Cementless femoral fixation by means of bone ingrowth has been successful in total hip arthroplasty in patients with sufficient bone quality. Consistent bone ingrowth and resultant long-term success involve many factors, including surgical technique, initial mechanical stability achieved at time of implantation, stem design and material, and implant surface. One potential method for achieving faster, more consistent initial bone ingrowth is use of the osteoconductive ceramic hydroxyapatite. In addition, more stable initial fixation most likely improves long-term outcome. In this article, we review the criteria for successful cementless femoral fixation and the long-term results reported in the literature.