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Review Article | | Peer-Reviewed

Clinical Guideline for Non-Surgical Treatment of Osteonecrosis of the Femoral Head (2025 Edition)

Cheng Zhixiang,  Ding Zheng,  Wan Li,  Wang Dequan,  Tian Demin,  Li Pei,  Jin Xiaohong,  Zhao Zhongmin,  Jia Yifan,  Xu Mingmin,  Lei Guangchun,  Dai Fucheng,  Gao Deshuai,  Xu Pei,  Xing Gengyan,  Liu Yanqing*
Published in International Journal of Pain Research (Volume 2, Issue 2)
Received: 26 March 2026     Accepted: 15 April 2026     Published: 29 April 2026
Views:       Downloads:
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Abstract

Background: Osteonecrosis of the femoral head (ONFH) is a prevalent and refractory condition in orthopedic clinical practice. In recent years, an increasing number of patients have been diagnosed in the early stages of the disease. Consequently, traditional surgical interventions alone can no longer satisfy current clinical needs, highlighting the urgent demand for effective non-surgical management strategies. Objective: This guideline aims to provide a standardized framework for the non-surgical treatment of ONFH. It focuses on how to rationally and effectively apply these methods to delay disease progression, improve hip joint function, postpone or even avoid surgery, and ultimately achieve the goal of hip preservation. Methods: This guideline systematically evaluates and synthesizes evidence on the application of various non-surgical treatment modalities in the prevention and management of ONFH. These modalities include general therapy, pharmacotherapy, physical therapy, traditional Chinese medicine, minimally invasive interventions, and rehabilitation. Conclusion: The rational and evidence-based application of non-surgical treatments is of great significance for patients with early-stage ONFH. By following this guideline, clinicians can develop individualized, comprehensive non-surgical regimens that effectively control risk factors, alleviate symptoms, retard the collapse of the femoral head, preserve native hip function, and improve patients' quality of life, thereby reducing the long-\term need for hip arthroplasty.

Published in International Journal of Pain Research (Volume 2, Issue 2)
DOI 10.11648/j.ijpr.20260202.12
Page(s) 38-55
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2026. Published by Science Publishing Group
Previous article
Keywords

Osteonecrosis of the Femoral Head, Non-Surgical Treatment, Therapeutics, Guideline

1. Introduction
Osteonecrosis of the femoral head (ONFH) is a common and frequently occurring clinical disease that often causes hip joint pain and functional impairment, with a high disability rate. In recent years, its incidence has been increasing. Late-stage patients often require total hip arthroplasty (THA), placing a heavy burden on patients, families, and society. Therefore, at the early stage of ONFH, receiving standardized, individualized non-surgical treatment, including platelet-rich plasma (PRP), extracorporeal shock wave therapy (ESWT), ozone therapy, and cell therapy, can significantly delay disease progression, improve hip joint function, and postpone or even avoid surgery, which is of great significance to ONFH patients.
Although previously published expert consensuses and clinical guidelines
[1-14]
on ONFH have greatly promoted the standardization of ONFH diagnosis and treatment, no comprehensive clinical guideline specifically addressing non-surgical treatment of ONFH has been identified. To further enhance clinicians' capacity for standardized ONFH management, the Society of Platelet Rich Plasma Medicine (Chinese Aging Well Association), the Society of Painology (Chinese Aging Well Association), the Shock Wave Medical Professional Committee (Chinese Research Hospital Association), and the Editorial Board of the Chinese Journal of Painology organized experts to jointly formulate this guideline, based on high-level evidence-based literature published domestically and internationally, combined with domestic clinical experience, following multiple rounds of discussion and revision.
2. Guideline Development Methodology
The literature search period covered from database inception through June 2025. Chinese search terms included: osteonecrosis of the femoral head, avascular necrosis of the femoral head, ischemic necrosis, aseptic necrosis, etc. English search terms included: osteonecrosis of the femoral head, femoral head necrosis, avascular necrosis, aseptic necrosis, etc. Well-known domestic and international databases, including Wanfang, CNKI, PubMed, and Cochrane Library, were systematically searched. Priority was given to high-quality evidence-based literature, including systematic reviews, meta-analyses, randomized controlled trials (RCTs), case-control studies, cohort studies, expert consensuses, and clinical guidelines. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used for evidence quality grading and recommendation strength classification (Table 1)
[15-17]
. After multiple rounds of discussion and online voting, this guideline was finalized.
Table 1. GRADE Evidence Quality Grading and Recommendation Strength.

Grade

Evidence Quality

Description

High (A)

Evidence Quality

Very confident that the estimate is close to the true value

Moderate (B)

Evidence Quality

Moderately confident in the estimate; it is likely close to the true value, but there is a possibility of a substantial difference

Low (C)

Evidence Quality

Limited confidence in the estimate; it may differ substantially from the true value

Very Low (D)

Evidence Quality

Very little confidence in the estimate; it is likely to differ substantially from the true value

Grade

Recommendation Strength

Description

Strong (1)

Recommendation Strength

Most patients would choose the recommended approach; most clinicians should accept it; >70% of expert panel members agree

Weak (2)

Recommendation Strength

Many but not all patients would choose it; clinicians should review evidence with patients; 50–70% of panel members agree

No clear recommendation (3)

Recommendation Strength

Benefits and harms are balanced; insufficient evidence; <50% of panel members agree
GRADE = Grading of Recommendations Assessment, Development and Evaluation
3. Overview
3.1. Definition
ONFH, also known as avascular necrosis or aseptic necrosis of the femoral head, is a pathological process in which venous stasis, impaired or interrupted arterial blood supply to the femoral head leads to death of bone cells and bone marrow components, and subsequent impairment of repair processes. ONFH is a common cause of hip disability, manifesting as persistent hip pain, limited mobility, and reduced quality of life, placing a heavy burden on patients and their families
[6]
.
3.2. Epidemiology
To date, no global epidemiological data on ONFH has been published. ONFH predominantly affects young and middle-aged adults, with peak incidence at 40–50 years of age. In China, the prevalence of non-traumatic ONFH in individuals aged 15 years and above is 0.725%
[18]
, with an overall upward trend
[7]
. Prevalence is higher in males than females (1.02% vs. 0.51%) and higher in northern than southern China (0.85% vs. 0.61%)
[9]
. High-risk groups include individuals with alcoholism, steroid abuse, smoking
[19]
, diabetes, and hypercoagulable states.
3.3. Classification and Etiology
ONFH is classified etiologically into traumatic ONFH and non-traumatic ONFH.
3.3.1. Traumatic ONFH
Mainly caused by direct disruption of blood supply to the femoral head due to femoral head fracture, femoral neck fracture, acetabular fracture, hip dislocation, or severe hip sprain or contusion. It predominantly affects young adults with a clear history of trauma.
3.3.2. Non-traumatic ONFH
The etiology is not fully elucidated. Common precipitating factors include long-term use of corticosteroids, chronic excessive alcohol consumption, lipid metabolism disorders, coagulation dysfunction, and decompression sickness
[10, 11]
.
3.4. Pathogenesis
The pathophysiological mechanism of ONFH involves various factors (mechanical, chemical, etc.) that disrupt the blood circulation of the femoral head, leading to death of bone cells and bone marrow cells, impairing repair, and subsequently causing structural changes in the femoral head, resulting in hip pain and functional impairment
[7]
. The pathological changes of ONFH manifest as cell necrosis in the early stage, and coexistence of necrosis and repair in the middle and late stages. The main pathogenesis theories include venous outflow obstruction, arterial occlusion, fat embolism, vascular disease and intravascular coagulation, osteocyte and bone marrow fat cell necrosis, increased blood viscosity, and micro-fracture theories
[1-14]
.
3.5. Diagnosis and Differential Diagnosis
3.5.1. Diagnostic Criteria
(1) Clinical Manifestations
ONFH typically presents as deep pain in the periarticular hip region (82% in the inguinal area, 15% in the buttock, 3% in the proximal thigh), with gradual progression. Pain is initially more prominent with weight-bearing and partially relieved by rest; in late stages it may progress to persistent rest pain. Approximately 35% of patients have referred knee pain.
(2) Imaging Examinations
MRI is the gold standard for ONFH diagnosis with a sensitivity of 99%: (i) T1WI: subchondral band-like low signal (specificity 98%), surrounding a central high-signal necrotic zone; (ii) T2WI: "double-line sign" (inner high-signal ring + outer low-signal ring), with fat-suppressed sequences showing diffuse bone marrow edema in the femoral head-neck region (indicating collapse risk); (iii) DWI sequence: elevated apparent diffusion coefficient in early ischemic areas (sensitivity 93%).
X radiography is a basic screening tool: (i) early findings include patchy sclerosis/cystic changes in the femoral head with a positive rate <30%; (ii) progressive stage shows the "crescent sign" (subchondral fracture) and femoral head deformity; (iii) late stage shows joint space narrowing and acetabular cystic changes
[5]
.
CT is used to assess the degree of collapse. It has superior clarity and positive rate for subchondral fractures compared to MRI and plain films. Coronal reconstruction clearly shows the subchondral fracture line, with a detection rate 40% higher than plain films. Disappearance of the "asterisk sign" and trabecular disorganization are early specific findings.
Other imaging modalities serve as supplementary tools: radionuclide tomography has relatively high sensitivity but lower specificity
[20]
. Digital subtraction angiography is an invasive examination and not used routinely.
(3) Other Examinations
Hip arthroscopy
[21]
and bone tissue biopsy (tissue obtained only during surgical procedures) may also be used.
3.5.2. Differential Diagnosis
ONFH lacks specific clinical features in its early stages and may be confused with other hip conditions, leading to misdiagnosis or missed diagnosis.
1) Hip osteoarthritis. More common in middle-aged and elderly patients; persistent pain with morning stiffness; radiographically characterized by joint space narrowing and osteophyte formation, whereas early ONFH has normal joint space with "crescent sign" or "double-line sign" in the necrotic zone.
2) Transient osteoporosis. Presents as acute hip pain with bone marrow edema; MRI shows homogeneous low signal on T1WI and homogeneous high signal on T2WI without band-like signals of necrotic foci; lesions typically resolve spontaneously within 3–12 months
[22]
.
3) Bone infarction. Occurs in the diaphysis or metaphysis; MRI shows "map-like" necrotic foci without subchondral fractures or femoral head collapse; CT may show calcification or ossification in the medullary cavity.
4) Hip tuberculosis. Associated with systemic symptoms such as low-grade fever and night sweats; radiographically shows joint surface destruction and cold abscess; positive PPD test and T-SPOT test.
5) Ankylosing spondylitis with hip involvement. Predominantly in adolescent males; HLA-B27 positive; sacroiliac joint involvement precedes hip involvement; late-stage joint ankylosis.
6) Pigmented villonodular synovitis. MRI shows diffuse synovial thickening with T2WI low-signal nodules; joint aspiration reveals blood-stained effusion
[13]
.
3.6. Staging of ONFH
An ideal ONFH staging system should accurately reflect the pathological process, stage, location, extent, and degree of collapse of necrosis, and be able to guide treatment and prognosis. The ARCO (Association Research Circulation Osseous) staging system
[8]
and Chinese staging system
[22]
are widely used in clinical practice.
3.6.1. ARCO Staging
ARCO staging combines plain radiography, CT, MRI, and bone scanning to determine the location and size of necrotic areas, providing greater value in establishing diagnosis, evaluating efficacy, and prognosis (Table 2).
Table 2. ARCO Staging of ONFH (2019 Version).

Stage

Stage 1

Stage 2

Stage 3A (Early)

Stage 3B (Late)

Stage 4

Imaging

Normal X-ray/CT; abnormal bone scan or MRI

Abnormal X-ray, CT, and MRI

Subchondral fracture on X-ray or CT

Subchondral fracture on X-ray or CT

Osteoarthritis on X-ray

Examination

Bone scan, MRI

X-ray, CT, bone scan, MRI

X-ray, CT

X-ray, CT

X-ray

Description

Low-signal band in necrotic zone on MRI; cold area on bone scan; normal X-ray

Sclerosis, local osteoporosis, or cystic changes; no evidence of subchondral fracture or collapse

Subchondral fracture/partial collapse; femoral head collapse ≤2 mm

Subchondral fracture/partial collapse; femoral head collapse >2 mm

Hip osteoarthritis with joint space narrowing; acetabular changes
ARCO = Association Research Circulation Osseous
3.6.2. Chinese Staging
The Chinese staging system incorporates symptoms, signs, and early imaging features of bone necrosis in each stage, along with assessment of necrosis volume and degree of joint involvement. Each stage is further subdivided into subtypes, making it more operationally practical (Table 3).
Table 3. Chinese Staging of ONFH.

Stage

Clinical Manifestations

Imaging

Pathological Changes

Stage I (Preclinical, no collapse) Ia: small, <15%; Ib: medium, 15–30%; Ic: large, >30%

None

MRI(+); bone scan(+); X-ray(-); CT(-)

Bone marrow tissue necrosis, osteocyte necrosis

Stage II (Early, no collapse) IIa: small, <15%; IIb: medium, 15–30%; IIc: large, >30%

None or mild

MRI(+) X-ray(±) CT(+)

Absorption of necrotic foci, tissue repair

Stage III (Intermediate, pre-collapse) IIIa: small, <15%; IIIb: medium, 15-30%; IIIc: large, >30%

Onset of pain, limping, moderate-to-severe pain, limited internal rotation

MRI T2WI shows marrow edema; CT shows subchondral fracture; X-ray shows an interruption in the outer contour of the femoral head, "crescent sign" positive

Subchondral fracture or necrotic bone fracture

Stage IV (Middle-late, collapse stage) IVa: mild <2mm; IVb: medium 2–4mm; IVc: severe >4mm

Severe pain, worsened limping, all ROM limited

X-ray shows femoral head collapse, normal joint space

Femoral head collapse

Stage V (Late, osteoarthritis)

Severe pain, all ROM severely restricted

X-ray shows flattened femoral head, narrowed joint space, acetabular cystic/sclerotic changes

Cartilage involvement, osteoarthritis
Note: ONFH refers to osteonecrosis of the femoral head. The assessment of the necrotic area is performed using MRI or CT coronal plane images, and the necrotic volume is evaluated based on the number of affected planes. In stage III, the risk of collapse is assessed by determining the proportion of the crescent sign to the length of the joint surface on frog-leg or upright X-rays. In stage IV, the degree of collapse is evaluated by measuring the depth of joint surface collapse on anteroposterior or frog-leg X-ray films. For patients who present with hip pain but show no femoral head collapse on X-ray, further MRI and CT examinations are required. The presence of bone marrow edema or subchondral bone plate fracture suggests that the necrosis has progressed to stage III. If femoral head collapse and hip pain have persisted for more than six months, significant degeneration of the articular cartilage (stage V) is indicated.
3.7. Non-Surgical Treatment of ONFH
ONFH treatment includes conservative therapy, minimally invasive therapy, and surgical therapy (Table 4). Non-surgical treatment refers to conservative and minimally invasive therapy, encompassing general treatment, medication, TCM therapy, physical therapy, minimally invasive therapy, and rehabilitation. It aims to interrupt the vicious cycle of ischemia-necrosis-collapse at an early stage, primarily through strategies such as improving microcirculation (e.g., ESWT, hyperbaric oxygen), regulating bone metabolism (e.g., bisphosphonates, lipid-lowering drugs), and inhibiting apoptosis (e.g., cell therapy), thereby delaying disease progression. It is mainly indicated for early-to-middle stage ONFH patients, as well as late-stage patients who cannot or are unwilling to undergo surgery. Non-surgical treatment is an important option for hip preservation in early ONFH. Individualized treatment plans should be formulated based on the location and extent of necrosis, staging, and the patient's general condition.
Table 4. Common Treatment Methods for ONFH.

Category

Treatment Type

Representative Techniques/Drugs

Applicable Stages

Contraindications

Conservative

General Therapy

Health education, psychological therapy, self-management

All ONFH stages (combined with other modalities)

None

Conservative

Medication

Technetium [99Tc] MDP, TCM, lipid-lowering drugs, anticoagulants, osteogenic drugs

Stage I-III (early-to-middle stage);

also as adjunct

See individual drug contraindications

Conservative

TCM Therapy

Internal TCM treatment,

external TCM treatment

All ONFH stages

None

Conservative

Physical Therapy

ESWT, pulsed electromagnetic field, hyperbaric oxygen

ESWT: Stage I, II; EMF/HBO as adjuncts

See individual technique contraindications

Conservative

Rehabilitation

ROM training, muscle strengthening, TCM rehabilitation

Throughout entire treatment course

None

Minimally Invasive

Minimally Invasive Intervention

PRP, cell therapy, ozone, radiofrequency

Pre-collapse Stage I–III

Active malignancy, severe immune/hematologic disorders, uncontrolled infection, organ failure

Minimally Invasive

Minimally Invasive Surgery

Core decompression (various techniques)

ARCO Stage I, II; Stage III A may be considered

Collapse >2mm, involvement >30%, unable to comply with post-op restrictions

Surgical

Hip-Preserving Surgery

Bone grafting, osteotomy, metal rod implantation

Stage I–III (early-to-middle stage)

Uncontrolled infection, coagulopathy, severe cardiopulmonary dysfunction

Surgical

Joint Replacement

Total hip replacement, hip resurfacing

Stage III–IV with severe functional loss or moderate-to-severe pain

Uncontrolled infection, coagulopathy, severe cardiopulmonary dysfunction
ONFH = osteonecrosis of the femoral head; PRP = platelet-rich plasma; ESWT = extracorporeal shock wave therapy; ARCO = Association Research Circulation Osseous
3.7.1. General Treatment
General treatment mainly includes health education
[23-25]
, psychological therapy
[26-28]
, and self-management
[1-14, 29]
, and should be integrated throughout the entire ONFH treatment process (Table 5). Health education helps patients understand the causes, treatment methods, and precautions for ONFH, emphasizing the importance of alcohol cessation, smoking cessation, blood glucose control, weight reduction, and avoidance of excessive weight-bearing. The overall mental health status of ONFH patients is generally poor, requiring targeted psychological treatment and intervention. Self-management includes lifestyle modification, protective weight-bearing, weight control, and use of assistive devices (canes, crutches, walking frames); wheelchairs are not recommended.
Table 5. Evidence Quality and Recommendation Strength for General Treatment of ONFH.

Treatment Type

Evidence Level

Recommendation Strength

Health Education

[23-25]

B

1

Psychological Therapy

[26-28]

B

1

Self-Management

[1-14, 29]

A

1
3.7.2. Medication
Although no specific drug has been established for the prevention and treatment of ONFH, the role of pharmacotherapy in overall ONFH management continues to grow
[4]
. Drugs commonly used in clinical treatment of ONFH include bisphosphonates, TCM preparations, osteogenic drugs, anticoagulants, and lipid-lowering drugs
[4]
. Although common bisphosphonates such as zoledronic acid and alendronate can inhibit osteoclast formation, they do not improve ONFH outcomes
[30-36]
. Technetium [99Tc] methylene diphosphonate (MDP) is a China-original radiopharmaceutical that can improve hip joint function in early ONFH and exert bone-protective effects
[37-39]
. TCM preparations are also widely applied in ONFH management
[40-52]
. Cervus and cucumis polypeptides injection
 [53-56] 
and levodopa-benserazide
 [57, 58] 
are used to promote bone repair and enhance osteogenic activity. Enoxaparin
[59-61]
is employed to improve intraosseous microcirculation and prevent thrombus formation. Simvastatin
[62-64] 
is administered to regulate lipid metabolism and reduce the risk of corticosteroid- or alcohol-induced osteonecrosis. Evidence Quality and Recommendation Strength for Pharmacotherapy of ONFH (Table 6).
Table 6. Evidence Quality and Recommendation Strength for Pharmacotherapy of ONFH.

Drug Category

Common Drugs

Evidence Level

Recommendation Strength

Bisphosphonates

[30]

*NOT recommended: Zoledronic acid

[31-35]

A

1

*NOT recommended: Alendronate

[31-36]

A

1

Technetium [99Tc] MDP

[37-39]

B

1

TCM

[40-
52]

Xianling Gubao Capsules

[47-49]

A

1

Tongluo Shenggu Capsules

[50, 51]

B

2

Gutouyusheng Capsules

[52]

B

2

Osteogenic drugs

Cervus and Cucumis Polypeptides Injection

[53-56]

A

1

Levodopa-benserazide

[57, 58]

B

3

Anticoagulants

Enoxaparin

[59-61]

B

2

Lipid-lowering drugs

Simvastatin

[62-64]

B

2
*High-quality evidence indicates that zoledronic acid and alendronate do not improve outcomes in ONFH patients; therefore, this guideline does NOT recommend their use for ONFH.
3.7.3. Physical Therapy
Physical therapy, as a non-invasive treatment modality, plays an important role in ONFH management. It mainly includes ESWT
[2, 65-71]
, hyperbaric oxygen (HBO)
[72-76]
, and pulsed electromagnetic field (PEMF) therapy
[77, 78]
(Table 7). These can improve local blood circulation, promote bone tissue repair, alleviate pain, and improve quality of life. The main mechanisms of ESWT in ONFH treatment include tissue repair and remodeling, adhesion release, vasodilation and angiogenesis, analgesia and nerve terminal blockade, dense tissue lysis, and inflammation/infection control
[2]
.
Table 7. Evidence Quality and Recommendation Strength for Physical Therapy of ONFH.

Treatment

Evidence Level

Recommendation Strength

ESWT

[2, 65-71]

A

1

Hyperbaric Oxygen

[72-76]

A

1

Pulsed Electromagnetic Field

[77, 78]

B

2
ESWT = extracorporeal shock wave therapy
3.7.4. Traditional Chinese Medicine Treatment
TCM treatment mainly includes internal TCM therapy and external TCM therapy. External TCM therapy primarily encompasses acupuncture
[79, 80]
, needle-knife
[81-83]
, and silver needle/endothermic needle therapy
[84-86]
(Table 8).
Table 8. Evidence Quality and Recommendation Strength for TCM Treatment of ONFH.

Treatment

Evidence Level

Recommendation Strength

Acupuncture

[79, 80]

B

2

Needle-knife

[81-83]

B

2

Silver needle / Endothermic needle

[84-86]

B

2
3.7.5. Minimally Invasive Treatment
Image-guided PRP injection, cell therapy, core decompression (CD), ozone therapy, and radiofrequency therapy have shown great potential in the prevention and treatment of ONFH (Table 9) .
(1) Platelet-Rich Plasma (PRP)
PRP is a plasma concentrate derived from the patient's own peripheral blood by centrifugation, containing a high concentration of platelets. Multiple studies have shown that PRP, used alone or in combination with other therapies, can effectively relieve pain and improve hip joint function. The main mechanisms by which PRP treats ONFH include inducing angiogenesis and promoting osteogenesis to accelerate bone healing, inhibiting inflammatory responses in necrotic foci, and preventing glucocorticoid-induced cell apoptosis
[87-90]
.
(2) Cell Therapy
Cells can be administered via intravascular infusion, percutaneous catheter infusion, or core decompression infusion to promote bone tissue and vascular regeneration in the necrotic zone, alleviate hip symptoms, and delay ONFH progression. Cell therapy types discussed in this guideline (focused on non-surgical approaches) include local injection or infusion modalities:
1) Adipose tissue derivatives
[91-107]
: Including stromal vascular fraction (SVF) , autologous fat grafting (AFG), microfat, nanofat, adipose-derived stem cells (ADSCs), preadipocytes, and extracellular matrix (ECM).
2) Bone marrow tissue derivatives: Including bone marrow buffy coat, bone marrow aspirate concentrate (BMAC), bone marrow-derived cell therapies (BMDCT), bone marrow stem cells (BMSCs), bone marrow mesenchymal stem cells (BMMSCs), bone marrow mononuclear cells (BMMNCs), and bone marrow-derived exosomes.
3) Stem cell therapy: Mesenchymal stem cells (MSCs), induced pluripotent stem (iPS) cells, and transgenic cells. MSCs derived from bone marrow, adipose tissue, and umbilical cord have multipotent differentiation potential and paracrine functions, promoting tissue repair and anti-inflammatory effects.
(3) Core Decompression (CD)
[108-111]
CD creates a decompression channel within the femoral head, breaks the intraosseous hypertension environment, facilitates new blood vessel formation, and thereby delivers more nutrients and oxygen to the ONFH area to promote bone tissue repair, delay femoral head collapse, relieve pain, and improve hip function. CD types include traditional single-port CD, small-diameter dual-channel drilling CD, multi-port fine-needle CD, and modified CD.
Main indications: (i) pre-collapse lesions (ARCO Stage 1 and 2);ii) small to medium lesions, femoral head involvement <30% or Kerboul angle <200°; (iii) patients who cannot tolerate more extensive hip-preserving surgery.
(4) Ozone Therapy
[112-114]
Studies have shown that intra-articular ozone injection, autologous ozone blood reinfusion, and ozone perfusion can alleviate hip pain, restore hip function, reduce ONFH volume, reduce bone marrow edema, and prevent premature femoral head collapse.
(5) Radiofrequency Therapy
[115-117]
Pulsed radiofrequency (PRF) of hip joint branches is an alternative therapeutic approach for ONFH-related hip pain. Lumbar sympathetic nerve radiofrequency thermocoagulation is also a commonly used clinical treatment method for ONFH.
Table 9. Evidence Quality and Recommendation Strength for Minimally Invasive Treatment of ONFH.

Treatment

Subtype

Evidence Level

Recommendation Strength

PRP

[8
7-90]

—

A

1

Cell Therapy

[91-
107]

SVF

[96, 97]

B

1

BMAC

[98-100]

A

1

BMMNCs

[101-103]

A

2

BMMSCs

[98, 104-107]

A

1

Core Decompression (CD)

[108-111]

—

A

1

Ozone Therapy

[112-114]

—

B

1

Radiofrequency Therapy

[115-117]

—

B

2
PRP = platelet-rich plasma; SVF = stromal vascular fraction; BMAC = bone marrow aspirate concentrate; BMMNCs = bone marrow mononuclear cells; BMMSCs = bone marrow mesenchymal stem cells; CD = core decompression
3.7.6. Rehabilitation
Rehabilitation is an important component of non-surgical treatment for ONFH (Table 10)
[1-14, 29, 118, 119]
. ONFH should be detected and treated early. Early and active hip joint functional exercise is encouraged to promote ‘qi-blood’ circulation, improve hip joint stability, and facilitate functional recovery. Exercise should be predominantly active, supplemented by passive movement, gradually increasing in range and frequency based on ONFH staging. Early rehabilitation training is conducted in weight-reduced conditions with muscle strength, endurance, and ROM training, which is beneficial for maintaining and improving hip function and preventing muscular atrophy.
Main ONFH rehabilitation exercises include supine leg raises, seated hip abduction/adduction, standing leg raises, supported squats, and internal rotation-abduction exercises, performed 200 times per day divided into 3–4 sessions.
Table 10. Evidence Quality and Recommendation Strength for Rehabilitation of ONFH.

Treatment

Evidence Level

Recommendation Strength

Rehabilitation Therapy

[1-14, 118, 119]

A

1
3.7.7. Combination Therapy
All of the above ONFH treatment methods have established efficacy and high safety profiles. In clinical practice, different treatment modalities are often combined to achieve better outcomes. Combination regimens include: CD+Cell Therapy (bone marrow buffy coat)
 [120-128]
, CD+BMAC
[98, 99, 129]
, CD+BMDCT
[130, 131]
, CD+BMSCs
[132-138]
, CD+BMMSCs
[98, 139-142]
, CD+PRP
[88, 143-148]
, CD+Medication
[129, 149, 150]
, PRP+Cell Therapy
 [88]
, PRP+Radiofrequency
[151]
, PRP+Silver Needle
[152]
, ESWT+BMSCs
[153]
, ESWT+BMMSCs
[154]
, ESWT+Medication
 [94, 155]
, and Silver Needle+Ozone
[156]
. Common two-modality combination protocols and their evidence levels are presented in Table 11.
Table 11. Evidence Quality and Recommendation Strength for Combination Therapy of ONFH.

Combination Regimen

Evidence Level

Recommendation Strength

CD + Cell Therapy (bone marrow buffy coat)

[120-128]

B

2

CD + BMAC

[98, 99, 129]

A

1

CD + BMDCT

[130, 131]

A

1

CD + BMSCs

[132-138]

A

1

CD + BMMSCs

[98, 139-142]

A

1

CD + PRP

[88, 143-148]

A

1

CD + Medication

[129, 149, 150]

A

1

PRP + Cell Therapy

[88]

B

2

PRP + Radiofrequency

[151]

C

2

PRP + Silver Needle

[152]

C

2

ESWT + BMSCs

[153]

C

2

ESWT + BMMSCs

[154]

B

2

ESWT + Medication

[94, 155]

B

2

Silver Needle + Ozone

[156]

C

2
CD = core decompression; BMAC = bone marrow aspirate concentrate; BMDCT = bone marrow-derived cell therapy; BMSCs = bone marrow stem cells; PRP = platelet-rich plasma; BMMSCs = bone marrow mesenchymal stem cells; ESWT = extracorporeal shock wave therapy
3.8. Efficacy Assessment
3.8.1. Clinical Evaluation
1) Hip symptom assessment: e.g., Visual Analogue Scale (VAS) for pain.
2) Functional assessment: e.g., Harris Hip Score, Reconstruction Hip Score (RHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).
3) Gait analysis.
3.8.2. Radiological Evaluation
1) Plain radiography (bilateral hip AP and frog-lateral views): To assess femoral head contour collapse, joint space, and acetabular changes.
2) CT or MRI: To assess femoral head collapse and bone marrow edema.
4. Conclusion
With the rapid development of stem cells, 3D-printed scaffolds, gene therapy, and digital therapeutics, it is hoped that in the future, precise regeneration of necrotic zones and individualized rehabilitation will be achievable. Artificial intelligence will integrate imaging, omics, and dynamic monitoring data to predict collapse risk early and adjust treatment plans in real time, enabling more ONFH patients to recover a high quality of life while avoiding surgery. Multidisciplinary collaboration and real-world research will provide more comprehensive and individualized diagnostic and treatment plans for ONFH patients.
Abbreviations

ADSCs

Adipose-Derived Stem Cells

AFG

Autologous Fat Grafting

ARCO

Association Research Circulation Osseous

BMAC

Bone Marrow Aspirate Concentrate

BMDCT

Bone Marrow-Derived Cell Therapies

BMMNCs

Bone Marrow Mononuclear Cells

BMMSCs

Bone Marrow Mesenchymal Stem Cells

BMSCs

Bone Marrow Stem Cells

CD

Core Decompression

ECM

Extracellular Matrix

ESWT

Extracorporeal Shock Wave Therapy

GRADE

Grading of Recommendations Assessment, Development And Evaluation

iPS

Induced Pluripotent Stem

MDP

Methylene Diphosphonate

MSCs

Mesenchymal Stem Cells

ONFH

Osteonecrosis of the Femoral Head

PRP

Platelet-Rich Plasma

RCTs

Randomized Controlled Trials

RHS

Reconstruction Hip Score

SVF

Stromal Vascular Fraction

TCM

Traditional Chinese Medicine

THA

Total Hip Arthroplasty

VAS

Visual Analogue Scale

WOMAC

Western Ontario and Mcmaster Universities Osteoarthritis Index
Author Contributions
Cheng Zhixiang: Conceptualization, Formal analysis, Resources, Writing – original draft
Ding Zheng: Conceptualization, Data curation, Methodology
Wan Li: Conceptualization, Data curation, Methodology
Wang Dequan: Conceptualization, Data curation, Methodology
Tian Demin: Conceptualization, Data curation, Methodology
Li Pei: Conceptualization, Data curation, Methodology
Jin Xiaohong: Conceptualization, Data curation, Methodology
Zhao Zhongmin: Conceptualization, Data curation, Methodology
Jia Yifan: Conceptualization, Data curation, Methodology
Xu Mingmin: Conceptualization, Data curation, Methodology
Lei Guangchun: Conceptualization, Data curation, Methodology
Dai Fucheng: Conceptualization, Data curation, Methodology
Xing Gengyan: Conceptualization, Data curation, Methodology, Supervision, Writing – review & editing
Liu Yanqing: Conceptualization, Data curation, Methodology, Supervision, Writing – review & editing
Conflicts of Interest
All authors declare no conflicts of interest.
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    Zhixiang, C., Zheng, D., Li, W., Dequan, W., Demin, T., et al. (2026). Clinical Guideline for Non-Surgical Treatment of Osteonecrosis of the Femoral Head (2025 Edition). International Journal of Pain Research, 2(2), 38-55. https://doi.org/10.11648/j.ijpr.20260202.12

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    Zhixiang, C.; Zheng, D.; Li, W.; Dequan, W.; Demin, T., et al. Clinical Guideline for Non-Surgical Treatment of Osteonecrosis of the Femoral Head (2025 Edition). . 2026, 2(2), 38-55. doi: 10.11648/j.ijpr.20260202.12

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    Zhixiang C, Zheng D, Li W, Dequan W, Demin T, et al. Clinical Guideline for Non-Surgical Treatment of Osteonecrosis of the Femoral Head (2025 Edition). . 2026;2(2):38-55. doi: 10.11648/j.ijpr.20260202.12

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  • @article{10.11648/j.ijpr.20260202.12,
  author = {Cheng Zhixiang and Ding Zheng and Wan Li and Wang Dequan and Tian Demin and Li Pei and Jin Xiaohong and Zhao Zhongmin and Jia Yifan and Xu Mingmin and Lei Guangchun and Dai Fucheng and Gao Deshuai and Xu Pei and Xing Gengyan and Liu Yanqing},
  title = {Clinical Guideline for Non-Surgical Treatment of Osteonecrosis of the Femoral Head (2025 Edition)},
  journal = {International Journal of Pain Research},
  volume = {2},
  number = {2},
  pages = {38-55},
  doi = {10.11648/j.ijpr.20260202.12},
  url = {https://doi.org/10.11648/j.ijpr.20260202.12},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ijpr.20260202.12},
  abstract = {Background: Osteonecrosis of the femoral head (ONFH) is a prevalent and refractory condition in orthopedic clinical practice. In recent years, an increasing number of patients have been diagnosed in the early stages of the disease. Consequently, traditional surgical interventions alone can no longer satisfy current clinical needs, highlighting the urgent demand for effective non-surgical management strategies. Objective: This guideline aims to provide a standardized framework for the non-surgical treatment of ONFH. It focuses on how to rationally and effectively apply these methods to delay disease progression, improve hip joint function, postpone or even avoid surgery, and ultimately achieve the goal of hip preservation. Methods: This guideline systematically evaluates and synthesizes evidence on the application of various non-surgical treatment modalities in the prevention and management of ONFH. These modalities include general therapy, pharmacotherapy, physical therapy, traditional Chinese medicine, minimally invasive interventions, and rehabilitation. Conclusion: The rational and evidence-based application of non-surgical treatments is of great significance for patients with early-stage ONFH. By following this guideline, clinicians can develop individualized, comprehensive non-surgical regimens that effectively control risk factors, alleviate symptoms, retard the collapse of the femoral head, preserve native hip function, and improve patients' quality of life, thereby reducing the long-\term need for hip arthroplasty.},
 year = {2026}
}

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  • TY  - JOUR
T1  - Clinical Guideline for Non-Surgical Treatment of Osteonecrosis of the Femoral Head (2025 Edition)
AU  - Cheng Zhixiang
AU  - Ding Zheng
AU  - Wan Li
AU  - Wang Dequan
AU  - Tian Demin
AU  - Li Pei
AU  - Jin Xiaohong
AU  - Zhao Zhongmin
AU  - Jia Yifan
AU  - Xu Mingmin
AU  - Lei Guangchun
AU  - Dai Fucheng
AU  - Gao Deshuai
AU  - Xu Pei
AU  - Xing Gengyan
AU  - Liu Yanqing
Y1  - 2026/04/29
PY  - 2026
N1  - https://doi.org/10.11648/j.ijpr.20260202.12
DO  - 10.11648/j.ijpr.20260202.12
T2  - International Journal of Pain Research
JF  - International Journal of Pain Research
JO  - International Journal of Pain Research
SP  - 38
EP  - 55
PB  - Science Publishing Group
SN  - 3070-1562
UR  - https://doi.org/10.11648/j.ijpr.20260202.12
AB  - Background: Osteonecrosis of the femoral head (ONFH) is a prevalent and refractory condition in orthopedic clinical practice. In recent years, an increasing number of patients have been diagnosed in the early stages of the disease. Consequently, traditional surgical interventions alone can no longer satisfy current clinical needs, highlighting the urgent demand for effective non-surgical management strategies. Objective: This guideline aims to provide a standardized framework for the non-surgical treatment of ONFH. It focuses on how to rationally and effectively apply these methods to delay disease progression, improve hip joint function, postpone or even avoid surgery, and ultimately achieve the goal of hip preservation. Methods: This guideline systematically evaluates and synthesizes evidence on the application of various non-surgical treatment modalities in the prevention and management of ONFH. These modalities include general therapy, pharmacotherapy, physical therapy, traditional Chinese medicine, minimally invasive interventions, and rehabilitation. Conclusion: The rational and evidence-based application of non-surgical treatments is of great significance for patients with early-stage ONFH. By following this guideline, clinicians can develop individualized, comprehensive non-surgical regimens that effectively control risk factors, alleviate symptoms, retard the collapse of the femoral head, preserve native hip function, and improve patients' quality of life, thereby reducing the long-\term need for hip arthroplasty.
VL  - 2
IS  - 2
ER  -

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Author Information

  • Cheng Zhixiang

    Department of Painology, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China

    http://orcid.org/0000-0003-0867-685X

  • Ding Zheng

    Department of Rehabilitation Medicine, Xiangtan Central Hospital, Xiangtan, China

  • Wan Li

    Department of Painology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China

    http://orcid.org/0000-0001-5438-0932

  • Wang Dequan

    Department of Painology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China

    http://orcid.org/0000-0003-3931-5133

  • Tian Demin

    Department of Painology, Weihai Municipal Hospital Affiliated to Shandong University, Weihai, China

    http://orcid.org/0009-0008-6530-3180

  • Li Pei

    Department of Orthopedics, The Affiliated Central Hospital of Shenyang Medical College, Shenyang, China

    http://orcid.org/0009-0009-3289-2430

  • Jin Xiaohong

    Department of Painology, The First Affiliated Hospital of Soochow University, Soochow, China

  • Zhao Zhongmin

    Department of Painology, Taizhou People's Hospital Affiliated to Nanjing Medical University, Taizhou, China

  • Jia Yifan

    Department of Painology, Renmin Hospital of Wuhan University, Wuhan, China

    http://orcid.org/0000-0001-9393-722X

  • Xu Mingmin

    Department of Interventional Ultrasound, Zhejiang Rongjun Hospital, Jiaxing, China

  • Lei Guangchun

    Pain Rehabilitation Center, Chengdu Bayi Orthopedic Hospital, Chengdu, China

  • Dai Fucheng

    Department of Painology, Zhenjiang First People's Hospital, Zhenjiang, China

  • Gao Deshuai

    Department of Painology, Sir Run Run Hospital Affiliated to Nanjing Medical University, Nanjing, China

    http://orcid.org/0009-0000-1910-5660

  • Xu Pei

    Department of Painology, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China

  • Xing Gengyan

    Department of Orthopedics, The Third Medical Center, Chinese PLA General Hospital, Beijing, China

    http://orcid.org/0000-0003-2445-8676

  • Liu Yanqing

    Department of Painology, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China;Department of Painology, Weihai Municipal Hospital Affiliated to Shandong University, Weihai, China

    Contact Email

    http://orcid.org/0000-0002-7347-0789

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  • Abstract
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  • Document Sections

    1. 1. Introduction
    2. 2. Guideline Development Methodology
    3. 3. Overview
    4. 4. Conclusion
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  • Abbreviations
  • Author Contributions
  • Conflicts of Interest
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