Pyrocarbon Shoulder Replacement for Patients Under 60

A pyrocarbon shoulder replacement replaces only the humeral side of the shoulder (the “ball”) with a smooth, carbon-surfaced implant and retains your native glenoid. In patients under 60, this may last as long (or longer) as a traditional shoulder replacement.

• What is it? The formal name is pyrocarbon hemiarthroplasty. “Hemi” means half. The surgeon replaces the arthritic humeral head or “ball” with a stem and a new pyrolytic carbon head or “ball” and does not put in a plastic glenoid component.
• How does it compare with an anatomic total shoulder replacement? In large registries of younger patients, the chance of needing another operation within ten years is lower. A total shoulder tends to give somewhat better function on average, and the two implants fail in different ways.
• What decides how well it works? Sizing and positioning the new ball correctly matters most, along with the shape of the socket. The socket still wears, but slowly, and most of the wear happens in the first year.

What is a pyrocarbon shoulder replacement?

The shoulder is a ball-and-socket joint. The ball is the humeral head, the top of the upper arm bone. The socket is the glenoid, a shallow dish on the shoulder blade. In arthritis, the smooth cartilage covering both surfaces wears away and bone rubs on bone.

An anatomic total shoulder replacement, or anatomic TSA, replaces both sides. A metal ball goes on the arm bone, and a plastic (polyethylene) component is cemented into the socket. “Anatomic” means the ball stays on the arm and the socket stays on the shoulder blade, as in a normal shoulder. A reverse shoulder replacement swaps them — see What Is a Reverse Shoulder Replacement?

A pyrocarbon hemiarthroplasty replaces only the ball. The implant has a graphite core with an outer layer of pyrolytic carbon, a very hard and very smooth form of carbon. Your own socket stays, and the new ball glides against it.

It comes in two designs:

• Stemmed pyrocarbon head. The pyrocarbon ball sits on a thin metal tray attached to a stem placed down the canal of the arm bone.
• Pyrocarbon resurfacing cap. A pyrocarbon cap fits over the reshaped head of the arm bone, held by a short post, with no stem.

The stemmed design is the one cleared by the FDA for use in the United States.

Why not just replace both sides?

Total shoulder replacement is the standard operation for shoulder arthritis, and it works well. Its weak point in younger patients is the plastic socket. Over years of use, the cemented socket component can loosen from the bone. Loosening is among the leading reasons a total shoulder is redone in younger patients [3][5].

Patients under 60 live longer with their implant and usually ask more of it. That means more years of load on the socket component. A pyrocarbon hemiarthroplasty avoids putting plastic and cement in the socket at all.

The trade-off is that your own socket now carries the load. The reason for choosing pyrocarbon over a metal ball is that pyrocarbon wears cartilage much less than metal in laboratory testing [15]. Socket wear still happens after a pyrocarbon replacement, but it is slower.

How does it compare with a total shoulder replacement in patients under 60?

How long it lasts

Australia’s national joint registry compared 403 pyrocarbon resurfacing caps with 1,952 total shoulders in patients under 65. The total shoulders came from the five designs with the lowest revision rates in the registry. At ten years, 7.7% of the pyrocarbon group and 9.0% of the total shoulder group had needed another operation. The difference was not statistically significant [3]. More than nine in ten patients in both groups still had their original implant.

The stemmed design shows the same pattern. In Australia, stemmed pyrocarbon heads in patients under 55 were revised at a rate no different from total shoulders [5]. In New Zealand, revision rates were similar for stemmed pyrocarbon heads and total shoulders in patients under 60 [4].

In one series of 103 shoulders in young, active patients, 94% still had their original stemmed pyrocarbon implant at five years and 89% at ten years [1].

How well the shoulder works

Here the total shoulder has the edge. In New Zealand’s registry, patients under 60 with a total shoulder scored better on a standard shoulder questionnaire than matched patients with a stemmed pyrocarbon head. The gap was large enough for patients to notice [4]. A smaller study comparing implant types found greater improvement in function and pain after total shoulder replacement [6].

That does not mean pyrocarbon patients do poorly. In the series of 103 shoulders, 88% of patients were satisfied. Of those still working, 92% went back to work, and of those playing sports, 93% went back to sport [1].

How each one fails

Option	What is replaced	Main reasons it is redone	Longest follow-up in these studies
Stemmed pyrocarbon head	Ball only, with a stem in the arm bone	Instability, pain, socket wear, a ball that is too large	10 years, one surgical series
Pyrocarbon resurfacing cap	Surface of the ball only, no stem	Implant breakage, pain	10 years, Australian registry
Anatomic total shoulder	Ball and socket, with a plastic socket component	Socket loosening, instability	10 years, same Australian registry comparison

Sources for the table: [1][3][5][7][17].

Who is a good candidate?

The patients in these studies were mostly in their early to mid 50s [1][3][7][8]. The most common reason for the operation is osteoarthritis. It is also used for avascular necrosis, where part of the ball collapses after losing its blood supply. Other uses are arthritis after a fracture and arthritis after repeated dislocations [13]. Patients whose arthritis followed a fracture scored lower in the early months than patients with osteoarthritis or avascular necrosis [13].

The shape of the socket matters. In many arthritic shoulders, the socket wears unevenly toward the back, and the ball drifts backward with it. Surgeons can correct this with reaming, which means smoothing the socket with a rounded cutting tool so it is centered and matches the new ball. In young patients with this wear pattern, reaming combined with a pyrocarbon head did not shorten implant survival [1]. In a separate group of 41 such shoulders, 95% still had their implant at an average of four and a half years [14].

Choosing between a pyrocarbon hemiarthroplasty and a total shoulder depends on the shape of the socket, the condition of the shoulder, activity level, and what the patient most wants to protect against. That decision is made with a surgeon after an examination and imaging.

What can go wrong?

The socket still wears

Pyrocarbon slows socket wear. It does not stop it. Across 12 studies and 536 patients, about one in five showed some socket erosion on x-ray at two years or later [10]. Erosion means the socket bone thins and the ball sits slightly deeper toward the body.

The pattern matters as much as the presence. In a group followed for five and a half years, the socket wore about 1.4 mm on average, and more than half of that wear happened in the first year [9]. In another group, the ball kept moving inward slowly between two years and about six years, by roughly a millimeter on average [8].

Erosion that keeps progressing does matter. Patients whose erosion increased over time had more pain, worse function, and a higher chance of another operation [1].

A ball that is too large

The strongest finding in this research is about sizing, not material. In the stemmed design, the pyrocarbon ball sits on a metal tray about 1.5 mm thick. That added thickness can make the new ball larger than the patient’s original one [2]. An oversized ball overstuffs the joint. It presses harder on the socket and puts tension on the surrounding tendons.

In one series, the ball ended up oversized or out of position in 29% of shoulders. Those patients had worse function, more complications, and more revisions [2]. In the later series of 103 shoulders, oversizing occurred in 24%. One in four of those shoulders needed another operation, compared with fewer than 2 in 100 when the ball matched the original anatomy [1].

Pyrocarbon does not protect the socket when the ball is too big. Head size and position are the central part of planning and performing the operation.

Infection and pain

Infection can occur after any joint replacement. In the US multicenter study of 157 patients, the three shoulders redone in the first two years were revised for pain or low-grade infection [7]. How these infections are prevented, found, and treated is covered in Can a Shoulder Replacement Get Infected?

What happens if a pyrocarbon replacement fails?

Most failed pyrocarbon replacements are converted to a total or reverse shoulder replacement. Across 12 studies, 63% of revisions were conversions to a reverse or total shoulder [10]. In the series of 103 shoulders, six of the seven revisions became reverse replacements. Those revisions happened on average about two and a half years after the first surgery [1].

The stemmed design uses a stem intended to be convertible, so a surgeon can later add a socket component or change to a reverse replacement.

These studies do not report how patients did after conversion compared with patients who had a total shoulder from the start.

How much is known about the long term?

Most results run five to ten years. Ten-year data come from one surgical group’s series and from the Australian registry [1][3]. Patients under 60 usually need a shoulder replacement to last well beyond that. Implant designs and surgical technique have also changed over the years these patients were treated, so older results may not fully reflect current implants.

---

Midhat Patel, MD is a fellowship-trained shoulder and elbow surgeon at Banner Health in Phoenix and Scottsdale, Arizona, and a Clinical Assistant Professor of Orthopaedic Surgery at the University of Arizona College of Medicine – Phoenix.

Sources

1. Stemmed pyrocarbon survival, oversizing, return to work and sport. 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. Prospective consecutive series, 103 shoulders (96 patients), mean age 56 ± 8 years, mean follow-up 5.6 years (2–10). Revision-free 94% at 5 years, 89% at 10 years; 7 revisions (6 to reverse, 1 to anatomic TSA), mean 31 months. Nonanatomic reconstruction with head oversizing in 24%: increased glenoid erosion OR 3.46 (95% CI 1.13–10.55, p = .0295); revision 25% vs 1.3% (p < .001). Progressive erosion: revision-free 72% vs 97% (p = .002). No survival difference with or without glenoid reaming. Satisfied 88% (91/103); return to work 92% (73/79); return to sport 93% (55/59). doi:10.1016/j.jse.2025.06.021
2. Metal tray as cause of oversizing; nonanatomic reconstruction. 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. Consecutive series, 64 patients aged ≤60 (mean 53), mean follow-up 33 months (24–60). Survival 92%; 5 revisions at mean 24 months. Nonanatomic reconstruction (center of rotation >3 mm from anatomic) in 29% (18/62), associated with lower function, more complications (subscapularis insufficiency, symptomatic erosion), and higher revision risk. 1.5-mm metal disc identified as main cause of oversizing. Return to work 91%, sport 88%. doi:10.1016/j.jse.2021.06.002
3. Pyrocarbon resurfacing vs anatomic TSA, 10-year revision; failure modes. McBride A, Hurley R, Gill D, et al. 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. National registry, patients <65 with OA, 2004–2022. 403 pyrocarbon resurfacings (mean age 52.5) vs 1,952 anatomic TSAs from the 5 prosthesis combinations with lowest 5-year cumulative percent revision, cemented polyethylene glenoids (mean age 58.6). 10-year cumulative percent revision 7.7% (95% CI 4.7–12.4) vs 9.0% (95% CI 7.4–11.0); revision risk did not differ (Cox models adjusted for age and sex). Leading revision cause: implant breakage 35% of pyrocarbon revisions; loosening 33.9% of TSA revisions. doi:10.1016/j.jse.2025.09.007
4. Stemmed pyrocarbon vs anatomic TSA under 60: function and revision. 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. National registry, 2000–2022. 159 stemmed pyrocarbon hemiarthroplasties, 5 revisions, 97% retention. Matched cohort <60 with OA: 48 pyrocarbon, 150 conventional HA, 550 aTSA. aTSA superior Oxford Shoulder Score vs pyrocarbon, difference exceeding MCID of 4.3. No difference in revisions per 100 component-years. doi:10.1016/j.jse.2023.01.020
5. Stemmed pyrocarbon vs TSA under 55; TSA revision reasons. Khoriati AA, McBride AP, Ross M, et al. 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. National registry, patients <55 with OA, 1999–2021, 1,564 procedures (159 stemmed pyrocarbon, 714 TSA, 260 reverse). No significant difference in revision rate for stemmed pyrocarbon or TSA when each compared with reverse. Leading revision causes: stemmed pyrocarbon, instability/dislocation 28.6%; TSA, instability/dislocation 20.6% and loosening 18.6%. Authors note lack of long-term data for stemmed pyrocarbon.
6. TSA vs pyrocarbon hemiarthroplasty function in a comparative series. Kleim BD, Garving C, Brunner UH. RSA, TSA and PyC hemi-prostheses: comparing indications and clinical outcomes using a second-generation modular short-stem shoulder prosthesis. Arch Orthop Trauma Surg. 2021. Comparative cohort; TSA showed significantly greater Constant score and pain improvement than pyrocarbon hemiarthroplasty.
7. US multicenter study: patient age, early revisions for pain or infection. 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. Prospective single-arm IDE study, 157 patients at 18 sites, enrolled 2015–2017, mean age 52.4 ± 10.9 (19–73). Mean follow-up 24.4 ± 1.2 months; 10 lost to follow-up; 3 revisions before 24 months for pain or low-grade infection. Composite Clinical Success 82.7% vs 66.8% for propensity score subclassification–derived historical cobalt-chromium HA cohort (n = 169), p < .001. Level III. doi:10.2106/JBJS.25.00054
8. Continued slow medialization at mid-term. Griswold BG, Berger JM, Davis BP, et al. Five-year radiographic and clinical outcomes of pyrocarbon hemiarthroplasty for glenohumeral arthritis and osteonecrosis. J Bone Joint Surg Am. 2025;107(24):2751–2762. Prospective cohort, 45 patients, mean age 52, mean follow-up 73 months. 7-year revision-free survival 95.7%. Humeral head medialization 2.9 ± 2.8 mm at 2 years to 4.0 ± 3.3 mm at final follow-up (p = .096). Acromiohumeral distance decreased >2 mm in 82.2% (p < .001). Glenoid morphology stable in most. Level II. doi:10.2106/JBJS.25.00163
9. Most socket wear occurs in the first year. 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. Single-center consecutive cohort, 31 of 34 patients (91%), mean follow-up 5.5 years (3.5–7). Mean medial glenoid erosion 1.4 mm; 0.8 mm in year 1 vs average 0.3 mm/year (p < .001). Implant survival 100%. Constant score 45.0 to 78.8; VAS pain 6.7 to 2.2 (p < .001). doi:10.1016/j.jse.2023.05.027
10. Erosion prevalence; conversion after failure. Park CN, Zhang GX, Chang J, et al. Pyrocarbon hemiarthroplasty of the shoulder: a systematic review and meta-analyses of clinical results. J Shoulder Elbow Surg. 2023. 12 studies, 536 patients, minimum 24-month follow-up; not restricted to patients under 60. Radiographic glenoid erosion 22.8%; implant position change 10.4%; tuberosity thinning 9.9%. Complication rate 8.6%; revision rate 7.7% (n = 41), 63% (n = 26) converted to reverse or total shoulder arthroplasty.
11. Rationale: lower cartilage wear in laboratory testing. McBride AP, Ross M, Hoy G, et al. 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. Cited here for its background statement that pyrocarbon was proposed because of markedly reduced wear rates in vitro. doi:10.1016/j.jse.2021.08.017
12. Reaming for posteriorly worn sockets. 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. Prospective CT-based cohort, 41 shoulders (35 patients), mean age 57.9, mean follow-up 4.5 years (2–9.5). Survival 95% (39/41); no revision for painful glenoid erosion. Glenoid retroversion 17.1° to 8.3° (p = .001). Total medialization 3.7 ± 3.2 mm (2.0 mm reaming, 1.7 mm erosion). Return to work 84%; all returned to sport. doi:10.1016/j.jse.2024.06.028
13. US regulatory status of the stemmed design. U.S. Food and Drug Administration. De Novo classification request for Tornier Pyrocarbon Humeral Head. DEN220012. Center for Devices and Radiological Health; 2022. Regulatory document, not peer-reviewed.
14. Resurfacing cap survival and implant fracture in a contemporary series. 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. Published online May 13, 2026. Prospective single-surgeon cohort, 119 shoulders (115 patients), mean age 56.5. 5-year survival 97.5% (3 revisions). 7 complications (5.9%), including 1 implant fracture. Glenoid erosion increased slightly, not significantly. Level IV. doi:10.2106/JBJS.25.00779
15. Implant fracture now uncommon. Kew M. Is pyrocarbon the future? Commentary on an article by Gregory Hoy, et al.: “PyroTITAN Pyrocarbon Hemiarthroplasty. Clinical and Radiographic Outcomes with Medium-Term Follow-up.” J Bone Joint Surg Am. 2026. Invited commentary; notes implant fracture is now an uncommon reason for revision and mean glenoid–spinoglenoid notch distance decrease of 2.01 mm at 3 years in the Hoy cohort.
16. Indications; lower early scores after fracture. Konarski AJ, Mohammed KD. The experience of stemmed pyrocarbon shoulder hemiarthroplasty in New Zealand: ten years of registry data. Bone Joint J. 2026. National registry 2014–2024, 288 stemmed pyrocarbon hemiarthroplasties in 277 patients, mean age 55 (20–86), mean follow-up 50 months. Indications: OA 53.5%, avascular necrosis 18.1%, trauma sequelae 16.7%, recurrent dislocation 13.2%. Oxford Shoulder Score 36.4 at 6 months, 40.8 at 5 years. Revision 0.75 per 100 component-years (95% CI 0.34–1.42). 6-month score lower after trauma than OA (p = .014) or avascular necrosis (p = .020). Use increased 2.3-fold.
17. Resurfacing cap revision reasons. Same registry as source 15. Pyrocarbon resurfacing <55 (n = 163): key revision reasons pain, prosthesis fracture, and infection; no pyrocarbon resurfacing revised for glenoid erosion. Cumulative percent revision at 6 years 8.9%.