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Pyrocarbon Shoulder Hemiarthroplasty

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Updated Oct 202644 citations
Illustration: shoulder

What is it

A pyrocarbon hemiarthroplasty is a half shoulder replacement for shoulder arthritis. The worn ball at the top of the arm bone is replaced with a smooth ball made of pyrocarbon, a very hard form of carbon, on a stem that sits inside the arm bone. Unlike a total shoulder replacement, the socket (the glenoid) is left in place, and the new ball moves against your own socket.

It is mainly considered for younger, active people with arthritis, in whom a plastic socket might wear out or loosen during their lifetime. It is a newer option: the first results were published within the last ten years, and the longest follow-up so far is about ten years.

Why pyrocarbon

Half replacements have been used for many years with metal balls made of cobalt-chrome. Their main problem is that the hard metal gradually wears away the socket, which can become painful and lead to further surgery [1]. Pyrocarbon is very smooth and much less stiff than metal, with a stiffness close to that of bone. The idea is that it is gentler on the socket, so the socket wears less and the shoulder lasts longer [2].

Who it may suit

The best results have been reported in people whose socket is worn evenly, whose rotator cuff tendons are healthy, and whose arthritis followed earlier dislocations, or followed collapse of the ball from loss of its blood supply (avascular necrosis) [3][4]. Results have been poorer when the socket is badly worn at the back, when the tendon at the front of the shoulder (the subscapularis) is torn or weak, and when the new ball is larger than the patient's own [3][4].

A pyrocarbon half replacement is not suitable when the rotator cuff is badly torn; a reverse shoulder replacement is usually used instead.

What the results show

Compared with a metal half replacement, pyrocarbon has done better in every published comparison. In the Australian joint registry, about 9% of pyrocarbon implants in people under 55 had needed further surgery by 6 years, against about 17% of metal half replacements [1].

On its own, the larger studies report that 94–97% of shoulders have not needed further surgery at 5 years, and about 89% at 10 years in the longest series [4][5]. Most patients have less pain and better movement, and many return to work and sport [4].

Compared with a total shoulder replacement, the rate of further surgery so far looks similar [6][7]. In two studies, people who had a total shoulder replacement had slightly better early function or slightly less pain, although most patients in both groups did well [7][8].

Downsides and risks

The general risks are those of any shoulder replacement, described on the total shoulder replacement page. The risks particular to a pyrocarbon half replacement are:

  • The socket can still wear. Pyrocarbon reduces socket wear but does not prevent it. Some wear has been seen on X-ray in roughly a quarter to a half of shoulders within several years, and when it progresses it is the main cause of pain and further surgery [9][4].
  • Pain that does not settle fully. Some people are left with ongoing aching without a clear cause. In one large study, about 1 in 6 shoulders had not improved as much as expected at 2 years, although few of them had needed further surgery [10].
  • The size has to be right. If the new ball is even slightly too large, the socket wears faster and further surgery becomes much more likely [4].
  • Breakage. Pyrocarbon is hard but brittle. Fracture of the implant is uncommon but has been reported, mainly with the resurfacing cap version [6].

If further surgery is needed, the stem can usually be left in place and the shoulder converted to a total or reverse shoulder replacement, because the socket has not been replaced [4].

How certain is the evidence

The results so far are encouraging but limited. There are no randomised trials, most studies follow patients for less than 6 years, and many come from the surgeons who helped develop the implants [11]. Most studies measure success by whether further surgery was needed, which can miss shoulders that remain painful but are not operated on again [10]. Longer-term results, and results from a wider range of hospitals, are still to come.

Questions you may want to ask

  • How worn is my socket, and is the wear even or mainly at the back?
  • Are my rotator cuff tendons healthy?
  • How would a half replacement compare with a total shoulder replacement for me?
  • What would happen if the socket wore down in future?

In more depth

Advanced reading: the deeper science (optional)

This section sets out the evidence in more detail, with the numbers from each study. Pyrocarbon hemiarthroplasty is a newer option, and the published results are worth reading closely: they are encouraging in some respects and disappointing in others, and the answer depends on what it is compared with.

Why pyrocarbon was introduced

A hemiarthroplasty (half replacement) replaces the ball of the shoulder and leaves the socket (glenoid) alone. That avoids the main long-term problem of a total shoulder replacement in younger, active people, which is loosening and wear of the plastic socket. With a traditional cobalt-chrome metal ball, however, the native socket tends to wear away over time, often painfully. Erosion of the socket has been reported in 28–43% of shoulders with metal heads [1]. In the Australian joint registry, metal half replacements in people under 55 reached revision rates of about 17% by 6 years, largely because of socket wear and pain [2].

Pyrolytic carbon (pyrocarbon) is a very hard, very smooth form of carbon, made by depositing carbon from a gas onto a graphite core at high temperature. It is much less stiff than cobalt-chrome, with an elastic modulus close to that of bone, and it causes little friction against cartilage. It has been used for decades in heart valves and in small-joint replacements in the hand and elbow [3]. In the laboratory, cartilage cells grown on pyrocarbon produced more of the type of collagen found in healthy joint cartilage than cells grown on cobalt-chrome [4]. The idea is simple: keep the socket, but change the ball so the socket wears less.

Three designs, three track records

Pyrocarbon has been used in the shoulder in three ways, and their results are different enough that one should not be judged by another.

Design How it works Track record
Stemmed head A pyrocarbon ball on a stem in the arm bone; the stem can stay if a later conversion is needed The best results and most of the recent data
Resurfacing cap A pyrocarbon cap fitted over the reshaped ball Registry revision similar to good total replacements, but breakage of the cap was the leading reason for revision [5]
Interposition (PISA) A loose pyrocarbon sphere placed between the arm bone and the socket The weakest results: erosion of the arm bone and failures in unevenly worn sockets [6][7]

A 2026 analysis pooling 1,117 patients found high survival for stemmed pyrocarbon heads and lower survival for caps and interposition spheres [8]. A resurfacing cap has been reported to fracture after 6 years without injury, with no bone grown onto it [9]. Everything below is about the stemmed head unless it says otherwise.

What the clinical series report

Study Shoulders Average follow-up Free of revision Notes
Garret 2019 [10] 65 2 years 95% Multicentre, prospective
Cointat 2022 [11] 64 2.8 years 92% Head not anatomic in 29%, with worse results
Hatzidakis 2026 [12] 157 2 years 3 revisions US approval study, 18 hospitals
Kleim 2024 [13] 31 5.5 years 100% 1.4 mm of socket wear
Garret 2024 [1] 45 6.2 years 96% 13% lost to follow-up
Ranieri 2025 [14] 41 4.5 years 95% Unevenly worn sockets, reamed at surgery
Griswold 2025 [15] 45 6.1 years 95.7% at 7 years Prospective
Boileau 2026 [16] 103 5.6 years 94% at 5 years, 89% at 10 Largest single series
Hoy 2026 [17] 119 5 years 97.5% One implant fracture
Droz 2026 [18] 27 2.7 years 93% Socket wear progressed in 46%

Most patients in these series were working and active. In the two series from Nice, 91–92% returned to work and 88–93% to sport, and 88% of patients in the larger one were satisfied [11][16].

Compared with a metal half replacement

Every comparison published so far favours pyrocarbon over a metal ball:

  • Australian registry, under 55: 8.9% of pyrocarbon caps had been revised by 6 years, against 17.1% of metal caps and 17.5% of metal stemmed half replacements [2].
  • US approval study: 82.7% of pyrocarbon shoulders met the study's definition of success at 2 years, against 66.8% in an earlier group treated with metal heads [12].
  • A Dutch private clinic: 2.3% of pyrocarbon half replacements were revised, against 12.8% with metal heads, over up to 7 years [19].
  • Fractures of the top of the arm bone: in people under 65, pyrocarbon heads gave better movement, less pain and better healing of the fractured bone than metal heads, although the stems used also differed [20].

Compared with a total shoulder replacement

For a younger person with arthritis, the more relevant comparison is an anatomic total shoulder replacement. On revision rates, registries find no clear difference. In the Australian registry's 2025 report, among people under 60 with osteoarthritis, 6.9% of stemmed pyrocarbon half replacements had been revised by 5 years, against 5.9% of stemmed total replacements, 6.0% of stemless total replacements and 5.6% of reverse replacements; the differences were not statistically significant. Only 107 pyrocarbon shoulders had reached 5 years in that analysis, and 10 had reached 10 years (AOANJRR 2025 Annual Report, Table ST110).

  • Pyrocarbon caps compared with the five best-performing total replacements in Australia: 7.7% against 9.0% revised at 10 years, with no difference in risk [5].
  • In New Zealand, revision rates did not differ, but people who had a total replacement scored better on the Oxford Shoulder Score, by more than the smallest difference patients notice. The authors concluded that a total replacement remains the implant of choice for the best early function [21].
  • In a matched comparison of 74 patients in each group, results at 2 years were similar. The total replacement group scored slightly better at 6 months and had slightly less pain at 2 years (0.45 against 1.06 on a 10-point scale) [22].

The socket still wears

Socket wear was the problem pyrocarbon was introduced to solve, and it is still the main reason these shoulders fail.

  • A pooled analysis of 536 patients found socket erosion on X-ray in 22.8% [23].
  • At about 6 years, wear was moderate in 24% of shoulders and severe in 8%, and 10 of 37 had worsened since surgery [1].
  • In a series from another centre, wear progressed in 12 of 26 patients (46%) within an average of 2.7 years [18].
  • The ball moved inwards by an average of 4 mm over 6 years in one series, and the space under the acromion narrowed in most patients [15].

Where wear was measured precisely, the amounts were small: 1.4 mm over 5.5 years in one series, most of it in the first year [13], and under 0.6 mm at 3 years on CT in another [24]. But wear matters when it happens. In the largest series, shoulders whose wear increased had more pain, worse function and lower survival (72% against 97%) [16].

Whether the material itself deserves the credit is debated. In a published letter, one surgeon argued that the pyrocarbon results resemble those of a metal half replacement combined with reshaping of the socket, and that the gains may come from patient selection and surgical technique rather than the material [25]. The authors agreed they had no metal comparison group [26]. No study has yet compared the two materials with the same stem, technique and socket preparation.

Revision does not capture every poor result

Most studies count success as not needing another operation. A painful half replacement in a younger person is often not revised, so these figures can look better than patients' experience. In the US approval study, 26 of 146 shoulders (18%) did not meet the definition of success at 2 years, but only 3 of those had been revised; most of the rest had not improved enough on the Constant score [27]. In one series, two shoulders were revised for ongoing pain with no wear or tendon problem found [1].

Getting the size right matters

The results depend heavily on matching the new ball to the patient's own anatomy.

  • In the largest series, the ball was oversized in 24% of shoulders. With an oversized ball, 25% needed revision, against 1.3% when the size was right [16].
  • In an earlier series, a ball that was not anatomically placed (in 29% of shoulders) was linked to worse function and more complications [11].
  • In another series, 46% of shoulders were overstuffed, and 7 of the 12 shoulders with worsening wear were among them. The authors noted that the metal disc under the pyrocarbon ball adds about 1.5 mm [18].

A surgical technique has been described to avoid overstuffing [28].

Who seems to do well

The best results have been reported in people with:

  • a socket that is worn evenly rather than at the back;
  • arthritis after earlier dislocations, or collapse of the ball from loss of its blood supply (avascular necrosis);
  • healthy rotator cuff tendons, particularly the subscapularis at the front of the shoulder [7][29][15].

Small series after an earlier Latarjet stabilisation have also been encouraging [30].

The poorest results have been reported:

  • with interposition spheres in sockets worn unevenly at the back, where 44% were revised, against 2% in evenly worn sockets [7]; in another series, 5 of 10 interposition implants were revised, all in this type of socket [31];
  • with a torn or weak subscapularis tendon [7];
  • when the ball is oversized [16].

Unevenly worn sockets treated with a stemmed head and reshaping of the socket have done well in one centre [14].

How strong is the evidence?

  • No randomised trials. The studies are case series, cohorts compared with earlier patients, and registry analyses.
  • Short follow-up. The pooled studies have a median of about 3 years [32], and few registry patients have reached 10 years.
  • Who did the studies. Much of the data comes from the centres that developed the implants, from very experienced surgeons, or from manufacturer approval studies. One paper's consultancy and royalty declarations were added after publication in a correction [33][9].
  • Socket treatment. Many patients also had their socket reshaped at the same operation, which makes it harder to tell what the material itself contributes [11][13][16].
  • Cost. Pyrocarbon heads cost more than metal ones.

What this means

  • Against a metal half replacement, the evidence consistently favours pyrocarbon.
  • Against a total shoulder replacement, revision rates look similar so far, and early function and pain have been slightly better with a total replacement in two studies. The pyrocarbon option keeps the socket intact, which leaves more choices for later surgery.
  • The socket can still wear, and how well the ball is sized matters a great deal.
  • Long-term results beyond 10 years, and results outside specialist centres, are not yet known.

Reviewed by Hand-authored 2026-10-27 — approved for publication by Dr Hirpara · 26 October 2026.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References for the advanced reading
  1. McBride AP, Ross M, Hoy G, Duke P, Page R, Peng Y, 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):755-62.
  2. Fares MY, Singh J, Boufadel P, Cohn MR, Abboud JA. Pyrocarbon hemiarthroplasty and the shoulder: biomechanical and clinical results of an emerging treatment option. Clin Shoulder Elb. 2024;27(1):110-8.
  3. Barret H, Garret J, Favard L, Bonnevialle N, Collin P, Gauci MO, et al. Long-term (minimum 10 years) survival and outcomes of pyrocarbon interposition shoulder arthroplasty. J Shoulder Elbow Surg. 2025;34(3):739-49.
  4. 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):421-37.
  5. Hoy G, Burrows K, McBride A, Ross M, Davis K, Warby S. PyroTITAN pyrocarbon shoulder hemiarthroplasty. J Bone Joint Surg Am. 2026.
  6. McBride A, Hurley R, Gill D, Du P, Duke P, Taylor F, 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):1209-18.
  7. 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):1594-600.
  8. Hatzidakis AM, Mauter L, Rossington AK, Venegoni M, Tashjian RZ. Quality and rate of recovery after Simpliciti anatomic total shoulder arthroplasty and Tornier pyrocarbon hemiarthroplasty: a propensity score-matched comparative study. J Shoulder Elbow Surg. 2026.
  9. Park CN, Zhang GX, Chang J, Zeng SL, Meyer LE, Hurley ET, et al. Pyrocarbon hemiarthroplasty of the shoulder: a systematic review and meta-analysis of clinical results. J Shoulder Elbow Surg. 2023;32(6):1323-32.
  10. Sanchez-Sotelo J. Pyrocarbon shoulder hemiarthroplasty seems to outperform metallic hemiarthroplasty at a short-term follow-up [commentary]. J Bone Joint Surg Am. 2026;108(8):529-30.
  11. Schemitsch GW, Carroll P, Henry P, Nam D, Sheth U. The use of pyrocarbon as a bearing surface in shoulder arthroplasty: a systematic review and meta-analysis. Shoulder Elbow. 2025;18(2):193-202.
  12. Garret J, Cuinet T, Ducharne L, van Rooij F, Saffarini M, Nover L, et al. 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):328-34.
  13. McBride AP, Ross M, Hoy G, Duke P, Page R, Peng Y, 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):755-62.
  14. Fares MY, Singh J, Boufadel P, Cohn MR, Abboud JA. Pyrocarbon hemiarthroplasty and the shoulder: biomechanical and clinical results of an emerging treatment option. Clin Shoulder Elb. 2024;27(1):110-8.
  15. Hannoun A, Ouenzerfi G, Brizuela L, Mebarek S, Bougault C, Hassler M, et al. Pyrocarbon versus cobalt-chromium in the context of spherical interposition implants: an in vitro study on cultured chondrocytes. Eur Cell Mater. 2019;37:1-15.
  16. McBride A, Hurley R, Gill D, Du P, Duke P, Taylor F, 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):1209-18.
  17. Barret H, Gauci MO, Langlais T, van der Meijden OA, Tran L, Boileau P. Pyrocarbon interposition shoulder arthroplasty in young arthritic patients: a prospective observational study. J Shoulder Elbow Surg. 2020;29(1):e1-10.
  18. Barret H, Garret J, Favard L, Bonnevialle N, Collin P, Gauci MO, et al. Long-term (minimum 10 years) survival and outcomes of pyrocarbon interposition shoulder arthroplasty. J Shoulder Elbow Surg. 2025;34(3):739-49.
  19. Aguilar-Gonzalez J, Vismara V, Lamo-Espinosa JM, Ranieri R, Aroca-Navarro JE, Sanchez-Sotelo J. Pyrocarbon implants in shoulder arthroplasty: a systematic review and meta-analysis. JSES Rev Rep Tech. 2026;6(3):100784.
  20. Pangaud C, Gonzalez JF, Galvin JW, Gauci MO, Boileau P. Fracture of pyrocarbon humeral head resurfacing implant: a case report. J Shoulder Elbow Surg. 2020;29(8):e306-12.
  21. Garret J, Harly E, Le Huec JC, Brunner U, Rotini R, Godêneche A. Pyrolytic carbon humeral head in hemi-shoulder arthroplasty: preliminary results at 2-year follow-up. JSES Open Access. 2019;3(1):37-42.
  22. Cointat C, Raynier JL, Vasseur H, Lareyre F, Raffort J, Gauci MO, et al. Short-term outcomes and survival of pyrocarbon hemiarthroplasty in the young arthritic shoulder. J Shoulder Elbow Surg. 2022;31(1):113-22.
  23. Hatzidakis AM, Garrigues GE, Mauter LA, de Gast A, Venegoni MR, Yang Y, et al. Clinical outcomes of pyrocarbon hemiarthroplasty: a short-term, multicenter study. J Bone Joint Surg Am. 2026;108(8):572-83. Epub 2025.
  24. 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.
  25. Ranieri R, Cointat C, Lacouture-Suarez J, 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):726-38.
  26. Griswold BG, Berger JM, Davis BP, Mauter L, Boyd M, Schuette HB, et al. Five-year radiographic and clinical outcomes of pyrocarbon hemiarthroplasty for glenohumeral arthritis and osteonecrosis. J Bone Joint Surg Am. 2025;107(24):2751-62.
  27. 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):421-37.
  28. Hoy G, Burrows K, McBride A, Ross M, Davis K, Warby S. PyroTITAN pyrocarbon shoulder hemiarthroplasty. J Bone Joint Surg Am. 2026.
  29. Droz LG, Damron AL, Hurley ET, Lorentz SG, Anakwenze OA, Boachie-Adjei YD, et al. Short- to midterm outcomes following pyrocarbon glenohumeral hemiarthroplasty: a retrospective review. J Shoulder Elb Arthroplast. 2026;10(4):100067.
  30. Douven DP, Geijsen GP, van Kampen PM, Heijnen SA, van Dijck R, van Eijk F, et al. Comparing revision rates and survival of pyrocarbon and non-pyrocarbon heads in total shoulder and hemi-shoulder arthroplasty. J Shoulder Elbow Surg. 2025;34(4):1016-23.
  31. Rotman D, Maman O, Kazum E, Chechik O, Maman E. Pyrolytic carbon head hemiarthroplasty vs. cobalt-chromium head for proximal humerus fractures: a short-term follow-up study. J Shoulder Elbow Surg. 2026;35(4):949-55.
  32. 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):1594-600.
  33. Hatzidakis AM, Mauter L, Rossington AK, Venegoni M, Tashjian RZ. Quality and rate of recovery after Simpliciti anatomic total shoulder arthroplasty and Tornier pyrocarbon hemiarthroplasty: a propensity score-matched comparative study. J Shoulder Elbow Surg. 2026.
  34. Park CN, Zhang GX, Chang J, Zeng SL, Meyer LE, Hurley ET, et al. Pyrocarbon hemiarthroplasty of the shoulder: a systematic review and meta-analysis of clinical results. J Shoulder Elbow Surg. 2023;32(6):1323-32.
  35. 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(6):2476-85.
  36. Carofino BC. Letter to the Editor regarding Kleim et al: “pyrocarbon hemiprostheses show little glenoid erosion and good clinical function at 5.5 years of follow-up”. J Shoulder Elbow Surg. 2024;33(8):e459-60.
  37. Kleim BD, Brunner UH. Response to Carofino regarding: “pyrocarbon hemiprostheses show little glenoid erosion and good clinical function at 5.5 years of follow-up”. J Shoulder Elbow Surg. 2024;33(8):e461-3.
  38. Sanchez-Sotelo J. Pyrocarbon shoulder hemiarthroplasty seems to outperform metallic hemiarthroplasty at a short-term follow-up [commentary]. J Bone Joint Surg Am. 2026;108(8):529-30.
  39. McBride A, D’Costa E, Duke P, Ross M. Pyrocarbon shoulder hemiarthroplasty: a surgical technique. Shoulder Elbow. 2026.
  40. Garret J, Godêneche A, Boileau P, Molé D, Etzner M, Favard L, et al. Midterm results of pyrocarbon interposition shoulder arthroplasty: good outcomes after posttraumatic osteonecrosis without malunion of the tuberosities. JSES Int. 2022;6(5):787-94.
  41. Lajoinie L, Garret J, van Rooij F, Saffarini M, Godêneche A. Pyrocarbon hemi-shoulder arthroplasty provides satisfactory outcomes following prior open Latarjet. J Shoulder Elb Arthroplast. 2024;8:24715492241292857.
  42. Hirakawa Y, Ode GE, Le Coz P, Onishi S, Baverel L, Ferrand M, et al. Poor results after pyrocarbon interpositional shoulder arthroplasty. J Shoulder Elbow Surg. 2021;30(10):2361-9.
  43. Schemitsch GW, Carroll P, Henry P, Nam D, Sheth U. The use of pyrocarbon as a bearing surface in shoulder arthroplasty: a systematic review and meta-analysis. Shoulder Elbow. 2025;18(2):193-202.
  44. Erratum to: Fracture of pyrocarbon humeral head resurfacing implant: a case report. J Shoulder Elbow Surg. 2021;30(3):e136.

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j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.