Osteonecrosis of the femoral head in the setting of alcohol abuse is a potential important cause of symptomatic hip disease in young patients. All cases of uncemented primary total hip arthroplasty (THA) with a primary operative diagnosis of osteonecrosis of the femoral head secondary to alcohol abuse treated at our institution from January 1990 to February 2002 were identified. Twenty-three patients with 28 hips were identified; all patients had advanced disease (subchondral collapse) that was unresponsive to conservative treatment modalities. Within 5 years of index THA, 2 patients were lost to follow-up, and 2 patients died from causes unrelated to their surgery. The remaining 19 patients underwent 24 THAs. Unilateral THA was performed in 14 patients, and bilateral THA was performed in 5 patients. Seventeen men and 2 women with an average age of 41.8 years (range, 30-59 years) at the time of THA were included in the study. The average duration to clinical follow-up was 7.6 years. There was significant improvement in hip pain and hip function scores. Seven THAs were revised at a mean 6.7 years following index THA. Five- and 10-year implant survivorship free of revision was 96% and 64%, respectively (Kaplan-Meier Survivorship Analysis). The continued use of alcohol was associated with a slightly increased risk of failure (61% implant survivorship at 10 years in those with continued alcohol intake vs 75% 10-year survivorship in those without).