to aTSA in patients under 60 and better than conventional metal HA on both retention and Oxford Shoulder Score. aTSA had numerically better Oxford scores than PyCHA at 6 months and 5 years.
Clinical outcomes and revision rates by device — the cohort series
The cohort series add what the registries omit — but they are single-arm, small, and almost all industry-linked. The registry analyses above report revision only; none measures a patient-reported outcome. The published cohort series below supply PROs, range of motion, and graded glenoid erosion — but each one is a single-arm case series (Level IV, no comparator), the largest is ~100 shoulders; follow-up is short-to-intermediate. They establish that each device improves shoulder scores against the patient’s own baseline; however, they do not establish superiority over aTSA or any other glenoid-sparing alternative.
Resurfacing (PHR): the contemporary third-generation resurfacing implant specifically has neither long-term revision nor any PRO follow-up.
Hemiarthroplasty — US: the U.S. experience with the currently available implant is anchored by Griswold 2025 (JBJS), drawn from the Stryker pyrocarbon IDE cohort plus a subsequent prospective follow-up: 45 patients at a mean 73 months. Every PRO improved past MCID (ASES 47->96, Constant 48->88, SANE 39->94, VAS pain 5.0->0.2), satisfaction was 97.8%, and 7-year revision-free survival was 95.7% — both revisions for infection, none for glenoid erosion or breakage.
Hemiarthroplasty — Boileau / European: the largest, longest evidence. The European stemmed device is the same Ascend Flex + pyrocarbon-head hardware as the U.S. implant, but placed with systematic head downsizing, anchored by the Boileau (Nice) and Garret/Godenèche (Lyon) groups, and corroborated by two independent European centers.
Cointat 2022 (64 shoulders, 92% survival at 3 yr), Garret 2024 (45 patients, 4.4% revision, scores maintained at 5–9 yr), and Boileau 2026 (103 shoulders, revision-free 94% at 5 yr and 89% at 10 yr) consistently show Constant rising from the mid-30s to ~80, SSV from ~35 to ~84, and return to work and sport above 90%. Mathon 2023 (Marseille; 41 shoulders, Constant 34->80 at 3 yr, 100% return to work, glenoid wear <0.6 mm on CT 3D modeling, no revisions) and Kleim 2024 (Munich/Agatharied; 31 shoulders, Constant 45->79 sustained to 5.5 yr, MCID surpassed in every diagnosis, medial glenoid erosion only ~0.3 mm/yr after a biphasic first year, 100% survival). Kleim independently reproduced Boileau’s finding that glenoid reaming does not drive more erosion.
The dominant, reproducible failure mechanism across the series was humeral-head oversizing: the pyrocarbon head sits ~2 mm proud of a metal head of equal diameter (a 1.5-mm support tray plus a 0.5-mm taper gap), nonanatomic reconstruction occurred in 24–29% of cases, and in Boileau’s series nonanatomic reconstruction carried a roughly 19-fold higher revision rate (25% vs 1.3%) along with worse erosion and function — which is why the group now downsizes the head by one size as routine.
What the cohort series add — and still cannot settle.
These series add to the registries: all three devices produce within-patient PRO gains exceeding MCID, durable to 5–10 years, with infrequent revision. However, there is still no well-controlled comparison against aTSA or any other glenoid-sparing alternative.
Summary
What the evidence supports:
• Resurfacing PHR (McBride): no detectable difference in revision risk versus best-in-class aTSA in patients <65 with OA — on a research-restricted device that is not available in the U.S., with shorter followup and thinner data, adjusted for age and sex only.
• AOA Annual Report: Stemmed pyrocarbon hemiarthroplasty not different from anatomic TSA with respect to revision rate at up to 7 years in patients <60 with OA.
• New Zealand registry: In comparison to conventional metal hemiarthroplasty, both pyrocarbon configurations are at least non-inferior; pyrocarbon may outperform metal hemi with respect to implant retention.
• Cohort series: For each device-and-technique combination studied, patient-reported and clinician scores rise from baseline by margins exceeding MCID and hold to 5–10 years — across the resurfacing device (Caughey), the U.S. stemmed implant (Griswold), and the European stemmed implant at five centers (Cointat, Garret, Boileau, Mathon, Kleim).
What the current evidence does not support:
• Any comparative effectiveness with respect to patient reported outcomes. The registries do not report PROs; the cohort series report PROs with clinically significant preoperative to postoperative gains, but lack well-controlled studies comparing clinical benefit relative of pyrocarbon to aTSA or other glenoid-sparing alternatives.
Conclusion
Future clinical research is needed define the indications, the appropriate implants, the surgical technique, and the clinical outcomes for pyrocarbon humeral arthroplasty relative to other methods for managing glenohumeral arthritis.
While the gold standard for comparing surgical treatments is a prospective randomized controlled trial, this is difficult to accomplish with meaningful numbers in a procedure performed on relatively few, highly selected patients. Authors therefore turn to propensity matching to compare separately collected series. The approach carries two challenges. The first is deciding which characteristics to match on — diagnosis? Walch type? how the glenoid was managed? length of follow-up? age? sex? The variables that most influence the result, such as Walch type and glenoid management, are often the very ones not recorded in the comparison series, so they cannot be matched even in principle. The second is attrition: cases are lost both because stricter matching discards more unmatched cases and because missing data remove others, so the compared groups end up a fraction of the original cohorts — sometimes a small one — and no longer fully representative of them. The commentary by Sanchez-Sotelo is required reading on this point (Pyrocarbon Shoulder Hemiarthroplasty Seems to Outperform Metallic Hemiarthroplasty at a Short-Term Follow-up. JBJS Am2026;108(8):529–530. DOI: 10.2106/JBJS.25.01142)
There is work to be done
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References
1. 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.
2. Australian Orthopaedic Association National Joint Replacement Registry. Hip, Knee and Shoulder Arthroplasty: 2025 Annual Report. Adelaide: AOA; 2025. Special Clinical Assessment: Shoulder Implant Choice — patients aged <60 years with OA (Table ST110, Figure ST77); data to 31 December 2024.
3. 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.
4. Caughey MA, Penny I, Frampton CM. Medium-term results of the Ascension Pyrotitan surface replacement and Pyrocarbon hemiarthroplasty in the shoulder. Semin Arthroplasty JSES. 2024;34(1):1–10. doi:10.1053/j.sart.2023.01.005.
5. 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.
6. 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.
7. Garret J, Cuinet T, Ducharne L, ReSurg, Godenèche 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.
8. 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.
9. Mathon P, Chivot M, Galland A, Airaudi S, Gravier R. Pyrolytic carbon head shoulder arthroplasty: CT scan glenoid bone modeling assessment and clinical results at 3-year follow-up. JSES Int. 2023;7:2476–2485. doi:10.1016/j.jseint.2023.06.028.
10. 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.
11. Lajoinie L, Garret J, van Rooij F, Saffarini M, Godenèche A. Pyrocarbon hemi-shoulder arthroplasty provides satisfactory outcomes following prior open Latarjet. J Shoulder Elb Arthroplast. 2024;8:24715492241292857. doi:10.1177/24715492241292857.
12. 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;34:739–749. doi:10.1016/j.jse.2024.05.026.
13. U.S. Food and Drug Administration, Center for Devices and Radiological Health. De Novo Classification Request for Tornier Pyrocarbon Humeral Head — Decision Summary. DEN220012. Silver Spring, MD: FDA; granted December 16, 2022. (Regulatory decision file for IDE G140202; documents the propensity-subclassified historical cobalt-chrome control [Tornier Flex CoCr, n=169] from the Aequalis Post-Market Outcomes Registry. The composite-clinical-success analysis was subsequently published as Hatzidakis 2026, ref 14.)
14. 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.
15. Sanchez-Sotelo J. Pyrocarbon Shoulder Hemiarthroplasty Seems to Outperform Metallic Hemiarthroplasty at a Short-Term Follow-up. Commentary on Hatzidakis et al. J Bone Joint Surg Am. 2026;108(8):529–530. doi:10.2106/JBJS.25.01142. (Independent JBJS commentary flagging the 43% missing control data as substantially weakening the study, the 2-year follow-up as very limited, the absence of radiographic assessment of humeral-head reconstruction, and the need to compare pyrocarbon HA with contemporary anatomic TSA using modern polyethylene.)