Evidence-Based Management and Functional Outcomes of Femoral Head Avascular Necrosis: A Systematic Review

Abstract

Avascular necrosis of the femoral head (AVNFH), also known as osteonecrosis of the femoral head, is a progressive musculoskeletal disorder caused by compromised blood supply to the femoral head, causing osteocyte death, structural collapse, pain, and functional disability. Despite advances in diagnostic imaging and treatment modalities, optimal management remains challenging because of multifactorial etiology and variable clinical presentation of the disease. To systematically evaluate the etiopathogenesis, evidence-based management strategies, and functional outcomes associated with AVNFH. A systematic review was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Electronic literature searches identified studies investigating etiology, management, and functional outcomes of AVNFH. Adult patients with traumatic or non-traumatic AVNFH across pre-collapse and post-collapse stages were included. Randomized controlled trials and observational studies evaluating surgical, biological, pharmacological, physical therapy, or arthroplasty interventions and reporting validated clinical outcomes were eligible. Methodological quality was assessed using the Cochrane Risk of Bias 2 tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. Twenty-two studies published between 2010 and 2023 met the eligibility criteria and were included in the review. Evidence demonstrated that corticosteroid exposure, alcohol consumption, trauma, and idiopathic factors were the main contributors to disease development. Joint-preserving procedures, particularly core decompression combined with biological augmentation techniques such as platelet-rich plasma, bone marrow-derived cellular therapies, and stem-cell-based interventions, consistently demonstrated improved functional outcomes and delayed disease progression. Vascularized grafting procedures enhanced femoral head vascularity and survivorship, while extracorporeal shock wave therapy and hyperbaric oxygen therapy provided clinically meaningful improvements in pain and function in early-stage disease. Pharmacological interventions showed variable effectiveness, with zoledronate failing to significantly prevent femoral head collapse. In advanced disease, bipolar hip arthroplasty and cementless total hip arthroplasty produced substantial functional improvement and reliable symptom relief. Risk-of-bias assessment indicated predominantly moderate methodological quality, with heterogeneity observed across study designs, interventions, and outcome measures. AVNFH is a multifactorial condition in which early diagnosis and timely intervention are critical for preserving hip function and delaying disease progression. Current evidence supports stage-specific management, with biologically augmented joint-preserving procedures demonstrating most favorable outcomes in pre-collapse disease, while arthroplasty remains definitive treatment for advanced femoral head collapse. Although regenerative therapies show considerable promise, further high-quality multicenter randomized controlled trials with standardized outcome measures and long-term follow-up are required to establish optimal treatment algorithms and strengthen the evidence base for clinical decision-making.