A Question Without a Single Right Answer
If you have been told you need a hip replacement, you may already have come across hip resurfacing as an alternative — and wondered which is "better." The honest answer is that neither procedure is better as a blanket statement. Both reliably relieve the pain of hip arthritis. They work in genuinely different ways, and they suit genuinely different patients. The right choice for you depends on your age, sex, bone quality, activity level, and the anatomy of your hip.
This article explains how the two procedures differ, what each does well, who is a good candidate for each, and what the long-term evidence actually shows. It also covers an important recent development — ceramic-on-ceramic resurfacing — that is starting to widen the patient group for whom resurfacing is a sensible option.
What's the Difference Between the Two Procedures?
Both procedures aim to do the same thing: replace the worn, painful surfaces of the hip joint with smooth, durable artificial surfaces. They differ in how much of your own bone is removed.
Total hip replacement removes the entire ball at the top of the thigh bone (the femoral head). A metal stem is inserted down the inside of the thigh bone, and a new ball — typically about 32-36mm in diameter — is fitted onto the top of that stem. The damaged socket is also lined with a new cup. The result is a fully reconstructed joint.
Hip resurfacing takes a more conservative approach. The natural ball is preserved and reshaped, then capped with a smooth metal or ceramic covering — a little like a dental crown fitted over a tooth. The socket is also lined with a matching cup. The diameter of the new ball remains close to your natural anatomy, often 50mm or more.
Total hip replacement removes the femoral head entirely and replaces it with a stemmed implant. Hip resurfacing preserves the femoral head and caps it with a metal or ceramic shell, leaving most of your natural bone intact.
The Case for Hip Resurfacing
Hip resurfacing offers several biomechanical advantages — but only for the right patient. When a patient is well-selected, the evidence is genuinely impressive.
A larger ball means greater stability. Because resurfacing keeps the natural diameter of the femoral head, the ball is significantly larger than in a total hip replacement. A larger ball is harder to dislocate. This is why patients with conditions that increase dislocation risk — for example, those with previous spinal fusion — can sometimes benefit more from resurfacing than from a standard replacement.
Bone is preserved. Because the femoral head is reshaped rather than removed, the bone stock of the upper thigh remains largely intact. Should you ever need revision surgery later in life — and joint replacements do not last forever — there is substantially more bone to work with than in a patient whose femoral head was removed years earlier.
Higher activity tolerance. Resurfacing patients can typically return to running, racquet sports, and other higher-impact activities that surgeons usually advise against after a standard hip replacement. Several professional athletes — including the tennis player Andy Murray, who had his resurfacing performed at the Royal Orthopaedic Hospital — have returned to competitive sport after the procedure.
A more natural-feeling hip. Many resurfacing patients describe the joint as feeling more like their own hip than a prosthetic one. This is partly biomechanical (the larger ball, the preserved bone) and partly psychological — but it is consistently reported in patient outcome studies.
The Case for Total Hip Replacement
Total hip replacement is not the conservative or "lesser" option. It is the most common joint replacement performed in the world for very good reasons.
It works for nearly any patient with hip arthritis. Resurfacing requires healthy femoral bone to support the cap; total replacement does not. For patients with osteoporosis, advanced disease, abnormal anatomy, or significantly weakened bone, total hip replacement is the safer and more reliable choice.
The track record is exceptional. Modern total hip replacement has been refined over six decades. Long-term registry data is enormous. Implants now routinely last 20 to 30 years, and patient satisfaction rates are among the highest in all of surgery.
It is more forgiving in technically difficult cases. If your hip has unusual anatomy, severe deformity, or a history of complex previous surgery, total replacement gives the surgeon more flexibility to reconstruct the joint correctly.
It is the standard for many older patients. For patients in their seventies and beyond, the activity advantages of resurfacing matter less, and the broader candidate criteria for total replacement matter more.
Who Is a Candidate for Hip Resurfacing?
This is the most important question — and the most honest answer requires being direct about who resurfacing does and does not suit.
Long-standing evidence has established that hip resurfacing works best in:
- Younger, active patients — typically under 65
- Men more reliably than women, when using metal-on-metal implants
- Patients with good bone quality, particularly in the femoral head
- Patients with larger anatomy — femoral head sizes of approximately 48mm and above
- Patients with osteoarthritis as the underlying cause, rather than rheumatoid disease or severe dysplasia
- Patients without metal sensitivity or significant kidney impairment
The sex difference is real and important. National Joint Registry data and long-term studies have consistently shown that women and patients with smaller anatomy have higher revision rates after metal-on-metal hip resurfacing. The reasons are partly anatomical (smaller components are biomechanically less forgiving) and partly biological (women appear to be more susceptible to soft-tissue reactions to metal wear particles).
For these reasons, traditional metal-on-metal hip resurfacing has historically been recommended primarily for active men with osteoarthritis and good-quality bone. That position is now changing — because of ceramic.
Ceramic-on-Ceramic Resurfacing — The Important New Development
The risks specific to metal-on-metal resurfacing — soft-tissue reactions, raised metal ion levels, the elevated revision rate in women — all stem from the metal bearing surfaces themselves. Replace the metal with ceramic, and those specific risks largely disappear.
Ceramic-on-ceramic hip resurfacing is now available in selected centres in the UK, including in Mr Hussain's practice. The two implants currently in clinical investigation in the UK are the H1 (Embody) and the ReCerf (MatOrtho), both undergoing approved clinical studies under the Medicines and Healthcare products Regulatory Agency.
The early evidence is genuinely encouraging. International multi-centre studies of ceramic-on-ceramic resurfacing have shown promising five-year survival rates and significant improvements in patient-reported outcomes. Critically for the question at hand, ceramic resurfacing appears to expand candidacy: it is showing good results in women and in smaller patients — groups for whom metal-on-metal resurfacing was less reliable. One study comparing women with ceramic resurfacing against women with conventional total hip replacement found significantly higher post-surgical activity levels and walking speeds in the ceramic resurfacing group.
Ceramic-on-ceramic resurfacing is a promising development, but the long-term data is still maturing. The metal-on-metal Birmingham Hip Resurfacing has 25-year follow-up evidence; ceramic resurfacing currently has around five years. For the right patient, ceramic resurfacing is a sensible option to discuss — but it should be offered honestly as a newer technology, not as a fully proven equivalent to long-established procedures.
What Does the Long-Term Evidence Show?
The Birmingham Hip Resurfacing — developed in Birmingham itself — is the most studied hip resurfacing implant in the world, with the longest follow-up data of any resurfacing device. The headline numbers, from independent studies and joint registries:
These outcomes compare favourably to total hip replacement at the same time points. The crucial caveat is that they are achieved in carefully selected patients, by surgeons who perform the procedure regularly. Outside those conditions, the numbers fall significantly.
Why the Surgeon's Experience Matters More Than the Procedure
If there is one finding from the National Joint Registry that should influence how patients choose, it is this: surgeon experience is one of the strongest predictors of how well a hip resurfacing performs over time. NJR data has shown that operations performed by low-volume surgeons carry a meaningfully higher risk of revision than the same operations performed by high-volume specialists.
This is even more important for resurfacing than for total replacement. Resurfacing is technically more demanding: the cup angle has to be precise, the femoral neck must not be notched, and the femoral head must be perfectly prepared. A standard total hip replacement is more forgiving of small technical variations.
"The choice between resurfacing and replacement is important. The choice of surgeon is at least as important. For resurfacing in particular, you want someone who does this often, who has been trained directly within the lineage of the people who developed it, and who knows when not to recommend it."
Mr Shakir Hussain, Consultant Orthopaedic SurgeonMr Hussain trained directly under Mr Ronan Treacy at the Royal Orthopaedic Hospital in Birmingham. Mr Treacy, alongside Mr Derek McMinn, co-developed the Birmingham Hip Resurfacing in the 1990s and has since performed more hip resurfacings than any other surgeon in the world. The training lineage matters: the techniques, patient selection criteria, and surgical judgement that produce the published long-term outcomes were not learned from textbooks but passed down directly from the surgeons who developed the procedure.
Mr Hussain is one of a small number of UK surgeons who continues to perform a high volume of hip resurfacing — including, where appropriate, the newer ceramic-on-ceramic technology — alongside conventional total hip replacement. This breadth matters: a surgeon who only does one procedure has only one answer to give.
How to Decide
Deciding between hip resurfacing and total hip replacement is rarely a decision to make alone. The most useful first step is a consultation with a surgeon who performs both procedures and who will give you an honest assessment of which suits your hip, your anatomy, and your life.
Bring your priorities to that conversation. Are you trying to remain active in sport? Is bone preservation important to you because of your age? Do you want to understand whether ceramic resurfacing might be a better option for your specific situation? A specialist hip surgeon should be able to discuss all of these honestly — and tell you when one option is genuinely better than the other for you.
If you are unsure whether you are a candidate for resurfacing, that is itself a useful question to bring to the consultation. The honest answer may be yes, may be no, or may be "you are a candidate for ceramic resurfacing but not for the traditional metal version." All three are valid answers — and far more useful than a one-size-fits-all recommendation.