Osteonecrosis of the Femoral Head: Evolution of Contemporary Management Strategies

Osteonecrosis of the femoral head (ONFH) is a progressive condition disproportionately affecting young adults and is a leading indication for total hip arthroplasty in young adults. This review aims to provide a contemporary overview of ONFH with emphasis on treatment strategies aimed to prevent femoral head collapse and disease progression as supported by recent clinical research from the past five years.

The 2019 revised ARCO classification has emerged as the most clinically applicable staging system, guiding treatment selection based on lesion size, location, and collapse status. Core decompression remains the surgical mainstay for pre-collapse disease. Recent evidence supports the addition of hip arthroscopy to improve clinical outcomes and increase native hip survival rates. Augmentation strategies including bone marrow aspirate concentrate (BMAC), mesenchymal stem cells (MSCs), bone grafting, and hip arthroscopy have demonstrated the most promising results when combined with core decompression in early-stage disease. Pharmacologic agents, including bisphosphonates and denosumab, have shown meaningful benefit in slowing disease progression but remain adjunctive. Total hip arthroplasty continues to demonstrate excellent long-term outcomes for post-collapse stages, even in younger patient populations. Management to prevent collapse and disease progression of ONFH remains a challenge. Joint preservation through early surgical intervention with augmentation strategies, such as addition of hip arthroscopy, bone grafting, and biologic regenerative biologic therapies represent promising advancements in ONFH management. However, the existing literature remains limited by heterogeneous study designs, small sample sizes, and inconsistent outcome reporting.