A 55-year-old male presented to us with history of pain right hip and limp for the past 12 years, with inability to walk for the past 10 days following a low energy trauma.
 The patient had past history of road traffic accident 15 years ago when he sustained injury to his right hemipelvis and was treated with upper tibial pin traction for 6 weeks. He was ambulant and pain free later. Past medical records were not available.
 He developed dull ache in his right hip and limp 3 years later. Pain was deep seated, aggravated on activities, and partially relieved with analgesics. The patient was able to walk unaided and perform activities of daily living and squat in Indian toilet.
 He sustained a low energy trauma while riding bicycle 10 days back, falling on his right hip. He experienced sharp pain with inability to weight bear on his right leg with restriction of right hip movements.
 The patient is a chronic alcoholic, taking about 300 mL/week over the past 30 years. CAGE questionnaire revealed 3 positive responses out of 4, indicating significant alcohol dependence. He is a nonsmoker. He has no history of hypertension, diabetes, tuberculosis, asthma, or chronic drug intake.
 Examination revealed a moderately built patient with stable vital parameters. Right side ASIS was elevated. Anterior joint tenderness and crepitus were present in right hip. He had fixed flexion deformity of 20 degrees, and all other movements of right hip were painful and restricted. 1 cm of supratrochanteric shortening was present.
 Investigations revealed normal blood parameters. 
 Plain X-ray pelvis with both hips revealed old vertical shear injury to right sacroiliac joint evidenced by cephalic migration of right hemipelvis; this is the result of previous trauma. The right hip showed superior articular surface irregularity with collapse of right femoral head. Fracture head of femur was found extending from superior to inferior articular surface (Figure 1). The left hip was found to be normal.
 CT pelvis with both hips with 3D reconstruction confirmed the fracture line in head of femur (Figure 2).
 A diagnosis of fracture head of femur right hip with underlying osteonecrosis was made based on history and imaging findings. Uncemented total hip replacement was planned due to gross destruction of femur head and acetabular degenerative changes. Intraoperatively, a deformed and fractured femoral head was found and was delivered out of acetabulum and sent for histopathological examination (Figure 3). Reconstruction was done with 52 mm Duraloc shell, polyethylene liner, and 11 size CORAIL femur stem (DePuy Johnson and Johnson) (Figure 4).
Histopathology of resected specimen revealed necrotic bone with reparative fibroblastic proliferation:consistent with osteonecrosis (Figure 5).