A preoperative discussion was held with the patient to review the various treatment options. The two most commonly proposed options included nonoperative management vs. total hip arthroplasty. However, the patient had significant pain and wanted to return to running. For this reason, she did not feel that either option would allow her to return to her previous activity level. Because of the relatively small area of segmental collapse and relatively preserved acetabular cartilage, the decision was made to go ahead with joint preservation. The proposed procedure included a surgical hip dislocation; the approach would allow complete visualization of the femoral head and acetabulum and would give ample exposure to proceed with head-preserving procedures or THA if needed. We discussed osteochondral autograft transplantation of a non-weight-bearing portion of her femoral head to the area of AVN on her femoral head if the cartilage was found to be in poor condition vs. bone grafting and elevation of the necrotic segment if the cartilage was acceptable. A lateral skin incision was made centered over the greater trochanter on the patient’s right hip. The fascia was split in line with the skin incision over the greater trochanter. A trochanteric flip osteotomy was performed from 5 mm anterior to the trochanteric overhang and directed distally and anteriorly exiting distal to the vastus ridge. A distal subvastus approach to the femur was carried out. The greater trochanteric piece was flipped anteriorly. Care was taken to break the anterior aspect of the fragment for later repositioning. The interval between the piriformis and gluteus minimus was dissected. A complete capsular exposure was performed. The entire anterior, superior, and posterior capsule was easily visualized utilizing this approach. A capsulotomy was carried out in a Z-shaped fashion. Care was taken not to injure the labrum proximally and at the level of the rim. Anterior and superior limbs of the capsule were then made. Distally we carried our capsulotomy to the level of the neck. The hip was dislocated with external rotation, and the foot was placed in an anterior position. She had damage to the anterosuperior acetabular cartilage. This entailed a delaminated area that measured approximately 1.5 cm × 4 mm in depth. The cartilage was of poor quality in this area. The acetabular cartilage damage was debrided and then the subchondral bone underwent microfracture. Attention was then turned to the femur. The patient had a large osteonecrotic lesion, which was adjacent to the fovea (Photos 1, 2, and 3). This measured at least 40 mm in diameter. The area of collapse was in the weight-bearing area of the femoral head. Three plugs of necrotic femoral head were removed from the area, each measuring 10 to 15 mm in depth (Photos 4 and 5). These three areas were then burred to a bleeding bony bed. Femoral bone cancellous autograft was harvested from the trochanteric bed where the trochanteric flip was performed and then placed into the depth of the osteochondral defect. Three osteochondral plugs were harvested from the lateral and anteromedial non-weight-bearing aspects of the femoral head. These measured, on average, between 6 and 11 mm in depth. These were then contoured to reconstruct the femoral head into the previous area of osteonecrosis. The osteochondral autograft appeared to sit flush in their receptor sites and were confirmed to have recontoured the head appropriately with an offset template (Photos 6 and 7). Bone marrow concentrate was injected under pressure into the femoral head through the fovea. Bone graft was then placed into the donor site, and it was felt that the femoral neck did not need screw fixation given the minimal bone graft taken. The hip was reduced and carried through a range of motion. The labrum appeared to be well reduced and stable to the rim where it was present. Intraoperative X-rays were obtained to evaluate the femoral head and placement of the trochanteric screws (intraoperative X-rays). Irrigation of the joint was carried out. The capsule was then closed with No. 1 Vicryl. The trochanteric flip osteotomy was reduced and fixed with three screws. The trochanteric bursa was closed over the screws. The fascia was closed with 0 Vicryl and 2-0 Monocryl in the subcutaneous tissue, and a 3-0 Monocryl was used to close the skin. The patient tolerated the procedure well and was transferred to the postoperative care unit in stable condition Figs. 14.1, 14.2, 14.3, 14.4, and 14.5.