Hip Resurfacing vs. Total Hip Replacement

My position, stated plainly

I counsel patients against hip resurfacing. It is not a better operation than a total hip replacement, it does not last longer, and the way it fails is worse.

I want to be fair about this, because the patients who ask me about resurfacing have almost always done genuine research. There is a real case for it and I will lay it out honestly below. But my reasoning has very little to do with surgical technique and almost everything to do with what a metal-on-metal bearing does inside the body over years — and with the fact that the thing patients want from resurfacing is already available without it.

What resurfacing actually is

In a total hip replacement, the arthritic femoral head is removed and replaced with a stem down the femur and a new ball on top, articulating against a socket implanted in the pelvis.

In hip resurfacing, the femoral head is kept and capped — reshaped and covered with a metal shell, like a crown on a tooth — which then articulates against a metal socket. The femoral neck is preserved, and considerably more of your own bone stays in place.

That bone preservation is the genuine idea behind the operation, and it is not a silly one.

Why it appeals — the honest case for it

If I only presented the drawbacks I would not be describing the conversation accurately. The arguments in favour are real:

Those points are why the operation exists and why some excellent surgeons still offer it. They are also, unfortunately, what the marketing leads with — while the failure pattern is much harder for a patient to find, because it tends to surface years later and often in a different surgeon's office.

The metal-on-metal problem

This is the heart of it. To cap a femoral head and keep the head large, the bearing has to be thin and strong — which in practice has meant metal articulating against metal. Nearly every resurfacing implant works this way.

Every bearing surface in the body wears. The question is what it wears into. A metal-on-metal bearing sheds cobalt and chromium particles and ions, and those do not stay put — they enter the surrounding tissue and the bloodstream.

In a proportion of patients, the body reacts to that debris:

That last one is why my view is as firm as it is. I have seen complete destruction of the abductor tendons from an adverse metal reaction, and that is not recoverable. A revision can exchange the implant. It cannot rebuild tendon that has been dissolved. A hip without functioning abductors does not walk normally afterwards, no matter what hardware replaces it.

Here is the part I think patients are rarely told plainly: the articulation in a hip resurfacing is the same metal-on-metal bearing that was used in metal-on-metal total hip replacements. It is not a related technology or a distant cousin. It is the same bearing surface, in a different housing.

And metal-on-metal total hips are gone. Some were formally recalled. Others were quietly withdrawn by the manufacturers. In plenty of cases no regulator had to act at all — surgeons simply stopped using them, because the failure pattern became obvious to everyone in the field. You do not need a recall notice to abandon a bearing you have watched fail.

Which leaves a question I genuinely cannot answer well: if the profession abandoned metal-on-metal articulations in total hip replacement, why is the same articulation still being marketed to patients as the premium, athletic option in a resurfacing? A small number of resurfacing implants do remain approved, but approval is not the same as a good idea, and it does not change what the bearing is made of or how it behaves.

A risk unique to resurfacing

Because resurfacing preserves the femoral neck, it also leaves the femoral neck able to break. Femoral neck fracture after resurfacing is a recognised complication with no equivalent in a total hip replacement, where that bone has been removed and replaced by the stem.

It is not common, but when it happens it means an unplanned second operation, converting to a total hip — the operation you were trying to avoid, now performed under worse circumstances.

Longevity and revision

Patients often assume resurfacing must last longer because less bone was removed. The durability record does not support that. Modern total hip replacement is one of the most reliable operations in medicine, with the large majority of implants still functioning decades later. Resurfacing does not match it.

And the revision picture cuts the opposite way from how it is usually presented. The bone-preservation argument says a resurfacing is easier to revise later. That is true in the straightforward case — but the failures that actually occur are frequently the metal-reaction ones, where the problem is not the bone at all. It is the soft tissue, and by the time it is recognised the damage may already be done.

For the wider picture on how long a modern hip lasts, see how long a hip replacement lasts.

But what about the athletes?

This is usually the real question underneath the question. Patients read that professional athletes have returned to elite sport after resurfacing, and they conclude — reasonably — that resurfacing must be the operation for people who want to stay active.

Here is my answer, and it is the most important paragraph on this page:

If the reason to consider resurfacing is that a total hip will limit your life, then the premise is simply not true in my practice. My direct anterior patients are every bit as active as anyone who has had a resurfacing — not less. Modern bearings, modern fixation, and a muscle-sparing approach have settled the activity question. You do not need to accept a metal-on-metal bearing to get your sport back.

More on what that looks like in what you can and can't do after a hip replacement.

What I do instead

My standard is a ceramic head on a highly cross-linked polyethylene liner, implanted through a muscle-sparing direct anterior approach.

That combination is why modern hip replacement results are what they are. It is not the flashiest answer. It is the one with the best evidence behind it.

The counterargument, and why I still disagree

A small number of experienced surgeons continue to perform hip resurfacing, generally in a narrow group — younger men with good bone quality and larger femoral heads — using implants that remain approved, and some report good results in that selected population. That is a real position held by capable people, and you should hear it from someone who holds it rather than only from me.

But I will be honest that I disagree with it, and not mildly. When a total hip fails it is usually a mechanical problem with a mechanical solution. When a resurfacing fails through an adverse reaction to metal debris, the damage reaches tissue that cannot be replaced — and I have seen where that ends. Given that a modern total hip already delivers both the durability and the activity, I am not willing to accept that risk on a patient's behalf, and I do not think it should be marketed as the better choice.

If you are weighing this decision and have been offered a resurfacing, it is exactly the sort of question worth a second opinion on — including from someone who performs the operation, so you hear both cases properly.