I have spent a large part of my surgical career resurfacing hips, and I have come to believe you cannot properly understand the operation without understanding where it came from. Hip resurfacing is one of the few procedures in orthopaedics that has been invented, set aside, brought back, nearly discredited, and then reborn in a new material, all within a single working lifetime.
That history matters because it still walks into my clinic. Patients arrive having read that resurfacing "was banned", or that it "fails", or that it is "not for women". Each of those statements describes one chapter of the story accurately and the whole story not at all. So this is the history as I understand it, written plainly, and an explanation of why I think it should reassure you rather than worry you.
The thread running through the whole account is a simple one. The idea behind resurfacing has been sound for a century. What changed, repeatedly, was the material the joint was made from. Get the bearing wrong and the operation fails and is blamed. Get the bearing right and it does exactly what it always promised.
The instinct behind resurfacing is deliberately conservative. Rather than cutting away the ball of the hip and replacing it with a stemmed implant, you reshape the worn surface of the patient's own femoral head and cap it, leaving the head and neck of the bone intact. The hip keeps its natural size and much of its own anatomy. It is an elegant idea, and surgeons reached for it long before they had materials that could deliver it.
In the first half of the twentieth century, Marius Smith-Petersen developed what became known as mould, or cup, arthroplasty: a smooth interpositional cup placed over the reshaped head, with the body left to form a new gliding surface around it. The concept was right and the result was unpredictable, because the materials of the day could not provide a durable, low-friction surface. In the early 1950s John Charnley tried a double-cup design lined with a then-novel plastic, Teflon, which wore out within a year or two and was abandoned.
Charnley's response shaped orthopaedics for the next fifty years. He turned away from resurfacing and toward low-friction total hip replacement: remove the head, fix a stem into the femur with bone cement, and articulate a small metal ball against a polyethylene socket. By the 1960s this had become the dominant operation for the arthritic hip, and deservedly so. In solving the wear problem of its era, total hip replacement also set the resurfacing idea quietly to one side.
The idea would not stay buried. Through the 1970s a number of surgeons, among them Gerard and Wagner in Europe and Amstutz and Freeman working on designs such as the THARIES, revived resurfacing in earnest. Their reasoning was the same as Smith-Petersen's: preserve the bone, keep the anatomy, and give younger patients an operation that did not commit them to a stemmed implant in their forties.
The designs of that decade paired a large metal head against a polyethylene socket, borrowing the bearing from total hip replacement. It was a reasonable choice and it proved to be the wrong one. A resurfacing head is much larger than a replacement head, and a large head sweeps a great deal of surface against the cup with every step. The thin polyethylene wore quickly, the wear debris loosened the components, and the preserved femoral neck sometimes fractured. By the early 1980s most surgeons had given up on resurfacing for the second time, and it acquired a reputation for failure that took years to shake.
This is worth pausing on, because it is the first time in the story that resurfacing was judged as a failure when the real culprit was the bearing surface. The principle was never the problem. The polyethylene was.
The breakthrough came from looking backwards. A small number of all-metal total hip replacements implanted in the 1960s, the McKee-Farrar design among them, had quietly lasted for decades. Their cobalt-chromium surfaces had proved that metal running against metal could be durable and biologically tolerated in a way that the polyethylene resurfacings never managed. The lesson was there to be drawn: change the bearing.
In Birmingham, Derek McMinn began developing a metal-on-metal resurfacing at the Royal Orthopaedic Hospital in the early 1990s. Working with Ronan Treacy, he refined the design into the Birmingham Hip Resurfacing, first implanted in July 1997. It used a large cobalt-chromium head against a closely matched metal cup, engineered so that a film of fluid would form between the surfaces and keep wear low. In carefully selected patients, typically younger, active people with larger bones, the results were good, with registry data later reporting that around nine in ten implants were still in place at ten years.
Through the 2000s metal-on-metal resurfacing spread across the world. I trained and began practising in the era this work created, in the city where much of it was done, and I have used metal-on-metal resurfacing in the patients for whom it remains a sound choice. For a window of about ten years it looked as though resurfacing had finally arrived for good.
Wide adoption exposed the limits of the bearing, and not every metal-on-metal design was equal. One implant in particular, the DePuy ASR, released more metal debris than others. When the National Joint Registry of England and Wales began publishing its data, the ASR showed revision rates far higher than expected, and concerns first raised at conferences in 2008 hardened into registry evidence over the following two years. In August 2010 the manufacturer issued a worldwide recall of the ASR, and the UK regulator, the Medicines and Healthcare products Regulatory Agency, issued safety alerts covering metal-on-metal hips.
The wider lesson was uncomfortable but valuable. Metal-on-metal surfaces shed tiny amounts of cobalt and chromium, and in some patients that debris provoked an inflammatory reaction that damaged the surrounding soft tissue, a problem now known as metallosis. The risk was greater with smaller components, because a smaller head is less able to maintain its protective film of fluid, and it was greater still when the cup was not positioned precisely. Smaller components meant, for the most part, women, who therefore carried more of the risk for less of the benefit.
Resurfacing contracted sharply, and for most women it closed altogether. This is the chapter most patients have read, and taken on its own it is a fair reason to be cautious. But read in sequence it is the same lesson for the third time. The verdict fell on a particular bearing material and on poor patient selection. It did not fall on the principle of resurfacing, which had nothing to do with the metal ions at all.
If a bearing material is the problem, the honest answer is to change the bearing material. Ceramic surfaces release no cobalt and no chromium, so the metal-ion concern that closed the operation to women simply does not arise with them. Ceramic is also among the lowest-wearing materials used anywhere in joint surgery, which matters most to exactly the younger, active patients that resurfacing was always meant to serve.
Two ceramic-on-ceramic resurfacing implants now bring the bone-preserving idea back without the metal problem. ReCerf, made by MatOrtho, carries the longer ceramic track record and published mid-term outcomes. The H1, developed at Imperial College London, is a monoblock, anatomically contoured ceramic implant developed to bring resurfacing to women and smaller-framed patients. Both are followed independently through the Beyond Compliance programme, a surveillance scheme that watches newly introduced implants more closely than ordinary registry follow-up. For the first time in well over a decade, the operation is open again to many of the patients it had been withdrawn from. You can read about both implants on the implants overview, and what the change means specifically for female patients on the hip resurfacing for women page.
Laid out as a timeline, the pattern is hard to miss. The operation keeps returning because the principle is sound; it keeps stumbling whenever the bearing is not equal to it.
Smith-Petersen's interpositional cup establishes the bone-preserving idea. The concept is right; the materials of the day are not.
Charnley's stemmed replacement becomes the standard operation for the arthritic hip, and resurfacing is set aside.
Resurfacing returns with a metal head on a polyethylene cup. The plastic wears quickly and the operation is abandoned for a second time.
Derek McMinn develops a metal-on-metal resurfacing at the Royal Orthopaedic Hospital; with Ronan Treacy it becomes the Birmingham Hip Resurfacing, first implanted in July 1997.
Metal-on-metal resurfacing spreads worldwide, with good ten-year results in well-selected, mostly younger and male, patients.
The DePuy ASR is recalled and regulators issue alerts on metal-on-metal hips. Concerns about metal debris, small components and women lead to a sharp contraction, and the operation closes for most women.
Ceramic-on-ceramic implants, ReCerf and the H1, remove the metal-ion problem and the size barrier, and bring resurfacing back, including for many women.
I find the history reassuring rather than alarming, and it shapes how I practise in three concrete ways.
The first lesson is that selection decides everything. Resurfacing rewards the right candidate and punishes the wrong one, and most of the failures in its history came from offering it to people whose anatomy or activity never suited it. I would rather tell a patient honestly that a total hip replacement is the better operation for them than place a resurfacing that should not have been placed.
The second lesson is that the bearing matters more than the marketing. The same principle succeeded or failed across seventy years purely on the surface it was made from, which is why I use ceramic, and why I do not offer metal-on-metal resurfacing to women under any circumstances.
The third lesson is that volume matters. Cup position, sizing and technique separated the good metal-on-metal results from the poor ones, and those things track surgeon experience more closely than almost anything else in joint surgery. I have performed more than 400 hip resurfacings across two implant systems, Adept and ReCerf, and I treat that experience as the safeguard the history says it is.
The history of resurfacing is not a reason to fear the operation. It is a reason to be careful about who performs it and what they put in.
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