BACKGROUND: Metal-on-metal hip resurfacing arthroplasty (MoM HRA) has emerged as an alternative to total hip arthroplasty (THA) for younger active patients with osteoarthritis (OA). Birmingham hip resurfacing is the most common MoM HRA in Alberta, and is therefore compared with conventional THA. OBJECTIVE: The objective of this study was to estimate the expected cost-utility of MoM HRA versus THA, in younger patients with OA, using a decision analytic model with a 15-year time horizon. METHODS: A probabilistic Markov decision analytic model was constructed to estimate the expected cost per quality-adjusted life-year (QALY) of MoM HRA versus THA from a health care payer perspective. The base case considered patients with OA aged 50 years; men comprised 65.9% of the cohort. Sensitivity analyses evaluated cohort age, utility values, failure probabilities, and treatment costs. Data were derived from the Hip Improvement Project and the Hip and Knee Replacement Pilot databases in Alberta, the 2010 National Joint Replacement Registry of the Australian Orthopaedic Association, and the literature. RESULTS: In the base case, THA was dominated by MoM HRA (incremental mean costs of -$583 and incremental mean QALYs of 0.079). In subgroup analyses, THA remained dominated when cohort age was 40 years instead of 50 years or when only men were assessed. THA dominated when the cohort age was 60 years or when only women were assessed. Results were sensitive to utilities, surgery costs, and MoM HRA revision and conversion probabilities. At a willingness-to-pay of Can $50,000/QALY, there was a 58% probability that MoM HRA is cost-effective. CONCLUSIONS: The results show that, on average, MoM HRA was preferred to THA for younger and male patients, but THA is still a reasonable option if the patient or clinician prefers given the small absolute differences between the options and the confidence ellipses around the cost-effectiveness estimates.