Avascular bone necrosis (AVN) of femoral head in renal allograft recipients receiving corticosteroid therapy is a disabling problem in this unique group of patients. The aim of this prospective study is to optimize a surgical policy for treatment of femoral head osteonecrosis amond kidney transplant recipients. Sixty hips with radiologically proven AVN in 45 recipients were categorized in two groups according to the grade of AVN. Early AVN: presented with hip pain, positive MRI but normal x-ray (group 1; 29 hips in 20 reciepients). Advanced AVN was encountered in 31 hips in 25 recipients (group 2). The mean serum creatinine, the number of acute rejection episodes and the incidence of chronic rejection were significantly higher in Group 2. Recipients of group 1 were managed by core decompression, while recipients of group 2 were subjected to cemented total hip replacement. Complete pain relief was atchieved and follow up MRI scans at 12-18 months postoperative showed regenerated femoral heads in 24 hips (82.7%). In Group 2,total hip arthroplasty relieved pain and improved function in all recipients within an average follow up period of 48 months. Moreover, the intra and postoperative courses were unremarkable in both groups. In conclusion, inspite of the feasibility of orthopaedic management, early detection of AVN by MRI warrant special attention to avoid the potential hazards of total hip replacement in this group of immunocompromized patients.