Many individual surgeons who perform hip resurfacing report high success and longevity rates. In contrast, national joint replacement registries report higher revision rates for resurfacing compared to total hip replacement, especially for women. Meta-analyses of random controlled trials have found no significant differences in complications, revisions, or functional outcomes. Historically, resurfacing implants have had a metal-on-metal bearing. Newer implants using ceramic-on-ceramic and ceramic-on-polyethylene are available in Europe, Canada, and Australia, and are being tested in the U.S. Currently, there is insufficient data on their performance to draw conclusions. At the end of the post, I explain why I chose to have a total replacement rather than resurfacing.
I’m not a medical professional, and I'm not offering medical advice. You should consult with a physician or other qualified medical professional for diagnosis, treatment, and advice. The content on this site is for informational purposes only.
Several surgeons report high success and low revision rates with resurfacing.
Thomas Gross states, “My hip resurfacing 17-year survivorship is currently 99% far surpassing all registry benchmarks for any age, diagnosis, or sex.”
A 2008 study of 110 hips resurfaced by Michael Fordyce found 96.3% survivorship at an average follow-up of 5.9 years (5 year minimum).
A 2015 study comparing outcomes from surgeon Fares S. Haddad between THA and HRA in patients younger than 55 at 10 years post-op found no differences in quality of life scores. However, researchers did find the HRA group had significantly higher function scores as well as a higher proportion of running and involvement in sport and heavy manual labor. Although some of the patients were randomly assigned, nearly half insisted on resurfacing, so some selection bias is possible.
A 2023 study of over 200 hips resurfaced by Peter Brooks reported a 1% revision rate at an average of 4 years follow-up in patients under 40. (The authors acknowledge that “patients unsatisfied with their hip resurfacing may have elected to have a revision performed at a different institution, and thus may not have been captured by this study.”)
A 2021 study comparing outcomes from surgeon Edwin Su between THA and HRA in patients younger than 35 at 5 years post-op found that “both groups improved by an equal amount after surgery” on various patient-reported outcomes. There was a higher revision rate in the THA group, due mainly to the failure of two ceramic-on-ceramic bearings. Patients were not randomly assigned.
A 2024 study of 427 hips resurfaced by Edwin Su with a mean follow-up time of 16 years (minimum 15 years) found a 95.1% survival rate (95.8% for femoral head sizes ≥ 48 mm, and 91.3% for heads < 48 mm).
HRA is generally avoided in older adults, whose lower bone density makes them more susceptible to femoral neck fractures and whose kidneys may not be able clear metal ions from metal-on-metal bearings. However, a 2025 study comparing outcomes from surgeon Edwin Su between THA and HRA in patients older than 65, at a minimum of 2 years post-op, concluded: “In carefully selected patients aged 65 years or older, HRA can provide comparable or superior outcomes to THA.”
In contrast to single-surgeon studies, registry data isn’t so rosy.
The Australian National Registry 2025 Lay Summary puts it simply: “Overall, resurfacing hip replacement has a higher rate of revision compared to primary total conventional hip replacement.”
A 2020 study of outcomes in the Australian joint registry with a maximum follow-up time of nearly 19 years found that resurfacing had higher rates of loosening, fracture, and revision compared with THA using CoC or HXLPE liners. The authors concluded: “We suggest that a THA with proven low revision rates might be the better choice, particularly for patients who are concerned about implant durability.”
A 2025 study of more recent outcomes in the Australian joint registry found that resurfacings had higher revision rates than the five best total hip replacement implants at a follow-up time of 17 years.
According to the UK National Registry 2025 Annual Report, revision rates for metal-on-metal resurfacing increase over time, particularly in women. The best-performing brand of resurfacing has a revision rate of 9.75% at 15 years. This contrasts with rates of less than 3% for the best-performing cemented (2.57%), uncemented (1.82%), and hybrid hip replacement (2.55%).
At 15 years post-op, females aged 55 to 64 years have lower revision estimates than males for all construct types, except metal-on-metal bearings, where revision estimates are markedly higher for females than males and also markedly higher than alternatives. For example, 15-year revision estimates with hybrid ceramic-on-polyethylene constructs in this group are 2.69% compared to metal-on-metal hip resurfacing of 21.63%.
Even in males aged 55 to 64 years, at 15 years post-surgery, ceramic-on-polyethylene constructs have low revision estimates of approximately 5%, while metal-on-metal resurfacings have revision rate of 8.92%.
A 2022 study analyzed over 11,000 hip resurfacing patients aged 50 or younger, with an average follow-up time of 7.6 years. The surgeries took place across 27 experienced resurfacing centers in 13 countries. 16 different metal-on-metal implants were included. Implant survivorship was 95% at 10 years and 90% at 22 years. Implant survivorship was higher in men: 99% at 10 years and 92.5% at 21 years. For women, implant survivorship was 90% at 10 years and 81.3% at 22 years. The overall revision rate was 3.6% with most common reasons for revision being implant loosening and adverse local tissue reactions.
A 2025 study at a university in France of 103 metal-on-metal resurfacings in patients under 30 found a 10.8-year survival rate of 98%.
A 2018 study of over 300 hips resurfaced with metal-on-metal implants at Washington University in St. Louis estimated a 5-year survival rate of 97.2% and a 10-year survival rate of 93.8%. When the data were filtered to patients younger than 60, with osteoarthritis as the primary diagnosis (as opposed to, say, dysplasia), and a femoral head ≥ 48 mm, survival estimates increased to 99.5% at 5 years, and 98.2% at 10 years. The authors claim that UCLA activity scores (1–10 scale) were “significantly greater” for the resurfaced group compared with a matched cohort of total replacement patients, but the average score was 0.4 points higher for the resurfacing group (8.0 versus 7.6). “Significantly greater” in that context just means that the relatively minor difference was statistically significant.
Those same authors published a 2025 study of over 200 patients with an average follow-up of 14 years. The survival rate at 15 years was 96.0%. Interestingly, the HRA patients with preoperative UCLA scores in the 7–10 range (indicating high activity levels) saw a slightly greater decrease in their activity scores compared to the THA group. In addition, a higher percentage of HRA patients attributed their change in activity level to “symptoms in their operatively treated hip” compared to THA patients (14.6% vs. 9.1%).
A 2009 randomized, double-blind study found no significant difference in gait speed and other functional outcomes between HRA and THA. A separate 2010 randomised controlled trial (RCT) focused on gait speed also found no significant difference. A 2019 RCT found that the HRA group better preserved a normal gait pattern at increasing walking speeds and also reached higher speeds. They found no difference in gait pattern at normal speeds and increasing inclines.
A 2010 systematic review and meta-analysis of 46 studies, each of which compared outcomes of resurfacing and total replacements, found that resurfacing may have better functional outcomes than total replacement, but that total replacement has been superior in terms of implant survival.
A 2010 double-blind randomized controlled trial sought to discern whether purported superior outcomes with resurfacing were due to bias in patient selection or the use of relatively small diameter heads in conventional THA (28 mm). 48 patients younger than 65 and all good candidates for both resurfacing and total replacement were randomized to receive either a resurfacing or a total replacement using matching, anatomically sized, large femoral heads. All implants were metal on metal. Researchers found no significant differences between the groups on gait speed, step-ups, hopping on one leg, hip flexor and abductor strength, UCLA activity scores, or other patient-reported outcomes. While metal-on-metal implants are no longer used in total hip replacements (due to wear complications), the study nonetheless suggests that the alleged performance benefits of resurfacing reside in their large diameter heads, rather than bone preservation.
A 2024 meta-analysis of 8 randomized controlled trials found no significant differences between resurfacings and total hip replacements in terms of revisions, dislocations, infection, aseptic loosening, pseudotumors, or clinical outcomes.
A 2023 meta-analysis of 18 randomized controlled trials found no statistically significant difference between resurfacing and total replacement in terms of complications, revisions, functional outcomes, or metal ion levels.
A 2025 meta-analysis compared outcomes between HRA and THA. Their abstract states, “Twenty RCTs from six countries were included. HRA had a similar revision rate, function scores, and blood levels of cobalt and chromium compared to THA.”
Their claim about blood levels of cobalt and chromium is highly misleading. Just two of the 20 studies in the meta-analysis compared the blood levels of cobalt and chromium between HRA and THA. Worse, both studies compared metal-on-metal HRA to metal-on-metal THA. But metal-on-metal THA implants are no longer in use precisely because they produce significant metal debris, which damages local tissues and enters the bloodstream. Even metal heads on HXLPE are barely in use due to concerns of metal debris at the head and neck junction. Metal-on-metal THAs have not been implanted in most major countries since 2016, if not earlier.
There’s no excuse for a meta-analysis in 2025 to include outcomes from failed, discontinued THA constructs — and then present conclusions as if they apply to THAs generally. (There’s also a minor misinterpretation around the heterogeneity of the two studies, but I’m not going to get into that.)
Other studies included in their meta-analysis for different outcomes may have included metal-on-metal THAs implants as well. I’m not going to dig further to confirm.
Resurfacing systems that use materials other than metal-on-metal are currently being tested. There are two ceramic-on-ceramic resurfacing systems (ReCerf and H1) and one metal-on-polyethylene system (Polymotion). ReCerf is available in Canada, Europe, and Australia. H1 — which was specifically designed to be used in patients with smaller hips and pelvises, including women — is now being used at the Cleveland Clinic in London. Polymotion is being used in clinical trials in the U.S. None of the three are currently FDA-approved for general use in the United States.
A 2023 study found that women undergoing ceramic-on-ceramic hip resurfacing returned to levels of gait function and activity similar to healthy controls unlike women who underwent THA.
A 2024 analysis of 185 CoC hip resurfacings at two-year follow-up found that there was no migration, osteolysis, loosening, or fractures. There were two revisions, one for acetabular component malposition and one for acetabular implant failure. One patient reported sciatic nerve palsy.
A 2025 study of 125 hips resurfaced using the ReCerf implant found a 98% survival rate at 5 years follow-up.
In contrast, the 2025 Annual Report from the British National Joint Registry states, “There have been more ceramic-on-ceramic resurfacing operations recently, but the numbers are still small and do not yet support the suggestion that the high revision rates seen with metal-on-metal resurfacing operations have been overcome.”
More specifically, “The 1- and 3-year revision estimates for ceramic-on-ceramic resurfacing appear similar to those for metal-on-metal resurfacing which are generally higher than for other unipolar variants. The revision estimates at five and seven years appear lower, but the numbers at risk at all time points in the ceramic-on-ceramic resurfacing group are low, so this report should be interpreted with caution.” They also note, “revision estimates in young women appear to already be much higher than in young men.”
Prior to the rapid on-set of symptoms, I was sprinting, doing 7- to 10-mile trail runs, and competing in weightlifting. The idea that resurfacing would allow me to continue all those things made it tempting. However, I decided against resurfacing for a number of reasons.
First, there are no highly experienced, high-volume surgeons performing resurfacing in my area — even though my area is the second largest city in the U.S. I wasn’t wild about traveling to another state or country for major surgery. Plus, what I did have access to are several of the top hip replacement surgeons and hospitals in the world (at UCLA, Cedars-Sinai, and USC). Choosing from those options seemed like a much more reassuring option.
Second, I didn’t want a metal-on-metal implant, because I didn’t want to worry about metal ions and ALTR for the rest of my life. And I wasn’t fond of trying one of the new ceramic-on-ceramic or ceramic-on-polyethylene resurfacing implants, because they’re new and unproven. (I even shied away from a ceramic-on-ceramic implant for my total replacement because I didn’t want to worry about a liner fracture.)
Third, I wasn’t sure that I was a good candidate anyway. I’m relatively small, and thus might not have a large enough femoral head and neck. Plus, I’m over 60. Even if my bone density is good now, it might diminish as I age, putting me at risk for a femoral neck fracture — especially if I’m trail running and doing Olympic lifts. I also have a cam deformity, which would have had to be “removed” as part of the resurfacing. Apparently, there’s a risk that reshaping my femoral neck could create a weakness, thereby increasing the risk of fracture.
Fourth, I considered what Dr. Pritchett said about really needing resurfacing. He said one should foresee 20 years of athletic use, otherwise a total replacement is fine. At 62, I really doubt I’ll be trail running and doing the Olympic lifts with significantly heavy weights beyond another decade. Hiking, squatting, and deadlifting? Sure. But a total replacement is fine for those activities.
The final piece of my decision was speculating a bit about what I would actually have to give up by choosing a total replacement over resurfacing.
As I discussed in a separate post, U.S. guidelines recommend against high-impact activities after a total replacement. However, newer European recommendations are more lax, and I suspect that the older U.S. guidelines were strongly influenced by the rapid wear of conventional polyethylene. I found no studies indicating that participation in high levels of activity or high-impact activities led to higher rates of revision when the liner was modern highly-crosslinked polyethylene rather than conventional polyethylene.
Of course, high-impact activities might cause damage in ways other than polyethylene wear, such as implant loosening — although again, that risk did not seem to materialize in any study that I found.
But even if engaging in high-impact activities does raise the risk of revision in a total replacement, does it raise it beyond the revision risk apparently present in resurfacing? In fact, might the reason that resurfacing seems to have a higher revision rate than total replacement be due to the fact that resurfacing is promoted to highly active people and those who want to continue to participate in high-impact sports?
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Posted June 2026.