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Hip resurfacing

114 citationsUpdated Sep 2026

Overview

Hip resurfacing is a viable alternative to total hip arthroplasty (THA) for well-selected patients, offering the potential benefits of bone preservation and the ability to resume high-level activity [14, 32]. The procedure is particularly attractive for young, active subjects who value functional capacity and future revision options [20, 22]. In men under 55 with osteoarthritis, survivorship of total hip resurfacing exceeds that of total THA [22]. For patients younger than 50 years, hip resurfacing is a valid alternative to THA, with a 10-year survival rate of 98.7% [61]. This outcome exceeds the stricter 2014 NICE survivorship criteria independently in men and women, even when performed on patients under 50 years old [1, 61]. In a selected population of young and/or active patients, short-term results are excellent with a low complication rate and 99% survivorship at 4 years [3].

Outcomes are heavily dependent on implant design, surgical technique, and patient selection [32]. When performed by experienced, high-volume arthroplasty surgeons using meticulous technique, hip resurfacing provides excellent results at short- to mid-term follow-up [26]. The functional outcome in patients 40 years old and younger was excellent [13]; however, the overall survival in this specific age group was unsatisfactory, with a 7-year survival of 90.5% [13]. The majority of patients with acceptable self-reported function at two years post-Birmingham Hip Resurfacing sustain these improvements to a median ten years [16]. If patient selection is judicious and surgical technique is meticulously followed, the procedure offers acceptable survivorship and enables patients to resume high-demand activities including sports [123]. The continued use of metal-on-metal hip resurfacing in this population is justified by both positive patient-reported outcomes and survivorship [4].

Hip resurfacing may be offered to patients with osteonecrosis [11] and to patients older than 65 years who fulfill specific criteria and understand the associated risks [2]. Women show promise as excellent candidates when experienced surgeons use refined and proper surgical technique [8]. However, resurfacing arthroplasty should be undertaken with caution by surgeons unfamiliar with the technique [7]. Revision rates are higher after resurfacing than after total hip arthroplasty [10]. Revisions and reoperations are more frequent and occur earlier with metal-on-metal hip resurfacing, except when discontinued devices are removed from the analyses [35]. Longer follow-up of resurfacing and direct comparisons trials are required to confirm findings regarding modern cementless femoral components in young patients [5].

Anatomy & Pathophysiology

Bony Anatomy

The hip is a multiaxial joint formed by the articulation between the pelvis and femur, connecting the axial skeleton and the lower extremity [76]. The hemipelvis comprises the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [76]. The acetabulum consists of an articular crescent-moon–shaped lunate surface and a nonarticular central fossa that serves as the attachment point for the ligamentum teres [76]. The femoral head forms two-thirds of a sphere, with a small central depression from which the ligamentum teres extends to connect to the acetabular notch [76].

The neck-shaft angle of the femur averages 125° [76], with a mean adult value of 130° ± 7° [82]. Normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [76], while the mean anteversion of the femoral neck is 10° ± 7° [82]. The weakest area in the femoral neck is located in the Ward triangle [82]. The calcar femorale is a medial area of dense trabecular bone that transfers stress from the femoral shaft to the inferior portion of the femoral neck [82]. Fractures of the proximal femur follow the path of least resistance [82].

Ligaments and Capsule

The hip is surrounded by a dense fibrous capsule extending from the periphery of the acetabulum to the intertrochanteric line of the femoral neck [76]. The capsule attaches anteriorly and posteriorly along the periphery of the acetabulum outside the labrum [77]. The basicervical region of the femoral neck and the intertrochanteric region of the femur are not intracapsular [77].

Three main ligaments support the hip: * Iliofemoral ligament: Y-shaped and the thickest and strongest of the three main ligaments, it limits external rotation, while its lateral arm limits extension of the joint [76]. It becomes taut in full extension, preventing anterior dislocation and hyperextension [77]. * Ischiofemoral ligament: Extends from the ischial margin of the acetabulum to the greater trochanter and restricts internal rotation motion [76]. * Pubofemoral ligament: Extends from the obturator crest of the pubic bone to the femoral neck and acts to limit abduction of the joint [76].

Deep fibers from these three ligaments merge to form the zona orbicularis, which circumvents the femoral neck [76]. The twisted orientation of the hip ligaments provides a screw mechanism for the hip in full extension [77]. The ligamentum teres originates in the cotyloid fossa and attaches on the fovea of the femoral head [77].

Labrum

The acetabular labrum is a fibrocartilaginous ring that extends the articulating surface area and increases femoral head coverage [76]. Its triangular cross-section contributes to its ability to create a pressurized seal of the central compartment of the hip during loading [76]. Only the external one-third of the labrum contains blood vessels, leaving the majority of the structure avascular and limiting its healing ability following injury [76]. The labrum is highly innervated, with the presence of both mechanoreceptors and nociceptors [76]. It is absent in the area of the inferior acetabular notch, where the transverse acetabular ligament serves as the continuation of the labrum [76]. The acetabular labrum provides stability to the hip joint in response to a distraction force and combined distraction and translation forces [128].

Vascular Anatomy

In adulthood, the major blood supply to the femoral head is from the medial femoral circumflex and lateral epiphyseal arteries [85]. The medial femoral circumflex artery is the main blood supply to the femoral head and terminates in the posterior aspect of the extracapsular arterial ring [82]. The lateral femoral circumflex artery gives rise to the anterior aspect of the extracapsular arterial ring [82]. The ascending cervical arteries originate from the extracapsular arterial ring and are divided into four distinct groups: lateral, medial, posterior, and anterior [82]. The lateral group of ascending branches is the main blood supply to the femoral head [82]. Fractures that disrupt the ascending blood flow to the lateral epiphyseal vessel have an increased risk of osteonecrosis [82]. The artery of the ligamentum teres arises from either the obturator or medial femoral circumflex artery and does not provide sufficient blood supply to maintain the viability of the femoral head [82].

From birth to approximately 4 years of age, the major blood supply to the femoral head comes from the medial and lateral femoral circumflex arteries with major contributions from the artery of the ligamentum teres [85]. From the age of 4 years to adulthood, the posterosuperior and posteroinferior retinacular arteries from the medial circumflex artery are the major blood supply [85].

Muscular Anatomy

The primary hip flexor muscles are the iliopsoas, rectus femoris, and sartorius muscles [80]. The gluteus maximus and hamstring muscles are the most important hip joint extensors [80]. The abductors of the hip are predominantly the gluteus medius and minimus muscles, which function together to maintain and abduct the femur during the stance phase of gait [80]. The external rotators of the hip include the obturator internus and externus, superior and inferior gemelli, quadratus femoris, and piriformis muscles [80]. The most consistent internal rotators of the hip joint are the gluteus medius and tensor fascia latae muscles [80].

The average range of motion of a normal hip is approximately 120° of flexion, 30° of extension, 45° of abduction, 20° to 30° of adduction, 35° of internal rotation, and 45° of external rotation [80]. Normal gait function requires hip flexion of 30°, hyperextension of 10°, abduction and adduction of 5°, and internal and external rotation of 5° [80].

Pathophysiology

Femoroacetabular impingement (FAI) is a pathomechanical process causing abnormal contact stresses and potential joint damage, potentially instigating osteoarthritis of the hip [104]. In FAI, distinct structural abnormalities produce repetitive impingement between the acetabulum and the femoral head-neck junction [41]. Three types of FAI are recognized: * Cam impingement: Involves femoral-based abnormalities such as an aspherical femoral head and reduced head-neck offset, resulting in repetitive abutment of the acetabular rim and femoral head-neck junction [41]. * Pincer impingement: Involves acetabular-based disorders such as acetabular retroversion, global overcoverage, and acetabular protrusio, creating abnormal abutment of the acetabular rim and femoral head-neck junction [41]. * Combined cam/pincer: A mix of the above features [41].

Impingement abnormalities can cause labral tears, degeneration, or ossification; acetabular cartilage delamination; and secondary osteoarthritis [41]. Hip microinstability refers to the femoral head micromotion within the acetabulum, which is a prolonged phenomenon that leads to cartilage damage and eventually osteoarthritis of the hip [86].

Hip resurfacing arthroplasty is a bone-conserving alternative to total hip arthroplasty indicated in the clinical setting of end-stage hip arthrosis in the patient with a structurally and morphologically appropriate femoral head and acetabular bone [34]. The best candidates for hip resurfacing are men under age 65 with osteoarthritis and relatively normal bony morphology [15]. Outcomes of hip resurfacing are dependent on preoperative characteristics of the proximal femur, with patients having higher-grade hips (earlier-stage disease) demonstrating better outcomes [37]. Patients whose hips have only a loss of articular cartilage and a relatively normal femoral head and neck make the best starting material for resurfacing [37].

Hip resurfacing significantly alters hip biomechanics, which may result in altered loading patterns with adaptive remodelling causing neck thinning [95]. Restoration of normal hip biomechanics is best achieved with hip resurfacing, as it accurately restored femoral offset without statistical difference compared to the non-operative hip [97]. Intraoperative mechanical injury of the femoral neck or malpositioning of the femoral component may lead to changes in loading patterns resulting in acute and chronic biomechanical femoral neck fractures [111]. High impaction forces significantly reduce the ultimate failure load of the femoral neck compared to low impaction forces [124]. Repetitive extreme motion of the involved hip and malposition of the implants can cause impingement after hip resurfacing arthroplasty [132]. To restore natural hip range of motion, surgeons performing hip resurfacing should aim to reproduce the natural femoral head-neck offset, especially in patients with morphological head-neck abnormalities [130].

The procedure did not change native extra-medullary hip geometry by more than 5 mm and/or 5 degrees compared to the non-operated side [109]. An acetabular component inclination of 50° and an anteversion of 25° allowed the most physiologic range of hip motion [103]. A 15° valgus orientation may represent the biomechanically optimal position for femoral prosthesis placement in hip resurfacing, effectively minimizing mechanical stress and strain while preserving physiological load transfer patterns [114]. Hip resurfacing resulted in restricted range of motion compared to dual mobility total hip arthroplasty, traditional total hip arthroplasty, and other models in all motions except adduction [119]. Radiographic estimation of the quality of the frontal anatomical hip restoration is of poor value to predict gait performances of total hip replacement patients [105]. At one-year postoperatively, both anterior and posterior approaches for hip resurfacing restored gait patterns comparable to healthy controls, with no significant differences in kinematics, kinetics, or spatiotemporal parameters [118]. The best predictor of change in bone mineral density at five years in the trochanteric area was acetabular component inclination [64]. High ion levels were associated with an abduction angle of more than 45° and repetitive extreme hip motion in revision cases [129]. Acetabular offset and height had a greater effect on range of motion due to bony impingement than femoral offset and height [143].

Clinical outcomes of hip resurfacing arthroplasty in patients with developmental dysplasia of the hip are satisfactory at short-term followup regarding clinical scores, biomechanics, and return to sports, but the 6% failure rate was higher than anticipated and limb-length discrepancies were not adequately corrected [122]. The large individual morphologic variability across all levels of dysplastic hips suggests the femoral prosthesis cannot be chosen on the basis of the severity of the subluxation alone [134]. Morphologic factors responsible for severe intra-articular lesions differ for cartilage degeneration and labral tears in patients with severe hip dysplasia [136].

Conversion of hip resurfacing to total hip arthroplasty yields survivorship inferior to that of primary total hip arthroplasty, with a relatively high complication rate [24]. Outcomes for conversion of hip resurfacing to total hip arthroplasty were particularly unfavorable when performed for specific indications such as adverse reaction to metal debris (ARMD) or aseptic loosening [24]. Patients revised for ARMD consistently demonstrated worse outcomes than those revised for other indications [24]. Femoral neck osteonecrosis, aseptic loosening, and femoral neck fracture may represent temporal manifestations along a common pathological continuum, with diagnosis largely determined by stage at detection [24]. ARMD may underlie progressive osteolysis and structural failure even without a clinically evident pseudotumor [24]. The most common indications for conversion of hip resurfacing to total hip arthroplasty are ARMDs, aseptic loosening, and femoral neck fracture [24]. Revision of failed hip resurfacing to total hip arthroplasty rapidly relieves pain and improves function in the early postoperative period [18]. The results of revision of failed hip resurfacing to total hip arthroplasty compare favourably with those for revision total hip arthroplasty, though longer term results are necessary [18]. Extensive soft tissue and abductor muscles dysfunctions were common in revision total hip arthroplasty for failed metal-on-metal hip arthroplasty, and a constrained acetabular component with repair of the hip abductors might be beneficial [133].

Hip resurfacing is a highly technical procedure requiring careful implant selection, meticulous preoperative planning, and exacting implant placement [67]. For experienced hip surgeons, the learning curve for avoiding early complications was short (25 cases or less), while the learning curve for achieving desired component positioning radiographically was much longer (75 to 100 cases or more) [49]. The functional performance results confirm the advantage of resurfacing over conventional hip replacement, helping explain the excellent radioclinical results reported for total hip resurfacing [28]. Hip resurfacing generates a more physiological gait than total hip replacement [105].

Classification

Arthritic Hip Grading: This system classifies the preoperative characteristics of the proximal femur to identify challenging hips and predict outcomes for total hip resurfacing [37]. The grade is associated with preoperative Harris hip score, occurrence of mild to moderate postoperative pain, preoperative and postoperative range of motion, preoperative and postoperative hip center of rotation, preoperative and postoperative horizontal femoral offset, preoperative and postoperative limb-length discrepancy, and acetabular radiolucencies [37]. Patients with higher-grade hips, indicating earlier-stage disease, demonstrate better outcomes [37]. Bone density assessment within this grading system is qualitative and subjective, with interobserver and intraobserver variability not yet established [37].

Other Considerations: Hip resurfacing is indicated in the clinical setting of end-stage hip arthrosis in the patient with a structurally and morphologically appropriate femoral head and acetabular bone [34]. The procedure is particularly embraced by young, active patients, particularly men under 55 with osteoarthritis [22]. It provides good function and comparable implant survival in patients with rheumatoid arthritis of the hip joint [25]. When experienced surgeons use refined and proper surgical technique, women show promise as excellent candidates for hip resurfacing as an alternative treatment for their debilitating hip conditions [8]. The importance of patient selection and surgical technique is highlighted in hip resurfacing arthroplasty [12].

The continued use of metal-on-metal hip resurfacing arthroplasty is justified by positive patient reported outcomes and survivorship in the appropriate population [4]. In a selected population of young and/or active patients, the short-term results of hip resurfacing are excellent with a low complication rate and 99% survivorship at 4 years [3]. Hip resurfacing seems to be a viable alternative to THA for well-selected patients [14]. When patients meet the appropriate selection criteria in the hands of experienced and high-volume arthroplasty surgeons, hip resurfacing provides excellent results at short- to mid-term follow-up [26]. Implant survival after hip resurfacing arthroplasty performed before 50 years of age was better than required by the NICE criterion, with a 10-year survival rate of 98.7% [61]. Hip resurfacings may be offered to patients older than 65 years who fulfill specific criteria and understand the associated risks [2]. Medium-term survivorship and functional scores of hip resurfacing are comparable to those from the pioneering center [6]. There was no significant clinical difference between patients treated with hip resurfacing and total hip arthroplasty in the short term [9].

The risk of revision for resurfacing due to metal-related pathologies is very low but is higher than in other types of bearings [135]. The Durom revision rate was slightly higher than the rate with other hip resurfacing systems and traditional total hip arthroplasty [66]. Revision of a primary hip resurfacing arthroplasty is associated with a high risk of rerevision [30]. Revision of failed hip resurfacing devices is associated with an increased risk for extensive acetabular defects [65]. Most revisions for femoral neck fracture after Birmingham Hip Resurfacing Arthroplasty were technically straightforward, with isolated femoral revisions performed in 71% of cases [38]. Functional outcome and survival at 5 years after revision for femoral neck fracture are comparable with that reported for primary total hip arthroplasty [38]. One-component revision is an effective procedure for hip resurfacing procedures that have failed as the result of an adverse reaction to metal wear debris [68]. The durability of well-fixed porous-coated acetabular components retained at revision surgery has been demonstrated [33]. The availability of unipolar femoral heads matching the socket dimensions potentially provides lifetime prosthetic solutions to the young patient with end-stage osteoarthritis [33]. Multivariate time-dependent analysis showed a greater effect of surgical technique and patient BMI on prosthetic survival over bone quality and component size [33]. Metal-on-metal resurfacing is justified in patients with risk factors such as BMI when other prosthetic solutions are inadequate [33]. The long-term efficacy of revision surgery using unipolar femoral heads matching socket dimensions remains unknown [33].

During the first 2 years after surface arthroplasty, retrieved Birmingham Hip Resurfacing components revealed wear rates substantially lower than conventional polyethylene bearings [36]. One-stage bilateral hip resurfacing arthroplasty is less costly for the health care system than two-stage procedures while maintaining comparable safety profiles [63]. The study established a new radiographic evaluation technique for hip resurfacing devices with short or no stems [69].

Clinical Presentation

Hip resurfacing is associated with a higher early complication rate than total hip arthroplasty [44]. Clinically, groin pain after hip resurfacing appears to be more common than after conventional hip replacement [115]. Adverse local tissue reactions are common in asymptomatic individuals after hip resurfacing arthroplasty [117]. In patients with asymptomatic pseudotumours following metal-on-metal hip resurfacing, repeated MARS-MRI scans within one year show little or no variation [51].

Diagnostic and Conversion Indications

Diagnostic approach: Hip arthroscopy plays a role in the investigation and treatment of the painful hip resurfacing arthroplasty, but a diagnosis before arthroscopy is critical to improved outcome [42].

Conversion indications: The most common indications for conversion of hip resurfacing to total hip arthroplasty are adverse reactions to metal debris (ARMD), aseptic loosening, and femoral neck fracture [24].

Conversion outcomes: Outcomes after conversion of hip resurfacing to total hip arthroplasty are particularly unfavorable when performed for specific indications such as ARMD or aseptic loosening [24]. Conversion of hip resurfacing to total hip arthroplasty with retention of the acetabular component is associated with elevated risks of infection and reoperation [58].

Investigations

Plain radiography: Conventional radiographs remain critical for the initial imaging evaluation of the hip, including the diagnosis of osteoarthritis [40]. A complete hip series consists of an anterior-posterior (AP) pelvis, a centered AP hip, a lateral view (frog-leg, cross-table, Dunn 45° or 90°), and a false-profile (Lequesne) view [40]. Osteoarthritis is categorized using the Kellgren-Lawrence or Tönnis classifications [40]. The femoral head-neck junction morphology is assessed using the alpha angle on radiographs, particularly the Dunn 45° view [40]. For metal-on-metal hip resurfacing, conventional radiograph templating is a useful method for preoperative planning of implant sizes [161]. Surgeon experience significantly influences the accuracy of predicting component size during this process [161]. Preoperative templating for hip resurfacing arthroplasty demonstrates variable reliability and fair accuracy, with surgeons tending to underestimate implant size [172]. A new radiographic evaluation technique for hip resurfacing devices with short or no stems was established in a 2008 study [69].

CT: CT scans effectively examine cortical and cancellous bone and create three-dimensional reconstructions of the hip for surgical planning [90]. Measurements of femoral head coverage and acetabular and femoral impingement can be performed reliably using CT images [90]. Three-dimensional CT with pelvic remodeling is indicated for preoperative planning for reconstruction associated with dysplasia surgery, femoroacetabular impingement, posttraumatic arthritis, or other complex primary total hip arthroplasty [101]. Low-dose CT with three-dimensional reformats is particularly useful in surgical planning of complex or borderline deformities [41].

MRI: MRI is the modality of choice for patients suspected of soft tissue or intra-articular pathology, given its superior sensitivity and specificity [90]. Magnetic resonance arthrography (MRA) is more appropriate than conventional MRI to determine injuries to the labrochondral structures and the ligamentum teres [90]. However, the utility of MRA in the accurate detection and staging of articular cartilage lesions is reduced, with sensitivity reported to be less than 50% compared with arthroscopic findings [90]. MRI is helpful in assessing complications of conventional and resurfacing hip arthroplasties, particularly those with metal-on-metal bearing systems [96]. Major MRI findings that help predict histologic ALVAL scores include synovial thickening, synovitis, synovial volume, abductor disruption, and soft-tissue edema [96].

Laboratory: Dual energy x-ray absorptiometry scan T-score tests should be routinely performed on all hip resurfacing patients pre-operatively [167]. The best predictor of change in bone mineral density at five years in the trochanteric area after hip resurfacing was acetabular component inclination [64]. The European multidisciplinary consensus statement recommends safety assessment for all patients with metal-on-metal bearings, involving x-rays and metal ion measurement, with closer follow-up for large head bearings and resurfacing [27].

Other Considerations: A thorough clinical examination is required to determine a differential diagnosis for hip pain, as many conditions present with similar symptoms [39]. Imaging findings should complement clinical examination findings to provide the most accurate diagnosis of hip pain [39]. Patients with symptomatic femoroacetabular impingement frequently present with activity-related groin pain exacerbated by hip flexion activities [41]. Physical examination in patients with femoroacetabular impingement typically exhibits restricted hip internal rotation in 90° of flexion [41]. The impingement test (flexion, adduction, internal rotation) elicits pain in femoroacetabular impingement but is not specific for the condition [41]. Femoral component loosening in hip resurfacing can occur without radiographic signs of subsidence or radiolucency, potentially leading to stem fracture due to atypical overloading [164].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physiotherapy, or pharmacological interventions. Surgical candidacy is defined primarily by patient demographics and disease severity rather than a documented failure of non-operative measures.

Operative

Indications: Total hip resurfacing is most appropriately used in young, active men, specifically those under 55 or 60 years of age, with osteoarthritis [22, 54]. This procedure offers functional capacity, bone conservation, and revision options that are embraced by this demographic, where survivorship exceeds that of total hip arthroplasty (THA) [22]. Metal-on-metal hip resurfacing appears effective for younger patients under age 30 [70], and hip resurfacing using a 2-piece polyethylene acetabular component has resulted in excellent function and implant survivorship with a low rate of complications at mid-term follow-up for advanced dysplasia [23]. However, the value of metal-on-metal hip resurfacing (MoMHR) in patients with secondary osteoarthritis resulting from developmental dysplasia of the hip (DDH) is questionable [50].

Surgical Approach / Technique: Patient selection and surgical technique are critical determinants of success in hip resurfacing arthroplasty [12]. In a cohort utilizing the Conserve Plus total hip resurfacing system for femoral neck fractures, a standard anterolateral approach was employed in each case [147]. The acetabular component was placed without screws using cementless press-fit fixation, while the femoral component was cemented in place [147]. The design of the Conserve Plus system reduced the acetabular shell thickness from 10 to 6 mm to provide greater bone conservation and reduce the incidence of femoral neck notching [147]. Additionally, reduced cylindrical and chamfer reaming of the femoral head effectively spared the femoral neck from notching in most cases with this updated design [147].

Implant Selection: Hip resurfacing with Birmingham Hip Resurfacing (BHR) demonstrates excellent survival rates in young patients with degenerative hip disease [113]. Ceramic-on-ceramic hip resurfacing has demonstrated excellent patient-reported outcome improvement and survival up to five years, irrespective of sex or implant size, comparing favourably to metal-on-metal hip resurfacing [48]. The Conserve Plus system utilizes a one-piece shell design that allows for bone conservation on the acetabular side [147].

Outcomes and Survivorship: At a minimum of ten years postoperatively, outcomes after BHR remained satisfactory, particularly for self-reported hip function, in patients aged less than 50 years [21]. Both navigation-assisted and conventional hip resurfacing arthroplasty achieve excellent 5- and 10-year survivorship with sustained patient-reported outcomes [17]. In the short term, there was no significant clinical difference between patients treated with hip resurfacing and those undergoing total hip arthroplasty [9]. For patients 40 years old and younger, functional outcomes were excellent, but overall survival was unsatisfactory with a 7-year survival of 90.5% [13]. In patients under 30 undergoing metal-on-metal hip resurfacing, the Kaplan–Meier survivorship estimate at 8 years was 95% [70]. The mean Harris Hip Score in this cohort was 88 [70]. Clinical scores and x-rays showed significant post-operative improvement in SF-12 and UCLA scores (P<0.0001) and range of motion scores (P<0.001) in patients under 30 [70]. Randomized controlled trials and comparative cohort studies have provided insufficient evidence to determine whether modern metal-on-metal hip resurfacing offers clinical advantages over standard total hip arthroplasty for active young patients [158].

Complications and Revision: Revision of failed hip resurfacing to total hip arthroplasty rapidly relieves pain and improves function in the early post-operative period [18]. An accurate diagnosis before hip arthroscopy improves the likelihood of a good outcome in managing painful hip resurfacing arthroplasty [60]. Complications include femoral neck fractures; one 58-year-old male sustained such a fracture during normal walking 8 weeks after hip resurfacing arthroplasty [163]. Possible causes included anterolateral notching of the femoral neck or previous factors [163]. Postoperative x-ray in this case showed minimal notching at the anterolateral femoral neck, a femoral component shaft angle of 137°, a neutral version angle, and an acetabular component abduction angle of 43° and anteversion of 6° [163]. Two cases of intertrochanteric fracture below BHR were successfully managed using non-operative methods [144]. In Australia, the 5-year cumulative percent revision for DDH was four times greater when MoMHR was used compared to primary conventional THA (12.0% compared to 3.0%) [50]. Some early results from Birmingham with a minimum follow-up of 6 years showed no significant increase in complications for MoMHR in patients with DDH [50], whereas other studies have shown more disappointing outcomes for MoMHR in this population [50]. Due to a high early failure rate of 8% and only 79% of patients reporting a good or excellent outcome, some authors have reduced the utilization of hip resurfacing in patients who are candidates for hip arthroplasty [19].

Monitoring and Consensus: Consensus statements define the benefits, risks, and uncertain issues related to metal-on-metal bearings, recommending safety assessment for all patients with closer follow-up for large head bearings and resurfacing involving x-rays and metal ion measurement [27].

Activity and Function: Eighty-seven percent of patients continued to take part in sporting activities following hip resurfacing [153]. In a study with a mean age at surgery of 54 years and a mean follow-up of 30 months, there was statistically significant improvement in UCLA activity scores from 4.4 to 6.8 (p<0.05) [153]. Oxford hip scores also showed statistically significant improvement from 43.4 to 17.7 following the procedure [153].

Complications

General Complication Rates and Survivorship: Resurfacing arthroplasty carries a higher early complication rate than total hip arthroplasty, with complications tending to occur early in the surgical learning curve [44, 166]. Long-term survivorship data remain favorable; the initial series of Conserve Plus hip resurfacing arthroplasties demonstrated an 83.5% 20-year survivorship, surpassing that of total hip arthroplasties in use 20 years ago in these young patients [62]. An independent single surgeon’s 7-year experience with Birmingham hip resurfacing reported a 91.5% survival rate at 7 years with revision as the endpoint [71]. This study represents the largest single-surgeon series of metal-on-metal hip resurfacing with long-term data and the second-best long-term implant survivorship for any type of hip arthroplasty ever published [43]. Although patient-reported outcomes and survivorship may be similar to contemporary total hip arthroplasty, the procedure raises questions about whether bone preservation and increased motion outweigh the small but real risk of metal-related complications [29].

Aseptic Loosening: In a series of 141 consecutive hip resurfacing arthroplasties, the main reason for revision was femoral loosening in the osteonecrosis group (4 of 46 hips; 8.7%) [149]. Necrotic areas were seen on femoral heads retrieved from patients with femoral loosening, whereas femoral heads were fixed tightly to components in patients with femoral-neck fractures [149]. Etiology may be an important risk factor for postoperative complications in hip resurfacing [149]. There were no conversions to total hip replacement consecutive to a loosening of the acetabular component in a series of metal-on-metal hybrid hip resurfacing [33]. The long-term efficacy of revision surgery for metal-on-metal hybrid hip resurfacing remains unknown [33].

Periprosthetic Fracture: In the same series of 141 consecutive hip resurfacing arthroplasties, femoral-neck fracture was the main reason for revision in the ankylosing spondylitis group (3 of 58 hips; 5.2%) [149]. Most revisions for femoral neck fracture after Birmingham Hip Resurfacing Arthroplasty were technically straightforward, with isolated femoral revisions performed in 71% of cases [38]. Functional outcome and survival at 5 years after revision are comparable with that reported for primary total hip arthroplasty [38].

Wear and Bearing Surface: During the first 2 years after surface arthroplasty, the retrieved Birmingham Hip Resurfacing components revealed wear rates substantially lower than conventional polyethylene bearings [36]. The first generations of surface replacement arthroplasty had been abandoned with high midterm failure rates, ranging from 12% to 60%, resulting from the femoral component design and the polyethylene bearing surface [31]. In hip resurfacing using highly cross-linked polyethylene, both femoral and acetabular bones are reasonably preserved compared with prior resurfacing methods [72].

Metal Ion Exposure: Hip resurfacing arthroplasty is associated with lower metal ion levels and revision risk compared with large-head metal-on-metal total hip arthroplasty [150]. Findings suggest that metal-on-metal hip resurfacing arthroplasty has a more favorable outcomes profile with reduced systemic metal ion exposure, reinforcing its role in younger, active patients [150].

Other Considerations: Multivariate time-dependent analysis showed a greater effect of surgical technique and patient BMI on prosthetic survival over bone quality and component size in metal-on-metal resurfacing [33]. Most of the early failures in a series of metal-on-metal hybrid hip resurfacing happened in the first 100 hips operated on, during the phase of development of the device and the procedure [33]. Further follow-up is required to assess the influence of sports on loosening and revision rates in hip resurfacing arthroplasty [55].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for light activities such as desk work, driving, or light activities of daily living.

Full activity (months): The provided evidence does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression, or sling/brace removal timing.

Functional milestones: The provided evidence does not report validated patient-reported outcome measure trajectories or specific outcome-measure benchmarks.

Other Considerations: In a selected population of young and/or active patients, short-term results of hip resurfacing are excellent with a low complication rate and 99% survivorship at 4 years [3]. The 83.5% 20-year survivorship of the first 400 Conserve Plus hip resurfacing arthroplasties surpasses that of total hip arthroplasties in use 20 years ago in these young patients, suggesting satisfactory lifelong durability of the device for almost all of the remaining patients [62]. A single-surgeon series of 6114 cases with 2–19 year follow-up represents the second-best long-term implant survivorship for any type of hip arthroplasty ever published [43]. An independent single surgeon's 7-year experience with Birmingham hip resurfacing reported a 91.5% survival rate at 7 years with revision as the endpoint [71]. Data at short-term followup suggest increased rates of groin pain after metal-on-metal THA or resurfacing arthroplasty versus THA using polyethylene or ceramic bearing surfaces [177]. The revision rate at short- to mid-term follow-up for professional dancers highlights the challenges of performing hip arthroplasty in this demanding patient population [56]. Five-year follow-up of the left hip and greater than 2-year follow-up of the right hip demonstrate that hip resurfacing is a viable option to consider for patients with polyostotic fibrous dysplasia [57]. The durability of well-fixed porous-coated acetabular components retained at revision surgery has been demonstrated in metal-on-metal hybrid hip resurfacing [33]. Most early failures in metal-on-metal resurfacing happened in the first 100 hips operated on, during the phase of development of the device and the procedure [33]. A high early failure rate of 8% and only 79% of patients reporting a good or excellent outcome led to reduced utilization of hip resurfacing in candidates for hip arthroplasty due to an unsatisfactory surgical learning curve [19].

Key Evidence

• [L3] Hip resurfacing exceeds the stricter 2014 NICE survivorship criteria independently in men and women even when performed on patients under 50 years old. [1] (10.1186/s13018-017-0579-y)
• [L4] We believe that hip resurfacings may be offered in the future to patients older than 65 years who fulfill the above criteria and understand the associated risks. [2] (10.1016/j.arth.2008.04.026)
• [L4] In a selected population of young and/or active patients, the short-term results of hip resurfacing are excellent with a low complication rate and 99% survivorship at 4 years. [3] (10.1016/j.otsr.2015.07.011)
• [L4] The continued use of metal-on-metal hip resurfacing arthroplasty in this population is justified by both positive patient reported outcomes and survivorship. [4] (10.1016/j.arth.2022.04.008)
• [L1] Longer follow-up of resurfacing and direct comparisons trials are required to confirm these findings. [5] (10.1016/j.arth.2008.11.032)
• [L4] Medium-term survivorship and functional scores of hip resurfacing are comparable to those from the pioneering center. [6] (10.1007/s11999-010-1438-x)
• [L2] Resurfacing arthroplasty should be undertaken with caution by those surgeons unfamiliar with the technique. [7] (10.1016/j.arth.2008.01.232)
• [L3] When experienced surgeons use refined and proper surgical technique, women show promise as excellent candidates for hip resurfacing as an alternative treatment for their debilitating hip conditions. [8] (10.1016/j.arth.2017.06.003)
• [L3] There was no significant clinical difference between the patients treated with hip resurfacing and total hip arthroplasty in the short term. [9] (10.1186/1749-799x-5-8)
• [L2] Revision rates are higher after resurfacing than after total hip arthroplasty. [10] (10.5435/00124635-201005000-00007)
• [L3] Hip resurfacing can be offered to patients with osteonecrosis. [11] (10.1007/s00402-009-0963-0)
• [L4] This report highlights the importance of patient selection and surgical technique in hip resurfacing arthroplasty. [12] (10.2106/jbjs.i.00341)
• [L3] The functional outcome of hip resurfacing in this cohort was excellent, but overall survival was unsatisfactory with a 7-year survival of 90.5%. [13] (10.1007/s00402-012-1640-2)
• [L3] Hip resurfacing seems to be a viable alternative to THA for well-selected patients. [14] (10.1016/j.arth.2009.05.034)
• [L5] Based on the review, the best candidates for hip resurfacing are men under age 65 with osteoarthritis and relatively normal bony morphology. [15] (10.1007/s11999-008-0558-z)
• [L3] The majority of patients with acceptable self-reported function at two years post-Birmingham Hip Resurfacing sustain these improvements to a median ten years. [16] (10.1302/0301-620x.101b11.bjj-2019-0663.r1)
• [L3] Both navigation-assisted and conventional hip resurfacing arthroplasty achieve excellent 5- and 10-year survivorship with sustained patient-reported outcomes. [17] (10.1016/j.arth.2026.05.008)
• [L4] The results compare favourably with those for revision total hip arthroplasty, though longer term results are necessary. [18] (10.1186/1749-799x-5-88)
• [L4] Because of a high early failure rate of 8% and only 79% of patients reporting a good or excellent outcome, the authors have reduced the utilization of hip resurfacing in their patients who are candidates for hip arthroplasty. [19] (10.2106/jbjs.j.01719)
• [L3] The specific advantages of hip resurfacing make the procedure a very attractive option for young subjects. [20] (10.1007/s00264-012-1555-0)
• [L3] The outcome after a Birmingham Hip Resurfacing, at a minimum of ten years postoperatively, remained satisfactory, particularly for self-reported hip function, in patients aged less than 50 years. [21] (10.1302/0301-620x.101b1.bjj-2018-0702.r1)
• [L5] Total hip resurfacing offers functional capacity, bone conservation, and revision options that are embraced by young, active patients, particularly men under 55 with osteoarthritis, where survivorship exceeds that of total THA. [22] (10.1016/j.arth.2007.05.050)
• [L3] Hip resurfacing using a 2-piece polyethylene acetabular component for advanced dysplasia has resulted in excellent function and implant survivorship with a low rate of complications at mid-term follow-up. [23] (10.1016/j.arth.2018.07.023)
• [L3] [24] (10.2106/jbjs.rvw.26.00037)
• [L3] The results suggest that hip resurfacing provides good function and comparable implant survival in patients with rheumatoid arthritis of the hip joint. [25] (10.1007/s00264-010-1046-0)
• [L3] When patients meet the appropriate selection criteria in the hands of experienced and high-volume arthroplasty surgeons, hip resurfacing provides excellent results at short- to mid-term follow-up. [26] (10.1186/1471-2474-14-161)
• [L5] The consensus statement defines benefits, risks, and uncertain issues related to metal-on-metal bearings, recommending safety assessment for all patients with closer follow-up for large head bearings and resurfacing involving x-rays and metal ion measurement. [27] (10.1016/j.otsr.2013.01.005)
• [L3] The present functional performance results confirm the advantage of resurfacing over conventional hip replacement, and help explain the excellent radioclinical results reported for total hip resurfacing. [28] (10.1016/j.otsr.2011.10.006)
• [L4] Although the patient-reported outcomes and survivorship may be similar to contemporary total hip arthroplasty, the procedure raises questions about whether bone preservation and increased motion outweigh the small but real risk of metal-related complications. [29] (10.2106/jbjs.21.00515)
• [L3] Revision of a primary hip resurfacing arthroplasty is associated with a high risk of rerevision. [30] (10.1007/s11999-015-4215-z)
• [L3] [31] (10.1007/s11999-009-1157-3)
• [L5] Hip resurfacing offers potential benefits for young patients by preserving bone and allowing high-level activity, but outcomes are heavily dependent on implant design, surgical technique, and patient selection. [32] (10.1302/0301-620x.105b5.bjj-2023-0015.r1)
• [L4] [33] (10.1016/j.arth.2008.04.017)
• [L5] [34] (10.5435/00124635-201104000-00008)
• [L1] Revisions and reoperations are more frequent and occur earlier with metal-on-metal hip resurfacing, except when discontinued devices are removed from the analyses. [35] (10.1007/s11999-014-3556-3)
• [L4] During the first 2 years after surface arthroplasty, the retrieved Birmingham Hip Resurfacing components revealed wear rates substantially lower than conventional polyethylene bearings. [36] (10.1016/j.arth.2008.06.022)
• [L2] [37] (10.1097/01.blo.0000192354.76792.bb)
• [L3] Most revisions were technically straightforward with isolated femoral revisions performed in 71% of cases, and functional outcome and survival at 5 years after revision are comparable with that reported for primary total hip arthroplasty. [38] (10.1016/j.arth.2012.04.035)
• [L5] Whereas hip arthroscopy plays a role in the investigation and treatment of the painful hip resurfacing arthroplasty, a diagnosis before arthroscopy is critical to improved outcome. [42] (10.1016/j.arthro.2015.12.039)
• [L4] This study represents the largest single-surgeon series of metal-on-metal hip resurfacing with long-term data and the second-best long-term implant survivorship for any type of hip arthroplasty ever published. [43] (10.1186/s13018-025-06076-5)
• [L2] Resurfacing arthroplasty is associated with a higher early complication rate than total hip arthroplasty. [44] (10.1016/j.arth.2008.01.235)
• [L3] Ceramic-on-ceramic hip resurfacing demonstrated excellent patient-reported outcome improvement and survival up to five years, irrespective of sex or implant size, comparing favourably to metal-on-metal hip resurfacing. [48] (10.1302/0301-620x.107b7.bjj-2024-1594.r1)
• [L2] For experienced hip surgeons, the learning curve for avoiding early complications was short (25 cases or less), while the learning curve for achieving desired component positioning radiographically was much longer (75 to 100 cases or more). [49] (10.1007/s11999-009-1106-1)
• [L4] [50] (10.1007/s00402-010-1153-9)
• [L3] Repeated MARS-MRI scans within one year in patients with asymptomatic pseudotumours after MoM hip resurfacing showed little or no variation. [51] (10.1302/0301-620x.95b12.32248)
• [L4] Resurfacing is most appropriately used in young (less than 60 years) and active men. [54] (10.1016/j.arth.2008.06.015)
• [L4] Further follow-up is required to assess the influence of sports on loosening and revision rates in hip resurfacing arthroplasty. [55] (10.1177/0363546506296606)
• [L3] However, the revision rate at short- to mid-term follow-up highlights the challenges of performing hip arthroplasty in this demanding patient population. [56] (10.1302/0301-620x.106b3.bjj-2023-0854.r1)
• [L5] Five-year follow-up of the left hip and greater than 2-year follow-up of the right hip demonstrate that hip resurfacing is a viable option to consider for patients with PFD. [57] (10.1097/nor.0000000000000554)
• [L4] These findings highlight that while this approach can be an effective option for failed hip resurfacing, appropriate caution is warranted to mitigate the elevated risks of infection and reoperation in this cohort. [58] (10.1016/j.arth.2026.04.027)
• [L4] Having an accurate diagnosis before hip arthroscopy improves the likelihood a good outcome. [60] (10.1016/j.arthro.2015.08.029)
• [Paper] Implant survival after hip resurfacing arthroplasty performed before 50 years of age was better than required by the NICE criterion (10-year survival rate 98.7%), indicating that HRA is a valid alternative to total hip arthroplasty in patients younger than 50 years. [61] (10.1016/j.otsr.2017.10.018)
• [L3] The 83.5% 20-year survivorship of this initial series surpasses that of total hip arthroplasties in use 20 years ago in these young patients, suggesting satisfactory lifelong durability of the device for almost all of the remaining patients. [62] (10.1302/0301-620x.103b7.bjj-2020-2256.r1)
• [Paper] One-stage bilateral hip resurfacing arthroplasty is less costly for the health care system than two-stage procedures while maintaining comparable safety profiles. [63] (10.1016/j.otsr.2020.01.011)
• [L2] The best predictor of change in BMD at five years in the trochanteric area was acetabular component inclination. [64] (10.1016/j.arth.2012.09.012)
• [L3] Revision of failed hip resurfacing devices is associated with an increased risk for extensive acetabular defects. [65] (10.1007/s00402-015-2364-x)
• [L4] The Durom revision rate was slightly higher than the rate with other hip resurfacing systems and traditional total hip arthroplasty. [66] (10.1016/j.otsr.2012.10.018)
• [L3] Hip resurfacing is a highly technical procedure requiring careful implant selection, meticulous preoperative planning, and exacting implant placement. [67] (10.1016/j.arth.2023.05.073)
• [L3] One-component revision is an effective procedure for hip resurfacing procedures that have failed as the result of an adverse reaction to metal wear debris. [68] (10.1016/j.arth.2013.04.011)
• [L2] The study established a new radiographic evaluation technique for hip resurfacing devices with short or no stems. [69] (10.1016/j.arth.2007.09.021)
• [L4] [70] (10.1016/j.arth.2012.07.043)
• [L3] The study presents an independent single surgeon's 7-year experience with Birmingham hip resurfacing, reporting a 91.5% survival rate at 7 years with revision as the endpoint. [71] (10.1016/j.arth.2009.10.010)
• [L3] Both femoral and acetabular bones are reasonably preserved compared with prior resurfacing methods. [72] (10.1016/j.arth.2016.03.013)
• [L3] RHA significantly alters hip biomechanics, which may result in altered loading patterns with adaptive remodelling causing neck thinning. [95] (10.1007/s00402-010-1070-y)
• [L4] Restoration of normal hip biomechanics is best achieved with hip resurfacing, as it accurately restored femoral offset without statistical difference compared to the non-operative hip. [97] (10.1186/1749-799x-6-65)
• [L5] An acetabular component inclination of 50° and an anteversion of 25° allowed the most physiologic range of hip motion. [103] (10.1016/j.arth.2008.07.021)
• [L5] FAI is a pathomechanical process causing abnormal contact stresses and potential joint damage, potentially instigating osteoarthritis of the hip. [104] (10.1007/s11999-008-0646-0)
• [Paper] Radiographic estimation of the quality of the frontal anatomical hip restoration is of poor value to predict gait performances of THR patients. [105] (10.1016/j.otsr.2019.12.020)
• [L3] The procedure did not change native extra-medullary hip geometry by more than 5 mm and/or 5 degrees compared to the non-operated side. [109] (10.1016/j.otsr.2015.04.004)
• [L4] Intraoperative mechanical injury of the femoral neck or malpositioning of the femoral component may lead to changes in loading patterns resulting in acute and chronic biomechanical femoral neck fractures. [111] (10.2106/jbjs.h.01113)
• [L3] Hip resurfacing with BHR has excellent survival rates in young patients with degenerative hip disease. [113] (10.1016/j.arth.2016.12.044)
• [L5] A 15° valgus orientation may represent the biomechanically optimal position for femoral prosthesis placement in HRA, effectively minimizing mechanical stress and strain while preserving physiological load transfer patterns. [114] (10.1186/s13018-025-06370-2)
• [L4] Groin pain after hip resurfacing appears to be more common than after conventional hip replacement. [115] (10.1016/j.arth.2008.11.086)
• [L3] [117] (10.1097/corr.0000000000001882)
• [L3] At one-year postoperatively, both approaches restored gait patterns comparable to healthy controls, with no significant differences in kinematics, kinetics, or spatiotemporal parameters. [118] (10.1186/s13018-025-06457-w)
• [L5] Hip resurfacing resulted in restricted range of motion compared to the other three models in all motions except adduction. [119] (10.1016/j.arth.2012.08.017)
• [L4] Clinical outcomes of hip resurfacing arthroplasty in patients with DDH are satisfactory at short-term followup regarding clinical scores, biomechanics, and return to sports, but the 6% failure rate was higher than anticipated and limb-length discrepancies were not adequately corrected. [122] (10.1007/s11999-008-0456-4)
• [Paper] If patient selection is judiciously done and surgical technique is meticulously followed, hip resurfacing offers acceptable survivorship, satisfactory range of motion and enables patients to resume high demand activities including sports. [123] (10.1007/s00264-015-2731-9)
• [L5] High impaction forces significantly reduce the ultimate failure load of the femoral neck compared to low impaction forces. [124] (10.1016/j.arth.2010.01.108)
• [L5] The acetabular labrum provides stability to the hip joint in response to a distraction force and combined distraction and translation forces. [128] (10.1007/s00167-015-3555-2)
• [L3] High ion levels were associated with an abduction angle of more than 45° and repetitive extreme hip motion in revision cases. [129] (10.1016/j.arth.2011.11.009)
• [L5] To restore natural hip ROM, surgeons performing hip SRA should aim to reproduce the natural femoral head-neck offset, especially in patients with morphological head-neck abnormalities. [130] (10.1016/j.arth.2007.09.011)
• [L4] Although no significant factors were found to explain the impingement, it appears that repetitive extreme motion of the involved hip and malposition of the implants can cause impingement after hip resurfacing arthroplasty. [132] (10.2106/jbjs.j.01771)
• [L4] Extensive soft tissue and abductor muscles dysfunctions were common, and a constrained acetabular component with repair of the hip abductors might be beneficial. [133] (10.1016/j.arth.2016.04.033)
• [L4] The large individual morphologic variability across all levels of dysplastic hips suggests the femoral prosthesis cannot be chosen on the basis of the severity of the subluxation alone. [134] (10.1097/blo.0b013e3181576052)
• [L4] While the risk of revision for resurfacing due to metal-related pathologies is very low, it is higher than in other types of bearings. [135] (10.1530/eor-23-0099)
• [L3] Morphologic factors responsible for severe intra-articular lesions differ for cartilage degeneration and labral tears in patients with severe hip dysplasia. [136] (10.1016/j.arthro.2016.01.060)
• [L5] Acetabular offset and height had a greater effect on ROMBI than femoral offset and height. [143] (10.1016/j.arth.2009.03.024)
• [L4] The authors successfully managed two cases of intertrochanteric fracture below Birmingham Hip Resurfacing using non-operative methods. [144] (10.1016/j.injury.2008.10.040)
• [L3] [147] (10.1016/j.arth.2007.05.017)
• [L3] [149] (10.1016/j.arth.2013.05.033)
• [L3] Although the usage of large-head MoM THA is largely historic, our findings suggest that MoM hip resurfacing arthroplasty has a more favorable outcomes profile with reduced systemic metal ion exposure, reinforcing its role in younger, active patients, where conventional or large-head THA may fall short. [150] (10.2106/jbjs.rvw.25.00204)
• [L3] [153] (10.1007/s00264-010-1053-1)
• [L1] RCTs and CCTs have provided insufficient evidence to determine whether modern metal-on-metal hip resurfacing offers clinical advantages over standard total hip arthroplasty for the treatment of hip disease in active young patients. [158] (10.1016/j.arth.2010.07.008)
• [L3] Conventional radiograph templating for metal-on-metal hip resurfacing is a useful method for preoperative planning of implant sizes, and surgeon experience plays a significant role in the accuracy of predicting component size. [161] (10.1016/j.arth.2010.07.024)
• [L5] [163] (10.1016/j.arth.2010.11.017)
• [L5] Femoral component loosening in hip resurfacing can occur without radiographic signs of subsidence or radiolucency, potentially leading to stem fracture due to atypical overloading. [164] (10.1007/s00402-009-0913-x)
• [L2] Resurfacing arthroplasty is associated with a higher early complication rate than total hip arthroplasty, with complications tending to occur early in the surgical learning curve. [166] (10.1016/j.arth.2008.01.234)
• [L3] We recommend that dual energy x-ray absorptiometry scan T-score tests should be routinely performed on all hip resurfacing patients pre-operatively. [167] (10.1186/1749-799x-7-1)
• [L4] EBRA software can be used to reliably assess the version of resurfacing cups when radiographs are of sufficient quality. [171] (10.1016/j.arth.2009.08.020)
• [L4] Preoperative templating for hip resurfacing arthroplasty showed variable reliability and fair accuracy, with surgeons tending to underestimate implant size. [172] (10.1016/j.arth.2009.01.022)
• [L4] Our data at short-term followup suggest increased rates of groin pain after metal-on-metal THA or resurfacing arthroplasty versus THA using polyethylene or ceramic bearing surfaces. [177] (10.1007/s11999-010-1356-y)

See Also

• Femoroacetabular impingement
• Total hip replacement
• Adverse reaction to metal debris
• Hip arthroscopy
• Intertrochanteric fracture

References

[1] Metal-on-metal hip resurfacing in patients younger than 50 years: a retrospective analysis. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0579-y

[2] Hip Resurfacing in an 88-Year-Old Patient?. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.04.026

[3] Excellent short-term results of hip resurfacing in a selected population of young patients. Orthopaedics & Traumatology: Surgery & Research. 2015. DOI: 10.1016/j.otsr.2015.07.011

[4] Hip Resurfacing: A Single Surgeon U.S. Series With Minimum Ten-Year Follow-up. The Journal of Arthroplasty. 2022. DOI: 10.1016/j.arth.2022.04.008

[5] Success of Modern Cementless Femoral Components in Young Patients: A Systematic Review and Meta-analysis of Total Hip Arthroplasty and Hip Resurfacing. Do the Results Justify Hip Resurfacing?. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.11.032

[6] What is the Midterm Survivorship and Function After Hip Resurfacing?. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-010-1438-x

[7] Hip Resurfacing in Women: Cause for Concern? Clinical Results from an Independent Center. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2008.01.232

[8] Interventions for Improving Hip Resurfacing Outcomes in Women: A High-Volume, Retrospective Study. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.06.003

[9] Metal on metal hip resurfacing versus uncemented custom total hip replacement - early results. Journal of Orthopaedic Surgery and Research. 2010. DOI: 10.1186/1749-799x-5-8

[10] Modern Metal-on-metal Hip Resurfacing. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201005000-00007

[11] Hip resurfacing and osteonecrosis: results from an independent hip resurfacing register. Archives of Orthopaedic and Trauma Surgery. 2009. DOI: 10.1007/s00402-009-0963-0

[12] Hip Resurfacing: Patient and Treatment Options. Journal of Bone and Joint Surgery. 2009. DOI: 10.2106/jbjs.i.00341

[13] Results of metal-on-metal hip resurfacing in patients 40 years old and younger. Archives of Orthopaedic and Trauma Surgery. 2012. DOI: 10.1007/s00402-012-1640-2

[14] Early Return to Function After Hip Resurfacing. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2009.05.034

[15] Is Patient Selection Important for Hip Resurfacing?. Clinical Orthopaedics & Related Research. 2009. DOI: 10.1007/s11999-008-0558-z

[16] Predicting changes in the status of patient-reported outcome measures after Birmingham Hip Resurfacing. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b11.bjj-2019-0663.r1

[17] 10-Year Results of Metal-on-Metal Hip Resurfacing with Computer-Assisted Navigation. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.05.008

[18] Revision of failed hip resurfacing to total hip arthroplasty rapidly relieves pain and improves function in the early post operative period. Journal of Orthopaedic Surgery and Research. 2010. DOI: 10.1186/1749-799x-5-88

[19] Unsatisfactory Surgical Learning Curve with Hip Resurfacing. Journal of Bone and Joint Surgery. 2011. DOI: 10.2106/jbjs.j.01719

[20] Hip resurfacing in patients under thirty years old: an attractive option for young and active patients. International Orthopaedics. 2012. DOI: 10.1007/s00264-012-1555-0

[21] The outcome and survival of metal-on-metal hip resurfacing in patients aged less than 50 years. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b1.bjj-2018-0702.r1

[22] Why Total Hip Resurfacing. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2007.05.050

[23] Polyethylene Hip Resurfacing to Treat Arthritis and Severe Acetabular Insufficiency. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.07.023

[24] Clinical Outcomes and Survivorship After Conversion of Metal-on-Metal Hip Resurfacing to Total Hip Arthroplasty. JBJS Reviews. 2026. DOI: 10.2106/jbjs.rvw.26.00037

[25] Hip resurfacing for rheumatoid arthritis: independent assessment of 11-year results from an international register. International Orthopaedics. 2010. DOI: 10.1007/s00264-010-1046-0

[26] The outcomes of hip resurfacing compared to standard primary total hip arthroplasty in Men. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-161

[27] European multidisciplinary consensus statement on the use and monitoring of metal-on-metal bearings for total hip replacement and hip resurfacing. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.01.005

[28] Functional performance after hip resurfacing or total hip replacement: A comparative assessment with non-operated subjects. Orthopaedics & Traumatology: Surgery & Research. 2012. DOI: 10.1016/j.otsr.2011.10.006

[29] Considering the Use of Metal-on-Metal Hip Resurfacing in Young Male Patients. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.21.00515

[30] What Is the Rerevision Rate After Revising a Hip Resurfacing Arthroplasty? Analysis From the AOANJRR. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-015-4215-z

[31] Hip Resurfacing Data from National Joint Registries: What Do They Tell Us? What Do They Not Tell Us?. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-009-1157-3

[32] Hip resurfacing. The Bone & Joint Journal. 2023. DOI: 10.1302/0301-620x.105b5.bjj-2023-0015.r1

[33] Eleven Years of Experience With Metal-on-Metal Hybrid Hip Resurfacing. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2008.04.017

[34] Hip Resurfacing. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201104000-00008

[35] Hip Resurfacing versus Total Hip Arthroplasty: A Systematic Review Comparing Standardized Outcomes. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-014-3556-3

[36] In Vivo Wear Rate of the Birmingham Hip Resurfacing Arthroplasty. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.06.022

[37] Optimizing Patient Selection and Outcomes with Total Hip Resurfacing. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000192354.76792.bb

[38] Femoral Neck Fracture After Birmingham Hip Resurfacing Arthroplasty. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.04.035

[39] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Summary.

[40] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Radiography.

[41] Aaos Comprehensive Orthopaedic Review 3. Nonarthroplasty Surgical Treatment of the Hip > I. Femoroacetabular Impingement.

[42] Editorial Commentary: Hip Arthroscopy Plays a Role in Painful Hip Resurfacing Arthroplasty but a Prearthroscopy Diagnosis Is Critical to Outcome. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2015.12.039

[43] Outcomes of metal-on-metal hip resurfacing arthroplasty: a single-surgeon series of 6114 cases with 2–19 year follow-up. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06076-5

[44] Prospective Multicenter Clinical Trial of Hip Resurfacing Arthroplasty. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2008.01.235

[48] Influence of head size and sex on the five-year survival of ceramic-on-ceramic hip resurfacing. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b7.bjj-2024-1594.r1

[49] The Learning Curve for Adopting Hip Resurfacing Among Hip Specialists. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-009-1106-1

[50] Metal-on-metal hip resurfacing: a critical review. Archives of Orthopaedic and Trauma Surgery. 2010. DOI: 10.1007/s00402-010-1153-9

[51] Asymptomatic pseudotumours after metal-on-metal hip resurfacing show little change within one year. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b12.32248

[54] Metal-on-Metal Hip Resurfacing. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2008.06.015

[55] Sports after Hip Resurfacing Arthroplasty. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506296606

[56] Clinical outcomes and return to dance after total hip arthroplasty or hip resurfacing in professional dancers. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b3.bjj-2023-0854.r1

[57] Hip Resurfacing for Treatment of Advanced Hip Osteoarthritis in a Patient With Polyostotic Fibrous Dysplasia: Five-Year Follow-Up. Orthopaedic Nursing. 2019. DOI: 10.1097/nor.0000000000000554

[58] Outcomes of Conversion of Hip Resurfacing Arthroplasty to Total Hip Arthroplasty with Retention of the Acetabular Component. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.04.027

[60] The Role of Hip Arthroscopy in Investigating and Managing the Painful Hip Resurfacing Arthroplasty. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.08.029

[61] Hip resurfacing before 50 years of age: A prospective study of 979 hips with a mean follow-up of 5.1 years. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2017.10.018

[62] The 20-year results of the first 400 Conserve Plus hip resurfacing arthroplasties. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b7.bjj-2020-2256.r1

[63] Is the economic and social cost of one-stage bilateral hip resurfacing lower than two-stage procedures? Retrospective case-control study of 260 hips. Orthopaedics & Traumatology: Surgery & Research. 2020. DOI: 10.1016/j.otsr.2020.01.011

[64] Patterns of Changes in Femoral Bone Mineral Density Up To Five Years After Hip Resurfacing. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.09.012

[65] Increased risk for extended acetabular reconstruction in failed hip resurfacing as compared to failed total hip arthroplasty. Archives of Orthopaedic and Trauma Surgery. 2015. DOI: 10.1007/s00402-015-2364-x

[66] Durom hip resurfacing system: Retrospective study of 644 cases with an average follow-up of 34 months. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2012.10.018

[67] Hip Resurfacing in Teenagers. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2023.05.073

[68] One-Component Revision of Failed Hip Resurfacing from Adverse Reaction to Metal Wear Debris. The Journal of Arthroplasty. 2014. DOI: 10.1016/j.arth.2013.04.011

[69] Metal-on-Metal Hip Resurfacing. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2007.09.021

[70] The Results of Metal-On-Metal Hip Resurfacing in Patients Under 30 Years of Age. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.07.043

[71] The Birmingham Hip Resurfacing Prosthesis. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2009.10.010

[72] Hip Resurfacing Using Highly Cross-linked Polyethylene: Prospective Study Results at 8.5 Years. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.03.013

[76] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Osseous and Ligamentous Anatomy.

[77] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > IV. Hip Capsule and Ligaments.

[80] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > V. Hip Joint Muscles.

[82] Aaos Comprehensive Orthopaedic Review 3. Fractures of the Hip > I. General Considerations.

[85] Aaos Comprehensive Orthopaedic Review 3. Surgical Anatomy of the Hip > VI. Neurovascular Structures Surrounding the Hip.

[86] Orthopaedic Knowledge Update Sports Medicine 6. Hip Microinstability > Introduction.

[90] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy and Biomechanics, Evaluation, Clinical Examination, and Imaging of the Hip > Imaging.

[95] Femoral neck resorption following hybrid metal-on-metal hip resurfacing arthroplasty: a radiological and biomechanical analysis. Archives of Orthopaedic and Trauma Surgery. 2010. DOI: 10.1007/s00402-010-1070-y

[96] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Summary.

[97] A comparison of leg length and femoral offset discrepancies in hip resurfacing, large head metal-on- metal and conventional total hip replacement: a case series. Journal of Orthopaedic Surgery and Research. 2011. DOI: 10.1186/1749-799x-6-65

[101] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > SECTION 1 EVALUATION OF THE ADULT PATIENT WITH HIP PAIN.

[103] Metal-on-Metal Hip Resurfacing. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.07.021

[104] The Concept of Femoroacetabular Impingement: Current Status and Future Perspectives. Clinical Orthopaedics & Related Research. 2009. DOI: 10.1007/s11999-008-0646-0

[105] Hip resurfacing generates a more physiological gait than total hip replacement: A case-control study. Orthopaedics & Traumatology: Surgery & Research. 2020. DOI: 10.1016/j.otsr.2019.12.020

[109] Computed tomography evaluation of hip geometry restoration after total hip resurfacing. Orthopaedics & Traumatology: Surgery & Research. 2015. DOI: 10.1016/j.otsr.2015.04.004

[111] Morphologic Analysis of Periprosthetic Fractures After Hip Resurfacing Arthroplasty. The Journal of Bone & Joint Surgery. 2010. DOI: 10.2106/jbjs.h.01113

[113] Birmingham Hip Resurfacing in Patients 55 Years or Younger: Risk Factors for Poor Midterm Outcomes. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2016.12.044

[114] A 15° valgus femoral prosthesis orientation optimizes biomechanics in hip resurfacing arthroplasty: a finite element analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06370-2

[115] Prevalence of Groin Pain after Hip Resurfacing. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.11.086

[117] Adverse Local Tissue Reactions are Common in Asymptomatic Individuals After Hip Resurfacing Arthroplasty: Interim Report from a Prospective Longitudinal Study. Clinical Orthopaedics & Related Research. 2021. DOI: 10.1097/corr.0000000000001882

[118] Comparison of anterior and posterior approaches for hip resurfacing arthroplasty: a gait analysis study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06457-w

[119] Computerized Range of Motion Analysis Following Dual Mobility Total Hip Arthroplasty, Traditional Total Hip Arthroplasty, and Hip Resurfacing. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2012.08.017

[122] Outcome of Hip Resurfacing Arthroplasty in Patients with Developmental Hip Dysplasia. Clinical Orthopaedics and Related Research®. 2008. DOI: 10.1007/s11999-008-0456-4

[123] Survivorship and clinical outcome of Birmingham hip resurfacing: a minimum ten years’ follow-up. International Orthopaedics. 2015. DOI: 10.1007/s00264-015-2731-9

[124] Does Impaction Matter in Hip Resurfacing? A Cadaveric Study. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.01.108

[128] Biomechanical evaluation contribution of the acetabular labrum to hip stability. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3555-2

[129] Chinese Experience With Metal-on-Metal Hip Resurfacing. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2011.11.009

[130] Painful Impingement of the Hip Joint After Total Hip Resurfacing: A Report of Two Cases. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2007.09.011

[132] Impingement Between the Acetabular Cup and the Femoral Neck After Hip Resurfacing Arthroplasty. Journal of Bone and Joint Surgery. 2011. DOI: 10.2106/jbjs.j.01771

[133] Outcome of Revision Total Hip Arthroplasty in Management of Failed Metal-on-Metal Hip Arthroplasty. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.04.033

[134] PRESIDENTIAL GUEST LECTURE: Anatomy of the Dysplastic Hip and Consequences for Total Hip Arthroplasty. Clinical Orthopaedics & Related Research. 2007. DOI: 10.1097/blo.0b013e3181576052

[135] Metal-on-metal hip resurfacing arthroplasty: is it safe and reliable? A synopsis of the past, the present, and the future of HRA. EFORT Open Reviews. 2024. DOI: 10.1530/eor-23-0099

[136] Factors Associated With Severity of Intra‐articular Lesions in Patients With Severe Hip Dysplasia. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.01.060

[143] Factors Affecting Bony Impingement in Hip Arthroplasty. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2009.03.024

[144] Intertrochanteric fracture below Birmingham Hip Resurfacing: Successful non-operative management in two cases. Injury. 2009. DOI: 10.1016/j.injury.2008.10.040

[147] Femoral Neck Fractures After Metal-on-Metal Total Hip Resurfacing. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2007.05.017

[149] Early Failure of the Durom Prosthesis in Metal-on-Metal Hip Resurfacing in Chinese Patients. The Journal of Arthroplasty. 2013. DOI: 10.1016/j.arth.2013.05.033

[150] Hip Resurfacing Arthroplasty Is Associated with Lower Metal Ion Levels and Revision Risk Compared with Large-Head Metal-on-Metal Total Hip Arthroplasty. JBJS Reviews. 2025. DOI: 10.2106/jbjs.rvw.25.00204

[153] Sporting and physical activity following hip resurfacing. International Orthopaedics. 2010. DOI: 10.1007/s00264-010-1053-1

[158] A Systematic Review of Modern Metal-on-Metal Total Hip Resurfacing vs Standard Total Hip Arthroplasty in Active Young Patients. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.07.008

[161] The Accuracy and Reliability of Preoperative Templating for Metal-on-Metal Hip Resurfacing. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.07.024

[163] Femoral Component Neck Fracture After Failed Hip Resurfacing Arthroplasty. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.11.017

[164] Lack of radiographic loosening signs in a hip resurfacing that failed by stem fracture. Archives of Orthopaedic and Trauma Surgery. 2009. DOI: 10.1007/s00402-009-0913-x

[166] Patients' Perceptions of Hip Resurfacing Arthroplasty. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2008.01.234

[167] Risk factor analysis for early femoral failure in metal-on-metal hip resurfacing arthroplasty: the effect of bone density and body mass index. Journal of Orthopaedic Surgery and Research. 2012. DOI: 10.1186/1749-799x-7-1

[171] Cup Anteversion in Hip Resurfacing: Validation of EBRA and the Presentation of a Simple Clinical Grading System. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2009.08.020

[172] Assessment of Accuracy and Reliability in Preoperative Templating for Hip Resurfacing Arthroplasty. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2009.01.022

[177] The Prevalence of Groin Pain After Metal-on-Metal Total Hip Arthroplasty and Total Hip Resurfacing. Clinical Orthopaedics & Related Research. 2010. DOI: 10.1007/s11999-010-1356-y