| Intervention | Indication/stage | Evidence summary (key numbers) | Implementation notes | Source | URL/NCT |
|---|---|---|---|---|---|
| Conservative management (weight-bearing restriction, pharmacotherapy, physical modalities) | Early/pre-collapse ONFH; individualized nonoperative care | 2024 systematic review included 11 studies from 376 records; conservative approaches may relieve symptoms and delay progression, but evidence remains heterogeneous and insufficient for strong efficacy conclusions (pqac-00000001) | Used mainly in early disease or when surgery is deferred/contraindicated; not clearly disease-modifying in advanced collapse | Goncharov 2024, *Medical Sciences* | https://doi.org/10.3390/medsci12030032 |
| Core decompression (CD) alone | Most commonly ARCO I-II; pre-collapse ONFH | Large retrospective cohort: 1,537 hips, overall CD failure rate 52.44%; failure associated with male sex, steroid/idiopathic etiology, seated occupation, older age, lower hemoglobin, longer disease duration, larger combined necrosis angle (AUC 0.935 prediction model) (pqac-00000027) | Widely used joint-preserving procedure; best suited to carefully selected pre-collapse lesions | Wei 2023, *BMC Musculoskeletal Disorders* | https://doi.org/10.1186/s12891-023-06321-0 |
| CD plus adjunctive therapy (pooled: cell therapy, bone grafting, tantalum rod, biologics) | Mainly precollapse ONFH, especially stage I-II | Meta-analysis of 20 studies/2,123 hips: higher HHS (MD 6.46), lower VAS (MD -0.99), lower stage progression (OR 0.32), lower collapse (OR 0.32), lower THA conversion (OR 0.35) versus CD alone; no serious adverse events reported (pqac-00000022) | Supports combined hip-preservation strategies when local expertise/resources available | Zhu 2021, *Bone & Joint Research* | https://doi.org/10.1302/2046-3758.107.bjr-2020-0418.r1 |
| CD plus cell therapy (network meta-analysis) | Joint-preserving treatment in ONFH, especially early disease | Network meta-analysis of 17 RCTs/918 hips: CD+cell therapy had best SUCRA for radiographic progression (96.4%), but no significant overall difference in THA conversion or HHS versus other interventions/nonoperative treatment (pqac-00000027, pqac-00000026) | Suggests radiographic benefit may exceed symptomatic/arthroplasty endpoint benefit; evidence mixed | Liu 2021, *BMC Musculoskeletal Disorders* | https://doi.org/10.1186/s12891-021-04808-2 |
| CD plus BMAC/PRP hip decompression | Precollapse corticosteroid-induced ONFH | 22 patients/35 hips; 7-year survivorship free from femoral head collapse 84% and free from THA 67%; worse outcomes with high modified Kerboul angle (HR 3.96) and continued corticosteroid use (HR 4.15) (pqac-00000032, pqac-00000033) | Real-world biologic augmentation strategy; candidate selection and stopping steroids matter | Houdek 2021, *Bone & Joint Open* | https://doi.org/10.1302/2633-1462.211.bjo-2021-0132.r1 |
| Autologous cultured MSC implantation | Idiopathic ONFH, ARCO < IIC | Phase I/II prospective trial, 8 patients: no cell-related adverse effects; 50% clinically improved at 1 year; none required THR in first year; at 8 years, 4/8 (50%) ultimately required THR after median ~574-576 days (pqac-00000035, pqac-00000034, pqac-00000036) | GMP-expanded autologous BM-MSCs delivered intraosseously; feasible but small-sample evidence | Blanco 2023, *Journal of Clinical Medicine* | https://doi.org/10.3390/jcm12062117 |
| Autologous bone marrow concentrate added to CD (short-term RCT) | Non-traumatic femoral head necrosis | Prospective randomized trial in 24 patients found no short-term clinical or radiologic benefit from adding bone marrow concentrate to CD over 2 years, despite increased CFU counts after centrifugation (from abstract) (pqac-00000024) | Illustrates inconsistency of BMAC evidence, especially in small short-term trials | Pepke 2016, *Orthopedic Reviews* | https://doi.org/10.4081/or.2016.6162 |
| Autologous bone marrow concentrate in stage III disease | Stage III non-traumatic ONFH | Randomized double-blind trial record later linked to publication titled “Inefficacy of autologous bone marrow concentrate in stage three osteonecrosis” (pqac-00000047) | Suggests diminished value once collapse is established | NCT01544712 / Hauzeur trial | NCT01544712 |
| Bone grafting / regenerative graft combinations | Early ONFH (ARCO 2A-C in trial protocols) | Phase 3 RCT protocol compared CD+DBM+PRF+concentrated bone marrow vs CD+lyophilized bone chips+PRF+concentrated bone marrow; primary endpoint MRI necrotic-area reduction at 12 months; enrollment 104, completed (pqac-00000045) | Reflects real-world use of graft plus marrow concentrate in hip-preserving centers | ClinicalTrials.gov AVN-13 | NCT01892514 |
| Tantalum rod insertion | Joint-preserving treatment, often pre-collapse/selected cases | Meta-analysis of 10 studies/550 hips: HHS improved by MD 30.35; radiographic progression 22.1%; femoral head collapse 10.2%; THA conversion 15.8% at mean 32.4 months (pqac-00000003) | Structural support option; often considered where surgeons aim to avoid arthroplasty in younger patients | Onggo 2020, *Journal of Hip Preservation Surgery* | https://doi.org/10.1093/jhps/hnaa020 |
| Hyperbaric oxygen therapy (HBO) | Femoral head necrosis, mostly early-stage studies | Meta-analysis of 10 studies (368 HBO-treated, 353 controls): clinical effect OR 3.84 (95% CI 2.10-7.02); significant benefit in Asian subgroup (pqac-00000003) | Available in selected centers; not universally adopted | Paderno 2021, *IJERPH* | https://doi.org/10.3390/ijerph18062888 |
| Extracorporeal shock wave therapy (ESWT) | ONFH, generally early disease | Meta-analysis of 9 studies/409 patients: improved HHS and VAS; MRI lesion metrics improved, but authors concluded it could not stop progression reliably (pqac-00000003) | Noninvasive adjunct; symptom-focused with uncertain structural protection | Mei 2022, *Physician and Sportsmedicine* | https://doi.org/10.1080/00913847.2021.1936685 |
| THA (total hip arthroplasty) | Post-collapse or end-stage ONFH (ARCO III-IV/IV) | U.S. nationwide surgery data: THA was 94.97% of surgical management (9,814/10,334) (pqac-00000028); stage III vs IV cohort of 876 patients found stage III had shorter operative time, less bleeding, fewer 1-year readmissions/complications, and higher 1-year HHS; long-term difference not significant (pqac-00000003) | Dominant real-world intervention for advanced disease; outcomes somewhat better when performed before most advanced degeneration | Ng 2023; Wang 2024 | https://doi.org/10.1186/s42836-023-00176-5 ; https://doi.org/10.1186/s13018-024-04617-y |
| Huo Xue Tong Luo capsules (pharmacologic/traditional medicine) | ARCO stage II ONFH | 44 patients/66 hips, mean follow-up 7.95 years: 69.7% had no progression in pain or collapse; only 1.5% required THA; 5-, 10-, and 15-year survivorship 96.97%, 69.15%, 40.33% (pqac-00000052) | Region-specific long-term observational/clinical evidence; not standard global care | He 2021, *Frontiers in Pharmacology* | https://doi.org/10.3389/fphar.2021.773758 |
| NCT06123481 Autologous Bone Marrow Aspirate Treatment for Early-Stage Osteonecrosis | Early-stage ONFH | Recruiting interventional study; enrollment 192 (trial registry listing) (pqac-00000044) | Large contemporary marrow-based study may clarify real-world value of aspirate augmentation | ClinicalTrials.gov | NCT06123481 |
| NCT01605383 Mesenchymal Stem Cells in Osteonecrosis of the Femoral Head | ONFH treated with CD vs CD+autologous MSC tissue-engineering product | Phase I/II randomized prospective open-label/blinded-assessor trial; enrollment 23; completed; primary endpoints safety/feasibility over 12 months; secondary endpoints include modified Kerboul angle, gadolinium enhancement, VAS, SF-36, WOMAC (pqac-00000046) | Important translational MSC trial using ex vivo expanded autologous cells on allogenic bone scaffold | ClinicalTrials.gov | NCT01605383 |
| NCT01892514 Randomized Clinical Trial for the Treatment of ONFH | Early-stage ONFH (ARCO 2A-C) | Phase III randomized double-masked trial; enrollment 104; completed; primary endpoint MRI reduction in total necrotic area at 12 months; secondary endpoints VAS, HHS, WOMAC, structural preservation (pqac-00000045) | Directly compares two marrow/graft regenerative strategies after CD | ClinicalTrials.gov | NCT01892514 |
| NCT04233125 Core Decompression With or Without Cement Packing for ONFH | Symptomatic precollapse ARCO I-II ONFH | Phase I/II randomized parallel trial; enrollment 37; completed; compares CD vs CD+PMMA; primary endpoint progression-free survival at 5 years; secondary endpoints conversion-free survival/THA, HHS, WOMAC, SF-36 (pqac-00000049, pqac-00000048) | Practical surgical optimization trial for pre-collapse disease | ClinicalTrials.gov | NCT04233125 |
| NCT00821470 Treatment of Osteonecrosis of the Femoral Head by Bone Marrow Transplantation | ARCO stage 1-2 ONFH | Phase I pilot; enrollment 21; completed; core decompression vs CD+autologous bone marrow implantation; primary endpoint WOMAC at 60 months; secondary endpoint progression to fractural stage (pqac-00000044) | Early landmark marrow-implantation trial conceptually underpinning later cell-therapy approaches | ClinicalTrials.gov | NCT00821470 |
| NCT01544712 Controlled Study of Stage 3 Osteonecrosis Treatment by Bone Marrow | Stage III non-traumatic ONFH | Randomized double-blind parallel trial; enrollment 50; completed; CD+40 mL concentrated autologous bone marrow vs CD+saline; primary endpoint need for total prosthesis at 24 and 60 months (pqac-00000047) | Useful registry example of later-stage biologic augmentation testing | ClinicalTrials.gov | NCT01544712 |


*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.*