Here at Children’s Hospital of Philadelphia (CHOP), we continue to build our reputation as one of the world leaders in hip care for adolescents and young adults. In addition to procedures like periacetabular osteotomy and derotational osteotomies of the femur, which we have offered for years, the Young Adult Hip Preservation Program will soon begin offering total hip arthroplasty (THA) for select patients who have exhausted hip preservation options. Attending surgeon Christopher J. DeFrancesco, MD, who joined our Orthopedic Center in 2025, recently sat down to discuss this new option for young adults.
Question: Total hip arthroplasty has not traditionally been considered an option for people in their 20s. Why is that changing?
Dr. Defrancesco: One reason that hip replacement (total hip arthroplasty) is now more often considered in younger patients is because hip replacements are expected to last longer than ever. The materials used in older generations of implants would wear down, leaving an implant life expectancy of 15 to 20 years. But, with the advent of highly cross-linked polyethylene - a special plastic used as a liner in the modern artificial hip - uncomplicated hip replacements may be expected to last 20 to 30 years or more. This means that someone who gets a hip replacement in their 20s might expect to need one or two hip revision surgeries in their lifetime (rather than three or four).
Another reason hip replacement is becoming more common is that we have more options in terms of implants that might match the anatomy of smaller patients. For our smallest patients, we can even have custom implants made specifically for them.
How long can a young person expect to keep a replacement hip before another is necessary?
The true answer right now is that we don't know for sure. We think that modern hip implants last 20 to 30 years or longer. It's tough to estimate because we really haven't seen a high frequency of failures since adopting highly-cross-linked polyethylene in the last 20 years or so. The result is that we aren't sure when modern implants can be expected to "wear out." That said, I think it is likely that a person who gets a THA in their 20s will need one or two subsequent surgeries during their lifetime, probably to exchange the implant's liner.
What criteria would a patient present with for your team to start considering total hip arthroplasty?
Hip replacement is not offered to just anyone who has a troublesome hip. It is really reserved for those people that have exhausted hip preservation efforts. These are generally people who have lost the cartilage on their femur or have developed a severely misshapen joint that leads to motion deficits and arthritis.
What are some of the causes of hip degradation so pronounced that total replacement is needed at an early age?
One of the most common reasons for hip degeneration in a young patient is avascular necrosis (AVN) of the femoral head. In this condition, the blood supply to the ball of the hip joint is compromised, leading to softening and then collapse of the weight-bearing portion of the ball. The ball then becomes increasingly irregularly shaped, and the hip becomes a "square peg in a round hole." This leads to irreversible cartilage damage.
AVN can be idiopathic (random), as in Legg-Calve-Perthes disease. It can also happen due to trauma, sickle cell disease, high-dose corticosteroid administration (as in rheumatologic disease or cancer treatment), or slipped capital femoral epiphysis (SCFE).
What is the youngest age you would consider for total hip arthroplasty?
There is no specific cutoff for when a hip replacement may be considered, and hip replacements have been performed in patients under the age of 10. Having end-stage joint damage is more important than age.
Other surgical options include hip arthroscopy, periacetabular osteotomy and derotation osteotomy. When would you recommend these rather than total replacement?
I would emphasize that these three options are hip preservation options, meaning that they are aimed at improving the function of a joint where the cartilage surfaces are intact, and the shape of the hip ball and socket are both round. Hip replacement is reserved for patients with cartilage loss (advanced arthritis) or misshapen hip joints that don't function correctly.
Is the total hip replacement procedure for young adults different than for older adults, and if so, how? (For example, some adult total hip replacement cases are now outpatient; is it the same for young adults?)
Total hip replacement in young patients is very similar to that for adults with a few exceptions:
- Some young patients have complex deformities of the hip, so they may require custom implants to fit their unique anatomy.
- Some of these patients require osteotomies of the bones to re-align them at the time of hip replacement.
- Some children are so small that custom implants may have to be used to fit their anatomy.
However, in most patients, it is very similar to the surgery in older adults. Most of our patients at CHOP will spend one night in the hospital after hip replacement.
Many young people who see the hip team at CHOP are experiencing life-limiting pain. Explain how this factors into decision making about their surgical options.
Being active not only affects one's physical health; it directly impacts mental well-being, too. For some patients who are in pain and have lost their mobility, they feel secluded from their friend group, lonely and sad. For children and young adults without good hip preservation options, hip replacement can help them get back on their feet, out of the house, back to school and more.
When evaluating options, what role does the patient play in decision making?
The patients and their families share the decision making for surgery. Good candidates for THA are those severely limited by pain who have exhausted all hip preservation options. Patient families have to be well informed and understand the post-operative expectations and rehab.
Why is it important for a young person to consider a pediatric hip surgeon and a pediatric institution (rather than an adult institution) for total hip replacement and other complicated hip procedures?
At CHOP, we have the expertise to talk you through multiple different surgical approaches and tailor a plan appropriate for you. Additionally, many patients who are hip replacement candidates at our institution have consultant doctors at CHOP (e.g., hematology). For these patients, staying inside the CHOP system has incredible value.
Your residency and fellowship training includes Hospital for Specialty Surgery (HSS), CHOP, and Boston Children’s. What in your experience has prepared you to offer total hip arthroplasty for younger patients?
I have been extremely fortunate to train at some amazing places under legendary mentors. Although I went into pediatric orthopedics, some of my closest mentors at HSS were joint replacement doctors. I have kept in touch with them over the years and maintained my interest in the field. At CHOP, I trained with Dr. Wudbhav Sankar in hip preservation techniques. And, at Boston Children's, I honed my hip arthroscopy skills. All of these experiences have helped me to understand the hip more completely. More recently, I have completed a visiting clinicianship at HSS within the joint replacement department. It has been amazing to see my old mentors welcome me back and help me build my unique practice.
Before medical school, you worked as a mechanical engineer. Do you use this knowledge base in your everyday practice?
Absolutely. Engineering is a great background for someone interested in medicine, especially surgery. Engineering is all about solving problems. And mechanical engineering is about fixing or designing things that move to perform a function - and isn't that what our bodies do?
To discuss a challenging case or learn more about our approaches for young adults, please reach out to me at DEFRANCESC@chop.edu .
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Here at Children’s Hospital of Philadelphia (CHOP), we continue to build our reputation as one of the world leaders in hip care for adolescents and young adults. In addition to procedures like periacetabular osteotomy and derotational osteotomies of the femur, which we have offered for years, the Young Adult Hip Preservation Program will soon begin offering total hip arthroplasty (THA) for select patients who have exhausted hip preservation options. Attending surgeon Christopher J. DeFrancesco, MD, who joined our Orthopedic Center in 2025, recently sat down to discuss this new option for young adults.
Question: Total hip arthroplasty has not traditionally been considered an option for people in their 20s. Why is that changing?
Dr. Defrancesco: One reason that hip replacement (total hip arthroplasty) is now more often considered in younger patients is because hip replacements are expected to last longer than ever. The materials used in older generations of implants would wear down, leaving an implant life expectancy of 15 to 20 years. But, with the advent of highly cross-linked polyethylene - a special plastic used as a liner in the modern artificial hip - uncomplicated hip replacements may be expected to last 20 to 30 years or more. This means that someone who gets a hip replacement in their 20s might expect to need one or two hip revision surgeries in their lifetime (rather than three or four).
Another reason hip replacement is becoming more common is that we have more options in terms of implants that might match the anatomy of smaller patients. For our smallest patients, we can even have custom implants made specifically for them.
How long can a young person expect to keep a replacement hip before another is necessary?
The true answer right now is that we don't know for sure. We think that modern hip implants last 20 to 30 years or longer. It's tough to estimate because we really haven't seen a high frequency of failures since adopting highly-cross-linked polyethylene in the last 20 years or so. The result is that we aren't sure when modern implants can be expected to "wear out." That said, I think it is likely that a person who gets a THA in their 20s will need one or two subsequent surgeries during their lifetime, probably to exchange the implant's liner.
What criteria would a patient present with for your team to start considering total hip arthroplasty?
Hip replacement is not offered to just anyone who has a troublesome hip. It is really reserved for those people that have exhausted hip preservation efforts. These are generally people who have lost the cartilage on their femur or have developed a severely misshapen joint that leads to motion deficits and arthritis.
What are some of the causes of hip degradation so pronounced that total replacement is needed at an early age?
One of the most common reasons for hip degeneration in a young patient is avascular necrosis (AVN) of the femoral head. In this condition, the blood supply to the ball of the hip joint is compromised, leading to softening and then collapse of the weight-bearing portion of the ball. The ball then becomes increasingly irregularly shaped, and the hip becomes a "square peg in a round hole." This leads to irreversible cartilage damage.
AVN can be idiopathic (random), as in Legg-Calve-Perthes disease. It can also happen due to trauma, sickle cell disease, high-dose corticosteroid administration (as in rheumatologic disease or cancer treatment), or slipped capital femoral epiphysis (SCFE).
What is the youngest age you would consider for total hip arthroplasty?
There is no specific cutoff for when a hip replacement may be considered, and hip replacements have been performed in patients under the age of 10. Having end-stage joint damage is more important than age.
Other surgical options include hip arthroscopy, periacetabular osteotomy and derotation osteotomy. When would you recommend these rather than total replacement?
I would emphasize that these three options are hip preservation options, meaning that they are aimed at improving the function of a joint where the cartilage surfaces are intact, and the shape of the hip ball and socket are both round. Hip replacement is reserved for patients with cartilage loss (advanced arthritis) or misshapen hip joints that don't function correctly.
Is the total hip replacement procedure for young adults different than for older adults, and if so, how? (For example, some adult total hip replacement cases are now outpatient; is it the same for young adults?)
Total hip replacement in young patients is very similar to that for adults with a few exceptions:
- Some young patients have complex deformities of the hip, so they may require custom implants to fit their unique anatomy.
- Some of these patients require osteotomies of the bones to re-align them at the time of hip replacement.
- Some children are so small that custom implants may have to be used to fit their anatomy.
However, in most patients, it is very similar to the surgery in older adults. Most of our patients at CHOP will spend one night in the hospital after hip replacement.
Many young people who see the hip team at CHOP are experiencing life-limiting pain. Explain how this factors into decision making about their surgical options.
Being active not only affects one's physical health; it directly impacts mental well-being, too. For some patients who are in pain and have lost their mobility, they feel secluded from their friend group, lonely and sad. For children and young adults without good hip preservation options, hip replacement can help them get back on their feet, out of the house, back to school and more.
When evaluating options, what role does the patient play in decision making?
The patients and their families share the decision making for surgery. Good candidates for THA are those severely limited by pain who have exhausted all hip preservation options. Patient families have to be well informed and understand the post-operative expectations and rehab.
Why is it important for a young person to consider a pediatric hip surgeon and a pediatric institution (rather than an adult institution) for total hip replacement and other complicated hip procedures?
At CHOP, we have the expertise to talk you through multiple different surgical approaches and tailor a plan appropriate for you. Additionally, many patients who are hip replacement candidates at our institution have consultant doctors at CHOP (e.g., hematology). For these patients, staying inside the CHOP system has incredible value.
Your residency and fellowship training includes Hospital for Specialty Surgery (HSS), CHOP, and Boston Children’s. What in your experience has prepared you to offer total hip arthroplasty for younger patients?
I have been extremely fortunate to train at some amazing places under legendary mentors. Although I went into pediatric orthopedics, some of my closest mentors at HSS were joint replacement doctors. I have kept in touch with them over the years and maintained my interest in the field. At CHOP, I trained with Dr. Wudbhav Sankar in hip preservation techniques. And, at Boston Children's, I honed my hip arthroscopy skills. All of these experiences have helped me to understand the hip more completely. More recently, I have completed a visiting clinicianship at HSS within the joint replacement department. It has been amazing to see my old mentors welcome me back and help me build my unique practice.
Before medical school, you worked as a mechanical engineer. Do you use this knowledge base in your everyday practice?
Absolutely. Engineering is a great background for someone interested in medicine, especially surgery. Engineering is all about solving problems. And mechanical engineering is about fixing or designing things that move to perform a function - and isn't that what our bodies do?
To discuss a challenging case or learn more about our approaches for young adults, please reach out to me at DEFRANCESC@chop.edu .
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Young Adult Hip Preservation Program