In percutaneous pedicle screw (PPS) fixation of the osteoporotic spine, rigid screw fixation obtaining strong stabilization is important for achieving successful treatment outcomes. However, in patients with severe osteoporosis, it is difficult to obtain PPS fixation with sufficient stability. PPS fixation has potential disadvantages with respect to maintaining secure stabilization in comparison to conventional pedicle screw fixation. In PPS fixation, bone grafting to achieve posterior spine fusion is generally not applicable and transverse connectors between the rods cannot be used to reinforce the fixation. Various augmentation methods, including additional hooks, sublaminar bands, and hydroxyapatite (HA) sticks, are available for conventional pedicle screw fixation. On the other hand, there has been no established augmentation method for PPS fixation. Recently, we developed a novel augmentation technique for PPS fixation using HA granules. This technique allows the percutaneous insertion of HA granules into the screw hole along the guidewire prior to insertion of the PPS. We have used this augmentation technique for PPS fixation in various spine surgeries in patients with osteoporosis. In our previous studies, biomechanical analyses demonstrated that PPS fixation was significantly enhanced by augmentation with HA granules in the osteoporotic lumbar spine. Furthermore, augmentation with HA granules was considered to decrease the incidence of screw loosening and implant failure following PPS fixation in patients with osteoporotic spine. In this article, we describe the surgical procedures of the augmentation method using HA granules and summarize our data from the biomechanical analysis of augmentation for PPS fixation. We also review the surgical outcomes of PPS fixation with augmentation using HA granules.