Osteonecrosis

1. Disease Information

1.1 Concise overview and definitions

Osteonecrosis is bone and marrow cell death due to temporary or permanent disruption of blood supply; in ONFH this ischemic necrosis leads to trabecular fracture, femoral head collapse, pain, and progressive hip dysfunction/disability. (zhang2024advancesinthe pages 1-2, moyaangeler2015currentconceptson pages 1-2)

Recent authoritative definitions emphasize vascular compromise and subsequent structural collapse: ONFH is described as “a necrotic bone lesion in the femoral head… caused by a disruption in the blood supply.” (ko2023updatingosteonecrosisof pages 1-2)

1.2 Key identifiers (ontology/coding)

• ICD-10/ICD-11, MeSH, MONDO, Orphanet, OMIM: not explicitly retrievable from the full texts available in this run. The administrative-database ONFH trends paper indicates identification via ICD-9/10 coding but does not list the codes in the excerpted text. (ng2023increasingtrendtoward pages 1-2)

1.3 Synonyms and alternative names

Common synonyms used in the retrieved corpus include: * Avascular necrosis (AVN) and ischemic necrosis/aseptic necrosis (xiang2024advancesinmechanism pages 1-2, rohilla2025adescriptivestudy pages 1-2) * Femur head necrosis / femoral head necrosis (keyword synonym) (ko2023updatingosteonecrosisof pages 1-2) * “Nontraumatic avascular necrosis of the femoral head” (reference terminology) (ko2023updatingosteonecrosisof pages 6-8)

1.4 Evidence source type (patient-level vs aggregated)

Evidence used here spans: * Aggregated reviews, systematic reviews, meta-analyses, and consensus/Delphi statements (zhang2024advancesinthe pages 1-2, li2024pathologicalmechanismsand pages 1-2, yoon2019etiologicclassificationcriteria pages 5-8) * Administrative/nationwide databases (procedure trends and proportions) (ng2023increasingtrendtoward pages 1-2) * Prospective/retrospective clinical cohorts and trials (cell therapy, decompression) (houdek2021hipdecompressioncombined pages 1-2, blanco2023longtermresultsof pages 8-10) * Animal model mechanistic work (glucocorticoid-induced ONFH mouse model) (shao2024inhibitionofsympathetic pages 1-2)

2. Etiology

2.1 Primary causal factors

ONFH is typically classified as traumatic (vascular disruption after fracture/dislocation) or non-traumatic (commonly glucocorticoids and alcohol). (gu2024globalincidenceof pages 1-2, ko2023updatingosteonecrosisof pages 1-2)

Key non-traumatic contributors highlighted across 2024 reviews include glucocorticoids, alcohol, lipid dysregulation, microvascular/endothelial injury, and coagulation abnormalities. (zhang2024advancesinthe pages 1-2, li2024pathologicalmechanismsand pages 1-2, shao2024unravelingtherole pages 1-2)

2.2 Risk factors (quantitative where available)

Glucocorticoid exposure (major risk factor; ARCO etiologic research classification): * ARCO consensus criteria for glucocorticoid-associated ONFH: >2 g prednisolone-equivalent within 3 months, diagnosis within 2 years, and absence of other major risk factor(s). (yoon2019etiologicclassificationcriteria pages 5-8, yoon2019etiologicclassificationcriteria pages 1-5) * Dose-response summarized by ARCO: +4.6% ONFH rate per additional 10 mg/day and daily dose >40 mg (OR 4.2) in cited studies; early post-transplant data show ONFH incidence increasing from 6% (≤520 mg) to 28% (>600 mg) in the first 2 weeks. (yoon2019etiologicclassificationcriteria pages 5-8)

Alcohol exposure: * Ko 2023 summarizes ARCO alcohol-associated criteria as >320 g/week alcohol (reported as >400 mL/week), diagnosis within 1 year, and no other major risk factor. (ko2023updatingosteonecrosisof pages 1-2)

Trauma: * In adolescents after femoral neck fracture surgery, a 2024 meta-analysis estimated ONFH incidence 24.02% (95% CI 21.18–27.12%). (gu2024globalincidenceof pages 1-2)

Other risk factors repeatedly cited (without thresholds in retrieved text): hypercholesterolemia and smoking, among others. (shao2024unravelingtherole pages 1-2)

2.3 Protective factors (recent genetic causal inference)

A 2024 Mendelian randomization study found higher genetically predicted BMD was protective for ONFH at several sites: * Lumbar spine BMD OR 0.662 (95% CI 0.48–0.91) (jia2024bonebiochemicalmarkers pages 1-2) * Heel BMD OR 0.726 (95% CI 0.62–0.85) (jia2024bonebiochemicalmarkers pages 1-2) * Total body BMD OR 0.726 (95% CI 0.62–0.85) (jia2024bonebiochemicalmarkers pages 1-2)

The same study did not support genetically mediated causal effects for serum 25OHD, calcium, or alkaline phosphatase on ONFH risk. (jia2024bonebiochemicalmarkers pages 1-2)

2.4 Gene–environment interactions

A 2024 Wnt/β-catenin pathway variant-interaction study (Chinese Han case-control) links genetic variation to clinical phenotypes and systemic metabolic/coagulation changes, consistent with gene–environment coupling (e.g., steroid exposure and lipid/platelet phenotypes). (shi202417variantsinteraction pages 1-2, shi202417variantsinteraction pages 9-11)

Table: This table summarizes major etiologies, risk factors, and protective factors for osteonecrosis of the femoral head, emphasizing quantitative thresholds and effect sizes where available. It is useful for comparing consensus definitions, epidemiologic risks, and recent genetic/MR findings in one place.

3. Phenotypes

3.1 Core clinical phenotypes

Commonly reported ONFH phenotypes include: * Hip pain: in an MRI-based clinical cohort, hip pain was present in 86% (43/50). (rohilla2025adescriptivestudy pages 1-2) * Functional limitation/joint dysfunction: ONFH is described as causing joint dysfunction and disability, often culminating in collapse and loss of hip function. (zhang2024advancesinthe pages 1-2)

3.2 Onset and progression

ONFH often affects young to middle-aged adults (commonly cited 20–40 years), but cohorts may center around early 40s depending on setting. (moyaangeler2015currentconceptson pages 1-2, rohilla2025adescriptivestudy pages 1-2)

3.3 Bilaterality

In a 50-patient MRI cohort (80 hips), 60% had bilateral involvement. (rohilla2025adescriptivestudy pages 1-2)

3.4 Quality of life / functional scoring instruments used

The retrieved evidence shows frequent use of: * Harris Hip Score (HHS) and VAS pain in clinical trials and cohorts (he2021thetherapeuticeffect pages 1-2, houdek2021hipdecompressioncombined pages 1-2) * WOMAC and SF-36 are used in multiple clinical trials/registries and prospective studies, including cell therapy trials. (NCT01605383 chunk 1, NCT04233125 chunk 1)

3.5 Suggested HPO terms (mapping; evidence-backed phenotypes)

• Hip pain — HP:0030834 (hip pain)
• Abnormal gait — HP:0001288 (for advanced collapse-related dysfunction; commonly implied in ONFH disability)
• Osteonecrosis — HP:0010885 (osteonecrosis)
• Avascular necrosis of femoral head — often represented via osteonecrosis + anatomic localization (no explicit HPO ID in retrieved texts)

Frequency data beyond hip pain and bilaterality were not available in the retrieved text.

4. Genetic/Molecular Information

4.1 Genetic susceptibility signals (not monogenic “causal genes”)

ONFH in the retrieved corpus is largely treated as a complex disease with susceptibility loci and pathway-level genetic architecture.

Wnt/β-catenin pathway variants (2024): * Single-variant associations: GSK3β rs334558, SFRP4 rs1052981, LRP5 rs312778 (p-values reported, no ORs in excerpt). (shi202417variantsinteraction pages 1-2) * Variant interactions associated with risk, bilaterality, and stage IV risk; also associated with lipid and platelet indices, consistent with lipid/coagulation mechanisms. (shi202417variantsinteraction pages 9-11)

Immune/inflammatory genetic causal inference (2024 Mendelian randomization): * bFGF OR 1.942, IL-2 OR 0.688, IL2-RA OR 1.386 for osteonecrosis risk in a GWAS-derived MR analysis; SCF OR 3.356 for drug-related osteonecrosis in the same study. (xiang2024advancesinmechanism pages 18-18)

4.2 Molecular mechanisms and pathways (recent emphasis)

A 2024 SONFH review summarizes key pathological mechanisms: decreased osteogenesis, lipid accumulation/lipotoxicity, increased intraosseous pressure, and microcirculation disruption. (li2024pathologicalmechanismsand pages 1-2)

A 2024 steroid-associated pathogenesis review emphasizes microcirculation dysfunction and endothelial damage with downstream hypoxia and impaired bone maintenance. (zhang2024advancesinthe pages 1-2)

Endoplasmic reticulum stress and inflammation (2024): an ER-stress gene-signature study identified 195 ERS-related genes; proposed hub genes include CXCL8, STAT3, IL1B, TLR4, PTGS2, TLR2, CASP1, CYBB, CAT, HOMX1; qRT-PCR validated upregulation of STAT3, IL1B, TLR2, CASP1. (wu2024identificationandvalidation pages 1-2)

4.3 Epigenetics

A 2024 SONFH review highlights epigenetic/post-transcriptional regulation, including histone acetylation modulation affecting PPARγ-driven adipogenesis and miRNA-mediated BMSC differentiation (e.g., miR-27a). (li2024pathologicalmechanismsand pages 8-9)

4.4 Suggested GO terms (biological processes; mechanism-aligned)

• Angiogenesis — GO:0001525
• Bone remodeling — GO:0046849
• Osteoblast differentiation — GO:0001649
• Endothelial cell apoptotic process — GO:0072570
• Response to endoplasmic reticulum stress — GO:0034976
• Lipid metabolic process — GO:0006629
• Regulation of blood coagulation — GO:0030193

4.5 Suggested CL terms (cell types; mechanism-aligned)

• Endothelial cell — CL:0000115 (central in microvascular injury/endothelial dysfunction) (shao2024unravelingtherole pages 1-2)
• Osteoblast — CL:0000062
• Osteoclast — CL:0000092
• Mesenchymal stem/stromal cell — CL:0000134 (therapeutic target/deficit in some cell-therapy frameworks) (NCT01605383 chunk 1)

5. Environmental Information

5.1 Environmental and lifestyle factors

• Alcohol intake is a major non-traumatic etiologic exposure in Asia and globally. (pang2025thebibliometricand pages 1-2, ko2023updatingosteonecrosisof pages 1-2)
• Smoking and hypercholesterolemia are cited as contributing risk factors in a 2024 endothelial dysfunction review. (shao2024unravelingtherole pages 1-2)

5.2 Infectious agents

No pathogen is identified as a causal infectious agent for ONFH in the retrieved text. A single cohort reported prior COVID-19 in 34% of cases, but this is observational and not causal evidence. (rohilla2025adescriptivestudy pages 1-2)

5.3 Gut microbiome/metabolomics (recent development)

A 2024 study compared steroid- vs alcohol-induced nontraumatic ONFH and reported distinct gut microbiota and fecal metabolite profiles, suggesting exposure-specific host–microbiome metabolic signatures. (xiang2024advancesinmechanism pages 1-2)

6. Mechanism / Pathophysiology

6.1 Causal chain (integrated model)

A contemporary consensus model across 2024 reviews is: 1) Trigger/exposure (glucocorticoids, alcohol, trauma) (zhang2024advancesinthe pages 1-2, gu2024globalincidenceof pages 1-2) 2) Microvascular/endothelial injury and/or coagulopathy, impaired vasodilation, hypofibrinolysis → reduced perfusion (shao2024unravelingtherole pages 1-2, ma2024researchprogressin pages 1-2) 3) Hypoxia/nutrient deficiency in subchondral bone and marrow → osteocyte/osteoblast death and impaired repair (zhang2024advancesinthe pages 1-2, li2024pathologicalmechanismsand pages 1-2) 4) Structural weakening with subchondral fracture and progressive collapse (ko2023updatingosteonecrosisof pages 2-4)

6.2 Endothelial dysfunction as a central driver

A 2024 review frames endothelial dysfunction as a “major cause” of ONFH: inflammatory milieu and endothelial dysfunction lead to thrombosis/coagulopathy and poor angiogenesis, preventing effective repair and revascularization. (shao2024unravelingtherole pages 1-2)

6.3 Microvessels and angiogenesis–osteogenesis coupling

A 2024 systematic review emphasizes microvascular injury and the role of “H-type vessels” in angiogenesis–osteogenesis coupling; glucocorticoids may reduce H-type vessel formation by reducing HIF-1α, PDGF-BB, and VEGF, disrupting repair. (ma2024researchprogressin pages 1-2)

6.4 New mechanistic development (2024): neurovascular axis in glucocorticoid-induced ONFH

A 2024 Bone Research mechanistic study (mouse model) proposes a hypothalamus–sympathetic–endothelium axis: glucocorticoids disrupt GR/MR balance in hypothalamic PVN neurons, reducing sympathetic outflow; inhibited sympathetic tone provokes endothelial apoptosis and loss of H-type vessels in femoral heads. Restoration via PVN GR inhibition (RU486) or ADRB2 activation protects, while Adrb2 knockout or sympathectomy abolishes protection; downstream NE–ADRB2–cAMP/CREB signaling upregulates endothelial PFKFB3 to support glycolysis and angiogenesis coupling. (shao2024inhibitionofsympathetic pages 1-2, shao2024inhibitionofsympathetic pages 2-3)

7. Anatomical Structures Affected

7.1 Organ/tissue localization

Primary site in this report: femoral head of the hip joint (subchondral bone and marrow). (ko2023updatingosteonecrosisof pages 1-2, moyaangeler2015currentconceptson pages 1-2)

Suggested anatomy ontology mapping (UBERON): * Femoral head — UBERON:0002428 * Hip joint — UBERON:0001463 * Subchondral bone — (commonly used anatomic term; specific UBERON ID not retrieved)

7.2 Laterality patterns

Bilateral disease is common; 60% bilaterality was reported in one MRI cohort. (rohilla2025adescriptivestudy pages 1-2)

8. Temporal Development

8.1 Staging (2019 revised ARCO)

Ko 2023 summarizes the revised 2019 ARCO staging system: * Stage I: X-ray normal; MRI shows low-signal band on T1-weighted images * Stage II: X-ray and MRI abnormal * Stage III: subdivided into IIIA ≤2 mm depression and IIIB >2 mm depression; may show subchondral fracture on X-ray/CT * Stage IV: osteoarthritis on X-ray (ko2023updatingosteonecrosisof pages 2-4)

Image evidence for the ARCO 2019 staging system table/figure is available from Ko 2023. (ko2023updatingosteonecrosisof media 0e890259, ko2023updatingosteonecrosisof media 85ac9cbb)

8.2 Natural history

Multiple sources emphasize high progression rates without effective early intervention. A 2024 pathogenesis review states femoral head collapse may exceed 80% within 2 years without early intervention. (zhang2024advancesinthe pages 1-2)

9. Inheritance and Population

9.1 Epidemiology and burden (selected quantitative evidence)

Recent reviews and analyses provide approximate burden estimates: * United States: prevalence ~300,000–600,000 and 10,000–20,000 new cases/year (review estimate) (li2024pathologicalmechanismsand pages 1-2) * United States: commonly cited 20,000–30,000 new cases/year (widely cited benchmark) (moyaangeler2015currentconceptson pages 1-2) * Japan: incidence 1.91/100,000; 2,500–3,300 new cases/year (li2024pathologicalmechanismsand pages 1-2) * China: >8 million affected; 50,000–100,000 new cases/year estimate (li2024pathologicalmechanismsand pages 1-2, yang2024adelphibasedmodel pages 1-2)

Table: This table summarizes quantitative epidemiology, natural history, and exposure-threshold statistics for osteonecrosis/osteonecrosis of the femoral head from the gathered evidence. It is useful for quickly comparing disease burden, progression risk, and major etiologic thresholds across populations and studies.

9.2 Population demographics

Typical affected age is young to middle-aged adults; an MRI cohort had mean age 41.2. (rohilla2025adescriptivestudy pages 1-2, moyaangeler2015currentconceptson pages 1-2)

Sex distribution may skew male in some cohorts (e.g., 62% male in MRI cohort). (rohilla2025adescriptivestudy pages 1-2)

9.3 Inheritance pattern

No Mendelian inheritance pattern is supported in the retrieved corpus; genetic evidence is mainly susceptibility loci and pathway-level associations. (shi202417variantsinteraction pages 1-2, jia2024bonebiochemicalmarkers pages 1-2)

10. Diagnostics

10.1 Imaging

Diagnostic evaluation relies on radiography followed by MRI for early detection. * First radiographic changes may be cystic and sclerotic changes; however, radiographs are often insufficient early. (moyaangeler2015currentconceptson pages 1-2) * MRI is emphasized as a benchmark for early diagnosis and for staging systems like ARCO. (moyaangeler2015currentconceptson pages 1-2, rohilla2025adescriptivestudy pages 1-2)

10.2 Diagnostic staging/classification systems

Systems referenced include ARCO, Ficat and Arlet, Steinberg, and lesion-size measures such as the modified Kerboul angle (used as prognostic selection for decompression and biological augmentation). (rohilla2025adescriptivestudy pages 1-2, houdek2021hipdecompressioncombined pages 1-2)

10.3 Biomarkers (emerging)

Reviews and omics studies suggest potential biomarkers related to lipid metabolism, ER stress, and immune-inflammatory pathways, but none are established as standard clinical diagnostics in the retrieved evidence. Examples include ER-stress hub genes and lipid biomarkers (TG, HDL) as predictors in steroid-induced ONFH models. (jia2024predictingsteroidinducedosteonecrosis pages 12-12, wu2024identificationandvalidation pages 1-2)

10.4 Genetic testing

No clinical genetic testing algorithm or gene panel recommendation was identified in the retrieved text.

11. Outcome / Prognosis

11.1 Collapse and arthroplasty endpoints

Advanced ONFH often leads to arthroplasty. A 2024 endothelial dysfunction review states >80% eventually undergo total joint arthroplasty; U.S. administrative data show THA dominates surgical management (~95%). (shao2024unravelingtherole pages 1-2, ng2023increasingtrendtoward pages 1-2)

11.2 Prognostic factors

Prognostic factors for collapse include imaging-based lesion size/location and CT evidence of subchondral fracture, along with clinical and behavioral factors. * A 2024 Delphi-based prognostic model identified imaging and clinical factors (pain presence, JIC classification, necrotic area, weight-bearing reduction, anterolateral pillar preservation, subchondral fracture on CT) and achieved C-index 0.88. (yang2024adelphibasedmodel pages 1-2)

A long-term ARCO stage II pharmacologic cohort found LPA ≤60.9° predicted collapse risk (HR 3.87). (he2021thetherapeuticeffect pages 1-2)

12. Treatment

12.1 Current applications / real-world implementation patterns

In contemporary U.S. practice, THA remains the dominant surgical approach; joint-preserving procedures (core decompression, grafting) are a minority but have increased in younger patients. (ng2023increasingtrendtoward pages 1-2)

12.2 Joint-preserving procedures

Core decompression is the most widely used joint-preserving procedure, but failure rates can be high in real-world cohorts. (liu2021efficacyofvarious pages 1-2)

Adjunctive biologics/cell therapies show mixed but generally favorable meta-analytic signals for reducing collapse and THA conversion compared with CD alone, with heterogeneity and stage-dependence. (zhu2021comparisonofcell pages 1-2, liu2021efficacyofvarious pages 8-10)

12.3 Regenerative/cell therapy

Evidence spans: * Mid-term cohort: CD + BMAC + PRP in corticosteroid-induced precollapse ONFH showed 84% collapse-free and 67% THA-free survivorship at 7 years. (houdek2021hipdecompressioncombined pages 1-2) * Phase I/II MSC therapy: feasibility and safety with some clinical improvement; 50% eventually required THR over 8-year follow-up in small sample. (blanco2023longtermresultsof pages 8-10)

12.4 Total hip arthroplasty

A large 2024 cohort (876 THA patients) reported better short-term perioperative outcomes and 1-year HHS for ARCO stage III vs stage IV, but similar longer-term complication profiles, emphasizing stage at intervention influences early recovery. (li2024pathologicalmechanismsand pages 1-2)

12.5 Clinical trials (ClinicalTrials.gov; NCT identifiers)

Multiple interventional trials evaluate marrow/cell augmentation and procedural variants, including: * NCT01892514 (Phase 3, completed, n=104): CD + grafting + PRF + concentrated BM (MRI necrotic area reduction at 12 months as primary endpoint). (NCT01892514 chunk 1) * NCT01605383 (Phase I/II, completed, n=23): CD + autologous expanded MSCs on allogenic bone scaffold vs CD alone; endpoints include modified Kerboul angle and QoL scores. (NCT01605383 chunk 1) * NCT04233125 (Phase 1/2, completed, n=37): CD vs CD+PMMA cement packing, 5-year progression-free survival primary endpoint. (NCT04233125 chunk 1) * NCT00821470 (Phase 1, completed, n=21): CD vs CD + autologous bone marrow implantation; WOMAC at 60 months. (NCT00821470 chunk 1) * NCT01544712 (randomized, double-blind, completed, n=50): stage 3 ONFH CD + concentrated BM vs saline; later publication suggests inefficacy in stage III. (NCT01544712 chunk 1)

Suggested MAXO terms (high-level; ontology mapping): * Core decompression — MAXO term for decompression procedure (not retrieved explicitly) * Total hip arthroplasty — MAXO term for hip replacement (not retrieved explicitly) * Autologous MSC transplantation — MAXO cell therapy (not retrieved explicitly)

Table: This table summarizes current treatment strategies for osteonecrosis of the femoral head, including conservative care, procedures, regenerative therapies, and major clinical trials. It highlights where evidence is strongest, how interventions are used in practice, and which studies provide key quantitative outcomes.

13. Prevention

Primary prevention is risk-factor modification where feasible: * Avoiding unnecessary high-dose or prolonged glucocorticoid exposure and minimizing cumulative dose where clinically appropriate, given clear dose-response risk. (yoon2019etiologicclassificationcriteria pages 5-8) * Alcohol moderation/cessation in high-risk individuals and ARCO-defined alcohol-associated ONFH populations. (ko2023updatingosteonecrosisof pages 1-2)

Secondary prevention includes surveillance/early imaging in high-risk patients. Early screening is highlighted in postoperative adolescent fracture populations given high ONFH incidence. (gu2024globalincidenceof pages 1-2)

14. Other Species / Natural Disease

No naturally occurring osteonecrosis syndromes in non-human species were retrieved in the accessible corpus for this run.

15. Model Organisms

A 2024 Bone Research study provides a detailed glucocorticoid-induced ONFH mouse model (12-week-old male C57BL/6; methylprednisolone dosing regimen) and mechanistic pathway linking hypothalamic sympathetic tone to endothelial injury and osteonecrosis. (shao2024inhibitionofsympathetic pages 1-2, shao2024inhibitionofsympathetic pages 3-4)

Suggested model-ontology mapping: * Mus musculus — NCBI Taxon:10090 (not in retrieved text but standard)

Recent developments and expert synthesis (2023–2024 highlights)

1) ARCO framework refinement and operationalization: Ko 2023 synthesizes ARCO etiologic criteria and the revised 2019 ARCO staging that splits stage III into IIIA/IIIB by ≤2 mm vs >2 mm depression, enabling more standardized pre-/post-collapse stratification in clinical research and registries. (ko2023updatingosteonecrosisof pages 2-4, ko2023updatingosteonecrosisof media 0e890259) 2) Mechanistic convergence on vascular biology: 2024 reviews increasingly treat endothelial dysfunction and microvascular impairment as central, with immune-inflammatory amplification and impaired angiogenesis–osteogenesis coupling as key downstream processes. (shao2024unravelingtherole pages 1-2, ma2024researchprogressin pages 1-2) 3) Neurovascular mechanism (2024): the hypothalamic-sympathetic-endothelial axis (ADRB2–CREB–PFKFB3) is a notable mechanistic advance, suggesting potential therapeutic targets beyond bone-centric approaches. (shao2024inhibitionofsympathetic pages 1-2, shao2024inhibitionofsympathetic pages 2-3) 4) Omics and biomarker directions (2024): transcriptomic and bioinformatics analyses implicate ER stress–inflammation networks (STAT3/IL1B/TLR2/CASP1) and lipid metabolism/radiomics predictors (TG/HDL + imaging features), supporting a shift toward risk prediction and early detection research. (jia2024predictingsteroidinducedosteonecrosis pages 12-12, wu2024identificationandvalidation pages 1-2)

Notes on citation requirements (PMIDs and abstract quotes)

• Many retrieved open-access articles provide DOIs and abstracts, but PMIDs are not consistently present in the extracted full-text snippets. Where PMIDs were requested, this report cannot reliably supply them from the retrieved context.
• Direct abstract quotations are provided only when the abstract text was present in the retrieved snippets (e.g., ClinicalTrials.gov records and several article abstracts). For some mechanistic papers (e.g., Bone Research 2024), the abstract text was not present in the extracted pages; therefore, direct quotes cannot be provided despite inclusion of mechanistic details from the main text/figures.

Supporting figure/table evidence

The revised 2019 ARCO staging table and representative imaging examples were retrieved as cropped images from Ko 2023. (ko2023updatingosteonecrosisof media 0e890259, ko2023updatingosteonecrosisof media 85ac9cbb)

References

1. (zhang2024advancesinthe pages 1-2): Jie Zhang, Jianze Cao, Yongfei Liu, and Haiyan Zhao. Advances in the pathogenesis of steroid-associated osteonecrosis of the femoral head. Biomolecules, 14:667, Jun 2024. URL: https://doi.org/10.3390/biom14060667, doi:10.3390/biom14060667. This article has 53 citations.

2. (moyaangeler2015currentconceptson pages 1-2): J. Moya-Angeler, Arianna L. Gianakos, J. Villa, A. Ni, and J. Lane. Current concepts on osteonecrosis of the femoral head. World journal of orthopedics, 6 8:590-601, Sep 2015. URL: https://doi.org/10.5312/wjo.v6.i8.590, doi:10.5312/wjo.v6.i8.590. This article has 672 citations and is from a peer-reviewed journal.

3. (ko2023updatingosteonecrosisof pages 1-2): Young-Seung Ko, Joo Hyung Ha, Jung-Wee Park, Young-Kyun Lee, Tae-Young Kim, and Kyung-Hoi Koo. Updating osteonecrosis of the femoral head. Hip & Pelvis, 35:147-156, Sep 2023. URL: https://doi.org/10.5371/hp.2023.35.3.147, doi:10.5371/hp.2023.35.3.147. This article has 45 citations.

4. (ng2023increasingtrendtoward pages 1-2): Mitchell K. Ng, Andriy Kobryn, Ivan J. Golub, Nicolas S. Piuzzi, Che Hang Jason Wong, Lynne Jones, and Michael A. Mont. Increasing trend toward joint-preserving procedures for hip osteonecrosis in the united states from 2010 to 2019. Arthroplasty, May 2023. URL: https://doi.org/10.1186/s42836-023-00176-5, doi:10.1186/s42836-023-00176-5. This article has 11 citations.

5. (xiang2024advancesinmechanism pages 1-2): Xiao-Na Xiang, Hong-Chen He, and Cheng-Qi He. Advances in mechanism and management of bone homeostasis in osteonecrosis: a review article from basic to clinical applications. International Journal of Surgery (London, England), 111:1101-1122, Sep 2024. URL: https://doi.org/10.1097/js9.0000000000002094, doi:10.1097/js9.0000000000002094. This article has 12 citations.

6. (rohilla2025adescriptivestudy pages 1-2): Bhawna Rohilla, Lavanya Dharmalingam, G. Kamalakannan, and Prabhu C S. A descriptive study on the role of magnetic resonance imaging in staging avascular necrosis of the hip joint: current trends and insights. Cureus, Jun 2025. URL: https://doi.org/10.7759/cureus.86867, doi:10.7759/cureus.86867. This article has 2 citations.

7. (ko2023updatingosteonecrosisof pages 6-8): Young-Seung Ko, Joo Hyung Ha, Jung-Wee Park, Young-Kyun Lee, Tae-Young Kim, and Kyung-Hoi Koo. Updating osteonecrosis of the femoral head. Hip & Pelvis, 35:147-156, Sep 2023. URL: https://doi.org/10.5371/hp.2023.35.3.147, doi:10.5371/hp.2023.35.3.147. This article has 45 citations.

8. (li2024pathologicalmechanismsand pages 1-2): Longyu Li, Shangkun Zhao, Zikuan Leng, Songfeng Chen, Yifang Shi, Lijun Shi, Jinfeng Li, Keya Mao, Hai Tang, Bin Meng, Yisheng Wang, Guowei Shang, and Hongjian Liu. Pathological mechanisms and related markers of steroid-induced osteonecrosis of the femoral head. Annals of Medicine, Nov 2024. URL: https://doi.org/10.1080/07853890.2024.2416070, doi:10.1080/07853890.2024.2416070. This article has 43 citations and is from a domain leading peer-reviewed journal.

9. (yoon2019etiologicclassificationcriteria pages 5-8): Byung-Ho Yoon, Lynne C. Jones, Chung-Hwan Chen, Edward Y. Cheng, Quanjun Cui, Wolf Drescher, Wakaba Fukushima, Valerie Gangji, Stuart B. Goodman, Yong-Chan Ha, Philippe Hernigou, Marc Hungerford, Richard Iorio, Woo-Lam Jo, Vikas Khanduja, Harry Kim, Shin-Yoon Kim, Tae-Young Kim, Hee Young Lee, Mel S. Lee, Young-Kyun Lee, Yun Jong Lee, Michael A. Mont, Takashi Sakai, Nobuhiko Sugano, Masaki Takao, Takuaki Yamamoto, and Kyung-Hoi Koo. Etiologic classification criteria of arco on femoral head osteonecrosis part 1: glucocorticoid-associated osteonecrosis. The Journal of arthroplasty, 34 1:163-168.e1, Jan 2019. URL: https://doi.org/10.1016/j.arth.2018.09.005, doi:10.1016/j.arth.2018.09.005. This article has 160 citations.

10. (houdek2021hipdecompressioncombined pages 1-2): Matthew T. Houdek, Cody C. Wyles, John-Rudolph H. Smith, Andre Terzic, Atta Behfar, and Rafael J. Sierra. Hip decompression combined with bone marrow concentrate and platelet-rich plasma for corticosteroid-induced osteonecrosis of the femoral head. Bone & Joint Open, 2:926-931, Nov 2021. URL: https://doi.org/10.1302/2633-1462.211.bjo-2021-0132.r1, doi:10.1302/2633-1462.211.bjo-2021-0132.r1. This article has 18 citations and is from a peer-reviewed journal.

11. (blanco2023longtermresultsof pages 8-10): Juan F. Blanco, Francisco J. Garcia-Garcia, Eva M. Villarón, Carmen da Casa, Helena Fidalgo, Miriam López-Parra, José A. Santos, and Fermín Sánchez-Guijo. Long-term results of a phase i/ii clinical trial of autologous mesenchymal stem cell therapy for femoral head osteonecrosis. Journal of Clinical Medicine, 12:2117, Mar 2023. URL: https://doi.org/10.3390/jcm12062117, doi:10.3390/jcm12062117. This article has 7 citations.

12. (shao2024inhibitionofsympathetic pages 1-2): Wenkai Shao, Bo Wang, Ping Wang, Shuo Zhang, Song Gong, Xiaodong Guo, Deyu Duan, Zengwu Shao, Weijian Liu, Lei He, Fei Gao, Xiao Lv, and Yong Feng. Inhibition of sympathetic tone via hypothalamic descending pathway propagates glucocorticoid-induced endothelial impairment and osteonecrosis of the femoral head. Bone Research, Nov 2024. URL: https://doi.org/10.1038/s41413-024-00371-3, doi:10.1038/s41413-024-00371-3. This article has 20 citations and is from a domain leading peer-reviewed journal.

13. (gu2024globalincidenceof pages 1-2): Bangning Gu, Fangming Yao, Peng Peng, Zijun Zeng, Wei He, and Qiushi Wei. Global incidence of osteonecrosis of the femoral head after femoral neck fracture surgery in adolescents: a meta-analysis. Journal of Orthopaedic Surgery and Research, Nov 2024. URL: https://doi.org/10.1186/s13018-024-05275-w, doi:10.1186/s13018-024-05275-w. This article has 3 citations and is from a peer-reviewed journal.

14. (shao2024unravelingtherole pages 1-2): Wenkai Shao, Ping Wang, Xiao Lv, Bo Wang, Song Gong, and Yong Feng. Unraveling the role of endothelial dysfunction in osteonecrosis of the femoral head: a pathway to new therapies. Biomedicines, 12:664, Mar 2024. URL: https://doi.org/10.3390/biomedicines12030664, doi:10.3390/biomedicines12030664. This article has 29 citations.

15. (yoon2019etiologicclassificationcriteria pages 1-5): Byung-Ho Yoon, Lynne C. Jones, Chung-Hwan Chen, Edward Y. Cheng, Quanjun Cui, Wolf Drescher, Wakaba Fukushima, Valerie Gangji, Stuart B. Goodman, Yong-Chan Ha, Philippe Hernigou, Marc Hungerford, Richard Iorio, Woo-Lam Jo, Vikas Khanduja, Harry Kim, Shin-Yoon Kim, Tae-Young Kim, Hee Young Lee, Mel S. Lee, Young-Kyun Lee, Yun Jong Lee, Michael A. Mont, Takashi Sakai, Nobuhiko Sugano, Masaki Takao, Takuaki Yamamoto, and Kyung-Hoi Koo. Etiologic classification criteria of arco on femoral head osteonecrosis part 1: glucocorticoid-associated osteonecrosis. The Journal of arthroplasty, 34 1:163-168.e1, Jan 2019. URL: https://doi.org/10.1016/j.arth.2018.09.005, doi:10.1016/j.arth.2018.09.005. This article has 160 citations.

16. (jia2024bonebiochemicalmarkers pages 1-2): Hai-feng Jia, Ze-ming Tian, Xue-zhen Liang, Han-zheng Li, Bo-wen Lu, Jian Zhang, and Gang Li. Bone biochemical markers, bone mineral density, and the risk of osteonecrosis of the femoral head: a mendelian randomization study. BMC Musculoskeletal Disorders, Dec 2024. URL: https://doi.org/10.1186/s12891-024-08130-5, doi:10.1186/s12891-024-08130-5. This article has 3 citations and is from a peer-reviewed journal.

17. (shi202417variantsinteraction pages 1-2): Chuankai Shi, Xin Li, Yu Sun, Zhenwu Du, Guizhen Zhang, Zhenjia Che, Qingyu Li, Shiliang Song, Jing Guo, Haoyan Sun, and Yang Song. 17 variants interaction of wnt/β-catenin pathway associated with development of osteonecrosis of femoral head in chinese han population. Scientific Reports, Mar 2024. URL: https://doi.org/10.1038/s41598-024-57929-8, doi:10.1038/s41598-024-57929-8. This article has 1 citations and is from a peer-reviewed journal.

18. (shi202417variantsinteraction pages 9-11): Chuankai Shi, Xin Li, Yu Sun, Zhenwu Du, Guizhen Zhang, Zhenjia Che, Qingyu Li, Shiliang Song, Jing Guo, Haoyan Sun, and Yang Song. 17 variants interaction of wnt/β-catenin pathway associated with development of osteonecrosis of femoral head in chinese han population. Scientific Reports, Mar 2024. URL: https://doi.org/10.1038/s41598-024-57929-8, doi:10.1038/s41598-024-57929-8. This article has 1 citations and is from a peer-reviewed journal.

19. (yoon2019etiologicclassificationcriteria pages 8-12): Byung-Ho Yoon, Lynne C. Jones, Chung-Hwan Chen, Edward Y. Cheng, Quanjun Cui, Wolf Drescher, Wakaba Fukushima, Valerie Gangji, Stuart B. Goodman, Yong-Chan Ha, Philippe Hernigou, Marc Hungerford, Richard Iorio, Woo-Lam Jo, Vikas Khanduja, Harry Kim, Shin-Yoon Kim, Tae-Young Kim, Hee Young Lee, Mel S. Lee, Young-Kyun Lee, Yun Jong Lee, Michael A. Mont, Takashi Sakai, Nobuhiko Sugano, Masaki Takao, Takuaki Yamamoto, and Kyung-Hoi Koo. Etiologic classification criteria of arco on femoral head osteonecrosis part 1: glucocorticoid-associated osteonecrosis. The Journal of arthroplasty, 34 1:163-168.e1, Jan 2019. URL: https://doi.org/10.1016/j.arth.2018.09.005, doi:10.1016/j.arth.2018.09.005. This article has 160 citations.

20. (pang2025thebibliometricand pages 1-2): Kai Pang, Huiying Li, Haifeng Chen, Zhentao Man, Dandan Wang, and Wei Li. The bibliometric and visualization analysis of alcohol-induced osteonecrosis of the femoral head: research trends and future directions (1998–2024). Journal of Orthopaedic Surgery and Research, Aug 2025. URL: https://doi.org/10.1186/s13018-025-06138-8, doi:10.1186/s13018-025-06138-8. This article has 1 citations and is from a peer-reviewed journal.

21. (ma2024researchprogressin pages 2-3): Tiancheng Ma, Yan Wang, Jianxiong Ma, Hongwei Cui, Xiaotian Feng, and Xinlong Ma. Research progress in the pathogenesis of hormone-induced femoral head necrosis based on microvessels: a systematic review. Journal of Orthopaedic Surgery and Research, Apr 2024. URL: https://doi.org/10.1186/s13018-024-04748-2, doi:10.1186/s13018-024-04748-2. This article has 26 citations and is from a peer-reviewed journal.

22. (ma2024researchprogressin pages 1-2): Tiancheng Ma, Yan Wang, Jianxiong Ma, Hongwei Cui, Xiaotian Feng, and Xinlong Ma. Research progress in the pathogenesis of hormone-induced femoral head necrosis based on microvessels: a systematic review. Journal of Orthopaedic Surgery and Research, Apr 2024. URL: https://doi.org/10.1186/s13018-024-04748-2, doi:10.1186/s13018-024-04748-2. This article has 26 citations and is from a peer-reviewed journal.

23. (jia2024predictingsteroidinducedosteonecrosis pages 12-12): Daqi Jia, Yue Zhang, Huaqiang Li, Chunfang Guo, Yipeng Wu, Xiangwen Shi, Li Yang, Jieyu Mo, Xia Liu, and Yongqing Xu. Predicting steroid-induced osteonecrosis of the femoral head: role of lipid metabolism biomarkers and radiomics in young and middle-aged adults. Journal of Orthopaedic Surgery and Research, Nov 2024. URL: https://doi.org/10.1186/s13018-024-05245-2, doi:10.1186/s13018-024-05245-2. This article has 9 citations and is from a peer-reviewed journal.

24. (xiang2024advancesinmechanism pages 18-18): Xiao-Na Xiang, Hong-Chen He, and Cheng-Qi He. Advances in mechanism and management of bone homeostasis in osteonecrosis: a review article from basic to clinical applications. International Journal of Surgery (London, England), 111:1101-1122, Sep 2024. URL: https://doi.org/10.1097/js9.0000000000002094, doi:10.1097/js9.0000000000002094. This article has 12 citations.

25. (yang2024adelphibasedmodel pages 1-2): Tong-jie Yang, Shi-yi Sun, Lei Zhang, Xing-ping Zhang, and Hai-jun He. A delphi-based model for prognosis of femoral head collapse in osteonecrosis: a multi-factorial approach. Journal of Orthopaedic Surgery and Research, Nov 2024. URL: https://doi.org/10.1186/s13018-024-05247-0, doi:10.1186/s13018-024-05247-0. This article has 8 citations and is from a peer-reviewed journal.

26. (liu2021efficacyofvarious pages 1-2): Quanzhe Liu, Wenlai Guo, Rui Li, and Jae Hyup Lee. Efficacy of various core decompression techniques versus non-operative treatment for osteonecrosis of the femoral head: a systemic review and network meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders, Nov 2021. URL: https://doi.org/10.1186/s12891-021-04808-2, doi:10.1186/s12891-021-04808-2. This article has 38 citations and is from a peer-reviewed journal.

27. (he2021thetherapeuticeffect pages 1-2): Xiao-Ming He, Min-Cong He, Peng Yang, Qing-Wen Zhang, Zhen-Qiu Chen, Wei He, and Qiu-Shi Wei. The therapeutic effect of huo xue tong luo capsules in association research circulation osseous (arco) stage ii osteonecrosis of the femoral head: a clinical study with an average follow-up period of 7.95 years. Frontiers in Pharmacology, Nov 2021. URL: https://doi.org/10.3389/fphar.2021.773758, doi:10.3389/fphar.2021.773758. This article has 20 citations.

28. (NCT01605383 chunk 1): Mesenchymal Stem Cells in Osteonecrosis of the Femoral Head. Banc de Sang i Teixits. 2015. ClinicalTrials.gov Identifier: NCT01605383

29. (NCT04233125 chunk 1): Core Decompression With or Without Cement Packing for ONFH. University of Minnesota. 1997. ClinicalTrials.gov Identifier: NCT04233125

30. (wu2024identificationandvalidation pages 1-2): Tingyu Wu, Weipeng Shi, Yinxue Zhou, Sijia Guo, Hua Tian, Yaping Jiang, Weiyan Li, Yingzhen Wang, and Tao Li. Identification and validation of endoplasmic reticulum stress-related genes in patients with steroid-induced osteonecrosis of the femoral head. Scientific Reports, Sep 2024. URL: https://doi.org/10.1038/s41598-024-72941-8, doi:10.1038/s41598-024-72941-8. This article has 10 citations and is from a peer-reviewed journal.

31. (li2024pathologicalmechanismsand pages 8-9): Longyu Li, Shangkun Zhao, Zikuan Leng, Songfeng Chen, Yifang Shi, Lijun Shi, Jinfeng Li, Keya Mao, Hai Tang, Bin Meng, Yisheng Wang, Guowei Shang, and Hongjian Liu. Pathological mechanisms and related markers of steroid-induced osteonecrosis of the femoral head. Annals of Medicine, Nov 2024. URL: https://doi.org/10.1080/07853890.2024.2416070, doi:10.1080/07853890.2024.2416070. This article has 43 citations and is from a domain leading peer-reviewed journal.

32. (ko2023updatingosteonecrosisof pages 2-4): Young-Seung Ko, Joo Hyung Ha, Jung-Wee Park, Young-Kyun Lee, Tae-Young Kim, and Kyung-Hoi Koo. Updating osteonecrosis of the femoral head. Hip & Pelvis, 35:147-156, Sep 2023. URL: https://doi.org/10.5371/hp.2023.35.3.147, doi:10.5371/hp.2023.35.3.147. This article has 45 citations.

33. (shao2024inhibitionofsympathetic pages 2-3): Wenkai Shao, Bo Wang, Ping Wang, Shuo Zhang, Song Gong, Xiaodong Guo, Deyu Duan, Zengwu Shao, Weijian Liu, Lei He, Fei Gao, Xiao Lv, and Yong Feng. Inhibition of sympathetic tone via hypothalamic descending pathway propagates glucocorticoid-induced endothelial impairment and osteonecrosis of the femoral head. Bone Research, Nov 2024. URL: https://doi.org/10.1038/s41413-024-00371-3, doi:10.1038/s41413-024-00371-3. This article has 20 citations and is from a domain leading peer-reviewed journal.

34. (ko2023updatingosteonecrosisof media 0e890259): Young-Seung Ko, Joo Hyung Ha, Jung-Wee Park, Young-Kyun Lee, Tae-Young Kim, and Kyung-Hoi Koo. Updating osteonecrosis of the femoral head. Hip & Pelvis, 35:147-156, Sep 2023. URL: https://doi.org/10.5371/hp.2023.35.3.147, doi:10.5371/hp.2023.35.3.147. This article has 45 citations.

35. (ko2023updatingosteonecrosisof media 85ac9cbb): Young-Seung Ko, Joo Hyung Ha, Jung-Wee Park, Young-Kyun Lee, Tae-Young Kim, and Kyung-Hoi Koo. Updating osteonecrosis of the femoral head. Hip & Pelvis, 35:147-156, Sep 2023. URL: https://doi.org/10.5371/hp.2023.35.3.147, doi:10.5371/hp.2023.35.3.147. This article has 45 citations.

36. (ng2023increasingtrendtoward pages 6-7): Mitchell K. Ng, Andriy Kobryn, Ivan J. Golub, Nicolas S. Piuzzi, Che Hang Jason Wong, Lynne Jones, and Michael A. Mont. Increasing trend toward joint-preserving procedures for hip osteonecrosis in the united states from 2010 to 2019. Arthroplasty, May 2023. URL: https://doi.org/10.1186/s42836-023-00176-5, doi:10.1186/s42836-023-00176-5. This article has 11 citations.

37. (zhu2021comparisonofcell pages 1-2): Shibai Zhu, Xiaotian Zhang, Xi Chen, Yiou Wang, Shanni Li, and Wenwei Qian. Comparison of cell therapy and other novel adjunctive therapies combined with core decompression for the treatment of osteonecrosis of the femoral head. Bone & Joint Research, 10:445-458, Jul 2021. URL: https://doi.org/10.1302/2046-3758.107.bjr-2020-0418.r1, doi:10.1302/2046-3758.107.bjr-2020-0418.r1. This article has 35 citations.

38. (liu2021efficacyofvarious pages 8-10): Quanzhe Liu, Wenlai Guo, Rui Li, and Jae Hyup Lee. Efficacy of various core decompression techniques versus non-operative treatment for osteonecrosis of the femoral head: a systemic review and network meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders, Nov 2021. URL: https://doi.org/10.1186/s12891-021-04808-2, doi:10.1186/s12891-021-04808-2. This article has 38 citations and is from a peer-reviewed journal.

39. (NCT01892514 chunk 1): Randomized Clinical Trial for the Treatment of Osteonecrosis of the Femoral Head. Istituto Ortopedico Rizzoli. 2013. ClinicalTrials.gov Identifier: NCT01892514

40. (NCT00821470 chunk 1): Treatment of Osteonecrosis of the Femoral Head by Bone Marrow Transplantation. Erasme University Hospital. 1999. ClinicalTrials.gov Identifier: NCT00821470

41. (NCT01544712 chunk 1): Jean-Philippe Hauzeur. Controlled Study of Stage 3 Osteonecrosis Treatment by Bone Marrow. University of Liege. 2004. ClinicalTrials.gov Identifier: NCT01544712

42. (goncharov2024conservativetreatmentin pages 1-2): Evgeniy Nikolaevich Goncharov, Oleg Aleksandrovich Koval, Eduard Nikolaevich Bezuglov, Aleksandr Aleksandrovich Vetoshkin, Nikolay Gavriilovich Goncharov, Manuel De Jesus Encarnación Ramirez, and Nicola Montemurro. Conservative treatment in avascular necrosis of the femoral head: a systematic review. Medical Sciences, 12:32, Jul 2024. URL: https://doi.org/10.3390/medsci12030032, doi:10.3390/medsci12030032. This article has 26 citations.

43. (houdek2021hipdecompressioncombined pages 5-6): Matthew T. Houdek, Cody C. Wyles, John-Rudolph H. Smith, Andre Terzic, Atta Behfar, and Rafael J. Sierra. Hip decompression combined with bone marrow concentrate and platelet-rich plasma for corticosteroid-induced osteonecrosis of the femoral head. Bone & Joint Open, 2:926-931, Nov 2021. URL: https://doi.org/10.1302/2633-1462.211.bjo-2021-0132.r1, doi:10.1302/2633-1462.211.bjo-2021-0132.r1. This article has 18 citations and is from a peer-reviewed journal.

44. (blanco2023longtermresultsof pages 1-2): Juan F. Blanco, Francisco J. Garcia-Garcia, Eva M. Villarón, Carmen da Casa, Helena Fidalgo, Miriam López-Parra, José A. Santos, and Fermín Sánchez-Guijo. Long-term results of a phase i/ii clinical trial of autologous mesenchymal stem cell therapy for femoral head osteonecrosis. Journal of Clinical Medicine, 12:2117, Mar 2023. URL: https://doi.org/10.3390/jcm12062117, doi:10.3390/jcm12062117. This article has 7 citations.

45. (blanco2023longtermresultsof pages 10-11): Juan F. Blanco, Francisco J. Garcia-Garcia, Eva M. Villarón, Carmen da Casa, Helena Fidalgo, Miriam López-Parra, José A. Santos, and Fermín Sánchez-Guijo. Long-term results of a phase i/ii clinical trial of autologous mesenchymal stem cell therapy for femoral head osteonecrosis. Journal of Clinical Medicine, 12:2117, Mar 2023. URL: https://doi.org/10.3390/jcm12062117, doi:10.3390/jcm12062117. This article has 7 citations.

46. (zhu2021comparisonofcell pages 11-12): Shibai Zhu, Xiaotian Zhang, Xi Chen, Yiou Wang, Shanni Li, and Wenwei Qian. Comparison of cell therapy and other novel adjunctive therapies combined with core decompression for the treatment of osteonecrosis of the femoral head. Bone & Joint Research, 10:445-458, Jul 2021. URL: https://doi.org/10.1302/2046-3758.107.bjr-2020-0418.r1, doi:10.1302/2046-3758.107.bjr-2020-0418.r1. This article has 35 citations.

47. (NCT04233125 chunk 2): Core Decompression With or Without Cement Packing for ONFH. University of Minnesota. 1997. ClinicalTrials.gov Identifier: NCT04233125

48. (shao2024inhibitionofsympathetic pages 3-4): Wenkai Shao, Bo Wang, Ping Wang, Shuo Zhang, Song Gong, Xiaodong Guo, Deyu Duan, Zengwu Shao, Weijian Liu, Lei He, Fei Gao, Xiao Lv, and Yong Feng. Inhibition of sympathetic tone via hypothalamic descending pathway propagates glucocorticoid-induced endothelial impairment and osteonecrosis of the femoral head. Bone Research, Nov 2024. URL: https://doi.org/10.1038/s41413-024-00371-3, doi:10.1038/s41413-024-00371-3. This article has 20 citations and is from a domain leading peer-reviewed journal.

Artifacts

• Edison artifact artifact-00
• Edison artifact artifact-01
• Edison artifact artifact-02