Osteonecrosis of the femoral head is a debilitating disease that primarily affects the young adult. As total hip arthroplasty is undesirable in this population, many alternatives to femoral head salvage have been reported; unfortunately, these options have stimulated much controversy and results have been less than ideal. Free vascularized fibular grafting to the femoral head, however, has shown some success, with a survival of greater than 10 years in more than 80% of cases, particularly in hips without subchondral collapse. This procedure may also benefit young patients with more advanced osteonecrosis of the femoral head by halting progression of collapse, prolonging reduction of symptoms, and postponing total hip replacement. The authors' experience with free vascularized fibular grafting for the management of femoral head osteonecrosis is shared in detail, with an overview of indications, preoperative evaluation, surgical techniques, and postoperative care.