Metal Hip Resurfacing
Metal Hip Resurfacing
Metal hip resurfacing is a bone-preserving surgical option used to treat advanced hip arthritis in carefully selected patients, particularly younger and highly active individuals with strong bone quality and suitable anatomy.
Unlike conventional total hip replacement, hip resurfacing preserves the femoral head and femoral neck.
Private hip resurfacing currently starts at $29,700 CAD, with the final treatment plan and cost confirmed following individual evaluation.
The damaged surface of the femoral head is reshaped and covered with a metal cap, while the hip socket is fitted with a matching metal component.
This creates a metal-on-metal bearing with a large femoral head that closely reproduces the natural dimensions of the hip.
Metal hip resurfacing has now been used clinically for more than two decades and has some of the longest follow-up available for modern hip resurfacing.
In appropriately selected patients—particularly younger active men with larger femoral head anatomy—long-term studies have reported strong implant survivorship and high levels of function.
Dr. John Antoniou provides metal hip resurfacing in Montreal for carefully selected patients from Quebec, elsewhere in Canada, the United States and internationally.
At a Glance
What Is Metal Hip Resurfacing?
Metal hip resurfacing is an alternative to total hip replacement for selected patients with advanced hip arthritis.
The procedure preserves substantially more femoral bone than a conventional total hip replacement.
During metal hip resurfacing:
- The patient's femoral head is preserved rather than removed
- Damaged cartilage and bone are reshaped
- A metal cap is placed over the femoral head
- The damaged hip socket is replaced with a matching metal component
- The natural femoral neck and femoral canal are preserved
The result is a large-diameter metal-on-metal articulation.
This large bearing more closely approximates the size of the patient's natural femoral head and can provide excellent joint stability.
Hip resurfacing is a specialized procedure and is not appropriate for every patient.
How Is Hip Resurfacing Different From Total Hip Replacement?
The primary difference is how much of the natural femur is preserved.
Total Hip Replacement
With conventional total hip replacement:
- The femoral head and neck are removed
- A stem is inserted into the femur
- A prosthetic ball is attached to the stem
- The hip socket is replaced
Hip Resurfacing
With hip resurfacing:
- The femoral head is retained
- The femoral head is reshaped rather than removed
- A cap is placed over the resurfaced femoral head
- The femoral neck is preserved
- No conventional femoral stem is inserted into the femoral canal
For younger patients who may potentially require another hip operation decades later, preserving femoral bone may be an important consideration.
However, this does not mean that future revision surgery is necessarily simple.
The appropriate initial procedure should be selected according to the patient's anatomy, bone quality, diagnosis, activity level and long-term goals.
What Are the Potential Advantages of Metal Hip Resurfacing?
For appropriately selected patients, potential advantages include:
- Preservation of the femoral head and neck
- Preservation of femoral bone stock
- Large femoral head size
- Excellent joint stability
- Low risk of dislocation compared with many conventional total hip replacement constructs
- Ability to maintain a high level of physical activity
- Strong long-term clinical track record in carefully selected patients
- Preservation of future surgical options
Studies have also reported high activity levels after hip resurfacing in selected patient populations.
The advantages of resurfacing should always be weighed against its specific risks, including metal-ion exposure, femoral neck fracture and the need for careful patient selection.
Who Is a Good Candidate for Metal Hip Resurfacing?
Metal hip resurfacing has produced its most predictable long-term results in a relatively specific patient population.
A strong candidate often has several of the following characteristics:
- Younger or middle-aged adult
- Highly active lifestyle
- Advanced hip osteoarthritis
- Strong bone density
- Healthy or reconstructable femoral head anatomy
- Larger femoral head size
- No major femoral head deformity
- No known significant metal sensitivity
- Good kidney function
- Desire to preserve femoral bone
- Understanding of the benefits and risks of metal-on-metal articulation
Age alone does not determine candidacy.
However, the strongest long-term evidence for metal resurfacing is in younger active men with larger femoral head sizes and good bone quality.
The U.S. Food and Drug Administration has similarly identified young males with larger femoral heads as the patient group most likely to be suitable for metal-on-metal hip resurfacing.
A detailed orthopedic assessment and imaging review are required before determining whether metal resurfacing is appropriate.
Can Women Have Metal Hip Resurfacing?
Metal hip resurfacing is generally less commonly recommended for women than for men.
Historically, women have experienced higher revision rates with several metal-on-metal resurfacing systems.
Factors contributing to this difference may include:
- Smaller average femoral head sizes
- Differences in anatomy
- Bone quality
- Higher risk of certain metal-related complications in some patient groups
Long-term Birmingham Hip Resurfacing research illustrates this difference.
In one study with approximately 20 years of follow-up, implant survivorship was reported at:
This does not mean that sex alone determines whether resurfacing is appropriate.
However, patient selection is particularly important.
With ceramic hip resurfacing now available in Canada, some women and patients with smaller anatomy who might not be ideal candidates for metal resurfacing may have another bone-preserving option to consider.
What Does the Long-Term Evidence Show?
More Than 20 Years of Follow-Up
One of the strongest advantages of traditional metal hip resurfacing is the amount of long-term clinical data now available.
A long-term study of Birmingham Hip Resurfacing reported approximately 96.5% implant survivorship at 20 years in male patients.
The same study reported lower survivorship in women, reinforcing the importance of patient selection.
Large Long-Term Evidence Base
A 2024 review examining more than 13,000 Birmingham Hip Resurfacing procedures found that most published studies reported strong long-term implant survivorship.
Across studies with at least 10 years of follow-up, survivorship varied according to patient population, implant, surgeon and follow-up duration.
Twenty-five of the 26 studies reviewed reported 10-year survivorship above 87%.
Comparison With Modern Total Hip Replacement
A 2025 analysis of National Joint Registry data compared currently used metal hip resurfacing implants with contemporary total hip replacement.
The analysis focused on male patients with larger resurfacing components.
At 18 years:
The resurfacing group had a somewhat higher overall risk of revision over the full study period.
This is an important reminder that metal hip resurfacing should not be presented as universally better or more durable than modern total hip replacement.
Its value lies in providing a different reconstructive option for carefully selected patients who may particularly value bone preservation, joint stability and high activity levels.
Why Patient Selection Matters So Much
Metal hip resurfacing is one of the procedures in orthopedic surgery where outcomes are particularly dependent on patient selection and surgical technique.
Important considerations include:
- Femoral head size
- Bone quality
- Hip anatomy
- Implant positioning
- Diagnosis
- Sex
- Kidney function
- Activity level
- Metal sensitivity
- Surgeon experience
Smaller femoral components have historically been associated with less predictable outcomes.
Accurate positioning of the acetabular component is also important because component orientation can influence wear and metal-ion production.
For this reason, hip resurfacing should be performed by surgeons with specific experience in the procedure.
What Are the Risks of Metal Hip Resurfacing?
All orthopedic surgery involves potential complications.
Risks associated with metal hip resurfacing can include:
- Infection
- Blood clots
- Femoral neck fracture
- Implant loosening
- Persistent pain
- Nerve or blood-vessel injury
- Heterotopic ossification
- Adverse local tissue reaction
- Elevated cobalt or chromium levels
- Need for revision surgery
Metal hip resurfacing also has risks specifically related to the metal-on-metal bearing surface.
What Should Patients Know About Metal Ions?
Metal-on-metal bearings release very small amounts of metal material through normal wear.
This can result in cobalt and chromium ions being detected in the blood.
Most patients with well-functioning metal resurfacing implants do not necessarily develop a clinical problem from these ions.
However, some patients can develop adverse reactions to metal debris or elevated metal-ion levels.
Potential symptoms requiring evaluation can include:
- New or increasing hip pain
- Swelling around the hip
- Change in walking ability
- Weakness
- Unusual noises or sensations from the hip
The relationship between a single blood metal-ion measurement and clinical problems is not straightforward.
Metal-ion results must therefore be interpreted together with symptoms, examination, imaging and implant position.
What Follow-Up Is Needed After Metal Hip Resurfacing?
Long-term follow-up is important for patients with metal-on-metal hip resurfacing.
For a well-functioning implant, follow-up generally includes periodic clinical and radiographic review.
Depending on the individual patient's implant, symptoms and risk factors, evaluation may also include:
- Blood cobalt and chromium measurements
- X-rays
- Ultrasound
- Metal-artifact-reduction MRI
- Other testing when clinically indicated
Patients with symptoms or factors associated with increased metal wear may require closer monitoring.
The appropriate surveillance program is individualized.
Is Metal Hip Resurfacing Still Used in 2026?
Yes.
Metal hip resurfacing continues to be used in carefully selected patients.
It is no longer considered an appropriate general solution for everyone requiring hip replacement.
However, modern evidence continues to support its use in selected patients, particularly younger active men with:
- Strong bone quality
- Larger femoral head anatomy
- Favourable hip anatomy
- Appropriate medical health
- A desire to maintain a high activity level
Metal resurfacing also has an important advantage over newer resurfacing technologies: decades of clinical follow-up.
For the right patient, it therefore remains a relevant bone-preserving surgical option.
How Has Ceramic Hip Resurfacing Changed the Options?
Ceramic hip resurfacing represents an important newer development.
It uses the same general bone-preserving resurfacing concept but replaces the metal-on-metal bearing with ceramic-on-ceramic articulation.
In 2026, the ceramic resurfacing system used by Dr. Antoniou became licensed in Canada.
Patient-specific authorization through Health Canada's Special Access Programme is therefore no longer required for the licensed system.
Ceramic resurfacing may be particularly worth considering for patients who:
- Prefer to avoid metal-on-metal articulation
- Have concerns about metal-ion exposure
- Have smaller anatomy
- May not fit the traditional ideal profile for metal resurfacing
- Want a bone-preserving surgical option
Ceramic resurfacing currently has encouraging published results through five years but does not yet have the decades of long-term follow-up available for traditional metal resurfacing.
Dr. Antoniou performs both metal and ceramic hip resurfacing, allowing implant selection to be individualized.
Metal vs Ceramic Hip Resurfacing
Both procedures preserve the femoral head and neck.
The primary difference is the bearing material.
Metal Hip Resurfacing
Metal resurfacing may be particularly appropriate for patients who:
- Fit the established ideal candidate profile
- Have excellent bone quality
- Have larger femoral head anatomy
- Lead a highly active lifestyle
- Want a procedure with more than two decades of clinical experience
- Understand the need for metal-ion surveillance when appropriate
Ceramic Hip Resurfacing
Ceramic resurfacing may be considered when a patient:
- Wants to avoid metal-on-metal articulation
- Prefers a ceramic bearing surface
- Has suitable anatomy and bone quality
- May not meet traditional metal resurfacing criteria
- Understands that ceramic resurfacing has a shorter clinical track record
There is no single implant technology that is best for every patient.
The appropriate choice depends on anatomy, bone quality, medical history, activity level and long-term goals.
Metal Hip Resurfacing vs Total Hip Replacement
Both procedures can effectively treat advanced hip arthritis, but they reconstruct the hip differently.
Metal Hip Resurfacing
Metal hip resurfacing:
- Preserves the femoral head and neck
- Uses a large-diameter bearing
- Preserves more femoral bone
- May support high activity levels in selected patients
- Uses a metal-on-metal articulation
- Requires specific candidacy criteria
Total Hip Replacement
Total hip replacement:
- Removes the femoral head and neck
- Uses a stem inserted into the femur
- Can use ceramic or metal femoral heads with polyethylene or ceramic bearings
- Is suitable for a much broader range of patients
- Has extensive long-term evidence
- Remains the preferred procedure for many patients
Neither procedure is automatically better.
The best procedure is the one most appropriate for the individual patient's condition.
What Happens if a Metal Hip Resurfacing Needs Revision?
A failed resurfacing implant can often be converted to a total hip replacement.
Because the femoral canal has not been used for a conventional stem during the original resurfacing procedure, femoral bone remains available for reconstruction.
However, revision should not automatically be described as easier than revision of a total hip replacement.
A 2026 systematic review of conversion from metal hip resurfacing to total hip replacement found that patients generally experienced substantial improvement in pain and function after revision.
However, complications were not negligible, and outcomes varied according to the reason the resurfacing failed.
Revisions for adverse reactions to metal debris can be particularly complex.
Revision complexity depends on:
- Reason for failure
- Bone quality
- Condition of the femoral head and neck
- Acetabular bone loss
- Metal-related tissue damage
- Implant position
- Fracture
- Infection
- Individual anatomy
The main advantage is that resurfacing preserves femoral bone initially—not that every future revision is automatically simple.
Recovery After Metal Hip Resurfacing
Recovery varies according to the patient's health, bone quality, surgical findings and rehabilitation.
The general pathway includes:
- Early mobilization following surgery
- Walking with an appropriate aid when required
- Physiotherapy
- Progressive strengthening
- Gradual return to everyday activities
- Ongoing follow-up
- Gradual return to recreational and athletic activities
Patients interested in running, skiing, hockey, tennis, cycling, weight training or other high-demand sports should discuss their goals with Dr. Antoniou.
Return to high-impact activity should only occur after appropriate healing.
Travelling to Montreal for Metal Hip Resurfacing
Dr. Antoniou evaluates patients from across Canada, the United States and internationally.
For patients outside Montreal, the evaluation may begin with review of:
- Medical history
- Symptoms
- X-rays and other appropriate imaging
- Previous treatment
- Activity goals
If metal hip resurfacing appears potentially appropriate, the clinic can then provide information regarding:
- Consultation
- Surgical planning
- Scheduling
- Travel to Montreal
- Private surgical care
- Postoperative recovery
- Physiotherapy planning
- Return travel
- Follow-up
Patients should discuss travel plans with the clinic before booking transportation or accommodation.
How Much Does Private Hip Resurfacing Cost?
Private hip resurfacing currently starts at:
$29,700 CADThe current private program includes the surgical pathway and related care.
The final treatment plan, services included and cost are confirmed after the patient's medical history, imaging and individual requirements have been reviewed.
Patients travelling from outside Canada should also consider exchange rates, travel and accommodation.
Why Choose Dr. John Antoniou for Metal Hip Resurfacing?
Dr. John Antoniou, MD, PhD, FRCSC, FAAOS, is an orthopedic surgeon specializing in hip and knee reconstruction and a Professor at McGill University.
His experience includes:
- More than 15,000 orthopedic procedures
- Extensive experience in hip resurfacing
- Experience with both metal and ceramic hip resurfacing
- Fellowship training in hip and knee reconstruction
- Extensive experience in complex hip reconstruction
- More than 200 peer-reviewed publications
- Past President of the Canadian Orthopaedic Association
- Fellow of the Royal College of Physicians and Surgeons of Canada
- Fellow of the American Academy of Orthopaedic Surgeons
- Membership in both the Hip Society and International Hip Society
Dr. Antoniou's approach is based on determining which procedure and implant best fit the patient's anatomy, bone quality, health, activity level and long-term objectives.
His private practice at Ortho Westmount provides consultation, surgery, postoperative care and rehabilitation planning within a dedicated orthopedic setting in Montreal.
Frequently Asked Questions About Metal Hip Resurfacing
How long does a metal hip resurfacing last?
Metal hip resurfacing has more than two decades of clinical follow-up.
Long-term results vary according to implant, patient selection, component size, surgeon and other factors.
In a published Birmingham Hip Resurfacing study, implant survivorship in male patients was approximately 96.5% at 20 years.
Other long-term studies have also reported strong outcomes in appropriately selected patients.
No implant has a guaranteed lifespan.
Is metal hip resurfacing appropriate for women?
Metal resurfacing is less commonly recommended for women because long-term studies have generally shown higher revision rates compared with carefully selected male patients.
However, sex alone does not determine candidacy.
Anatomy, femoral head size, bone quality, diagnosis and other individual factors must be evaluated.
Ceramic hip resurfacing may provide another bone-preserving option for some patients who are not ideal candidates for metal resurfacing.
Does metal hip resurfacing release metal ions?
Yes.
Because the bearing surface is metal-on-metal, small amounts of cobalt and chromium can be released through wear.
The amount varies between patients and depends on several factors, including implant design, size and positioning.
Not every patient with detectable or elevated metal ions develops a clinical problem.
What are the signs of a possible reaction to metal debris?
Symptoms that should be evaluated can include:
- New or worsening hip pain
- Swelling
- Weakness
- Change in walking ability
- New noises or sensations around the joint
Patients experiencing new symptoms should contact their orthopedic surgeon for appropriate evaluation.
Do I need metal-ion blood tests after resurfacing?
Not necessarily at every visit for every patient.
Blood cobalt and chromium testing may be appropriate depending on:
- Symptoms
- Implant characteristics
- Component position
- Individual risk factors
- Findings on clinical examination or imaging
Dr. Antoniou determines the appropriate follow-up strategy for each patient.
Is metal hip resurfacing better than total hip replacement?
Not universally.
Metal hip resurfacing may offer specific advantages for carefully selected younger and highly active patients, particularly bone preservation and a large femoral head.
Modern total hip replacement is also highly durable and is suitable for a much broader patient population.
The most appropriate procedure depends on the individual case.
Is metal hip resurfacing better than ceramic hip resurfacing?
Neither technology is best for every patient.
Metal resurfacing has a much longer clinical track record.
Ceramic resurfacing avoids metal-on-metal articulation and now has encouraging published five-year results.
The decision should be individualized according to anatomy, bone quality, medical factors and patient goals.
What happens if my resurfacing implant fails?
A failed hip resurfacing can often be converted to a total hip replacement.
The complexity depends on why the implant failed and the condition of the bone and surrounding tissues.
Revision after metal-related tissue reactions may be more complex than revision for some mechanical causes.
Can I return to sports after metal hip resurfacing?
Many appropriately selected patients return to high levels of activity following hip resurfacing.
The timing and type of activity should be individualized.
Running, jumping and other high-impact activities should only be resumed once adequate healing has occurred and after discussion with Dr. Antoniou.
Are metal-on-metal hip implants still used?
Yes, but metal-on-metal hip resurfacing is now reserved for carefully selected patients.
It should be distinguished from large-head metal-on-metal total hip replacements, which have had different performance and complication profiles.
Modern metal resurfacing continues to have a role in selected patients with appropriate anatomy and bone quality.
Can U.S. patients travel to Canada for metal hip resurfacing?
Yes.
Dr. Antoniou evaluates patients from the United States and internationally.
The initial assessment may begin with medical history and imaging review before travel arrangements are finalized.
How much does metal hip resurfacing cost?
Private hip resurfacing currently starts at $29,700 CAD.
The final treatment plan and price are confirmed after individual evaluation.
Considering Metal Hip Resurfacing?
If hip arthritis is affecting your activity and you are interested in a bone-preserving alternative to total hip replacement, a consultation can determine whether metal resurfacing, ceramic resurfacing or total hip replacement is most appropriate.
Dr. Antoniou evaluates patients from Montreal, across Canada, the United States and internationally.
Request a ConsultationA consultation can help:
- Review your diagnosis and imaging
- Assess your bone quality and anatomy
- Determine whether you are a candidate for hip resurfacing
- Compare metal and ceramic resurfacing
- Compare resurfacing with total hip replacement
- Discuss metal-ion considerations
- Review expected recovery and activity goals
- Discuss private surgery availability and pricing
- Plan treatment and travel when required
Have your case reviewed to determine whether metal hip resurfacing is appropriate for your anatomy, activity level and long-term goals.
Medical References for Final Page
- Fong S, et al. Long-term survivorship, complications and patient-reported outcomes following Birmingham Hip Resurfacing. 2024.
- Birmingham Hip Resurfacing at 20 years. Bone & Joint Journal.
- Griffin J, et al. Metal-on-metal hip resurfacing compared with contemporary total hip arthroplasty: analysis of National Joint Registry data. Bone & Joint Journal. 2025.
- U.S. Food and Drug Administration – Metal-on-Metal Hip Implants: Information for Orthopaedic Surgeons.
- Lari A, et al. Clinical Outcomes and Survivorship After Conversion of Metal-on-Metal Hip Resurfacing to Total Hip Arthroplasty: A Systematic Review. 2026.