The technique and outcome of surgery for the manifestations of secondary hyperparathyroidism are described. Forty-seven patients were analysed retrospectively over a 10-year period. Total parathyroidectomy and autotransplantation to the forearm was performed in all but five patients. Improvement occurred in 87 per cent of patients and there were no graft failures. Of six deaths, none was related to surgery. Four patients had recurrent hyperparathyroidism, three being graft dependent and one requiring re-exploration of the neck. Total parathyroidectomy and autotransplantation is a safe and effective approach. The major management problem was graft hyperplasia, seen in three of the 47 patients and managed by simple excision.