Transtrochanteric rotational osteotomy (TRO) is one of the joint-preserving surgical treatments for osteonecrosis of the femoral head (ONFH). It can prevent collapse of the femoral head as necrotic lesions in the weight-bearing portion can be moved sufficiently to less weight-bearing portion by anterior rotation, posterior rotation or varus angulation. Patient selection and preoperative planning are important to determine indications for TRO. It has been reported that successful TRO requires at least 34% of the weight-bearing area supported by the intact part of the femoral head. However, this ratio is difficult to preoperatively quantify according to the rotation angle using conventional two-dimensional MR images or X-rays. Therefore, we developed a method of simulating TRO using three-dimensional (3-D) models reconstructed from 3-D MR images and applied it to serial patients with types C1 and C2 osteonecrosis at stage 1 or 2. The simulation visualized positional changes of the necrotic lesion in the weight-bearing area and enabled quantitation of the postoperative intact ratio. Our surgical simulation is useful for evaluating the postoperative intact ratio and for determining indications for TRO as well as the optimal angle of femoral head rotation and varus angulation.