Long-term outcomes of resurfacing total hip arthroplasty in young active patients: an updated systematic review and meta-analysis

Abstract Background Resurfacing Total Hip Arthroplasty (R-THA) provides a bone-conserving alternative to Conventional Total Hip Arthroplasty (C-THA) for young, active patients. While concerns over metal-on-metal (MoM) bearings have reduced utilisation, contemporary data on well-performing devices such as the Birmingham Hip Resurfacing (BHR) demonstrate favourable medium- to long-term outcomes in appropriately selected patients, and novel ceramic-on-ceramic (CoC) resurfacing systems are emerging. This updated meta-analysis synthesises current evidence on 10-year survival, cumulative revision, and functional outcomes of R-THA in patients under 55 years of age. Methods This systematic review and meta-analysis followed PRISMA 2020 guidelines [1]. We searched PubMed/MEDLINE, Embase, and the Cochrane Central Register (January 2015 – February 2026) for studies reporting ≥ 10-year follow-up of R-THA in patients < 55 years of age or containing an extractable subgroup for this population. Risk of bias was assessed using the Newcastle–Ottawa Scale (NOS) [2] for cohort studies and the Cochrane Risk of Bias 2.0 tool for the single randomised trial. Random-effects meta-analysis (DerSimonian–Laird) was performed on logit-transformed proportions of implant survival and all-cause revision. Pre-specified sensitivity analyses excluded recalled implants (Durom). The certainty of evidence was considered using the GRADE framework [3]. Results Eleven studies comprising R-THA cohorts in young active patients met the inclusion criteria for quantitative synthesis; the sample is dominated by Birmingham Hip Resurfacing (BHR) cohorts and by the large-registry data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) [4], so the pooled estimates reflect well-performing BHR in selected patients treated at experienced centres rather than resurfacing arthroplasty as a class. The primary, time-dependent outcome—pooled 10-year Kaplan–Meier implant survival—was 95.0% (95% CI 94.4–95.6%; I² = 7.4%), corresponding to a cumulative percent revision of approximately 5.0% at 10 years. The pooled all-cause proportion of hips revised during study follow-up, a non-time-adjusted descriptor that is sensitive to follow-up length and is therefore interpreted only as supplementary, was 6.3% (95% CI 4.8–8.3%), with substantial heterogeneity (I² = 80.8%) driven largely by implant design. Sensitivity analysis restricted to BHR devices reduced heterogeneity considerably. The weighted mean Harris Hip Score was 93.3 points, reported descriptively only and subject to ceiling effects. Novel ceramic-on-ceramic hybrid resurfacing (ReCerf) has reported 5-year survival of 98.0% in an international multicentre cohort [5]; these data are short-term and are discussed as emerging evidence only. Conclusions In appropriately selected young active patients treated at experienced centres, R-THA—particularly the BHR—provides durable medium- to long-term survivorship and good functional outcomes. These findings predominantly reflect the BHR rather than resurfacing arthroplasty as a class. Large registry data indicate that selected contemporary C-THA constructs with crosslinked-polyethylene or ceramic-on-ceramic bearings achieve superior all-cause cumulative revision outcomes compared with the BHR in the same target population, and do so without jurisdiction-specific metal-ion surveillance [4]. R-THA should therefore be offered, after balanced counselling, as one reasonable option among several to informed, appropriately selected patients, and performed in experienced centres. Emerging ceramic-on-ceramic systems are promising but require long-term confirmatory data before their role can be defined.