We reviewed thirty-eight cases, in thirty-six patients, of fracture of the femur distal to the base of the neck incurred in conjunction with total hip replacement. There were thirteen preoperative, eighteen intraoperative, and seven postoperative fractures. The cases were contributed by thirteen surgeons. We found that the preoperative fractures with pre-existing disease in the hip joint were effectively treated by primary total hip replacement using custom-made femoral components with long necks or long stems, or both. The intraoperative femoral fractures usually occurred while the surgeon was reaming the canal, seating the femoral component, or manipulating the femur in patients who were predisposed to fracture. Theoretically these lesions can be treated like preoperative fractures, but this demands immediate access to custom-made femoral components with long necks or long stems, or both, along with an appreciation of the extent and significance of the fracture. Inadequate fixation was found to lead to painful non-union or late loosening of the femoral component in four of eighteen patients. Postoperative fractures occurred too rarely for us to draw any definite conclusions about management, except to say that surgical treatment can be hazardous and traction has been successful in this series and in other reports. Prophylactic measures, however, may help to prevent postoperative femoral fractures. Most of these fractures occur through a cortical defect near the tip of the femoral component. A long-stem femoral component may help to prevent postoperative fractures whenever a proximal cortical defect of the femur is present preoperatively or is created at surgery.