[Objective] This study aimed to evaluate the effect of femoral head and neck fenestration combined with autograft (light-bulb procedure) through a direct anterior approach (DAA) for early stage nontraumatic osteonecrosis of the femoral head (ONFH). [Methods] A retrospective cohort study was conducted on 54 hips undergoing the light-bulb procedure through the DAA (DAA group) and 62 hips undergoing traditional Watson-Jones approach (traditional group) from June 2014 to June 2018. Follow-up was conducted at 3 months, 6 months, 9 months, and semi-annually after suegery until 2 years. Visual analogue scale (VAS) pain scores was evaluated before discharge to assess the quality of functional recovery. The clinical effectiveness was evaluated by Harris hip scores (HHS) and range of motion (ROM). Patients were followed up with postoperative X-ray. Survival was compared between the 2 groups by radiographic progression and receiving total hip arthroplasty. [Results] All the patients had operation performed smoothly without serious complications. There were no statistical differences between the two groups in operation time, HHS 1 year after surgery, ROM, and survival rate based on postoperative imaging. Patients in DAA group had significantly better HHS within 9 months after surgery, and less bleeding and pain. [Conclusion] The light-bulb procedure through a DAA offers significantly better results for the treatment of early stage nontraumatic ONFH compared with traditional Watson-Jones approach.