Total hip arthroplasty is an operative procedure in which the diseased and destroyed hip joint is resected and replaced with a new bearing surface. Since its introduction into the surgical management of the arthritic hip in the early 1960s, total hip arthroplasty has helped alleviate the suffering of millions of patients throughout the world. Patients with coxarthrosis can now look to total hip arthroplasty as a reliable means of pain relief and improved function. While the operation has been successful over the years, problems have manifested themselves as the length of follow-up has increased. As total hip arthroplasty approaches its fourth decade of use, we outline these problems and the proposed solutions.