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Hip resurfacing

112 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Hip resurfacing arthroplasty is a viable alternative to total hip arthroplasty for well-selected patients, particularly young, active individuals and men under 55 with osteoarthritis [14, 20, 22]. The procedure offers functional capacity, bone conservation, and revision options that are embraced by this demographic [22]. In selected populations of young and/or active patients, short-term results are excellent with a low complication rate and 99% survivorship at 4 years [3]. Longer follow-up of resurfacing and direct comparison trials are required to confirm findings regarding modern cementless femoral components in young patients [5].

Survivorship data supports the procedure’s utility in younger cohorts. Hip resurfacing exceeds the stricter 2014 NICE survivorship criteria independently in men and women, even when performed on patients under 50 years old [1]. 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%, indicating that hip resurfacing is a valid alternative to total hip arthroplasty in patients younger than 50 years [61]. The continued use of metal-on-metal hip resurfacing arthroplasty in this population is justified by both positive patient-reported outcomes and survivorship [4].

Patient selection and surgical technique are critical determinants of outcome [12]. When patients meet 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]. 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]. Resurfacing arthroplasty should be undertaken with caution by those surgeons unfamiliar with the technique [7]. 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]. Hip resurfacing can also be offered to patients with osteonecrosis [11].

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 three bones: the ilium, ischium, and pubis, which unite at the triradiate cartilage within the concave acetabulum [76]. The acetabulum comprises 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 depression at its center from which the ligamentum teres extends to connect to the acetabular notch [76].

The neck-shaft angle of the femur averages 125° [76], while the mean femoral neck-shaft angle in the adult is 130° ± 7° [82]. Normal version, defined as the head-neck angle in the frontal plane, averages 15 to 20° [76], whereas 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 hip 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: The thickest and strongest of the three main ligaments, it functions to limit external rotation, while its lateral arm limits extension of the joint [76]. It becomes taut in full extension, preventing anterior dislocation and hyperextension of the hip [77]. * Ischiofemoral ligament: Provides support posteriorly and restricts internal rotation motion [76]. * Pubofemoral ligament: Acts to limit abduction of the joint [76].

Deep fibers from the iliofemoral, ischiofemoral, and pubofemoral ligaments merge to form the zona orbicularis [76]. The twisted orientation of the hip ligaments provides a screw mechanism for the hip in full extension [77].

Labrum

The acetabular labrum is a fibrocartilaginous ring that extends the articulating surface area and increases femoral head coverage [76]. The labrum is triangular in cross section, which 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]. The labrum is absent in the area of the inferior acetabular notch, where the transverse acetabular ligament serves as its continuation [76]. The acetabular labrum provides stability to the hip joint in response to a distraction force and combined distraction and translation forces [128].

Vascular Supply

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 group of ascending branches from the extracapsular arterial ring 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 does not provide sufficient blood supply to maintain the viability of the femoral head [82].

Pathophysiology and Biomechanics

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]. Impingement abnormalities can cause labral tears, acetabular cartilage delamination, and secondary osteoarthritis [41].

Hip resurfacing arthroplasty is a bone-conserving alternative to total hip arthroplasty indicated for end-stage hip arthrosis in patients with a structurally and morphologically appropriate femoral head and acetabular bone [34]. Femoral neck fracture is the most common early complication of hip resurfacing, a complication not associated with total hip arthroplasty [34]. 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].

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]. The procedure of total hip resurfacing did not change native extra-medullary hip geometry by more than 5 mm and/or 5 degrees compared to the non-operated side [109]. 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].

Optimal component positioning is critical for biomechanical success. An acetabular component inclination of 50° and an anteversion of 25° allowed the most physiologic range of hip motion in metal-on-metal hip resurfacing [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]. 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].

Postoperative complications and functional outcomes are influenced by implant position and patient activity. Repetitive extreme motion of the involved hip and malposition of the implants can cause impingement after hip resurfacing arthroplasty [132]. High ion levels were associated with an abduction angle of more than 45° and repetitive extreme hip motion in revision cases of metal-on-metal hip resurfacing [129]. The best predictor of change in bone mineral density at five years in the trochanteric area after hip resurfacing was acetabular component inclination [64]. 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].

Classification

Patient Selection Criteria

The optimal candidates for hip resurfacing are men under age 65 with osteoarthritis and relatively normal bony morphology [15]. This procedure is particularly embraced by young, active patients, specifically men under 55 with osteoarthritis [22]. Indications require end-stage hip arthrosis in a patient with a structurally and morphologically appropriate femoral head and acetabular bone [34]. Patients with higher-grade hips, defined as those with earlier-stage disease, demonstrate better outcomes [37]. The best starting material consists of hips with only loss of articular cartilage and a relatively normal femoral head and neck [37]. When experienced surgeons employ refined and proper surgical technique, women show promise as excellent candidates [8]. Hip resurfacings may be offered to patients older than 65 years who fulfill specific criteria and understand the associated risks [2]. In a selected population of young and/or active patients, short-term results are excellent with a low complication rate [3]. When patients meet 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]. Hip resurfacing seems to be a viable alternative to total hip arthroplasty for well-selected patients [14]. Patient selection and surgical technique are important factors in hip resurfacing arthroplasty [12].

Indications by Diagnosis

Hip resurfacing provides good function and comparable implant survival in patients with rheumatoid arthritis of the hip joint [25]. Modern designs of resurfacing have been reported to have encouraging short- to mid-term results in patients with Ficat stage III or IV osteonecrosis of the femoral head [157].

Survivorship and Outcomes by Age and Gender

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]. In a selected population of young and/or active patients, hip resurfacing has a 99% survivorship at 4 years [3]. Medium-term survivorship and functional scores of hip resurfacing are comparable to those from the pioneering center [6].

Comparison with Total Hip Arthroplasty

There was no significant clinical difference between the patients treated with hip resurfacing and total hip arthroplasty in the short term [9]. The Durom revision rate was slightly higher than the rate with other hip resurfacing systems and traditional total hip arthroplasty [66]. During the first 2 years after surface arthroplasty, retrieved Birmingham Hip Resurfacing components revealed wear rates substantially lower than conventional polyethylene bearings [36].

Surgical Technique and Risk Factors

The procedure is technically demanding, which is reflected by the initial clinical experience in the United States [34]. Femoral neck fracture, a complication not associated with THA, is the most common early complication of hip resurfacing [34]. Multivariate time-dependent analysis showed a greater effect of surgical technique and patient BMI on prosthetic survival over bone quality and component size [33]. Most early failures of metal-on-metal resurfacing happened in the first 100 hips operated on, during the phase of development of the device and the procedure [33]. The arthritic hip grading system has limitations as bone density is assessed only qualitatively and there is a subjective component in the assessment [37]. The interobserver and intraobserver variability in bone density and arthritic hip grade have not been established [37].

Revision and Complications

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 risk of revision for resurfacing due to metal-related pathologies is very low, but it is higher than in other types of bearings [135]. Revision of failed hip resurfacing to total hip arthroplasty rapidly relieves pain and improves function in the early postoperative period [18].

Specific Clinical Scenarios

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 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]. The long-term efficacy of revision surgery retaining the acetabular component remains unknown [33].

Clinical Presentation

Patient Selection and Indications

Hip resurfacing serves as a viable alternative to total hip arthroplasty for well-selected patients [14], offering specific advantages that make it an attractive option for young subjects [20]. In prospective longitudinal studies, candidates were required to possess normal acetabular and proximal femoral bone morphology without osteopenia or osteoporosis [117]. Indications included patients whose desired postoperative athletic level involved impact activities such as running or jumping, or activities that would place a traditional hip replacement at risk for dislocation [117]. A separate study included patients with noninflammatory degenerative joint disease, including osteoarthritis, traumatic arthritis, congenital hip dysplasia, or osteonecrosis [108].

Conversely, the value of metal-on-metal hip resurfacing in patients with secondary osteoarthritis resulting from developmental dysplasia of the hip is questionable [50]. The 5-year cumulative percent revision for developmental dysplasia of the hip was four times greater with metal-on-metal hip resurfacing compared to primary conventional total hip arthroplasty (12.0% compared to 3.0%) [50]. Exclusion criteria in one study included evidence of active infection in the affected hip [108], documented allergy to cobalt, chromium, or molybdenum [108], morbid obesity defined as three times the normal body weight [108], and neuromuscular or neurosensory deficiencies that might adversely affect gait or weightbearing and limit the ability to evaluate device safety and effectiveness [108]. Further exclusions comprised the need for structural bone grafting [108], active hepatitis or HIV infection without immunological suppression [108], women of childbearing age or pregnancy [108], documented psychiatric disorder [108], and previous hemiresurfacing, total resurfacing, bipolar, unipolar, or total hip arthroplasty surgery [108].

Sex and Demographics

Sex does not appreciably affect implant survivorship, and women may be excellent candidates for resurfacing with proper surgical technique [112]. The effect of sex on revision rates disappeared when adjusted for component size and surgical technique [112]. Consequently, male and female patients with ASR prostheses require equal vigilance, as both groups face similar risks of revision surgery and adverse local tissue reaction [47]. Outcomes after Birmingham Hip Resurfacing remained satisfactory at a minimum of ten years postoperatively, particularly for self-reported hip function, in patients aged less than 50 years [21].

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]. With careful patient selection, attention to surgical technique, and vigilant clinical follow-up, metal-on-metal hip resurfacing remains a promising treatment option for the young and active adult [107]. Return to work after hip resurfacing was feasible for almost all young patients [46]. However, the revision rate at short- to mid-term follow-up highlights the challenges of performing hip arthroplasty in professional dancers [56].

Functional Outcomes and Quality of Life

Functional performance results confirm the advantage of resurfacing over conventional hip replacement, helping explain the excellent radioclinical results reported for total hip resurfacing [28]. Both navigation-assisted and conventional hip resurfacing arthroplasty achieve excellent 5- and 10-year survivorship with sustained patient-reported outcomes [17]. For a population of carefully selected patients with adequate bone stock, hip resurfacing arthroplasty provides significant and reproducible short-term improvements in patient quality of life, irrespective of preoperative mental well-being [116].

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]. Hip resurfacing arthroplasty offers numerous benefits over total hip replacements, including increased preservation of natural bone, improved range of motion, and lower dislocation risks [106].

Complications and Adverse Events

Resurfacing arthroplasty is associated with a higher early complication rate than total hip arthroplasty [44], and groin pain after hip resurfacing appears to be more common than after conventional hip replacement [115]. The learning curve for avoiding early complications was short (25 cases or less) for experienced hip surgeons, while the learning curve for achieving desired component positioning radiographically was much longer (75 to 100 cases or more) [49]. A high early failure rate of 8% and only 79% of patients reporting a good or excellent outcome led some authors to reduce the utilization of hip resurfacing in patients who are candidates for hip arthroplasty [19].

Adverse local tissue reactions are common in asymptomatic individuals after hip resurfacing arthroplasty [117]. Repeated MARS-MRI scans within one year in patients with asymptomatic pseudotumours after metal-on-metal hip resurfacing showed little or no variation [51]. The consensus statement recommends safety assessment for all patients with metal-on-metal bearings, with closer follow-up for large head bearings and resurfacing involving x-rays and metal ion measurement [27]. 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]. Many intraoperative findings in hip arthroscopic surgery are related to age at onset of symptoms [53].

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 after conversion were particularly unfavorable when performed for specific indications such as adverse reaction to metal debris or aseptic loosening [24]. The most common indications for conversion were adverse reaction to metal debris, aseptic loosening, and femoral neck fracture [24]. Patients revised for adverse reaction to metal debris consistently demonstrated worse outcomes than those revised for other indications [24]. While conversion with retention of the acetabular component 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].

In obese patients, the pooled complication rate was 9.83% versus 4.7% in nonobese patients following hip resurfacing arthroplasty [106]. The pooled revision rate was 1.15% for obese patients and 3.70% for nonobese patients [106]. The difference in postoperative UCLA scores, complication rates, and revision rates between obese and nonobese patients following hip resurfacing arthroplasty were deemed not statistically significant [106].

Investigations

Plain radiography: Conventional radiographs remain critical in the initial imaging evaluation of the hip [40]. A complete hip series usually 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]. The femoral head-neck junction morphology is often assessed using the alpha angle on radiographs [40]. Radiographs, particularly the Dunn 45° view, may be more accurate for determining the alpha angle measurement than CT or MRI [40]. Conventional radiograph templating is a useful method for preoperative planning of implant sizes for metal-on-metal hip resurfacing [161]. Surgeon experience plays a significant role in the accuracy of predicting component size during radiograph templating [161]. Preoperative templating for hip resurfacing arthroplasty showed variable reliability and fair accuracy, with surgeons tending to underestimate implant size [172]. EBRA software can be used to reliably assess the version of resurfacing cups when radiographs are of sufficient quality [171].

CT: CT scans are effective for examining cortical and cancellous bone and can be used to 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].

MRI: MRI is the modality of choice for patients suspected of soft tissue or intra-articular pathology due to 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]. 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]. Repeated MARS-MRI scans within one year in patients with asymptomatic pseudotumours after MoM hip resurfacing showed little or no variation [51].

Ultrasonography: Ultrasonography provides real-time dynamic assessment of the hip and is useful in diagnosing soft-tissue abnormalities about the hip joint [78]. It can be an effective modality to identify musculotendinous disruptions, effusions associated with intra-articular pathology, or inflammatory conditions such as bursitis [90].

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 was acetabular component inclination [64].

Clinical Examination: A thorough clinical examination is required to determine a differential diagnosis for hip pain, as many conditions present with similar symptoms [39]. Findings from imaging studies should complement clinical examination findings to provide the most accurate diagnosis [39]. Patients with symptomatic femoroacetabular impingement frequently present with activity-related groin pain exacerbated by hip flexion activities [41]. Physical examination for femoroacetabular impingement includes restricted hip internal rotation in 90° of flexion and a positive impingement test (flexion, adduction, internal rotation) [41]. The impingement test elicits pain but is not specific for femoroacetabular impingement [41].

Postoperative and Complication Assessment: The European multidisciplinary consensus statement recommends safety assessment for all patients with metal-on-metal bearings, including closer follow-up for resurfacing involving x-rays and metal ion measurement [27]. Hip arthroscopy plays a role in the investigation and treatment of the painful hip resurfacing arthroplasty [42]. A diagnosis before arthroscopy is critical to improved outcome in the investigation of painful hip resurfacing arthroplasty [42]. Femoral component loosening in hip resurfacing can occur without radiographic signs of subsidence or radiolucency [164]. The absence of radiographic signs of loosening can potentially lead to stem fracture due to atypical overloading [164].

Other Considerations: Hip resurfacing is a highly technical procedure requiring careful implant selection, meticulous preoperative planning, and exacting implant placement [67].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, NSAIDs, or injections. Hip resurfacing is presented as a surgical intervention for patients who are candidates for hip arthroplasty [19].

Operative

Indications: Hip resurfacing is most appropriately used in young (less than 60 years) and active men [54]. The procedure offers functional capacity, bone conservation, and revision options that are embraced by young, active patients, particularly men under 55 with osteoarthritis [22]. The specific advantages of hip resurfacing make the procedure a very attractive option for young subjects under thirty years old [20]. Metal-on-metal hip resurfacing appears to be an effective procedure for younger patients under 30 years of age, with a Kaplan–Meier survivorship estimate at 8 years of 95% [70]. Hip resurfacing may be offered in the future to patients older than 65 years who fulfill specific criteria and understand the associated risks [2].

Implant Selection: 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]. The resurfacing prosthetic design was improved to provide greater bone conservation while also reducing the incidence of femoral neck notching [147].

Comparison with Total Hip Arthroplasty: Total hip resurfacing offers survivorship that exceeds that of total total hip arthroplasty in men under 55 with osteoarthritis [22]. However, 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]. Registry data has shown that the results obtained by the generality of surgeons do not replicate the results of selected series, with higher failure rates associated with the use of resurfacing in the majority of patients, the exception being men with one or more of the authors disclosing potential or pertinent conflicts of interest [154].

Complications and Revision: 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]. A femoral neck fracture can occur after metal-on-metal total hip resurfacing, potentially caused by anterolateral notching of the femoral neck [163]. The authors successfully managed two cases of intertrochanteric fracture below Birmingham Hip Resurfacing using non-operative methods [144]. Having an accurate diagnosis before hip arthroscopy improves the likelihood a good outcome in managing the painful hip resurfacing arthroplasty [60].

Monitoring and Guidelines: The European multidisciplinary consensus statement recommends safety assessment for all patients with metal-on-metal bearings, with closer follow-up for large head bearings and resurfacing involving x-rays and metal ion measurement [27].

Complications

General Complication Rates and Survivorship: Resurfacing arthroplasty carries a higher early complication rate than total hip arthroplasty, with adverse events clustering during the initial surgical learning curve [166]. Long-term data demonstrate robust implant durability; the initial series of Conserve Plus hip resurfacing arthroplasties achieved an 83.5% 20-year survivorship, surpassing that of total hip arthroplasties used two decades prior in similar young patient populations [62]. Independent single-surgeon series report a 91.5% survival rate at 7 years with revision as the endpoint [71]. The largest single-surgeon series of metal-on-metal hip resurfacing with long-term data represents the second-best long-term implant survivorship for any type of hip arthroplasty ever published [43]. In patients under 30 years of age, the Kaplan–Meier survivorship estimate for metal-on-metal hip resurfacing was 95% at 8 years [70].

Learning Curve and Surgical Technique: Most early failures in an eleven-year experience with metal-on-metal hybrid hip resurfacing occurred within the first 100 hips operated, coinciding with the development phase of the device and procedure [33]. Multivariate time-dependent analysis indicates that surgical technique and patient BMI exert a greater effect on prosthetic survival than bone quality or component size in metal-on-metal resurfacing [33].

Aseptic Loosening: Femoral loosening was the primary reason for revision in the osteonecrosis group, affecting 4 of 46 hips (8.7%) [149]. Retrieved femoral heads from patients with femoral loosening exhibited necrotic areas [149]. Etiology may serve as an important risk factor for postoperative complications in hip resurfacing [149]. In an eleven-year experience with metal-on-metal hybrid hip resurfacing, there were no conversions to total hip replacement consecutive to loosening of the acetabular component [33]. The long-term efficacy of revision surgery using unipolar femoral heads matching the socket dimensions remains unknown [33].

Periprosthetic Fracture: Femoral-neck fracture was the main reason for revision in the ankylosing spondylitis group, occurring in 3 of 58 hips (5.2%) [149]. In these cases, femoral heads were fixed tightly to the components, contrasting with the necrotic areas seen in loosening cases [149].

Metal-Related Complications and Wear: The procedure raises questions about whether bone preservation and increased motion outweigh the small but real risk of metal-related complications [29]. However, hip resurfacing arthroplasty presents a more favorable outcomes profile with reduced systemic metal ion exposure compared with large-head metal-on-metal total hip arthroplasty [150]. During the first 2 years after surface arthroplasty, retrieved Birmingham Hip Resurfacing components revealed wear rates substantially lower than conventional polyethylene bearings [36].

Other Considerations: In hip resurfacing using highly cross-linked polyethylene, both femoral and acetabular bones are reasonably preserved compared with prior resurfacing methods [72]. Further follow-up is required to assess the influence of sports on loosening and revision rates in hip resurfacing arthroplasty [55]. 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].

Recovery

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]. 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]. There was no significant clinical difference between patients treated with hip resurfacing and total hip arthroplasty in the short term [9]. 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]. 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 results suggest that hip resurfacing provides good function and comparable implant survival in patients with rheumatoid arthritis of the hip joint [25].

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)
• [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)
• [L4] Return to work after hip resurfacing was feasible for almost all these young patients. [46] (10.1016/j.otsr.2020.07.009)
• [L2] Male and female patients who had hip resurfacing arthroplasty with implantation of the ASR prosthesis should be followed with equal vigilance as both are at similar risk of revision surgery and adverse local tissue reaction. [47] (10.1007/s11999-016-4860-x)
• [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)
• [L3] Many intraoperative findings in hip arthroscopic surgery are related to age at onset of symptoms. [53] (10.1177/2325967117737480)
• [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)
• [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)
• [L3] [106] (10.2106/jbjs.rvw.24.00133)
• [L4] With careful patient selection, attention to surgical technique, and vigilant clinical follow-up, metal-on-metal hip resurfacing remains a promising treatment option for the young and active adult. [107] (10.2106/jbjs.j.01848)
• [L1] [108] (10.1097/blo.0b013e318159dd60)
• [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] [112] (10.1016/j.arth.2010.03.033)
• [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] For a population of carefully selected patients who have adequate bone stock, hip resurfacing arthroplasty provides significant and reproducible short-term improvements in patient quality of life, irrespective of preoperative mental well-being. [116] (10.1016/j.arth.2012.01.022)
• [L3] [117] (10.1097/corr.0000000000001882)
• [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)
• [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] 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)
• [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] [154] (10.1016/j.arth.2015.04.030)
• [L3] [157] (10.1302/0301-620x.98b7.36676)
• [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
• Hip arthroscopy
• Adverse reaction to metal debris
• Intertrochanteric fracture
• Total hip replacement

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

[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

[46] Return to work after hip resurfacing. Orthopaedics & Traumatology: Surgery & Research. 2020. DOI: 10.1016/j.otsr.2020.07.009

[47] Are Females at Greater Risk for Revision Surgery After Hip Resurfacing Arthroplasty With the Articular Surface Replacement Prosthesis?. Clinical Orthopaedics & Related Research. 2016. DOI: 10.1007/s11999-016-4860-x

[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

[53] Relationship Between Age at Onset of Symptoms and Intraoperative Findings in Hip Arthroscopic Surgery. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117737480

[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

[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.

[78] Orthopaedic Knowledge Update Sports Medicine 6. Imaging of the Hip > Introduction.

[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.

[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

[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

[106] No Difference in Outcomes, Complications, or Revision Rate for Obese vs. Nonobese Patients Following Hip Resurfacing Arthroplasty. JBJS Reviews. 2024. DOI: 10.2106/jbjs.rvw.24.00133

[107] A Survey on the Prevalence of Pseudotumors with Metal-on-Metal Hip Resurfacing in Canadian Academic Centers. Journal of Bone and Joint Surgery. 2011. DOI: 10.2106/jbjs.j.01848

[108] Effect of Changing Indications and Techniques on Total Hip Resurfacing. Clinical Orthopaedics & Related Research. 2007. DOI: 10.1097/blo.0b013e318159dd60

[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

[112] Sex as a Patient Selection Criterion for Metal-on-Metal Hip Resurfacing Arthroplasty. The Journal of Arthroplasty. 2011. DOI: 10.1016/j.arth.2010.03.033

[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

[116] Are Hip Resurfacing Arthroplasties Meeting the Needs of Our Patients?. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2012.01.022

[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

[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

[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

[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

[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

[154] Comparison of Acetabular Bone Resection, Offset, Leg Length and Post Operative Function Between Hip Resurfacing Arthroplasty and Total Hip Arthroplasty. The Journal of Arthroplasty. 2015. DOI: 10.1016/j.arth.2015.04.030

[157] Hip resurfacing for osteonecrosis. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b7.36676

[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