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Perforation of the femoral shaft by the prosthetic stem as a complication of total hip replacement is not well described in the literature. We studied twelve patients with this complication in order to define the predisposing factors, optimum management, and long-term outcome. Each patient was found to have one or more of the following factors: female sex, osteoporosis, previous fracture, or previous surgery. Once the complication was recognized, management consisted of protected weight-bearing for six weeks. All but two of the patients were asymptomatic after an average follow-up of five years. Judging from the long-term roetgenographic follow-up, penetration of the femoral shaft does not appear to seriously compromise the fixation of the femoral component.