The treatment of symptomatic osteonecrosis of the femoral head presents a challenge, particularly in young patients with significant femoral head deformity. Whereas retention of the femoral head is widely accepted as the goal of early treatment, attempts to reconstitute the femoral head are usually unsuccessful, and some form of replacement arthroplasty must be considered. When subchondral fracture and segmental collapse have occurred, especially if accompanied by degenerative changes in the acetabulum, hip reconstruction is usually recommended. Advanced stage avascular necrosis of the femoral head remains a particularly challenging disease to treat because it most commonly affects young, active patients in the third through fifth decades of life. Treatment of patients in this demographic is challenging in that a functional and durable hip operation is required. In the majority of patients requiring hip reconstruction, total hip replacement is the procedure of choice. Utilizing contemporary instrumentation and techniques, results in patients with osteonecrosis are becoming more predictable. Our efforts remain focused on improving the durability and long-term survivorship of total hip replacement. In this article we will review the information available on total hip arthroplasty and its various forms.