Hip Resurfacing vs Replacement: Who Still Benefits From Resurfacing

The question usually arrives in the exam room the same way: a 52-year-old who still runs trail races, or coaches wrestling, or hauls drywall for a living, sits across from the surgeon and asks, “Isn’t there something that saves more of my bone?” The hip has been aching for three years. The X-ray shows cartilage worn down to bare bone. And somewhere online, this patient has read about hip resurfacing.

Fifteen years ago, that conversation happened constantly. In some countries, resurfacing briefly accounted for nearly one in ten hip surgeries. Today it makes up less than 1 percent of hip procedures in the United States, not because the idea failed, but because we learned exactly who it helps and, just as important, who it quietly harms.

That narrowing is actually good news. For the right patient, resurfacing still earns its place. The trick is knowing whether you’re that patient.

What is hip resurfacing, exactly?

Picture the hip as a ball rotating in a socket. Osteoarthritis grinds away the smooth cartilage coating both surfaces until bone scrapes on bone: that’s the deep groin ache and the stiffness that makes tying shoes feel like a project.

Hip resurfacing addresses the problem the way a dentist crowns a damaged tooth. The surgeon reshapes the worn femoral head, the ball at the top of the thigh bone, and caps it with a polished metal dome anchored by a short peg. The socket side gets a thin metal cup pressed into the pelvis. The femoral head and neck stay largely intact, and the hollow canal of the thigh bone is never opened.

Compare that with a total hip replacement, where the surgeon cuts off the femoral head entirely and drives a stem several inches down into the thigh bone to hold an artificial ball. Both operations relieve arthritis pain reliably. The difference is how much of your original skeleton is left when the surgeon closes the incision.

One detail matters more than any other: every resurfacing system in mainstream use pairs a metal ball against a metal socket. Total replacements moved on years ago to ceramic or metal heads gliding on highly cross-linked plastic, combinations with excellent long-term wear data. That single engineering fact, metal on metal, explains nearly everything about why resurfacing went from rising star to niche procedure, and it should sit at the center of any decision you make.

Hip resurfacing vs hip replacement: what's actually different?

Side by side, the two operations look more like cousins than twins. The incision, anesthesia, and hospital course are similar. What differs is the hardware and what it demands of your anatomy.

	Hip resurfacing	Total hip replacement
Bone removed	Surface of the femoral head only	Entire femoral head; canal of thigh bone opened for a stem
Ball size	Near-natural, typically 44–54 mm	Smaller artificial head, commonly 28–36 mm
Bearing surfaces	Metal on metal	Ceramic or metal on cross-linked plastic; ceramic on ceramic
Dislocation risk	Very low, thanks to the large ball	Low, roughly 1–2% depending on approach
Unique risk	Femoral neck fracture (~1–2%); metal ion reactions	Stem-related thigh pain; plastic wear over decades
Typical candidate	Active men under ~60 with strong bone and osteoarthritis	Nearly anyone with end-stage hip arthritis
If it fails	Usually convertible to a standard replacement	Revision surgery, more involved on the femoral side

Read that table with one eye on the future. The bone a resurfacing preserves isn’t sentimental: it’s a bank account. A 50-year-old may plausibly outlive any implant, and starting with more femur makes the second operation, if one comes, closer to a first-time replacement than a salvage job.

Which is better, hip replacement or hip resurfacing?

Honest answer: for most people, a modern total hip replacement is the better-supported choice, and the evidence isn’t particularly close.

National joint registries: the databases that track hundreds of thousands of implants in countries like Australia, the UK, and Sweden, consistently show higher overall revision rates for resurfacing than for conventional replacement. When implants fail early in women, in smaller patients, and in people with weaker bone, those failures show up in the averages, and they did, loudly, through the 2010s.

But averages hide subgroups. Pull out one specific population, men under roughly 55 to 60, with osteoarthritis rather than inflammatory disease, large enough anatomy to fit a femoral component of about 48 mm or more, operated on by surgeons who do resurfacing regularly, and the registry picture changes. In that group, survivorship of well-established resurfacing designs runs in the mid-90s percent at ten years, competitive with total replacement in the same young, hard-driving patients.

Meanwhile, total replacement has quietly gotten very good for everyone. Long-term registry analyses suggest roughly six in ten standard hip replacements are still functioning 25 years after surgery, and modern bearing materials wear far more slowly than the plastics of the 1990s. Young age is no longer the disqualifier for replacement it once was.

So the real question isn’t which operation wins in the abstract. It’s whether you belong to the narrow slice of patients where resurfacing’s advantages, preserved bone, a near-natural ball, exceptional stability, outweigh a metal-on-metal bearing’s risks. For perhaps 95 percent of people with hip arthritis, they don’t.

Why did hip resurfacing nearly disappear?

The rise and fall happened fast. Through the mid-2000s, resurfacing was orthopedics’ answer for the young arthritis patient: keep the bone, keep the big ball, keep running. Adoption soared, close to 10 percent of hip procedures in Australia at the peak, and popular in the UK as well.

Then the metal-on-metal reckoning arrived. Around 2010, evidence accumulated that certain metal-on-metal hips, mostly conventional replacements fitted with large metal heads, but some resurfacing designs too, shed cobalt and chromium particles into surrounding tissue and the bloodstream. In a minority of patients, those particles triggered inflammatory reactions that destroyed muscle and bone around the joint, sometimes with few warning symptoms. Several implant systems were withdrawn from the market. Regulators in the US and Europe tightened oversight and recommended ongoing monitoring for anyone carrying a metal-on-metal bearing.

Resurfacing absorbed collateral damage from designs that performed far worse than its best implants, but it also had genuine problems of its own: unacceptably high failure rates in women and in patients with small components. Surgeons responded rationally. Usage collapsed to under 1 percent of hip procedures in the US, only a small number of resurfacing designs remain in mainstream use, and the operation concentrated in the hands of a modest group of high-volume specialists.

That concentration is worth pausing on. Resurfacing is technically less forgiving than replacement, component position tolerances are tight, and a slightly tilted cup accelerates wear. The procedure’s best published results come almost exclusively from surgeons who perform it often. The average orthopedic surgeon in the US may do few or none per year.

Who still benefits from hip resurfacing?

A composite of the ideal candidate, drawn from registry data and specialist consensus, looks like this:

• A man, typically under about 60. Not as a matter of preference: the failure data diverge sharply by sex and component size, as the next section explains.
• Osteoarthritis as the diagnosis. Inflammatory arthritis, significant hip dysplasia, or bone death (avascular necrosis) involving a large portion of the femoral head all weaken the very bone the implant depends on.
• Strong, dense bone. The femoral neck stays in place and must bear load; osteoporosis or long-term steroid use tips the scales toward replacement.
• Larger anatomy. Femoral components of roughly 48 mm and up perform dramatically better. Smaller heads concentrate wear and shed more metal.
• Genuinely high physical demands. Distance runners, competitive athletes, martial artists, farmers, firefighters, people whose life plans involve repetitive impact that would make a surgeon think hard about decades of plastic wear.
• Normal kidney function and no known metal sensitivity, since the kidneys clear metal ions and hypersensitivity can provoke local reactions.

There’s a second, less obvious beneficiary: the patient thinking two operations ahead. A 45-year-old will likely need revision surgery someday no matter which implant is chosen. Resurfacing first, replacement later is a sequence some specialists favor for the very young, because converting a resurfacing generally leaves the surgeon with a nearly untouched femur to work with.

None of this is self-diagnosable from a checklist. Bone density, head size, and anatomy come from imaging and measurement, which is exactly why this decision runs through a surgeon who performs both operations.

Why sex and bone size change the math

This is the part of the resurfacing story that deserves the most careful telling, because it can sound like gatekeeping and is actually geometry.

Resurfacing components come in sizes matched to the patient’s own femoral head. Smaller heads create two engineering problems at once. First, a smaller metal-on-metal bearing runs closer to the edge of its lubrication limits, so any slight malposition produces disproportionate wear and metal release. Second, a smaller femoral neck leaves a thinner margin of bone around the implant’s peg, raising fracture risk.

Women, on average, have smaller femoral heads and lower bone density than men of the same age, averages, not rules, but averages that showed up unmistakably in the registries. Revision rates for resurfacing in women ran several times higher than in men across multiple national databases. Layer on an unresolved question about circulating cobalt and chromium ions during the childbearing years, ions do cross the placenta, and while no harm has been demonstrated, long-term data are thin, and most specialist centers stopped offering resurfacing to women altogether.

The same size logic applies to smaller-framed men. A man whose anatomy fits only a 44 mm component faces worse odds than one who fits a 52 mm component, regardless of anything else on his chart.

What the evidence does not say is that women or smaller patients are out of options. Total hip replacement performs superbly across sexes and sizes, and newer bearing materials have largely erased the old worry that a young, active woman would simply wear out a plastic liner. Different anatomy, different best answer: that’s the whole message.

What are the downsides of hip resurfacing?

Every operation charges a toll. Resurfacing’s toll booth has a few lanes replacement doesn’t.

Femoral neck fracture. Because the neck of the thigh bone remains and keeps bearing weight, it can crack, usually within the first few months, before bone fully adapts. Registries put the risk around 1 to 2 percent. When it happens, the fix is conversion to a total replacement.

Metal ion reactions. The signature risk. Cobalt and chromium particles from the bearing can inflame surrounding tissue, occasionally forming fluid collections or soft-tissue masses (sometimes called pseudotumors) that damage muscle and bone. Most patients never develop them; a minority do, and some feel little pain until damage is advanced. This is why lifelong follow-up, periodic exams, and blood metal-level tests or specialized MRI when indicated, comes bundled with the operation.

A narrower safety margin in surgery. Component positioning tolerances are tighter than in replacement, so surgeon experience carries unusual weight.

Logistics. With so few high-volume resurfacing surgeons in the US, many candidates travel for the procedure, which complicates follow-up and adds cost.

Residual groin discomfort. A small percentage of patients report irritation where the hip flexor tendon passes over the relatively large implant edge, usually manageable, occasionally persistent.

Set against all that, resurfacing gives up remarkably little in pain relief. Studies comparing well-selected resurfacing and replacement patients find similar improvements in pain and function. The downsides live in the risk column, not the relief column, which is exactly why candidate selection dominates this decision.

How long will hip resurfacing last?

The honest answer comes in two halves, and both matter.

Across all patients ever given a resurfacing, including the women and small-component patients who should arguably never have received one, durability looks mediocre. Registry revision rates for resurfacing as a whole ran roughly twice those of conventional replacement over the first decade, which is a big reason the procedure contracted.

Restrict the view to today’s actual candidates, and the picture brightens considerably. In men under about 55 to 60 with osteoarthritis and components of 48 mm or larger, implanted by experienced surgeons, ten-year survivorship of established designs sits around 95 percent in registry and specialist-center data. High-volume centers have published series with roughly nine in ten implants still functioning at 15 to 20 years in ideal candidates. Those are strong numbers for any hip implant in a young, active population.

Two caveats keep this honest. First, the best long-term figures come disproportionately from a handful of expert centers; your local results depend heavily on your surgeon’s resurfacing volume. Second, “surviving” means the implant hasn’t been revised: it doesn’t guarantee the joint feels perfect, and ongoing metal-ion surveillance continues for the implant’s whole life.

For comparison, a modern total hip replacement in the same young man carries excellent odds too: registry analyses suggest most standard replacements last well past 15 years, with roughly six in ten reaching 25. In well-chosen patients, the durability race is close enough that the decision usually turns on other factors, bone preservation, activity plans, and tolerance for metal-ion monitoring.

Should you worry about metal ions in your blood?

Worry is the wrong verb; monitor is the right one.

Any metal-on-metal bearing releases microscopic cobalt and chromium particles as its surfaces glide. In a well-positioned, well-functioning resurfacing, the amounts are small and blood levels typically stay low and stable. The kidneys clear the ions continuously. Millions of people have lived for decades with metal implants of various kinds without systemic illness.

Problems arise when wear accelerates, usually because a component sits at a poor angle, and ion release climbs. Locally, that can inflame tissue around the hip. Systemically, at very high sustained levels, cobalt has been linked in rare case reports to effects on the heart, thyroid, hearing, and vision. Those cases are genuinely uncommon and are overwhelmingly associated with malfunctioning implants, not routine ones.

The practical response is a surveillance routine, and regulators in both the US and UK recommend one for metal-on-metal hip patients. Expect some combination of:

• Periodic clinical check-ins, even when the hip feels perfect
• Blood tests measuring cobalt and chromium levels, with rising trends prompting closer looks
• Specialized MRI (designed to see around metal) if levels climb or symptoms appear
• A lower threshold for imaging if you develop new groin pain, swelling, or a change in walking

Two groups deserve special caution flags: people with impaired kidney function, who clear ions less efficiently, and women who may become pregnant, since ions cross the placenta and long-term data are limited. Both concerns are already baked into modern candidacy criteria, one more reason the ideal-candidate profile looks the way it does.

Can you run and play sports after hip resurfacing?

This is the promise that draws most people to resurfacing in the first place, so it deserves a clear-eyed look.

The mechanical case is real. The resurfaced ball is nearly the size of your natural one, which makes dislocation rare and preserves a natural-feeling range of motion. The load passes through the femoral head and neck the way it always did, rather than being rerouted down a stem. Observational studies of resurfacing patients report high rates of return to demanding activity, running, tennis, skiing, martial arts, manual labor, and surveys of specialist surgeons show they’re generally more permissive about repetitive impact after resurfacing than after replacement.

Now the honesty portion. Much of that evidence is observational and comes from motivated patients treated at expert centers, which flatters the results. There’s no randomized trial proving a resurfacing patient runs better or longer than a replacement patient. And total hip patients are far from housebound: most return to hiking, cycling, swimming, golf, doubles tennis, and skiing, and plenty run recreationally, though many surgeons still counsel moderation with high-mileage impact on a plastic bearing over decades.

Timing matters more than ambition in the first year. The retained femoral neck needs months to adapt to its new loading pattern, and fracture risk concentrates in that early window. Most resurfacing protocols hold off on impact activity for roughly six months to a year, building through walking, cycling, and strength work first.

If your identity is genuinely built around impact sport, resurfacing has a legitimate edge worth discussing. If you mostly want to hike pain-free and chase grandchildren, both operations will get you there.

What does recovery from hip resurfacing look like?

Day to day, the first six weeks after resurfacing look a lot like the first six weeks after replacement: a fact that surprises people expecting a “smaller” operation to mean a smaller recovery.

Resurfacing is actually a slightly bigger surgical exposure than many modern replacements, because the surgeon must work around an intact femoral head rather than removing it. Expect a hospital stay of a night or two (some centers discharge the same day), a few weeks on crutches or a walker, and structured physical therapy focused on hip strength and gait. Most desk workers return to work within a few weeks; physically demanding jobs take two to three months.

Where the paths diverge is philosophy. Replacement patients with smaller implant heads often follow early movement precautions to protect against dislocation. Resurfacing patients worry less about dislocation, the big ball is inherently stable, and more about the femoral neck, which is why impact and heavy loading wait several months while bone remodels around the implant.

Sensible milestones, which your surgical team will tailor:

• Weeks 1–3: walking with support, gentle range-of-motion work, wound care
• Weeks 3–6: transition off walking aids, stationary cycling, most daily activities
• Months 2–4: progressive strength training, swimming, longer walks; driving typically resumes earlier once off pain medication and reaction times normalize
• Months 6–12: gradual return to impact activity if cleared

One recovery task is unique to resurfacing: showing up for surveillance. The follow-up visits and metal-level checks in years one, two, and beyond aren’t optional extras. They’re how the rare problem gets caught while it’s still small.

How much does hip resurfacing cost?

In the United States, resurfacing and total hip replacement usually land in the same broad financial neighborhood, because the big cost drivers, operating room time, anesthesia, implant hardware, hospital stay, rehabilitation, are similar for both.

Published estimates for hip arthroplasty procedures at US hospitals vary enormously by region and facility, with total billed charges commonly running from roughly $30,000 to $50,000 or more before insurance adjustments. What you actually pay depends far more on your coverage than on which operation you choose. A few practical realities:

• Insurance generally treats both the same way. Medicare and most commercial plans cover hip resurfacing when it’s medically appropriate, under the same umbrella as joint replacement. Prior authorization requirements vary, so confirm before scheduling.
• Travel is the hidden line item. Because high-volume resurfacing surgeons are scarce, many candidates travel out of state. Flights, lodging for a companion, and follow-up trips add real money that never appears on a hospital bill.
• Surveillance has a cost tail. Periodic metal-level blood tests and occasional specialized imaging over the implant’s lifetime are inexpensive individually but continue indefinitely.
• Network status trumps sticker price. An in-network replacement can cost you far less out of pocket than an out-of-network resurfacing, even if the hospitals’ list prices look similar.

The most useful move is unglamorous: ask each facility’s billing office for a written estimate tied to the specific procedure codes, and ask your insurer for your projected out-of-pocket cost under your plan. Estimates in hand beat averages on the internet every time.

If resurfacing fails, what happens next?

Every implant conversation should include the exit plan, and here resurfacing holds one of its strongest cards.

When a resurfacing fails, a femoral neck fracture, loosening, or a metal-related tissue reaction, the standard solution is conversion to a total hip replacement. Because the original operation never opened the femoral canal, the surgeon typically finds a nearly virgin femur: the head comes off, a standard stem goes in, and the femoral side of the revision resembles a first-time replacement more than a salvage operation. Studies of conversions done for fracture or straightforward loosening generally report outcomes approaching those of primary hip replacement.

The asterisk involves metal reactions. If an adverse tissue response has damaged muscle and bone around the joint before it’s caught, the revision becomes more complex and the results less predictable, soft tissue, once destroyed, doesn’t fully return. This is the strongest practical argument for taking surveillance seriously: the difference between an easy conversion and a hard one is often simply how early the problem was found.

Contrast this with revising a total replacement, where removing a well-fixed stem from inside the femur can require splitting the bone and rebuilding with longer implants. It’s routine work for revision specialists, but it consumes bone stock each time.

This is why some surgeons frame resurfacing for the very young patient as buying a good first decade or two at low future cost: if it lasts, wonderful; if it doesn’t, you’ve likely landed where you would have started anyway, with bone to spare. That logic only holds, though, for patients whose risk of early metal-related failure is genuinely low, which brings everything back, once again, to candidate selection.

When should you see a doctor about hip pain?

Long before anyone debates implants, hip pain deserves a proper diagnosis, groin and hip symptoms can come from arthritis, tendon problems, hernias, spine conditions, and more, and the treatments differ completely.

Make a routine appointment if you notice:

• Hip or groin pain persisting beyond a few weeks despite rest and activity changes
• Stiffness that makes shoes, socks, or getting out of a car noticeably harder
• A limp, or pain that’s shortening your walking distance month over month
• Pain that wakes you at night or aches at rest
• Painkillers or anti-inflammatory approaches doing less than they used to

Seek prompt or urgent care for red flags: inability to bear weight after a fall or twist, sudden severe hip pain, fever or chills alongside joint pain, or a hip that looks deformed. A hip that can’t take weight needs imaging, not patience.

If you’ve already had a resurfacing or replacement, add these to the call-your-surgeon list: new or worsening groin pain months or years after a well-functioning implant, a sensation of clicking or squeaking with swelling, sudden pain after impact (in a resurfaced hip, this can signal a femoral neck fracture), calf swelling or warmth, or drainage and redness at the old incision. Fever with a painful implant is an emergency-level concern, since joint infections move fast.

None of this is meant to alarm, most hip pain has an unglamorous, treatable explanation. The point is that early evaluation widens your options. Arthritis caught early responds to exercise therapy, activity modification, and weight management strategies; surgery is the last chapter, not the first.

Frequently asked questions

How long will hip resurfacing last?

In well-selected patients, typically active men under about 60 with osteoarthritis and larger components, registry data show roughly 95 percent of resurfacings surviving ten years, and specialist centers report about nine in ten still functioning at 15 to 20 years. Across all patients historically, results were worse, largely due to failures in women and small-component recipients who are no longer considered candidates. Surgeon experience with resurfacing strongly influences durability.

What are the downsides of hip resurfacing?

The main downsides are femoral neck fracture in roughly 1 to 2 percent of patients, metal ion release from the metal-on-metal bearing that occasionally triggers damaging tissue reactions, lifelong monitoring with blood tests and sometimes specialized MRI, and very narrow candidacy. Few surgeons perform the procedure regularly, so many patients must travel. Pain relief, however, is comparable to total hip replacement in appropriate candidates: the trade-offs sit in the risk column, not the relief column.

Which is better, hip replacement or hip resurfacing?

For most people, total hip replacement is the better-supported operation, with excellent durability across ages, sexes, and bone quality using modern ceramic and cross-linked plastic bearings. Resurfacing competes only in a narrow group: younger, active men with strong bone, larger hip anatomy, and osteoarthritis, treated by experienced resurfacing surgeons. In that subgroup, ten-year results are comparable, and resurfacing adds preserved bone and exceptional stability. Outside it, replacement wins clearly.

How much does hip resurfacing cost?

In the US, resurfacing generally costs about the same as total hip replacement, with hospital charges for hip procedures commonly running roughly $30,000 to $50,000 or more before insurance. Medicare and most commercial plans cover resurfacing when medically appropriate. Your out-of-pocket cost depends on your plan and network status far more than the procedure itself. Factor in travel expenses if the nearest high-volume resurfacing surgeon is out of state, plus ongoing surveillance testing.

Who is a good candidate for hip resurfacing?

The strongest candidates are men under about 60 with hip osteoarthritis, dense healthy bone, anatomy large enough for a femoral component of roughly 48 mm or more, normal kidney function, and no metal sensitivity. High activity demands, running, competitive sport, heavy physical work, strengthen the case. Inflammatory arthritis, significant bone death in the femoral head, osteoporosis, and small anatomy all point toward total replacement instead. Imaging and measurement, not a checklist, settle candidacy.

Can women get hip resurfacing?

Most specialist centers no longer offer resurfacing to women, based on registry evidence rather than preference. Women’s smaller average femoral head size and lower bone density translated into revision rates several times higher than men’s, and questions remain about circulating metal ions during childbearing years, since ions cross the placenta. Total hip replacement performs excellently in women of all ages with modern bearings, so anatomy simply points to a different best answer.

Is hip resurfacing still done in the United States?

Yes, but rarely: it accounts for under 1 percent of US hip procedures, down from its mid-2000s peak. Only a small number of resurfacing designs remain in mainstream use, and the operation has concentrated among a modest group of high-volume specialists. That concentration is arguably good for patients, because resurfacing is technically less forgiving than replacement, and published results are consistently better in experienced hands. Many candidates travel to reach such surgeons.

Can I run after hip resurfacing?

Many patients do. Observational studies report high rates of return to running, tennis, skiing, and other impact activities after resurfacing, and surgeons are generally more permissive about repetitive impact than after replacement, since there’s no plastic bearing to wear and the near-natural ball resists dislocation. Expect to wait roughly six months to a year before impact activity, though, because the retained femoral neck needs time to adapt and early fracture risk is real.

What happens if hip resurfacing fails?

The standard solution is conversion to a total hip replacement. Because resurfacing never opens the femoral canal, the surgeon usually finds a nearly untouched thigh bone, and the conversion resembles a first-time replacement, with generally good outcomes when done for fracture or loosening. The exception is an advanced metal-related tissue reaction that has damaged surrounding muscle and bone, which makes revision harder: a strong argument for keeping every scheduled surveillance visit.

Do I need blood tests after hip resurfacing?

Plan on periodic monitoring for the life of the implant. Regulators in the US and UK recommend surveillance for metal-on-metal hip patients, typically including clinical check-ins and blood tests measuring cobalt and chromium levels, with specialized MRI if levels rise or symptoms appear. A well-functioning resurfacing usually shows low, stable levels. The tests exist to catch the uncommon accelerating-wear problem early, when fixing it is straightforward rather than complicated.

References

• MedlinePlus: Hip Replacement
• MedlinePlus Medical Encyclopedia: Hip joint replacement
• NHS: Hip replacement
• Cleveland Clinic: Hip Replacement

This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor about your individual situation.