Osteonecrosis of the femoral head accounts for as many as 18% of total hip arthroplasties performed in western countries. The young age of affected patients and the potentially poor outcome have sparked an interest in alternative treatment modalities. Extracapsular placement of a vascularized fibular graft in the subchondral region of the femoral head has shown great promise as a treatment option. The authors have used this procedure in the treatment of 646 symptomatic hips, of all grades of osteonecrosis, with a follow-up of 1 to 17 years. The resultant 10-year survival rate of greater than 80% suggests that this procedure may be preferable to total hip arthroplasty for the young patient with osteonecrosis of the femoral head.