Prognostic factors in the management of osteonecrosis of the femoral head: A systematic review.

BACKGROUND: Several hip preserving techniques have been described for the management of osteonecrosis of the femoral head (ONFH). This systematic review identified prognostic factors in the treatment of ONFH that are associated with treatment failure and conversion to total hip arthroplasty (THA). MATERIAL AND METHODS: This study followed the PRISMA guidelines. The literature search was conducted in November 2021. All clinical trials comparing two or more treatments for femoral head osteonecrosis were accessed. A multivariate analysis was performed to investigate the association between baseline characteristics and the surgical outcome. A multiple linear model regression analysis through the Pearson Product-Moment Correlation Coefficient (r) was used. RESULTS: Data from 88 articles (6112 procedures) were retrieved. Female gender was associated with increased time to THA (P = 0.03) and reduced rate of THA (P = 0.03). Longer symptom duration before treatment was associated with shorter time to failure (P = 0.03). Increased pre-treatment VAS was associated with reduced time to failure (P = 0.03) and time to THA (P = 0.04). Reduced pre-treatment hip function was associated with increased rate of THA (P = 0.02) and failure (P = 0.005). Patient age and BMI, aetiology, time from surgery to full weight bearing and the side did not show evidence of a statistically significant association with the surgical outcome. CONCLUSION: Male gender, longer symptom duration before treatment, higher VAS scores, and lower HHS scores were negative prognostic factors after treatment for osteonecrosis of the femoral head.

Return to sport after arthroscopic surgery for femoroacetabular impingement.

BACKGROUND: Femoroacetabular impingement (FAI) is common among the active and young population. The present study analysed the rate of return to sport, related influencing factors, and the sport activity level according to the Hip Outcome Score - Sport-Specific Subscale (HOS-SSS). METHODS: The literature search was performed in December 2020. All clinical trials investigating HOS-SSS and/or return to sport after arthroscopic treatment for FAI were considered for inclusion. The outcomes of interest were to analyse the rate of return to sport and the sport activity level according to the HOS-SSS in patients who underwent arthroscopic osteoplasty for FAI. RESULTS: Data from 41 studies (4063 procedures) were retrieved. A total of 88.75% (581 of 655) of patients returned to sports within a mean of 37.4 ± 16.5 months. The HOS-SSS score improved from 45.0 ± 10.6 to 73.1 ± 9.5 (P < 0.0001) at last follow-up. The following baseline characteristics evidenced positive association with post-operative activity level: lighter weight (P = 0.01), younger age (P = 0.001), Tönnis angle grade I (P = 0.009), greater HHS (P = 0.01), NAHS (P < 0.0001) and HOS-ADL (P = 0.01). CONCLUSION: Arthroscopic treatment for FAI resulted in excellent results in terms of return to sport. Moreover, lighter weight and younger age, greater HHS, NAHS, HOS-ADL at baseline were positively associated with post-operative sport activity level. LEVEL OF EVIDENCE: IV, systematic review.

Arthroscopic versus mini-open rotator cuff repair: A meta-analysis.

BACKGROUND: An all-arthroscopic rotator cuff repair (ASR) may result in less postoperative pain and better functional outcomes than the mini-open (MOR) approach. This meta-analysis provides an updated assessment of the current literature which compares the clinical outcomes of mini-open versus all arthroscopic rotator cuff repair techniques. MATERIAL AND METHODS: The main online databases were accessed in October 2021. All the trials directly comparing primary ASR versus MOR for rotator cuff rupture were accessed. Studies concerning revision settings were not eligible, nor where those combining the surgical procedures with other adjuvants. RESULTS: A total of 21 articles were retrieved. Data from 1644 procedures (ASR = 995, MOR = 649) were collected. The mean follow-up was 26.7 (6.0-56.4) months. Comparability was found between ASR and MOR groups at baseline with regards to age (P = 0.3), gender (P = 0.7) and mean duration of the follow-up (P = 0.7). No difference was found between ASR and MOR with regard to surgical duration (P = 0.05), Constant score (P = 0.2), University of California at Los Angeles Shoulder (P = 0.3), American Shoulder and Elbow Surgeons Shoulder (P = 0.5), VAS (P = 0.2), forward flexion (P = 0.3), abduction (P = 0.3), external rotation (P = 0.2), internal rotation (P = 0.7), re-tear (P = 0.9), adhesive capsulitis (P = 0.5). CONCLUSION: Arthroscopic and mini-open rotator cuff repair result in similar clinical outcomes. Male gender and older age lead to greater rates of rotator cuff re-tears, while longer surgical duration was associated with a greater rate of adhesive capsulitis.

Matrix-induced autologous chondrocyte implantation (mACI) versus autologous matrix-induced chondrogenesis (AMIC) for chondral defects of the knee: a systematic review.

INTRODUCTION: Chondral defects of the knee are common and their treatment is challenging. SOURCE OF DATA: PubMed, Google scholar, Embase and Scopus databases. AREAS OF AGREEMENT: Both autologous matrix-induced chondrogenesis (AMIC) and membrane-induced autologous chondrocyte implantation (mACI) have been used to manage chondral defects of the knee. AREAS OF CONTROVERSY: It is debated whether AMIC and mACI provide equivalent outcomes for the management of chondral defects in the knee at midterm follow-up. Despite the large number of clinical studies, the optimal treatment is still controversial. GROWING POINTS: To investigate whether AMIC provide superior outcomes than mACI at midterm follow-up. AREAS TIMELY FOR DEVELOPING RESEARCH: AMIC may provide better outcomes than mACI for chondral defects of the knee. Further studies are required to verify these results in a clinical setting.

Gait symmetry - A valid parameter for pre and post planning for total knee arthroplasty.

OBJECTIVES: We aimed to determine whether GS can help to plan and rearrange the treated side by using IMUs to measure the joint angle of the hip, knee, and ankle. We hypothesized that the kinematics in healthy individuals for both sides are approximately equal during walking. METHODS: IMUs were used to measure the joint angles of 25 healthy participants during walking. The participants performed the 10-meter walk test. The normalized symmetry index (SInorm) was used to calculate the symmetry of joint angles for the hip, knee, and ankle throughout the gait cycle. RESULTS: The SInorm demonstrated high symmetry between both legs; and the ranges were -1.5% and 1.1% for the hip, -3.0% and 3.1% for the knee, and -12% and 9.2% for the ankle joint angle throughout the gait cycle. CONCLUSION: The SInorm provides strong information that can be helpful in the planning process for the surgeries. Further, the IMUs system gives the possibility to measure the patients before their surgeries and use their data to plan and rearrange for the operated side.

Analysis of the pulmonary function in patients undergoing vertebral body tethering for adolescent idiopathic scoliosis.

PURPOSE: The literature concerning the effects of scoliosis correction on pulmonary function (PF) is scarce and solely related to spinal fusion. Vertebral body tethering (VBT) represents a new option for scoliosis correction; however, its effects on PF have not yet been investigated. As VBT is a fusion-less technique that does not limit the dynamics of the chest wall, it is expected not to have a negative impact on PF despite the anterior surgical approach. METHODS: We analyzed the PF preoperatively and compared it with the PF at 6-weeks, 6-months and 12-monthts postoperatively. Considered parameters were total lung capacity (TLC), forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) expressed as percentages. A change of more than 10% was considered clinically significant. RESULTS: Before VBT, overall TLC, FEV1 and FVC measured 98 ± 15%, 85 ± 16% and 91 ± 17%, respectively. Six weeks after surgery, all parameters were comparable to the preoperative values (TLC 96 ± 17%, FEV1 84 ± 14%, FVC 90 ± 16%) and remained so at the last follow-up (TLC 99 ± 15%, FEV1 89 ± 9%, FVC 86 ± 9). While a reduction in FEV1 and FVC was observed at 6-weeks and 6-months in patients with thoracic or double curves compared to thoracolumbar curves, no significant differences were observed at the 12-months follow-up. CONCLUSIONS: VBT does not cause a reduction in PF values at a short-term follow-up.

Comparable outcome for autografts and allografts in primary medial patellofemoral ligament reconstruction for patellofemoral instability: systematic review and meta-analysis.

PURPOSE: This study updates the current evidence on the role of allografts versus autografts for medial patellofemoral ligament (MPFL) reconstruction in patients with patellofemoral instability. METHODS: The study was performed according to the PRISMA guidelines. In March 2021, a literature search in the main online databases was performed. Studies reporting quantitative data concerning primary MPFL reconstruction using an allograft were considered for inclusion. The Coleman Methodology Score was used to assess the methodological quality of the selected articles. RESULTS: Data from 12 studies (474 procedures) were retrieved. The mean follow-up was 42.2 (15-78.5) months. The mean age was 21.1 ± 6.2 years. 64.9% (285 of 439) of patients were female. At the last follow-up, the Tegner (p < 0.0001), Kujala (p = 0.002) and the Lysholm (p < 0.0001) scores were minimally greater in the autografts. The similarity was found in the rate of persistent instability sensation and revision. The allograft group evidenced a lower rate of re-dislocations (p = 0.003). CONCLUSION: Allografts may represent a feasible alternative to traditional autograft for MPFL reconstruction in selected patients with patellofemoral instability. Allograft tendons yielded similar PROMs, rates of persistent instability, and revision. Allograft reconstructions tended to have modestly lower re-dislocation rates. LEVEL OF EVIDENCE: IV.

Closed suction drainages in Lower Limb Joint Arthroplasty: A level I evidence based meta-analysis.

INTRODUCTION: The role of closed suction drainage during elective total joint arthroplasty is still unclear. The present study compared the use of closed suction drains to no drainage for elective total knee arthroplasty (TKA) and in total hip arthroplasty (THA) through a meta-analysis of randomized clinical trials (RCTs). METHODS: Following the PRISMA guidelines, a meta-analysis of randomized controlled trials identified in December 2021. All randomized clinical trials comparing the use of closed suction drains to no drainage for elective THA or TKA were considered. RESULTS: Twenty-five RCTs were included in the final analysis. 49% (1722 of 3505) of patients received no-drainage, and 51% (1783 of 3505) received closed suction drainage. There was no evidence of a statistically significant evidence between the two groups in occurrence of postoperative infections (P = 0.4), mean total postoperative hemoglobin (P = 0.2) or length of hospital stay (P = 0.1). The no-drainage group showed a lower rate of blood transfusion (P < 0.0001). CONCLUSION: There is no evidence to support the routine use of closed suction drainage in THA or TKA patients. LEVEL OF EVIDENCE: Level I, meta-analysis of randomized clinical trials.

Surgical versus conservative management of traumatic proximal adductor longus avulsion injuries: A systematic review.

BACKGROUND: Proximal avulsion injuries of the adductor longus have been managed both conservatively and operatively with good clinical outcomes, but there is no consensus on which option yields the best results. Thus, the present study aimed to review the available literature, comparing the outcomes and the time to return to sports with different management options. MATERIAL AND METHODS: This study was conducted according to the PRISMA statement. The literature search was conducted in September 2020. All the clinical trials investigating the management of traumatic proximal adductor longus avulsion injuries were considered for inclusion. Only studies reporting data from athletes were considered. The outcomes of interest were the time to return to sport and return to preinjury activity level. RESULTS: Data from 46 patients were retrieved. The mean follow-up was 24.6 ± 23.8 months. The study population was represented by male athletes with a mean age of 30.0 ± 4.8. Mean stump retraction was 3.3 ± 0.6 cm in the surgical and 1.7 ± 0.6 in the conservative cohort (P = 0.07). The rate of patients returning to prior activity level was similar in the two groups, but surgically treated patients required a longer time to return to sport (3.9 ± 1.5 months vs. 2.2 ± 1.0 months, P = 0.0001). CONCLUSION: Conservative management for traumatic avulsion of the proximal adductor longus insertion may produce shorter time to return to sport. Both conservative and operative strategies allowed to achieve similar pre-injury activity level. LEVEL OF EVIDENCE: IV, systematic review.

Increased range of motion but otherwise similar clinical outcome of arthroscopy over open osteoplasty for femoroacetabular impingement at midterm follow-up: A systematic review.

BACKGROUND: A systematic review was conducted comparing patient reported outcomes measures (PROMs), functional scores, and the rate of complications between arthroscopic and open treatment for femoroacetabular impingement (FAI) at mid-term follow-up. MATERIAL AND METHODS: This systematic review was performed according to the PRISMA guidelines. The literature search was performed in October 2020. All clinical trials treating FAI using open osteoplasty or arthroscopic surgery were considered for inclusion. Only articles reporting >12 months follow-up were included. RESULTS: Data from 97 articles (9981 procedures) were collected. At a mean 19.2 months follow-up there was no difference between the two cohorts. At a mean follow-up of 38 months, the external rotation was increased in the arthroscopic group (P < 0.0001). The modified Harris Hip Score scored greater in favour of the open osteoplasty group (P = 0.04), as did the Hip Outcome Score - Activities of Daily Living subscale (P = 0.01). At a mean 45.1 months the arthroscopic group presented greater external rotation (P < 0.0001) and SF-12 Mental (P = 0.04). The modified Harris Hip Score was greater in favour of the open osteoplasty group (P = 0.03), as was the HOS-ADL (P = 0.01). Regarding complications, the arthroscopic group experienced lower rates of subsequent revisions (P < 0.0001). CONCLUSION: Based on the significant reduction of revisions-rate and significant increase in range of motion, arthroscopy treatment for the management of FAI may be recommended.

Prognostic factors for isolated medial patellofemoral ligament reconstruction: A systematic review.

BACKGROUND: Evidence concerning the influence gender, age, and the time elapsed from the first dislocation to surgery in the outcomes of Medial Patella Femoral Ligament (MPFL) reconstruction are lacking. This systematic review was conducted to investigate whether patient characteristics have an influence in the clinical outcomes of MPFL reconstruction for patients with patellofemoral instability. MATERIAL AND METHODS: This study followed the PRISMA guidelines. The main databases were accessed in February 2021. All the studies reporting outcomes of primary MPFL reconstruction in patients with recurrent patellofemoral instability were considered for inclusion. A multivariate analysis diagnostic tool was used to analyse the association between age, gender and time from injury to surgery and the surgical outcomes at last follow-up. RESULTS: A total of 50 articles (2037 procedures) were included. The mean follow-up was 40.90 ± 24.8 months. The mean age was 23.6 ± 3.9 years. 64.3% (1309 of 2037 patients) were female. The mean time from injury to surgery was 64.5 ± 48.9 months. Women showed no statistically significant association with the Kujala score or complications. Older patients had a reduced risk to incur re-dislocations (P = 0.01) and revisions (P = 0.01). Longer time from injury to surgery was associated with greater risk to incur re-dislocations (P = 0.01), and with lower Kujala score (P < 0.0001). No other statistically significant association was evidenced. CONCLUSION: The time span from the first patellar dislocation to the surgical reconstruction was a negative prognostic factor, while sex had no influence on surgical outcomes. The role of patients age on surgical outcomes remains unclear.

Arthroscopic labral repair for femoroacetabular impingement: A systematic review.

BACKGROUND: The present systematic review investigated return to sport, patient reported outcome measures (PROMs), complications and subsequent progression to total hip arthroplasty (THA) in patients undergoing arthroscopic labral repair for FAI. MATERIAL AND METHODS: Following the PRISMA statement, the literature search was performed in February 2021. The outcomes of interest were: rate of return to sport, modified Harris Hip Score (mHHS), the subscales Activities of Daily Living and Sport-Specific Subscale of the Hip Outcome Score (HOS-ADL and HOS-SSS, respectively). Complications, revision surgeries and progression to total hip arthroplasty were recorded. RESULTS: Data from 210 procedures were retrieved. The mean follow-up was 34.0 (24.0-42.5) months. The mean age of the patients was 32.0 (20.0-47.0) years, while the mean BMI was 20.9 (20.1-21.7) kg/m2. 52.8% (111 of 210 patients) were women. At 24-month follow-up, 100% of the patients had returned to sport. At a mean of 34 months follow-up, the mean mHHS increased by 25.5% (P = 0.02), the mean HOS-ADL by 23.0% (P = 0.03), the mean HOS-SSS by 32.8% (P = 0.001). No complications were observed. The rate of revision was 4.3% (9 of 210 procedures). At a mean of 37.9 ± 7.5 months, 1.9% of patients (4/210) underwent THA. CONCLUSION: Arthroscopic labral refixation for FAI yields reliably positive clinical outcomes, with a low rate of revision and conversion to THA.

Tourniquet use during knee arthroplasty: A Bayesian network meta-analysis on pain, function, and thromboembolism.

BACKGROUND: The role of a tourniquet for knee arthroplasty remains controversial. The present Bayesian network meta-analysis investigated the role of various protocols for tourniquet inflation for knee arthroplasty, assessing data on pain control, clinical and functional outcomes, and the rate of deep vein thrombosis (DVT). MATERIAL AND METHODS: The present Bayesian network meta-analysis was conducted according to the PRISMA guidelines. In March 2021, all clinical trials investigating the role of tourniquet use for knee arthroplasty were considered for inclusion. Groups were divided into those which used a tourniquet in knee arthroplasty procedures versus those which completed the procedure without tourniquet, or with varying protocols of tourniquet use. The hierarchical random-effects model analysis was adopted in all comparisons. RESULTS: Data from 54 articles (5497 procedures) were retrieved. The absence of tourniquet group evidenced the lowest rate of DVT, and scored the lowest in the visual analogic scale (VAS) at 24-48 h, 1, 3, and 12 months follow-up. The same group evidenced the greatest gain of motion at 3-days, 1 week, 1 month, 3 months, 6 months, and 12 months follow-up, and the highest Knee Society Rating System scores at 1, 3, and 12 months follow-up. Of the outcome data assessed, the straight-leg-raise test was markedly inconsistent: therefore, no recommendations from this test can be made. CONCLUSION: With regards to the endpoints considered in the present study, knee arthroplasties undertaken without the use of a tourniquet perform better overall.

No benefits of minimally invasive total hip arthroplasty via Watson-Jones approach: A retrospective cohort study.

INTRODUCTION: There is controversy about the role of minimally invasive surgery (MIS) for total hip arthroplasty (THA). The present study aimed to investigate whether a MIS approach has a positive impact on the outcome of THA via the Watson-Jones anterolateral approach. Clinical scores and radiological findings of minimally and standard invasive exposures were evaluated and compared. METHODS: The present study was conducted according to the STROBE statement. Patients operated between 2017 and 2018 in two different orthopaedic institutions was performed. Patients with symptomatic coxarthrosis reducing considerably patient's quality of life were asked to participate in the present study. Patients were divided into two THA groups: MIS and standard invasive surgery (SIS). Surgical procedures were performed in by two experienced surgeons via the Watson-Jones approach. RESULTS: Data from 140 patients were collected (70 patients for each group) at two years follow-up. Leg length discrepancy was greater in the MIS cohort (P = 0.01). The Stiffness subscale of the WOMAC score resulted minimally increased in the SIS group (P = 0.03). The overall WOMAC score and the other subscales resulted similar between the two groups. Femoral offset, acetabular offset, cup orientation, cup inclination, VAS resulted similar between the two cohorts. Only a case of revision in the SIS group was reported. CONCLUSION: THA via the Watson-Jones approach achieves short terms excellent results. Surgery performed via a MIS approach does not provide any superior outcome compared to the SIS in terms of radiographic findings and clinical scores at two years follow-up.

Identification of co-expression network correlated with different periods of adipogenic and osteogenic differentiation of BMSCs by weighted gene co-expression network analysis (WGCNA).

BACKGROUND: The differentiation of bone marrow mesenchymal stem cells is a complex and dynamic process. The gene expression pattern and mechanism of different periods of adipogenic and osteogenic differentiation remain unclear. Additionally, the interaction between these two lineage determination requires further exploration. RESULTS: Five modules that were most significantly associated with osteogenic or adipogenic differentiation of BMSCs were selected for further investigation. Biological terms (e.g. ribosome biogenesis, TNF-α signalling pathway, glucose import and fatty acid metabolism) along with hub transcription factors (e.g. PPARG and YY1) and hub miRNAs (e.g. hsa-mir-26b-5p) were enriched in different modules. The expression pattern of 6 hub genes, ADIPOQ, FABP4, SLC7A5, SELPLG, BIRC3, and KLHL30 was validated by RT-qPCR. Finally, cell staining experiments extended the findings of bioinformatics analysis. CONCLUSION: This study identified the key genes, biological functions, and regulators of each time point of adipogenic and osteogenic differentiation of BMSCs and provided novel evidence and ideas for further research on the differentiation of BMSCs.

Membrane scaffolds for matrix-induced autologous chondrocyte implantation in the knee: a systematic review.

INTRODUCTION: Chondral defects of the knee are common and their management is challenging. SOURCE OF DATA: Current scientific literature published in PubMed, Google scholar, Embase and Scopus. AREAS OF AGREEMENT: Membrane-induced autologous chondrocyte implantation (mACI) has been used to manage chondral defects of the knee. AREAS OF CONTROVERSY: Hyaluronic acid membrane provides better outcomes than a collagenic membrane for mACI in the knee at midterm follow-up is controversial. GROWING POINTS: To investigate whether hyaluronic acid membrane may provide comparable clinical outcomes than collagenic membranes for mACI in focal defects of the knee. AREAS TIMELY FOR DEVELOPING RESEARCH: Hyaluronic acid membrane yields a lower rate of failures and revision surgeries for mACI in the management of focal articular cartilage defects of the knee compared with collagenic scaffolds at midterm follow-up. No difference was found in patient reported outcome measures (PROMs). Further comparative studies are required to validate these results in a clinical setting.

Placebo effect in pharmacological management of fibromyalgia: a meta-analysis.

INTRODUCTION: The management of fibromyalgia involves a combination of pharmacological and non-pharmacological treatments. SOURCE OF DATA: Recently published literature in PubMed, Google Scholar and Embase databases. AREAS OF AGREEMENT: Several pharmacological and non-pharmacological strategies have been proposed for the management of fibromyalgia. However, the management of fibromyalgia remains controversial. The administration of placebo has proved to be more effective than no treatment in many clinical settings and evidence supports the 'therapeutic' effects of placebo on a wide range of symptoms. AREAS OF CONTROVERSY: The placebo effect is believed to impact the clinical outcomes, but its actual magnitude is controversial. GROWING POINTS: A meta-analysis comparing pharmacological management versus placebo administration for fibromyalgia was conducted. AREAS TIMELY FOR DEVELOPING RESEARCH: Drug treatment resulted to be more effective than placebo administration for the management of fibromyalgia. Nevertheless, placebo showed a beneficial effect in patients with fibromyalgia. Treatment-related adverse events occurred more frequently in the drug treatment. LEVEL OF EVIDENCE: I, Bayesian network meta-analysis of double-blind randomized clinical trials.

Platelet-rich plasma versus steroids injections for greater trochanter pain syndrome: a systematic review and meta-analysis.

INTRODUCTION: Greater trochanter pain syndrome (GTPS) is characterized by a persistent and debilitating pain around the greater trochanter. GTPS can be caused by a combination of gluteus medius or minimus tendinopathy, snapping hip or trochanteric bursitis. SOURCE OF DATA: Recent published literatures identified from PubMed, EMBASE, Google Scholar, Scopus. AREAS OF AGREEMENT: Platelet rich plasma (PRP) and corticosteroids (CCS) injections are useful options to manage symptoms of GTPS. AREAS OF CONTROVERSY: Whether PRP leads to superior outcomes compared to CCS injections is unclear. GROWING POINTS: A systematic review and meta-analysis comparing PRP versus CCS in the management of GTPS was conducted. AREAS TIMELY FOR DEVELOPING RESEARCH: PRP injections are more effective than CCS at approximately 2 years follow-up.

Matrix-induced autologous chondrocyte implantation versus autologous matrix-induced chondrogenesis for chondral defects of the talus: a systematic review.

INTRODUCTION: Chondral defects of the talus are common and their treatment is challenging. SOURCE OF DATA: Recent published literatures. AREAS OF AGREEMENT: Membrane-induced Autologous Chondrocyte Implantation (mACI) and Autologous Matrix-Induced Chondrogenesis (AMIC) have been proposed as management for chondral defects of the talus. AREAS OF CONTROVERSY: It is debated whether AMIC provides greater outcomes compared to mACI for chondral regeneration. Several clinical studies showed controversial results, and the best treatment has not yet been clarified. GROWING POINTS: To investigate whether AMIC provide superior outcomes than mACI at midterm follow-up. AREAS TIMELY FOR DEVELOPING RESEARCH: AMIC exhibits similar clinical results to mACI. However, AMIC involves one single surgical procedure, no articular cartilage harvest and hence no morbidity from it, no need for chondrocyte expansion in a separate laboratory setting. For these reasons, AMIC may be preferred to mACI.

Failure and progression to total hip arthroplasty among the treatments for femoral head osteonecrosis: a Bayesian network meta-analysis.

INTRODUCTION: Osteonecrosis of the femoral head (ONFH) often leads to secondary osteoarthritis and total hip arthroplasty. SOURCE OF DATA: Recent published literatures. AREAS OF AGREEMENT: There has been increasing focus on the early intervention in ONFH patients to preserve the native hip articulation, reduce pain and improve function. AREAS OF CONTROVERSY: Efficacy of surgical strategies for ONFH is debated. Several clinical studies showed controversial results, and the best treatment has not yet been clarified. GROWING POINTS: To provide an overview over current treatment options for ONFH compares their failure rates and conversion to total hip arthroplasty (THA) rates. AREAS TIMELY FOR DEVELOPING RESEARCH: Core decompression (CD) augmented with autologous bone grafting plus the implantation of bone marrow concentrate can decrease the rate of failure and progression to THA rates compared to CD alone.