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A 72-year-old woman with bilateral hip dysplasia sustained atypical femoral fracture of the left subtrochanteric region. She underwent left total hip replacement with a long extensively porous coated femoral stem. The fracture healed with incorporation of the strut allograft after 8 months. A painful horizontal radiolucent line at the tip of the femoral stem was noted after 4 years, with resolution of symptoms after a period of protected weight bearing. We believe that total hip replacement for subtrochanteric atypical femoral fracture with pre-existing hip dysplasia is a feasible option and avoids a second operation for the treatment of osteoarthritis.