Hip resurfacing is a bone-preserving alternative to total hip replacement. Instead of removing the entire ball of your hip joint, the surgeon trims and reshapes it, then caps it with a smooth metal shell. A matching metal cup is placed in the hip socket. The result is a resurfaced joint that closely mimics your natural hip anatomy, using a much larger ball than a standard replacement.
How It Differs From Total Hip Replacement
In a total hip replacement, the surgeon removes the entire femoral head (the ball at the top of your thighbone) and a portion of the femoral neck, then inserts a metal stem down into the hollow center of the bone. A new ball is attached to the top of that stem. Hip resurfacing skips most of that. The femoral head stays in place, is trimmed down, and fitted with a metal cap that slides over it like a crown on a tooth. Your natural bone supports the implant from the inside rather than being replaced by a metal rod.
This difference matters for two reasons. First, resurfacing preserves far more of your original bone, which makes a future revision surgery easier if one is ever needed. Second, the ball used in resurfacing is significantly larger, averaging about 50 mm compared to 32 mm in a standard replacement. A bigger ball means better stability, a lower risk of dislocation, and hip mechanics that feel closer to a natural joint. The tradeoff is that resurfacing uses a metal-on-metal bearing surface, which introduces a unique set of concerns covered below.
Who Is a Good Candidate
The ideal candidate is a younger, active man under 65 with osteoarthritis, strong bone, and a larger frame. That profile matters because each factor affects how well the implant performs. Younger patients benefit most from bone preservation since they’re more likely to need a second surgery decades down the road. Larger-framed patients tend to have bigger femoral heads, which produce better results with the metal-on-metal bearing. And strong bone density is essential because the cap sits on top of living bone rather than replacing it.
Patients with osteoporosis or significantly reduced bone density are not good candidates. The FDA advises against resurfacing in anyone whose bones aren’t strong or healthy enough, and research has identified a bone mineral density below 0.65 g/cm² as a likely disqualifier. The cap relies on your existing bone for structural support, so weak bone raises the risk of a femoral neck fracture, the most serious early complication of the procedure.
Why Gender Matters
Women have substantially higher complication rates after hip resurfacing. A systematic review found that women were 2.5 times more likely to need a revision surgery and nearly six times more likely to develop adverse local tissue reactions compared to men. The primary explanation is anatomy: women tend to have smaller femoral heads, which means a smaller implant. Smaller metal-on-metal bearings generate more friction and wear debris. When researchers looked at Australian registry data, they found that revision rates were essentially equal between men and women once the femoral head size reached 50 mm or above, but women rarely have femoral heads that large.
This is a significant consideration. Twenty-year survival data for the Birmingham Hip Resurfacing system, the most studied device, shows 96.5% of implants still functioning in men versus 87% in women. Many surgeons now recommend traditional hip replacement for most female patients rather than resurfacing.
The Metal Ion Concern
Because both the ball and socket are metal, tiny particles are released as the surfaces slide against each other during normal use. Your body absorbs these particles, primarily cobalt and chromium, into the bloodstream. In most patients the levels remain low and cause no problems. In some, elevated metal ions trigger adverse reactions.
Local symptoms include hip or groin pain, swelling, weakness, numbness, or changes in your ability to walk. Systemic effects, though less common, can involve the skin (rashes), kidneys, thyroid, heart, and nervous system. Some patients have reported sensory changes like visual or hearing problems, cognitive changes, fatigue, and depression. This constellation of problems is sometimes called metallosis.
If your implant is functioning well and you have no symptoms, the FDA says routine follow-up with your surgeon every one to two years for a physical exam and imaging is sufficient. There’s no evidence that routine blood metal testing is necessary in asymptomatic patients. If symptoms develop, your surgeon will likely order blood work and imaging to check for tissue damage around the joint.
Femoral Neck Fracture Risk
The most concerning early complication is a fracture through the femoral neck, the narrow section of bone just below the cap. In one large surgical series, this occurred in 1.8% of cases (15 fractures in 842 procedures). These fractures typically happen within the first few months, often before the reshaped bone has fully healed and adapted to its new load pattern. When a femoral neck fracture occurs, the resurfacing implant is removed and converted to a total hip replacement. This is one of the reasons good bone density is a non-negotiable requirement for the procedure.
What Recovery Looks Like
Most surgeons will have you standing and putting some weight on your hip as soon as the day after surgery. You’ll use crutches or a walker for a few weeks. Physical therapy begins early and typically continues for several weeks, focusing on rebuilding strength and range of motion. Everyday activities like driving, light housework, and desk work are generally possible around six weeks after surgery. Full recovery takes a few months.
Return to work depends on what you do. A desk job might only require one to two weeks off. Physically demanding work takes longer, and your surgeon will guide that timeline based on your progress. The relatively quick recovery is one of the main appeals of resurfacing compared to traditional replacement, partly because the larger ball allows more natural movement patterns from the start.
Returning to Sports and High Activity
This is where resurfacing stands out. One prospective study found that 98% of resurfacing patients returned to sports of any impact level, and 82% returned specifically to high-impact activities. Patients in that study were cleared to resume activities as soon as they wished after a minimum six-week recovery period. The researchers concluded that resurfacing allows younger, more active patients to return to physical and sports activities without restriction.
That said, no long-term studies have specifically measured how high-impact activity affects wear rates or implant loosening over 15 to 20 years. The assumption, based on the large bearing surface and preserved bone mechanics, is that the joint handles impact well. But the honest answer is that long-duration data on heavily active patients is still accumulating.
Long-Term Durability
The longest published data comes from the Birmingham Hip Resurfacing system, which now has 20-year follow-up. In male patients, 96.5% of implants were still functioning at the 20-year mark. For women, that number drops to 87%. These are strong numbers, particularly for men, and they compare favorably with many total hip replacement designs over the same time frame. The combination of bone preservation and solid long-term survival is the core argument for choosing resurfacing in the right patient.