Introduction

At present, hip arthroplasty is one of the most successful medical procedures available to the world, in terms of pain relief, return to function, and improvement in the quality of life for patients with hip arthritis. However, the success rate of total hip arthroplasty (THA) is noticeably lower in younger and more active patients. Problems of prosthetic loosening, wear, osteolysis, and a shortening prosthetic life span have all been documented with higher frequency in younger patients.

The indications for hip arthroplasty in the very young adult are the same as that in older patients: significant pain, decreased function, and a poor quality of life because of hip arthritis. However, because of the relatively higher risks involved with the longevity of the prosthesis, both patients and surgeons alike are cautious before proceeding to arthroplasty in such young patients. Furthermore, these surgical procedures are often technically demanding because of underlying severe deformity of both the femur and pelvis and previous surgery.

Although arthroplasty is never performed cavalierly in pediatric patients and very young adults (younger than 30 years), pathologic conditions may be so severe that arthroplasty or arthrodesis is the only viable option. At present, hip arthrodesis is less commonly performed because of advances in arthroplasty techniques and materials. Yet, at times, arthrodesis may be considered in the very young patient. The general thought is that hip arthrodesis gives a good outcome with a near normal gait pattern. However, there have been no studies that have investigated the functional activities of daily living, which most likely would be severely limited by hip arthrodesis. There are no contemporary series that discuss and compare hip arthrodesis to THA or hip resurfacing arthroplasty (HRA). An active patient does not often accept arthrodesis as a viable treatment option.

Even with the known difficulties, several series have reported great success with THA in young patients. Previous studies on the clinical outcome or cost-effectiveness of THA have objectively rated it as one of the most successful interventions in modern day medicine. Uncemented components are the mainstay in most arthroplasty cases today, and clinical results have shown excellent longevity, with a 10-year survivorship of more than 95% documented in multiple reports.

HRA has recently been reintroduced as a possible alternative for young active patients with hip arthritis. Original reports from the developers of some of the newer HRA systems have shown excellent midterm results, with a 10-year survivorship of 98%. Furthermore, motion analysis laboratory studies have suggested more normal function for patients receiving HRA in comparison with patients receiving traditional THA. However, recent reports, in the national joint registries, of higher failure rates in some HRA systems have tempered some of the initial excitement for HRA. The higher revision rates coupled with concerns about metal ions, metal hypersensitivity reactions, and pseudotumors have thrown the future of resurfacing into ambiguity. One of the main criticisms of HRA is that it is much more technically demanding than THA, with a significantly steep learning curve. Nevertheless, many investigators maintain that HRA is an excellent treatment option for the very active and very young patient with end-stage hip disease.

The purpose of this article is to discuss end-stage hip pathologic conditions in pediatric and adolescent patients and the pros and cons of THA and HRA in adolescents and the very young adult and to put forward special issues that should be considered when treating these young patients.