Hip replacement surgery: which type of hip replacement is right for you?
Dr Imbuldeniya explains the main types of hip replacement, including the Röttinger approach which he uses for most of his patients, and how he decides which option is right for each person.
A hip replacement is one of the most reliable operations in modern medicine. More than 110,000 first hip replacements were carried out in England, Wales and Northern Ireland in 2025, and of the 1.8 million recorded by the National Joint Registry (opens in a new window >) since 2003, only around 3 in 100 have ever needed to be redone.
As a Consultant Orthopaedic Hip and Knee Surgeon at Cromwell Hospital, Dr Arj Imbuldeniya regularly sees people who are unsure what their options are when it comes to hip replacement surgery.
Many have read conflicting advice online about implants, cement and surgical approaches with unfamiliar names. In this guide, Dr Imbuldeniya explains the main types of hip replacement in plain English, including the Röttinger approach which he uses for most of his patients, and how he decides which option is right for each person.
What is a hip replacement?
The hip is a ball and socket joint. The ball is the rounded top of the thigh bone (the femoral head) and the socket is a cup in the pelvis (the acetabulum). Both are covered in cartilage, the smooth, slippery layer that lets the joint glide. When that cartilage wears away, bone starts to rub on bone, and the hip becomes painful and stiff.
A hip replacement, which doctors call a hip arthroplasty, removes the worn surfaces and replaces them with an artificial joint. By far the most common reason is osteoarthritis, the wear and tear arthritis behind around 9 in 10 hip replacements in the UK. Other reasons include rheumatoid arthritis, arthritis after an old injury, some hip fractures, and avascular necrosis, where the ball loses its blood supply and begins to collapse.
The aim is simple: less pain, better movement, and your life back.
Before the type, the timing
"The first question is not which hip replacement, but whether now is the right time for one. I see hip care go wrong in two opposite directions. Some people are offered an operation before the simpler things have had a fair chance: strengthening the muscles around the hip, losing weight where that matters, sensible pain relief and proper time with a good physiotherapist. Others are told to keep going for years, by which point the joint has collapsed, the muscles have wasted, and both the operation and the recovery are harder than they needed to be. Both usually come from seeing the wrong clinician at the wrong time."
"My approach is Biology-first. Surgery-last. We do the right things in the right order. That does not mean avoiding surgery; I replace hips most weeks, and when a hip genuinely needs replacing, a well-timed operation is one of the best things I can offer. It means making sure the foundations are in place first, so that the people who need an operation have one at the right moment and the people who do not are spared one."
"Over the last two years, 8 in 10 patients I saw did not go on to surgery. That figure covers everyone I see with knee and hip problems, and the other 2 in 10 needed an operation and had one."
"It may be time to talk about a hip replacement when pain wakes you at night, when the distance you can walk keeps shrinking, when putting on socks and shoes has become a struggle, or when the simpler measures have been tried properly and are no longer enough. Injections can settle a flare for some people, although the evidence for them in the hip is more modest than in the knee. An X-ray, alongside a careful examination and a proper conversation about your life, usually tells us where you are."
What are the different types of hip replacement?
"When people search for 'types of hip replacement', they usually mean one of three things: what is replaced, how the new parts are fixed to the bone, and the route the surgeon takes to reach the joint, which surgeons call the approach. I will take each in turn."
Total hip replacement
In a total hip replacement both the ball and the socket are replaced. The new ball sits on a stem that fits inside the thigh bone, and the new socket is a cup fixed into the pelvis, usually with a lining of very hard-wearing plastic or ceramic. For most people with advanced arthritis this remains the gold standard, with reliable pain relief, better movement and excellent durability. Of the hips replaced in the UK in 2015, fewer than 3 in 100 had needed redoing ten years later.
Partial hip replacement
A partial hip replacement, also called a hemiarthroplasty, replaces only the ball. It is used mainly for certain broken hips in older people, where the socket is still healthy. Because arthritis usually wears both sides of the joint, it is rarely the right choice for arthritis.
Hip resurfacing
"In hip resurfacing the ball is not removed. Instead it is reshaped and capped with metal, and the socket is lined with a metal cup. Because it keeps more of your own bone, it once appealed to many younger, active people. It is now a small and specialist operation: UK numbers peaked at around 6,000 a year in 2007 to 2008 and are now under 1,000, mostly in men. Results have been less good in women and in smaller hips, and because metal surfaces can shed tiny particles, patients need monitoring over the years."
"Resurfacing also relies on your own ball and the bone beneath it being healthy enough to hold the cap, so there are people for whom I would not recommend it."
"Where the bone is soft or thinning, as in osteoporosis, the neck of the thigh bone (the narrow part just below the ball) is at risk of breaking after surgery. Where the ball itself is damaged, for example in avascular necrosis, where part of it has lost its blood supply, or where there are large cysts (fluid-filled holes) in the bone, there is not enough sound bone for the cap to sit on. It is also a poor choice when the hip has grown into an unusual shape from a childhood condition such as dysplasia or Perthes disease, when the ball is small, in people with kidney problems, who cannot clear the metal particles easily, in anyone with a known metal allergy, and in women who may still become pregnant."
"For carefully selected people resurfacing can still be a good choice, but for most a total hip replacement is the safer and more predictable option."
"Resurfacing is back in the news because of a newer ceramic version. Both the cap and the cup are made of ceramic rather than metal, which avoids the problem of metal particles, and it comes in smaller sizes, so it may open resurfacing up again to women and people with smaller hips, who were advised against the metal versions. It has recently become available in the UK, and the early results are encouraging: in one series of 250 patients followed for up to 8 years, around 96 in 100 still had their original hip, and a small study found people walked more like those with healthy hips than after a standard hip replacement. These are still early results from small numbers, mostly from specialist centres, and it is too new to have the long-term National Joint Registry results we have for standard hip replacements. It is also a more technically demanding operation, and the rules about healthy bone above still apply."
"For now I would describe ceramic resurfacing as promising rather than proven, and worth discussing with a small number of younger, active people with good bone."
Cemented, uncemented, or hybrid?
The new parts have to be fixed firmly to your bone, and there are two ways to do it. In a cemented hip, a special bone cement acts like grout and holds the implant firmly from the day of surgery, which is often the better choice where bone is softer, as it tends to be in older people. In an uncemented hip, the implant has a rough coated surface that your own bone grows into over the following weeks, a bit like ivy gripping a wall; this works well where the bone is strong. A hybrid hip uses one of each, cementing one part and not the other.
"The right choice depends on your age, the strength of your bone and the shape of your hip. I plan it from your X-rays and confirm it during the operation."
What are the different surgical approaches to hip replacement?
The hip sits deep in the body, wrapped in strong muscles. To reach it, a surgeon has to go between or through some of them, and that route is the approach. The posterior approach goes in from behind and is the most common in the UK; the small muscles at the back of the hip are released and repaired at the end. The lateral approach goes in from the side, lifting part of the gluteal muscles, the ones that keep your pelvis level when you walk, and repairing them afterwards. The direct anterior approach goes in from the front, between muscles, and the Röttinger approach goes in from the front and side, also between muscles.
All of these can give excellent results in experienced hands, and no single approach is right for every patient.
What is the Röttinger approach?
The Röttinger approach was developed in Munich by the German surgeon Heinz Röttinger and first published in 2004. It reaches the hip through a natural gap between two muscles at the front and side of the hip, the tensor fascia lata and the gluteus medius, so nothing needs to be cut away from the bone and stitched back on.
"I trained in the Röttinger approach over around three years, observing at the OCM centre in Munich where it was developed, training in cadaver labs in Germany and the UK under expert supervision, and then performing it under proctorship before operating independently. It is now the approach I use for most of my hip replacements, and I am one of a small number of surgeons in the UK offering it."
"For patients, the difference is mostly felt in the first few weeks. Because the muscles that power walking stay attached, many suitable patients are up and walking on the day of surgery, and around 95% of my patients go home within 24 hours, often without the traditional restrictions on bending, crossing the legs or sleeping position. Approaches from the front and side have also been linked with a lower risk of the new hip dislocating."
It is important to be honest about the limits. The advantage is in early recovery: less pain and a quicker return to walking in the first weeks. By one year, studies show the results of the main approaches are broadly similar. The size of the scar matters far less than people think. What decides how well a hip does in the long run is that the right implant is chosen and positioned precisely, and that the rehabilitation afterwards is done well.
"Röttinger is also not right for every hip. I use a different approach, usually from the side or behind, for very stiff hips, for soft or fragile bone where the risk of a fracture during surgery is higher, for hips that have had previous surgery or contain old metalwork, for severe dysplasia, where the hip formed abnormally in childhood and the thigh bone needs reshaping, and for some people carrying a lot of weight around the hips. In each of those cases another approach is the safer operation for that person, and choosing it is part of doing the job properly."
The direct anterior approach vs the Röttinger approach
Patients often ask how the Röttinger approach differs from the direct anterior approach. Both go between muscles rather than through them, and both are good operations used by many excellent surgeons, so this is not a case of a good and a bad option.
The Röttinger route lies one gap further out to the side, and that brings some practical differences. There is less risk of a numb patch on the front of the thigh, which can happen after the direct anterior approach when a small skin nerve in that area is stretched; it is usually harmless and often settles, but it is common. The scar sits away from the groin crease, which lowers the risk of wound problems compared with the direct anterior approach. The top of the thigh bone is easier to reach, which helps in more muscular or more difficult hips. And the operation is done on a standard operating table, without the special traction table and X-ray during surgery that the direct anterior approach usually uses.
There are few trials comparing the two head to head, and both can fairly be called muscle-sparing. The approach matters, but the surgeon's experience with it and the plan around it matter more.
Which hip replacement is best?
"There is no single best hip replacement. Two people with the same X-ray can need different operations, because no two people are the same. When I plan a hip replacement I am weighing your age, the strength of your bone, the shape of your hip, your weight, your general health and any previous surgery, alongside what you want your hip for: getting back to tennis, caring for a partner, lifting grandchildren or simply walking the dog without pain."
"Goals need to be realistic and fit around real life, with its work, family and responsibilities, and the plan is built around you rather than around a favourite operation."
Recovery after hip replacement surgery
"Most people walk on the day of surgery or the day after, with a frame or crutches at first, and physiotherapy starts straight away. Most of the improvement in pain and walking comes in the first three months, and gains continue for up to a year. Biology first does not stop when an operation is needed: arriving stronger, with blood sugar well controlled, any anaemia treated and smoking stopped, makes surgery safer and recovery smoother, so I look at these things with my patients well before the day of the operation."
"Recovery also brings sensations that nobody tends to warn you about, from a leg that feels heavy as a log to bruising that appears at the ankle. I cover these, along with getting your home ready and when to call us, in a separate guide: Recovery after hip replacement: what nobody tells you."
Which hip replacement is right for you?
Hip replacement is a highly effective treatment for a painful, worn hip, and today's options, from total hip replacement and resurfacing to muscle-sparing approaches such as Röttinger, mean the operation can be matched to the person.
The most important decision, though, is not the implant or the approach. It is being assessed by someone who looks at the whole of you, tells you honestly whether you need an operation yet, and if you do, chooses the one that suits your hip and your life.
Hip care at Cromwell Hospital
"I see patients and operate at Cromwell Hospital, where a multidisciplinary orthopaedic team looks after a wide range of hip problems, from early arthritis and sports injuries to complex reconstruction and replacement surgery. Specialist assessment, advanced imaging, surgery and rehabilitation all happen within one hospital, and where an operation is needed, muscle-sparing techniques such as the Röttinger approach are used where they are the right choice."
