Hemiarthroplasty rather than total shoulder for glenohumeral arthritis: results with a pyrocarbon humeral head.

There is a surge of interest in the use of humeral hemiarthroplasty - rather than conventional total shoulder -  in the management of patients with glenohumeral arthritis. Many such procedures have been performed using a cobalt-chrome humeral head in the ream and run. Now there is growing use of Pyrocabon humeral heads with the idea that glenoid wear/humeral medialization could be lessened because of the special lubricating properties of their articular surface. 

Last month's post The Ream and Run - how much of an issue is glenoid wear? pyrocarbon vs. chrome cobalt? summarized some of the relevant data. 

This week a new study was published: Five-Year Radiographic and Clinical Outcomes of Pyrocarbon Hemiarthroplasty for Glenohumeral Arthritis and Osteonecrosis, which evaluated the progression of humeral head medialization in patients having pyrocarbon hemiarthroplasty. This was a methodologically strong study; it was a prospective FDA, IDE investigation. Standardized protocols were used from the start with predefined outcome measures. The inclusion rate was high: 45 of 54 potentially eligible patients. Rigorous imaging standards were imposed from the start and consistent across all time points. The radiographic analysis was blinded and used standardized software. The correlation analysis was formalized. Kaplan-Meier curves were carried out with 7 year survival rates. Radiographic measurements and patient reported outcomes were documented at three time points. 

Included patients had a mean age of 52 years and a mean follow-up of 73 months. In addition to the pyrocarbon humeral hemiarthroplasty, 60% had a glenoidplasty, 27% had glenoid drilling only, 9% had no glenoid treatment. 

Significant improvements were observed across all outcome measures. Patient satisfaction was 98%. The 7-year revision-free survival rate was 95.7%. Two patients were revised for infection. Posterior subluxation in decentered shoulders decreased from 27% preoperatively to 20% postoperatively. The mean medialization of the humeral head averaged 2.9  mm at the 2-year follow-up (1.5 mm/yr) and after that increased at a lower rate ( 0.3 mm/year) to an average of 4.0 mm at the time of the final follow-up of 6 years for an overall medialization of 0.66 mm/year. 

Interestingly, Pearson correlation analysis found no relationship between medialization and clinical outcomes. Patients with significant glenoid wear achieved the same results as those with minimal wear. Younger age was the only significant predictor of severe medialization (p=0.030), however this increased radiographic wear in younger patients did not correlate with worse clinical outcomes. In fact, none of the measured variables - including medialization, age, sex, glenoid morphology, and treatment type - correlated with clinical outcomes.

The wear in this pyrocarbon study can be compared to that in another 2025 study that used a chrome cobalt humeral head with reaming of the glenoid (the traditional ream and run): Characterizing glenoid wear after hemiarthroplasty with concentric glenoid reaming: a study of 113 arthroplasties at a mean of 6.7 years of follow-up. Both studies had similar age (59 yrs RnR and 52 yrs Pyro) and sex (92% RnR and 78% Pyro) profiles. 

The method of measuring medialization in the Pyro study

was similar to that used in Characterizing Glenoid Wear after Hemiarthroplasty with Concentric Glenoid Reaming: A Study of 113 Arthroplasties at a Mean of 6.7 Years

As seen in the figure below, the wear rates for the traditional ream and run do not appear inferior to those for Pyrocarbon. The traditional ream and run study demonstrated a plateau in wear beyond 6 years based on 11 time points. The trajectory of pyrocarbon wear is less certain in that it is based on 3 time points.

Both studies showed high satisfaction and improvement in clinical outcomes. The RnR study was retrospective with 113 of 408 patients included, 12 had open revision. The Pyro study was prospective with 45 of 54 patients included, 2 had open revision; the difference in revision rate was not statistically significant. Neither study found a relationship between glenoid wear and patient-reported outcomes. Formal correlation analysis (pyrocarbon) and group comparisons (ream-and-run) both showed that patients achieved excellent results (>97% satisfaction, significant functional improvement) regardless of wear amount. None of factors studied were associated with clinical outcome.

Clinical Implications: Humeral hemiarthroplasty - either traditional ream and run or pyrocarbon hemiarthroplasty - are important surgical considerations for young patients with glenohumeral arthritis, especially if they wish to avoid the risks and limitations associated with the polyethylene glenoid component used in total shoulder arthroplasty. Both procedures were associated with over 97% rate of satisfaction. While younger age was associated with increased wear, none of the factors considered in these studies - including glenoid wear - were associated with the clinical outcome.

While it seems that a randomized clinical trial may be useful in comparing these two procedures, there would be some challenges in such a study as pointed out in Is pyrocarbon better than a ream and run? - a randomized controlled trial

Different heads

Pileated woodpecker

White headed woodpecker

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link)
The total shoulder arthroplasty (see this link)
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

Same type of arthroplasty, different outcomes for the right and left shoulder.

 A 43 active man elected to have a left ream and run procedure after two previous surgeries:

13 years prior he had an acromioplasty followed by the insertion of a pain pump. 

Six years prior he underwent a rotator cuff repair.

Because of his good recovery of left shoulder comfort and function, two years later he elected a ream and run procedure on his previously unoperated right arthritic shoulder

At one year after his right shoulder surgery, 

he had good range of right shoulder motion but it was painful.

While the left shoulder showed no evidence of erosion, sequential x-rays of the right shoulder glenoid erosion becoming dramatically worse at six years after the ream and run.  

 Post op               1 yr                    3 yrs                     6 yrs

At 6 years post arthroplasty an aspiration showed no fluid

A revision procedure was carried out. 

Joint fluid obtained at surgery showed >1,300 WBC, 78% neutrophils

Frozen section of the collar membrane showed neutrophilic infiltration 

with >20 WBC per high power field. 

In spite of these findings, it was decided to proceed with a revision arthroplasty

After through debridement and irrigation, a reverse total shoulder was performed using the alternative center line without bone graft or base plate augmention. 

The patient was placed on Doxycline for 3 weeks until the intraoperative cultures finalized.

At three weeks after surgery the intraoperative cultures and PCR were negative.

Thus, two similar arthroplasties for similar indications in the same patient

wound up with two different treatments.

Two years after revision                  Ten years after primary

The patient reports "both shoulders are feeling great. I have had no pain since my revision.  I am only concerned that I am doing too much with my right. I know that I am more limited with lifting with a reverse so I am making sure I limit what I do with me right side".

Comment: It is interesting that the glenoid wear occurred on the previously unoperated shoulder rather than on the side with two prior procedures, one of which included the insertion of a pain pump. It is also interesting that even with the high white count of the joint fluid at surgery and the >20 WBC per high power field, the intraoperative cultures were negative. Finally, in spite of the erosion there was sufficient glenoid bone to secure a standard baseplate without bone graft or augment.

Speaking of erosion, here's the erosion resulting from the retreating Nisqually glacier

Mount Rainier

August 3, 2025

 

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

 

 

Is pyrocarbon better than a ream and run? - a randomized controlled trial

"We need a randomized controlled trial to determine whether patients with shoulder arthritis having a pyrocarbon humeral head have better outcomes than those having a ream and run".

In discussing this topic it may be worthwhile starting with a classic example of an orthopaedic RCT

A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee The reader will easily see the care exerted by the investigators to define the two groups to be compared (debridement vs sham surgery, the randomization, the blinding of the evaluators, the primary outcome measure (the Knee-Specific Pain Scale), and the outcomes ("At no point did either of the intervention groups report less pain or better function than the placebo group. Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinically meaningful difference.") Interestingly, in spite of this result, arthroscopic debridement for knee osteoarthritis is still being performed.

Before considering a randomized controlled trial, investigators must listen to this recent presentation: American Shoulder and Elbow Surgeons webinar on randomized controlled trials. This very well done webinar was both impressive and daunting. It pointed out the organization, cost and the challenges of RCTs.

Stimulated by the above, I started making a check list of questions to be answered before considering an RCT comparing pyrocarbon humeral hemiarthroplasty to the ream and run procedure. I suspect that there are others that should be included.

I. What should be the primary outcome variable (POV)?

    A. Wear rate

    B. Patient reported outcome measure (PROM)

        1. Final PROM

        2. Change in PROM

    B. Satisfaction

    C. Complication rate (e.g. infections)

    D. Revision rate

II. How long after surgery should the POV be assessed

III. For the selected POV, what are the published mean, median, standard deviation, and 90% confidence levels for 

    A. Pyrocarbon humeral hemiarthroplasty 

    B. Ream and run procedure

IV. How much change in the selected POV would be clinically significant (effect size)

V. What sample size would be necessary to detect a clinically significant change in the POV with reasonable statistical power (e.g. 80%) (see Sample size, power and effect size revisited: simplified and practical approaches in pre-clinical, clinical and laboratory studies)

VI. What percent of the potential candidates for the study would agree to be enrolled in a study that had their surgical procedure selected at random; in what ways do consenting and non-consenting patients differ? 

VII. What percent of those enrolled are likely to drop out before the desired followup time interval; in what ways do patients not completing the study differ from those that complete it?

VIII. What are the confounding variables and how will they be documented and included in the analysis

    A. The surgeon (experience, published outcomes)

    B. The component (make, size, stem, position)

    C. Patient demographics (age, sex, comorbidities)

    D. Preoperative pathology (type of arthritis, glenoid type, version, cuff status, centering, shoulder size, prior surgery)

    E. Simultaneous procedures (glenoid reaming (accepting or correcting glenoid version), biceps management (preservation, tenotomy, tenodesis), posterior capsular plication, rotator interval plication, cuff surgery, AC joint surgery)

IX. Study details

    A. How will decisions be made

    B. Prospective involvement of statistician

    C. Initial and followup meeting of investigators

    D. Where will data be housed

    E. Human subjects clearances

        1. Locally at each study site

        2. Centrally

    F. Staffing

    G. Funding

    H. How will blinding be managed (patient, followup, etc)

Comments welcome!


You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

 

Shoulder arthritis - second opinion,

Patients are encouraged to get a second opinion regarding the management of their shoulder arthritis.

Here's an example.

An active man in his late 60's presents with pain in his shoulder, but is still doing bench press with 30 pounds and has retained active elevation.  These CT images were obtained at his initial surgical consultation.

He was presented with the sole option of a reverse total shoulder (see this link) to help improve his shoulder performance.

    

This patient has clinical and radiographic findings that are commonly successfully managed with an anatomic total shoulder (see this link) or a ream and run procedure (see this link), should he continue to have disabling symptoms after a trial of rehabilitation exercises (see this link) and non-steroidal anti-inflammatory medications. A discussion of the pros and cons of these options is warranted.

You can support cutting edge shoulder research and education that are leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/RickMatsen or https://twitter.com/shoulderarth
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Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Primary glenohumeral arthritis: treatment with the ream and run in comparison to total shoulder arthroplasty - 10 year followup

Glenohumeral arthritis in shoulders with an intact rotator cuff is the most common indication for shoulder arthroplasty. 

The safety, effectiveness and durability of anatomic arthroplasty - the ream and run (RnR) or the anatomic total shoulder (TSA) - is widely recognized. 

The authors of Minimum 10-year Follow-up of Anatomic Total Shoulder Arthroplasty and Ream-and-Run Arthroplasty for Primary Glenohumeral Osteoarthritis studied the patients and the minimum 10-year outcomes for the RnR (n=34) and TSA (n=29). In this practice, the patients chose their surgical procedure after a discussion of the risks and benefits of each.

The two groups differed in a number of important preoperative characteristics. The RnR patients were significantly younger than the TSA patients (60 ± 7 vs 68 ± 8, p<0.001), predominantly male (97% vs 41%, p<0.001), and were healthier as reflected by the American Society of Anesthesiologists score (p=0.018). 

Patient-assessed preoperative and postoperative function was documented by the Simple Shoulder Test (SST)

The preoperative and the postoperative SST scores were higher for the patients having the ream and run procedure than for those having total shoulders.

Total shoulder

In the TSA group, the pain score decreased from a preoperative average of 6.6 ± 2.2 to 1.2 ± 2.3 (p < 0.001), and the SST score improved from and average of 3.8 ± 2.6 to 8.9 ± 2.6 at 10-year follow-up. (p < 0.001). The percent of maximum possible improvement averaged 64%. No patient in the TSA group required reoperation; notably there were no cuff tears or glenoid loosenings.

Ream and Run

In the RnR group, the pain score decreased from a preoperative average of 6.5 ± 1.9 to 0.9 ± 1.3 (p < 0.001), while the SST score improved from and average of 5.4 ± 2.4 to 10.3 ± 2.1 at 10-year follow-up (p < 0.001).  The percent of maximum possible improvement averaged 83%. 

Four patients  underwent single-stage exchange to another hemiarthroplasty because of painful stiffness. Two of these 4 patients had positive cultures for Cutibacterium. One patient required manipulation under anesthesia. No patients had conversion to a TSA or reverse total shoulder. 

At followup, a larger percentage of RnR patients could perform high-level shoulder functions: SST questions 7, 8, 9, 10, and 12.

As an example, a 15-year post RnR followup x-ray of the shoulder shown at the beginning of this post is shown below. Note the stable humeral fixation and the seating of the humeral head centered in the healed glenoid concavity.

This patient (now 71 years old) continues to use his arm for heavy physical work and recreation. He has excellent range of motion, comfort and function and now returns for an RnR on his opposite shoulder.

 

Comment: Patients with glenohumeral osteoarthritis and their surgeons have the choice of the ream and run and anatomic total shoulder. This is one of the few long term studies of the patients having each of the procedures. It is notable that young, healthy, male patients preferred the ream and run procedure after a discussion of the pros and cons of each. The RnR patients had higher levels of function both before and after surgery - particularly for the more demanding activities assessed by the Simple Shoulder Test.

As is necessary for all clinical outcome studies, this article reported the number of patients enrolled in the database and the number and reasons groups of patients were not included in the final analysis. This is the standard "Figure 1", which seems absent in many reports.

This figure shows the challenge in achieving long term followup on a high percentage of patients.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).