Hip Resurfacing

Introduction

Hip resurfacing is a type of hip surgery that treats a damaged hip joint by capping the worn bone rather than removing it. It is sometimes called a bone-conserving alternative to total hip replacement. For some carefully selected patients — often younger, more active adults with strong bones — hip resurfacing offers a way to keep more of the natural thigh bone (femur) while still relieving pain and restoring movement.

If your orthopaedic surgeon has raised hip resurfacing as a possible option, you likely already have a diagnosis such as advanced osteoarthritis of the hip and are weighing your surgical choices. This article explains what hip resurfacing is, how it compares with total hip replacement, who tends to be a good candidate, what the surgery and recovery involve, and what to think about for the long term. The decision between resurfacing and replacement is an individual one, made together with a surgeon who has examined you and reviewed your imaging.

What Is Hip Resurfacing?

The hip is a ball-and-socket joint. The “ball” is the rounded top of the femur (called the femoral head), and the “socket” is a cup-shaped part of the pelvis (called the acetabulum). Cartilage lines both surfaces so that the joint moves smoothly. When the cartilage wears away — from osteoarthritis, inflammatory arthritis, injury, or other causes — the bones rub directly against each other, which causes pain, stiffness, and loss of function.

In a total hip replacement, the surgeon removes the entire femoral head and a portion of the femoral neck and inserts a metal stem down into the hollow of the thigh bone. A new ball is attached to the top of this stem. The damaged socket is also resurfaced with a metal cup and a smooth liner.

In hip resurfacing (sometimes called hip resurfacing arthroplasty), the surgeon does not remove the femoral head. Instead, the damaged surface of the femoral head is trimmed and reshaped, and a smooth metal cap is fitted over it — a bit like putting a crown on a tooth. The socket side is treated similarly to a total hip replacement, with a metal cup fixed into the pelvis. The capped ball then articulates against the cup.

Because the femoral head and most of the femoral neck are preserved, less bone is removed during the operation. This is the central appeal of hip resurfacing: it conserves bone, which may matter if you are likely to need further hip surgery later in life.

Why Is Hip Resurfacing Performed?

Hip resurfacing is performed for the same reasons as total hip replacement: to relieve hip pain and improve function when the joint has become severely damaged and non-surgical treatments are no longer enough. The underlying conditions that lead to hip resurfacing include:

• Osteoarthritis — the most common reason. This is the gradual wearing away of joint cartilage with age, use, or genetic predisposition.
• Inflammatory arthritis — such as rheumatoid arthritis or ankylosing spondylitis, where the immune system attacks the joint lining.
• Post-traumatic arthritis — arthritis that develops years after a hip fracture or other injury.
• Avascular necrosis (osteonecrosis) — loss of blood supply to part of the femoral head, causing the bone to collapse. Resurfacing may be considered when only a limited portion of the femoral head is affected.
• Childhood hip conditions that have caused later joint damage, such as developmental dysplasia of the hip or slipped capital femoral epiphysis.

The general thresholds for considering surgery are similar in resurfacing and replacement: persistent hip pain that interferes with daily activities and sleep, significant loss of joint motion, and failure of non-surgical treatments such as activity modification, weight management, physiotherapy, anti-inflammatory medication, and (for some patients) joint injections.

Who Is a Candidate for Hip Resurfacing?

Hip resurfacing is not for everyone who needs hip surgery. Over the past two decades, the selection criteria have narrowed as long-term data has accumulated. Major orthopaedic societies and national guidance documents, including guidance from the UK’s National Institute for Health and Care Excellence (NICE) and the American Academy of Orthopaedic Surgeons, describe hip resurfacing as appropriate for a more specific group of patients than total hip replacement.

Age and activity level

Hip resurfacing is more often offered to younger and physically active adults — typically in their 40s and 50s, though there is no fixed cutoff. The reasoning is partly that these patients have stronger bone to support the resurfaced femoral head, and partly that preserving bone gives them more options if revision surgery is needed decades later.

Sex

Long-term registry data has shown that hip resurfacing has performed better in men than in women, on average. Several reasons have been suggested, including average femoral head size (smaller heads have shown higher failure rates with metal-on-metal bearings) and bone density patterns. As a result, current practice in many centres is more cautious about offering resurfacing to women, although it is not universally ruled out. This is a discussion to have with your surgeon.

Bone quality and femoral head size

For the resurfacing cap to be held securely, the underlying bone needs to be strong. Patients with significant osteoporosis, large cysts in the femoral head, or extensive bone loss from avascular necrosis are typically less suitable. A larger femoral head also tends to perform better with the bearing surfaces used in resurfacing.

Diagnosis

Resurfacing is more commonly considered for primary osteoarthritis. It is generally less suitable for severe inflammatory arthritis, severe deformity of the hip, or extensive avascular necrosis.

Kidney function and metal sensitivity

Most modern hip resurfacing devices use a metal-on-metal bearing, meaning both the cap and the cup are metal. Small amounts of metal ions (cobalt and chromium) can be released into the body. Patients with reduced kidney function, known sensitivity or allergy to metals, or who are pregnant or planning pregnancy soon are generally advised to consider other options.

Other factors

General fitness for surgery, body weight, expectations about activity afterwards, and willingness to attend long-term follow-up are also part of the conversation.

Alternatives to Hip Resurfacing

Before deciding on hip resurfacing, it is worth understanding the full range of options. Surgical alternatives are not the only consideration — many patients with hip arthritis can be managed without surgery for years.

Non-surgical management

For earlier or milder disease, doctors typically recommend a stepwise approach:

• Activity modification — reducing high-impact activities while staying active in lower-impact ways (swimming, cycling, walking).
• Weight management — even a modest reduction in body weight reduces the load across the hip.
• Physiotherapy — targeted strengthening of the muscles around the hip and core, and work on flexibility and gait.
• Pain medication — paracetamol and non-steroidal anti-inflammatory drugs are commonly used. Long-term use of these has its own considerations, which your doctor will discuss.
• Injections — corticosteroid injections into the hip can provide temporary relief for some patients. Other injection therapies are used variably.
• Walking aids — a cane used in the opposite hand can significantly reduce the load on a painful hip.

Total hip replacement

This is the main surgical alternative to resurfacing and is the most commonly performed hip operation worldwide. In total hip replacement, the femoral head is removed and replaced with a ball on a stem that is fixed into the thigh bone. Bearing surfaces in total hip replacement are usually ceramic-on-polyethylene or ceramic-on-ceramic, which avoids the metal-on-metal ion issue associated with most resurfacing designs.

Total hip replacement has a longer track record across more patient groups, performs reliably across a wider range of ages and bone qualities, and is generally the default operation unless there is a specific reason to consider resurfacing.

Hip osteotomy

In selected younger patients with hip dysplasia or specific shape abnormalities of the hip, an osteotomy — reshaping and repositioning the bone around the hip joint — may be considered. This is a different operation with different goals and is appropriate only for specific anatomies and earlier disease stages.

Hip arthroscopy

For specific problems such as labral tears or femoroacetabular impingement, keyhole hip arthroscopy may be considered. It is not a treatment for established severe arthritis.

Whether resurfacing, replacement, or a non-surgical approach is appropriate is a clinical decision that depends on your individual anatomy, disease stage, activity goals, and overall health. Many patients find it helpful to ask their surgeon to explain why resurfacing is — or is not — being recommended in their case.

Bearing Surfaces and Implant Designs

Hip resurfacing devices have changed over the decades. The current generation of metal-on-metal resurfacing implants emerged in the late 1990s and 2000s. Several different designs have been used worldwide, with varying long-term performance. A few important points are worth understanding:

• Metal-on-metal bearings are the dominant design in hip resurfacing. The metal is typically a cobalt-chromium alloy. Wear between the two metal surfaces releases very small particles and ions, which enter the bloodstream in low concentrations.
• Some metal-on-metal designs were withdrawn from the market after higher than expected failure rates, particularly with smaller femoral head sizes or in certain patient groups. National regulators and orthopaedic societies have issued guidance on follow-up for patients who received those specific implants.
• Modern designs in current use have been refined based on long-term data. Surgeons select an implant based on training, experience, and the patient’s anatomy.

If hip resurfacing is being considered, it is reasonable to ask which specific device your surgeon uses, what their experience with it is, and what the follow-up protocol will be.

Surgical Approaches

Hip resurfacing can be performed through several surgical approaches — that is, the route the surgeon takes through the soft tissues to reach the hip joint. The most commonly used approaches include:

• Posterior approach — from the back of the hip. This is the most commonly used approach for resurfacing because it provides good exposure of the femoral head, which is preserved in this operation and therefore needs to be worked around.
• Anterolateral or direct lateral approach — from the side. Used by some surgeons for resurfacing.
• Direct anterior approach — from the front. This approach is technically more demanding for resurfacing because of the difficulty of exposing the femoral head adequately while preserving it.

Each approach has its own pattern of muscle handling, post-operative recovery, and surgeon preference. The choice is usually based on what the operating surgeon does most often and most safely, rather than a strong difference in long-term outcome.

Preparing for Hip Resurfacing

Once the decision is made to proceed, preparation typically happens over several weeks. The goal is to enter surgery in the best possible condition and to have a recovery plan in place before you go in.

Medical assessment

A pre-operative assessment usually includes blood tests, an ECG (heart tracing), a chest X-ray if needed, and a review of your general health by an anaesthetist. Conditions such as high blood pressure, diabetes, heart disease, sleep apnoea, and kidney problems are checked and optimised. You will be asked about all medications, including supplements and traditional remedies. Some, particularly blood thinners and certain anti-inflammatory drugs, may need to be paused before surgery.

Dental check

Many surgeons recommend a dental check before joint replacement surgery, because untreated dental infection can spread through the bloodstream to a joint implant.

Smoking and alcohol

Stopping smoking before surgery improves wound healing and reduces lung complications. Cutting back on alcohol in the weeks before surgery is also commonly advised.

Physical preparation (“prehab”)

Doing some focused exercise in the weeks before surgery — sometimes called prehabilitation — can help with recovery. A physiotherapist may teach you exercises to strengthen the hip, thigh, and core muscles, and to practise using crutches or a walker.

Home preparation

Before surgery, it helps to prepare your home: remove loose rugs and trip hazards, arrange a comfortable chair with armrests, set up a place to sleep that is easy to get in and out of, and stock up on basic supplies. A raised toilet seat and a shower chair are often suggested for the first few weeks.

Arranging help

You will need some help at home in the first one to two weeks, with cooking, household tasks, and getting to follow-up appointments. Planning this in advance reduces stress later.

What Happens During Hip Resurfacing Surgery

Hip resurfacing is performed in an operating theatre under either general anaesthesia (you are fully asleep) or spinal anaesthesia (you are awake or lightly sedated, with the lower half of the body numb). The choice is made with the anaesthetist based on your medical history and preference.

The operation typically takes one and a half to three hours, depending on the surgeon, the approach, and the complexity of the case.

Step by step

1. Positioning — you are placed on the operating table on your side or back, depending on the approach.
2. Skin preparation and incision — the skin is cleaned thoroughly and an incision is made over the side or back of the hip. Resurfacing incisions are generally longer than those used in some total hip replacement approaches because more working space is needed around the preserved femoral head.
3. Exposing the joint — the surgeon works through the muscle layers to reach the joint capsule and then opens the capsule to see the hip.
4. Dislocating the hip — the femoral head is dislocated from the socket so both surfaces can be worked on.
5. Preparing the femoral head — using specialised guides and instruments, the damaged surface of the femoral head is trimmed and shaped to receive the cap. The underlying bone is preserved.
6. Fitting the cap — the metal cap is placed onto the prepared femoral head, usually with a small amount of bone cement to hold it in place.
7. Preparing the socket — the cartilage in the acetabulum is removed and the bone is shaped with reamers to fit the metal cup. The cup is then press-fitted into the bone, where it will be held by friction and by bone growing into its surface over time.
8. Relocating the hip — the new ball (the capped femoral head) is placed back into the new socket and tested for stability and range of motion.
9. Closing — the joint capsule, muscle layers, and skin are closed in sequence. A drain is sometimes used but often not.

Recovery and Healing

The hospital stay

Most patients stay in hospital for two to four days. Increasingly, with enhanced recovery protocols, this can be shorter. Standing and walking with a frame or crutches usually begins the same day as surgery or the next morning. Pain is managed with a combination of medications. Blood thinners are usually given to reduce the risk of clots.

The first two weeks

At home, you will use crutches or a walker, gradually increasing the amount of weight you put through the operated leg as instructed. Wound care is straightforward: keep the wound clean and dry until it has healed, and watch for signs of infection (increasing pain, redness, swelling, fluid leaking from the wound, fever).

Many surgeons advise hip precautions in the early weeks — avoiding certain positions (such as crossing the legs, bending the hip beyond 90 degrees, or turning the foot inwards) that could put the new joint at risk of dislocation. These precautions vary by surgical approach, so follow your team’s specific advice.

Weeks two to six

Most people transition from crutches to a single stick and then to walking unaided during this period. Physiotherapy continues, with a focus on regaining strength, balance, and a normal walking pattern. Many people can drive again around four to six weeks after surgery, once they can safely perform an emergency stop — your surgeon will confirm when this is appropriate.

Six weeks to three months

By six weeks, most patients are walking comfortably and resuming light daily activities. By three months, the soft tissues have largely healed, and patients are often back to most non-impact activities. Return to work depends on the type of job: desk-based work is often possible within a few weeks, while jobs involving heavy lifting or prolonged standing take longer.

Six months and beyond

Full recovery — including return to higher-level activities such as hiking, golf, doubles tennis, or cycling — usually takes six months to a year. Hip resurfacing is often chosen by patients who hope to return to more active lifestyles, and many do. High-impact sports (running, contact sports, singles tennis on hard courts) are a longer conversation with your surgeon; some surgeons permit them in selected patients while others advise against them.

Physiotherapy

Physiotherapy is a central part of recovery. A typical programme builds from gentle range-of-motion and walking work in the first weeks to strengthening, balance, and functional training over the following months. Following the programme — including doing exercises at home between sessions — has a strong effect on the final result.

Risks and Complications

Hip resurfacing is generally a safe operation in well-selected patients, but, like all major surgery, it carries risks. Understanding them is part of giving informed consent.

General surgical risks

• Bleeding during or after surgery.
• Infection — either in the wound or, less commonly, deep around the implant.
• Blood clots in the leg (deep vein thrombosis) or lungs (pulmonary embolism). Blood thinners and early mobilisation reduce this risk.
• Anaesthetic complications.
• Nerve or blood vessel injury around the hip.

Risks specific to hip resurfacing

• Femoral neck fracture — because the femoral neck is preserved in resurfacing (unlike total hip replacement, where it is removed), there is a small risk that it can fracture in the months after surgery, particularly if the bone is weaker than expected or if a fall occurs. This is more common in women, in patients with smaller bones, and in those with weakened bone.
• Metal ion release — metal-on-metal bearings release small amounts of cobalt and chromium ions. In most patients, levels remain low and cause no problems. In a small number, ion levels rise enough to require closer monitoring. A specific reaction called an adverse reaction to metal debris (ARMD) can develop around some implants, causing pain, swelling, and damage to soft tissues. Regular follow-up usually includes a check for this.
• Dislocation — less common than in total hip replacement, because the resurfaced ball is larger (closer to the natural size), but still possible, particularly in the early weeks.
• Loosening — over time, either component can become loose from the surrounding bone.
• Continued pain — a minority of patients have ongoing groin or thigh pain even after a technically successful operation.
• Leg length difference — less common in resurfacing than in total hip replacement, because the geometry of the hip is more naturally preserved.
• Need for revision surgery — if the implant fails or causes problems, conversion to a total hip replacement is usually possible. One reason patients choose resurfacing is that revision to a total hip replacement is often more straightforward than revising a failed total hip replacement.

Long-term follow-up

Because of the specific issues associated with metal-on-metal bearings, regulators and orthopaedic societies advise that patients with hip resurfacing implants have regular follow-up over the long term. This typically includes clinical review, X-rays, and, in some cases, blood tests for metal ion levels and imaging of the soft tissues around the hip. Attending these appointments is an important part of having had this operation.

Life After Hip Resurfacing

For most patients, life after hip resurfacing is a substantial improvement on life before it. Pain that limited walking, sleep, and work is often dramatically reduced. Many patients return to activities they had given up years before.

Activity levels

One of the reasons hip resurfacing is chosen by some patients is the hope of returning to higher-level activity than is generally recommended after total hip replacement. Walking, hiking, swimming, cycling, golf, doubles tennis, skiing, and similar activities are commonly possible. Whether higher-impact activities such as running, jumping sports, or martial arts are advisable depends on the patient, the implant, and the surgeon’s judgement. Returning to professional or very high-level sport is a discussion that goes beyond the standard advice.

Long-term outcomes

In well-selected patients — particularly younger men with primary osteoarthritis, good bone quality, and larger femoral head size — modern hip resurfacing implants have survived well past 10 years in many studies, with a substantial proportion still functioning at 15 years and beyond. Outcomes are less consistent in other patient groups, which is part of why selection has become stricter.

It is reasonable to think of any hip implant as something that may, eventually, need attention. Because hip resurfacing preserves bone in the femur, if revision is needed, it can usually be converted to a total hip replacement using standard implants. This is one of the long-term advantages that draws some patients toward resurfacing as a first operation.

Dental work and other surgeries

After any joint replacement or resurfacing, some doctors recommend antibiotic cover for certain dental procedures or other invasive procedures, particularly in the first two years. Practice varies; your surgeon and dentist can give specific advice.

Pregnancy

For women of childbearing age, the question of pregnancy with a metal-on-metal implant is one to discuss with both an orthopaedic surgeon and an obstetrician. Concerns about metal ion exposure to a developing baby are part of the reason resurfacing is less commonly offered to women who may become pregnant in the future.

Hip Resurfacing in Children and Adolescents

Hip resurfacing is not used in children. The growing skeleton is not suitable for this type of implant, and the underlying conditions affecting children’s hips (such as developmental dysplasia, Perthes’ disease, or slipped capital femoral epiphysis) are managed with different operations aimed at preserving and reshaping the natural joint. In the rare situations where severe joint damage occurs in late adolescence, the choice of surgery is made by paediatric and adult orthopaedic surgeons together.

Frequently Asked Questions

How is hip resurfacing different from total hip replacement?

The main difference is how much bone is removed. In total hip replacement, the entire femoral head is removed and a stem is fixed inside the thigh bone. In hip resurfacing, the femoral head is kept and capped with a metal cover. The socket is treated similarly in both operations. Total hip replacement is the more commonly performed operation, suitable across a wider range of patients; hip resurfacing is reserved for a more specific group.

Is hip resurfacing more painful or harder to recover from?

Recovery is broadly similar in the first weeks. Some patients feel that returning to higher-level activity is smoother after resurfacing, partly because of the larger ball size and partly because of patient selection. Pain management, wound healing, and physiotherapy follow much the same pattern.

How long will the implant last?

This depends on the patient, the implant, the surgical technique, and activity levels. In well-selected patients, modern hip resurfacing implants have lasted well over a decade in long-term studies. Your surgeon can give you a more personalised view based on your circumstances. Long-term follow-up appointments are important for catching any problems early.

Will I set off airport metal detectors?

Most modern metal implants can trigger airport security scanners. A medical letter from your surgeon explaining the implant can be helpful when travelling.

Can I have an MRI scan after hip resurfacing?

Most modern hip resurfacing implants are MRI-compatible, although the metal can cause some local distortion of the image around the hip. Tell the radiology team about your implant before any scan. Specialised MRI techniques are sometimes used to look at the tissues around the implant during follow-up.

If the implant fails, what happens?

If a resurfacing implant fails — for example, due to loosening, fracture, or a reaction to metal debris — it can usually be converted to a total hip replacement. Because the femoral head was preserved at the first operation, the surgeon has straightforward access to perform a standard hip replacement. Revision surgery is more involved than a first-time operation, but it is a well-established procedure.

What questions should I ask my surgeon?

Useful questions include: Why are you recommending resurfacing rather than total hip replacement for me? What implant do you use, and what is your experience with it? What are the specific risks in my case (age, sex, bone quality, diagnosis)? What is your follow-up protocol? What activities will I be able to return to, and which should I avoid? What happens if the implant needs to be revised later?

Conclusion

Hip resurfacing is a bone-conserving alternative to total hip replacement that can work well for a carefully selected group of patients. The decision between resurfacing and replacement — or between either operation and continued non-surgical management — depends on age, sex, bone quality, diagnosis, activity goals, and overall health. Modern practice favours total hip replacement for most patients but keeps resurfacing as a valuable option for certain younger, active adults with the right anatomy.

Whichever operation is chosen, the most important factors in a good outcome are accurate patient selection, an experienced surgical team, attention to recovery and physiotherapy, and long-term follow-up. The conversation with your own surgeon — who knows your imaging, your history, and your goals — is the place where these factors come together into a decision that fits you.