Hip Resurfacing vs. Total Hip Replacement: Understanding Your Options

Key Takeaways

• Hip resurfacing preserves more bone but is only suitable for specific patients
• Total hip replacement is more widely applicable and has longer track record
• Resurfacing is best for younger, active men with good bone quality
• Women and smaller patients face higher failure rates with resurfacing
• Both procedures provide excellent pain relief for appropriate candidates
• The “best” choice depends on your individual anatomy, age, activity level, and goals

When hip arthritis reaches the point where surgery becomes necessary, you may have two options: traditional total hip replacement or the less common hip resurfacing. Understanding the differences helps you have an informed conversation with your surgeon.

Understanding the Procedures

Total Hip Replacement (THR)

What’s removed:

• The entire femoral head (ball)
• Damaged cartilage from the socket

What’s implanted:

• Metal stem inserted into the femur
• Metal or ceramic ball attached to stem
• Metal cup in the socket
• Plastic or ceramic liner in the cup

The result:

• Completely artificial joint
• Various bearing surface options
• Decades of proven success

Hip Resurfacing

What’s removed:

• Surface of the femoral head (trimmed, not removed)
• Damaged cartilage from the socket

What’s implanted:

• Metal cap over the reshaped femoral head
• Metal cup in the socket
• Metal-on-metal bearing surface

The result:

• Preserves the natural femoral head and neck
• Larger ball diameter than traditional THR
• Bone conservation for potential future revision

Key Differences Compared

Bone Preservation

Resurfacing:

• Preserves femoral head and neck
• Less bone removed overall
• Easier potential revision to THR later
• “Saving” bone for the future

Total replacement:

• Removes femoral head entirely
• Stem extends into femoral canal
• Standard revision options available
• Well-established revision techniques

Stability and Dislocation Risk

Resurfacing:

• Larger ball diameter (typically 46-54mm)
• Very low dislocation risk (less than 1%)
• More natural hip biomechanics
• Greater range of motion before impingement

Total replacement:

• Smaller ball typically (though large heads available)
• Low dislocation risk with modern techniques (1-2%)
• Activity precautions may be needed initially
• Large head options available to reduce risk

Bearing Surfaces

Resurfacing:

• Metal-on-metal only
• Releases metal ions (cobalt, chromium)
• Requires monitoring of metal levels
• Concerns have limited use in some countries

Total replacement:

• Multiple options: ceramic-on-ceramic, ceramic-on-plastic, metal-on-plastic
• No metal ion concerns with non-metal bearings
• Different wear characteristics
• Can match to patient needs

Who Is a Candidate for Resurfacing?

Ideal Candidates

Demographics:

• Male (lower failure rate in men)
• Under 65 (typically)
• Large femoral head size (>48mm)
• Good bone quality

Physical factors:

• Active lifestyle
• Larger body frame
• No femoral head cysts or deformity
• Normal kidney function
• Not allergic to metal

Poor Candidates for Resurfacing

Demographics:

• Women (higher failure rates documented)
• Smaller patients with small femoral heads
• Older patients with osteoporosis

Medical factors:

• Kidney problems (can’t clear metal ions)
• Metal hypersensitivity
• Inflammatory arthritis
• Significant femoral head deformity
• Femoral neck issues

The Gender Issue

Studies have consistently shown:

• Women have 2-3x higher failure rates with resurfacing
• Smaller component sizes correlate with higher failure
• Women typically have smaller femoral heads
• This has led many surgeons to avoid resurfacing in women

Who Is a Candidate for Total Replacement?

Almost Everyone with Hip Arthritis

THR is appropriate for:

• Any gender
• Wide age range (though typically 50+)
• Various body sizes
• Different bone qualities
• Most medical conditions

Modern THR Options

Bearing surfaces:

• Ceramic-on-ceramic: Most wear resistant
• Ceramic-on-polyethylene: Excellent track record
• Metal-on-polyethylene: Well-established
• Large head options: Reduce dislocation risk

Fixation:

• Cementless: Most common in younger patients
• Cemented: Excellent for older patients or poor bone
• Hybrid: Combination approach

Outcomes Comparison

Pain Relief

Both procedures provide excellent pain relief:

• 95%+ report significant improvement
• Most patients pain-free or minimal pain
• Similar patient satisfaction for appropriate candidates

Longevity

Total hip replacement:

• 20-25 year survival: >90%
• Well-documented long-term outcomes
• Continued improvement in implant designs

Hip resurfacing:

• Variable results by patient selection
• Best results in young, active men: >95% at 15 years
• Concerning failure rates in women and small patients
• Longer follow-up data still accumulating

Activity Level

Resurfacing claims:

• More natural hip mechanics
• Better for high-demand activities
• Some surgeons allow more activities

THR reality:

• Modern THR allows high activity levels
• Large head options provide stability
• Many THR patients return to sports
• Difference may be minimal in practice

Complications

Resurfacing-specific risks:

• Metal ion release (all patients)
• ARMD (adverse reaction to metal debris)
• Femoral neck fracture (1-2%)
• Pseudotumors
• Requires monitoring

THR-specific risks:

• Dislocation (reduced with modern techniques)
• Leg length discrepancy
• Loosening over time
• Bearing wear

Both procedures:

• Infection (less than 1%)
• Blood clots
• Nerve injury (rare)

The Metal-on-Metal Concern

What Happened

Hip resurfacing uses metal-on-metal (MoM) bearings exclusively. This led to concerns:

Problems identified:

• Metal ion release into bloodstream
• Soft tissue reactions in some patients
• Pseudotumors around the hip
• Higher than expected revision rates in some designs
• Recalls of certain implants

Current status:

• Many surgeons stopped offering resurfacing
• Specific designs remain in use with good results
• Strict patient selection is crucial
• Regular monitoring required

Monitoring Requirements

If you have hip resurfacing:

• Regular blood tests for metal ion levels
• Imaging if symptoms develop
• Long-term follow-up important
• Report new hip symptoms promptly

Making the Decision

Questions for Your Surgeon

1. Am I a candidate for both procedures?
2. What are your results with each procedure?
3. How many of each do you perform yearly?
4. What’s your revision rate?
5. Given my specific situation, which do you recommend and why?

Factors to Consider

Favoring resurfacing:

• Young male patient
• Very active lifestyle
• Large anatomy
• Concern about bone preservation
• Surgeon with extensive experience

Favoring total replacement:

• Female patient
• Smaller anatomy
• Older age
• Osteoporosis or bone concerns
• Want to avoid metal ion monitoring
• Surgeon less experienced with resurfacing

The Reality

• 95%+ of hip replacements are THR
• Resurfacing is a niche procedure for specific patients
• THR technology continues to advance
• An excellent THR often better than a mediocre resurfacing

Recovery Comparison

Similar Recovery Trajectories

Both procedures have comparable recovery:

Hospital stay:

• 1-3 days for either
• Same-day discharge possible for both

Weight bearing:

• Usually immediate with walker
• Progress to cane over 2-4 weeks

Return to activities:

• Driving: 3-6 weeks
• Desk work: 2-4 weeks
• Full recovery: 3-6 months

Precautions Differ

After THR:

• Hip precautions may apply (avoid certain positions)
• Duration varies (6 weeks to lifetime depending on surgeon)
• Large head THR may have fewer precautions

After resurfacing:

• Typically fewer activity restrictions
• Lower dislocation concern
• Still need to protect healing

Costs and Insurance

Similar Costs

Both procedures cost roughly the same:

• $30,000-$50,000 total
• Most insurance covers both when medically necessary
• Medicare covers both
• Resurfacing may be harder to find

Access Issues

Finding a surgeon:

• THR: Widely available
• Resurfacing: Limited surgeons still perform it
• Travel may be needed for experienced resurfacing surgeon

Frequently Asked Questions

Why is resurfacing less common now?

Concerns about metal-on-metal bearings, higher failure rates in certain groups (women, small patients), and excellent results with modern THR have led many surgeons to favor total replacement.

Can resurfacing be converted to THR later?

Yes, this is one advantage of resurfacing—more bone is preserved. Conversion to THR is straightforward, though slightly more complex than a first-time THR.

Will my hip feel more normal with resurfacing?

Some studies suggest better proprioception (joint position sense) with resurfacing. However, differences in patient-reported outcomes between well-done procedures of either type are often minimal.

What about ceramic hip resurfacing?

Ceramic-on-ceramic hip resurfacing is being developed to address metal ion concerns. It’s not widely available yet and lacks long-term data, but may be a future option.

How do I find a surgeon experienced in resurfacing?

Ask potential surgeons about their volume and outcomes. Consider surgeons who do 20+ resurfacing procedures yearly. Be willing to travel for expertise if resurfacing is important to you.

---

Exploring hip treatment options? Read about when hip replacement becomes necessary or learn about physical therapy for hip arthritis.

Last medically reviewed: February 2025

Medical Disclaimer: This article is for informational purposes only and is not a substitute for professional medical advice. Discuss all surgical options with your orthopedic surgeon, who can evaluate your individual anatomy and recommend the best approach for your situation.