With the recent approval by the FDA of the Birmingham Hip Resurfacing Implant, there has been interest generated primarily by the implant manufacturer for surface replacement. This is a procedure that has been part of the orthopedic armamentarium for over 30 years. Historically, the surface replacement procedure has never been as popular or successful as total hip replacement. With the change in materials going to a metal-on-metal type of articulation, the procedure has improved and there is hope that this will be a more viable option in the future. 

The benefit of surface replacement is the ability to use a very large femoral head which allows better motion with lower risk of dislocation and by not violating the proximal femur to the same extent as a hip replacement, it has been touted as affording an easier revision. 

In reality, in the past, there has been more bone sacrifice on the socket side during a surface replacement thus compromising the ability of the surgeon to revise these procedures. Bone loss in the proximal or top part of the femur in revision surgery is not a difficult problem to deal with. However, bone loss on the socket side due to increased reaming for a surface replacement has traditionally made for more challenging revisions. 

With the advent of large head total hip replacement over the last few years and the use of one-piece acetabular metal-on-metal components, hip replacement has now progressed to a point where similar sized heads are available for hip replacement without having to perform a different type of procedure such as surface replacement. As a result of this, there has been a significant increase in the use of large head total hip replacements over the last 12 months. Many of the advantages previously attributed to surface replacement are now available with traditional hip replacement using the large head format. I predict that as a result of this, the interest in surface replacement will be somewhat dampened in the United States as most surgeons prefer to do a hip replacement procedure which is familiar and more straight forward then a surface replacement. The theoretical advantages of surface replacement have largely been accomplished by large head total hip replacements. Time will tell and I think we will see a shaking out of these differences over the next 12 to 24 months. 

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  1. Rochelle Taft

    So Dr. It has been a year since you wrote this. How does the argument settle out on this. I do not see a growing prefernce for THR, but instead one for resurfacing. How does the new larger head THR hold up overtime? I hear talk of the resurfacing of today lasting a lifetime. Can the THR hope for that?

  2. Dr. William Barrett

    Dear Rochelle,
    The facts are clear. Total Hip Replacement is done 95% of the time in patients with hip arthritis and resurfacing is done 5%. There is no data to support either total hip replacement or surface replacement lasting a life time unless your life is 15 years or less. Large head total hip replacement has functioned well for 8 years. So bottom line, surface replacement is still somewhat of an unknown with historical results that have never equalled total hip replacement.
    William Barrett

  3. Jim Keane

    Dr. Barret,

    I am 37 year old man suffering with oestoarthritus in both hips. Can a young man who has a THR stay active. What does active mean with regard to a hip replacement.

    It looks like I am on my way to a procedure on my left hip. I have heard a lot about the resurfacing but I just do not know.

    If I were to have the surgery, what would my level activity be afterwards. I have small children and look forward to coaching their sports teams. since the diagnosis I had to give up playing in and old fart Basketball league. Is there a chance I ever could play again.

  4. Mike Allanson

    Dr Barrett / potential hip operation patients,

    I read this article with great interest, having recently had a Birmingham Hip Resurfacing at QMC Nottingham.

    I have spent many hours researching this topic and find your quote “surface replacement is still somewhat of an unknown with historical results that have never equalled total hip replacement” somewhat out of line with several study papers i have managed to find on the internet. Indeed the results of those studies of up to 8 years post op analysis, have consistently equalled or bettered the quivelent data for THR.

    Your quotation looks pesimistic to say the least and i would encourage potential recipients of new hip joints to undertake significant internet research before discussing options with their medical representatives.

    One aspect not mentioned thus far on this topic is the issue of bone density. It is very imprtant that the bone density is adequate for the resurcing technique and this may remove the element of choice for many older patients, and some younger female patients also (apparently female bone density tends to be less than for the equivelent aged male).

    Hope this was of some interest / help.

    Mike Allanson

  5. Dr. William Barrett

    I appreciate your thoughts and am glad you are enjoying what sounds like a very good outcome. My point is that while there is considerable interest in resurfacing here in the U.S. alot of it is driven by direct to consumer advertising and not by objective data. True there are some recent midterm results that are promising but in joint replacement we are interested in what is happening at 10-15 years post op and we do not have data to suggest that resurfacing is as good or better than THA. The advantage of a larger head with resurfacing is diminished by large head THA. The concept of bone preservation in the proximal femur is real but may be offset if more bone is removed on the acetabular side. I feel it is a good idea to have centers following patients such as you to determine the results, risks and benefits.
    William Barrett

  6. Dr. William Barrett

    Dear Jim Keane,
    We recommend low impact sports(biking, swimming, hiking, doubles tennis). If the pain and arthritis is severe then a joint replacement may be needed with the realization that revision will be necessary down the road.
    William Barrett

  7. Dave O'Rielly


    Im an active 30 year old man given the option of Hip Surface or THR. At age 12 I had a hip and femur osteotomy due to legg perthes. Due to the prior operations, the Dr. mentioned that a resurface would be more difficult then usual. On top of that, I have about a 2 and a half inch leg differential. Which can only be fixed by replacement.

    Any thoughts on which option would be better.


  8. Dr. William Barrett

    Dear Dave,
    Thanks for your comments. I think at age 30 it would be best to avoid a joint replacement if at all possible. If you are at a point where there is no joint space left and some type of joint preserving procedure is not possible then I would favor a joint replacement for two reasons. One, it is easier to correct deformities that can occur as a result of Legg-Perthes disease with a total hip, with regard to off-set and length. The second is with the use of large head total hips, the range of motion and the activity level of hip replacement versus surface replacement, are relatively the same. In either case you want to follow a low impact lifestyle to try and get the most use out of any type of joint replacement. Good luck!
    William Barrett

  9. dr jason kronberg

    Dr. Barrett,

    Im a 36 year old pediatrician with bilateral FAI/CAM lesions…Im scheduled for surgery at the end of the month. All things being equal it would seem that I’d be a perfect candidate for a resurfacing procedure (on the right first – then left at a later date). My orthopedist described it as a Ferrari (resurfacing) vs. Toyota (THR) – i.e. more complicated and finicky but better performance vs reliable and trusted with less performance… I obviously stand all day and am somewhat active (Tennis/weightlifting/biking)…any thoughts?

  10. Peggy Moser

    Dr. Barrett …
    I was just told yesterday that I need total hip replacement. I really, really want at least one more opinion; probably two more opinions. Can you recommend hip specialists in the St. Louis area? Thanks!

  11. Dr. William Barrett

    Dear Peggy,
    A great way to search for Anterior hip surgeon is to go to This site has a surgeon locator and you can look up specifics about the type of hip procedure a doctor does by going to the advanced section on the physician locator. I search the St. Louis area and was not able to find a doctor that does Anterior. Maybe you could find one in the surrounding area.
    William Barrett

  12. Kim

    My husband, 49yrs, has severe hip pain and x-ray has revealed the following: Narrowing of the joint space, subarticular sclerosis and marginal osteophytes adn subarticular cyst formation. We have to decide on resurfacing or THR. The specialist was leaning toward resufacing but with the cyst formation there is now a question of which way we should go.
    Could you explain what this means and which procedure you would suggest?
    With thanks,

  13. Craig Reinhardt

    Dr. Barrett,

    I am a thirty year old canidate for some sort of hip procedure. I am researching, but have been unable to find a clear choice…THR or Birm. I have arthritis which is limiting my range of motion severely. I am very active, and hope to continue to be so. What does your research tell you??? Which one is better?? Longevity…etc. Too many questions.

  14. Dr. William Barrett

    Dear Craig,
    No clear cut but choice overall results are similar for both procedures re. post op activity. Total hip replacement has better long term results and majority of surgeons prefer total hip replacement over surface replacement.
    William Barrett