Introduction: The purpose of the current study is to present our 12-year experience with the free-vascularized fibular graft (FVFG) technique for osteonecrosis (ON) of the femoral head. Material and Methods: The results of 184 hips in 152 patients followed-up for a minimum period of 3 year and up to 12 years (average 6 years). All patients were evaluated yearly with regard to function as assessed with the Harris Hip Score (HHS), radiographic progression of the disease, and conversion to a total hip replacement (THR). The disease was bilateral in 101 patients (59%) and 34 of them (34%) had bilateral FVFG. Associated etiological factors included use of steroids (85 hips), consumption of alcohol (22 hips), trauma (27 hips), hemoglobinopathies (9 hips), autoimmune diseases (14 hips). Idiopathic osteonecrosis was present in the remaining 45 hips. The stage of ON according to the criteria of Steinberg was: stage II for 47 hips (23%), stage III for 50 hips (25%), stage IV for 83 hips(40%) and stage V for 24 hips (12%). Results: Excluding hips that were eventually treated with THA, the mean HHS had improved for all groups of the hips: from 85 to 96 points for the stage II hip, from 74 to 91 points for the stage III hips, from 69 to 85 points for the stage IV hips and from 61 to 76 points for the stage V hips. The increase was significant for all stages ( from p< 0.05 to p<0.001, paired two-tailed t test). Progressive collapse of the femoral head, acetabular changes, or loss of the joint space was noted in 5% of stage II hips, in 36% of stage III hips, in 48% in stage IV hips and in 61% of stage V hips. In this series 14 hips (8%) were eventually treated with THA: none that had been in stage II (0%), 1 of 45 that had been in stage III (2%), 9 of 77 that had been in stage IV (12%) and 4 of 23 that had been in stage V (17%). One case of septic arthritis and 2 cases of deep wound infections, all led to THA. Discussion. It is generally agreed now that ON of the hip can be arrested in most patients if the procedure performed prior to development of a subchondral fracture (stage I and II). In stage III fibular grafts may arrest or delay the progression of the disease. Even in those patients with more advanced ON, including those patients with collapse of the articular surface FVFG may be of benefit by prolonged reduction of symptoms and postponement of THR. Conclusions: The FVFG is the author’s favored technique in the management of ON of the femoral head. This technique importantly do not violate the joint capsule as the other bone grafting procedures (pedicled iliac crest, quadratus femoris graft), and in comparison with conventional grafts support the subchondral surface with a viable cortical strut (bone healing process) and enhance the revascularization process.