Management of Ficat stage III and IV osteonecrosis of the hip remains controversial. Because patients usually require a surgical intervention in their mid 30s, the initial procedure is often the first step in a lifelong treatment plan. Long-term results of total hip arthroplasty in these young, active patients have been disappointing. New alternative bearing surfaces (metal-on-metal, ceramic-on-ceramic, and highly cross-linked polyethylene) and improved methods of fixation may lead to better long-term results. Nevertheless, bone- and joint-preserving procedures, such as free-vascularized fibular graft, trapdoor grafting, redirectional osteotomy, or hemiresurfacing hip arthroplasty, should be considered. The choice of option depends on patient age, the cause of osteonecrosis, the extent of femoral head involvement, and the condition of the acetabular articular cartilage. The goals of treatment are to relieve pain, improve function, minimize morbidity, and maintain options for secondary procedures.