Innovations and future research directions on hip preservation management options for osteonecrosis of the femoral head

Abstract

Osteonecrosis of the femoral head remains a major cause of hip pain and disability in young and middle-aged adults and contributes substantially to total hip arthroplasty utilization in this population. Although hip-preserving strategies have expanded markedly, management remains heterogeneous and a universally accepted, stage-stratified algorithm is lacking. This minireview synthesizes contemporary hip-preservation options and highlights recent innovations and research directions within an Association Research Circulation Osseous-informed (multi-agent reinforcement learning) framework. Nonoperative and pharmacologic adjuncts may be used in pre-collapse disease, primarily for symptom control and as adjuncts to surgical preservation. Core decompression remains the foundational pre-collapse procedure, with technique variants, enabling technologies (robotic or arthroscopic assistance), and biologic augmentation-most commonly bone marrow aspirate concentrate-aimed at improving repair, while outcomes remain influenced by lesion characteristics and variability in biologic processing and delivery. When mechanical failure risk is prominent, structural reconstruction or internal support implants may be considered in selected patients. Overall, advances in biologically augmented decompression, structural support constructs, and emerging translational approaches (including acellular biologics, scaffold strategies, and imaging analytics) underscore a rapidly evolving field. Future progress will depend on multicenter, stage-stratified comparative studies with standardized lesion characterization, reproducible reporting of biologic preparation and dose, and harmonized clinical and imaging endpoints.

Keywords: Hip preservation; Avascular necrosis; Femoral head necrosis; Hip replacement; Hip preservation surgery; Femoral head avascular necrosis; Hip osteoarthritis

Core Tip: The past decade has brought substantial advances in hip preservation for Osteonecrosis of the femoral head, particularly through biologically augmented core decompression and innovative implants. Yet high-quality randomized evidence remains sparse, especially for comparative effectiveness across strategies and for long-term survivorship. There is an urgent need for multicenter, stage-stratified trials with standardized outcome measures to refine algorithms that truly balance joint preservation against timely total hip arthroplasty.