Treatment of mid- to late-stage ischemic necrosis of the femoral head is difficult, and without surgical intervention most patients’ disease will progress and joint replacement is often unavoidable. Many patients have to undergo joint revision surgery once or even several times in their lifetime, and there are still many problems with joint revision surgery, from the difficulty of surgery, intraoperative trauma to long-term results. Therefore, for this group of patients, a surgical method that preserves the femoral head is the ideal choice. The traditional vascularized bone flap transfer repair surgery is often more traumatic, and in response to this problem, we selectively perform minimally invasive bone flap transfer with a vascularized tip in some cases with satisfactory follow-up results. The vascularized bone flap or periosteal flap transfer is more popular because it does not require microscopic anastomosis, and the transplanted bone flap has an independent arteriovenous system, which can establish a connection with the blood flow around the lesion and re-establish the blood supply in the femoral head. The advantages of minimally invasive bone flap transfer with a vascularized tip are minimal interference with the periprosthetic tissues, access in the muscle space, no damage to hip flexion and abduction, minimal postoperative pain, aesthetic incision, rapid recovery, and no significant difference in operative time and intraoperative blood loss compared to traditional bone flap transfer. Even if it fails, it will not have any adverse effect on total hip replacement. Considering that young and middle-aged patients will surely face the huge psychological pressure and economic burden of revision surgery after artificial joint replacement, therefore, repairing and reconstructing the femoral head is still a treatment option with a retreat. However, it is worth noting that this procedure requires the surgeon to be familiar with the periprosthetic anatomy and to select the appropriate bone flap with vascular tip according to the vascular condition during surgery. Good exposure is a prerequisite for successful surgery, minimizing the length of the incision and the invasion of the periprosthetic tissue. However, small incisions should not be blindly pursued to increase excessive strain on the skin and soft tissues. The surgery should be familiar with the anatomy of the lateral vessels of the hip and rotator femur, and preoperative angiography can be routinely performed to determine the location of the vessels when available. Preoperative selection of the better vascular condition as the vascular tip will greatly improve the success rate of the surgery and reduce the operative time and intraoperative bleeding. This method is mainly suitable for young and middle-aged patients with Ficat stage II and III. After early and mid-term clinical follow-up, the clinical success rate is relatively low for Ficat stage IV cases with osteoarthritic manifestations. It should be used with caution in elderly patients over 60 years of age because of their poor osteogenic ability and the presence of endovascular lesions, so the failure rate of surgery is higher. When freeing the ascending gluteus medius branch vessels during surgery, avoid damaging the superior gluteal nerve to avoid postoperative gluteus medius paralysis; keep the integrity of the gluteus medius stop as much as possible when cutting the bone flap, and limit the cut muscle to a small portion of the anterolateral inferior gluteus medius. Care should be taken to avoid torsion and spasm of the vascular tissues, and postoperative treatment measures should be routinely taken to ensure the patency of the vascular tissues.