After disastrous outcomes due to wear-induced osteolysis in the 1980s, hip resurfacing arthroplasty has undergone a renaissance, mainly because of the introduction of metal-on-metal bearings. However, there are still problems associated with this technique, such as femoral neck fractures, neck thinning, and aseptic loosening, and their causes are still being investigated. During the last years, increasing evidence has shown that both the frequently used posterior approach to the hip as well as preparation of the femoral epiphysis can impair blood supply to the femoral head. In the presence of mechanical stresses (impaction, heat development during cement polymerization) during the implantation, the epiphysis might not be able to compensate for this. This paper summarizes the current understanding of the blood supply to the femoral head and proposes a way to preserve the viability after hip resurfacing.