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Forty-eight unilateral hip resurfacing arthroplasty patients were evaluated for cobalt and chromium levels. The metal ion trend of 42 well-functioning patients was compared with six sub-optimal functioning patients. Median metal ion levels were significantly higher for the sub-optimal group. For the well-functioning implants, the percentage of patients with increasing cobalt/chromium levels between two consecutive time-intervals (‘risers’) gradually decreased from 90/86% (0–3 months) to 22/22% (24–36 months). The percentage of patients with increasing metal ion levels was higher in the suboptimal group. The median absolute increase of this ‘risers’ subgroup was significantly lower for the well-functioning group at 12–24 months. Sub-optimal functioning MoM implants have a different metal ion trend than well-functioning implants, a higher chance of ‘risers’ and a larger absolute increase in time.