Tibial strut bone grafting and more recently fibular strut grating (vascularized) have been used in the treatment of aseptic necrosis of the femoral head. The authors evaluated the technical aspects and results of uncemented total hip arthroplasty after previous tibial bone grafting of the femoral head in patients with aseptic necrosis. Review of postoperative radiographs demonstrated that residual tibial graft prevented optimal femoral canal fit and positioning of the prosthetic stem in 10 of 13 hips (in the coronal plane). In the nine hips with a minimum 2-year follow-up period, two required revision for loosening of the femoral component. The authors recommend that, when performing an uncemented total hip arthroplasty in patients with previous strut grafting, special attention be directed to adequate graft removal, particularly in the lateral greater trochanteric fossa to prevent varus placement of the femoral component. An intraoperative anteroposterior radiograph with the final femoral broach in place may be useful in verifying adequate strut graft removal and optimal canal fill with proper prosthesis positioning.