I saw this patient today in our clinic and I thought it might be an interesting case to discuss.

This is a 35 year old male who is somewhat overweight (BMI about 35) and quite tall (6ft 5in -1.98cm) who has a past history of Perthes disease of the left hip at 7 and septic arthritis of the same hip at 12. He also had a valgus osteotomy at 27. He was referred to us with increasingly severe left hip pain, loss of function and sleep disturbance. He does a secretarial-type job with lots of walking around offices carrying folders or pushing a tolley with folders.

On exam, his has very restricted left hip movement (flexion 45-degrees with a fixed flexion deformity of 10-degrees, no IR or ER at all). His has a true leg length discrepency of 4cm.

His xrays, as posted, shows degenerative change with head flattening and loss of offset with a DHS in-situ with at least 3 broken screws.

How would you treat him? Arthroplasty at this stage or wait? If Arthroplasty, do it all in one procedure or remove the metalwork first and then do a total hip? What implant and bearing surface would people choose? Given his age, would anyone do an arthrodesis?