The results of 278 consecutive primary total hip arthroplasties performed with bone grafting for ace-tabular bone deficiencies were reviewed at an average of 9.0 years (range, 5–23) after surgery. All patients had underlying developmental dysplasia of the hip. For all hips, the grafts used were from the patients’ own resected femoral heads. All but three grafts were screwed to the supero-lateral aspect of the acetabular roof, the exceptions being grafts without internal fixation. Kaplan-Meier survivorship analysis predicted a rate of survival of the acetabular component at 10 years of 97% (95% confidence interval (CI), 94–100%) with revision for aseptic loosening as the endpoint, and of 82% (95% CI, 76–89%), when radiological loosening was used. Trabecular reorientation, as an indicator of graft incorporation, was seen in 89% of the joints between 1.5 and 5 years (mean 3 years), and delayed up to 7 years. Parametric survivorship analysis using the Cox proportional-hazards model indicated that trochanteric non-union, lateral placement of the socket, and delayed trabecular re-orientation of the bone graft, were risk factors for loosening of the acetabular component. Autogenous acetabular bone grafting will be of value for long-term success and has good potential for additional improvement of the results, provided these three risk factors are reduced. In order to promote the trabecular reorientation, we have gradually improved the surgical technique including sizing of bone graft and adaptation technique. By these alterations of the surgical technique, trabecular reorientation of the 51 joints operated after 1993 was completed by 4 years after surgery.