Chinese clinical practice guidelines for minimally invasive hip preservation techniques for femoral head osteonecrosis (2025 edition).

PURPOSE: Osteonecrosis of the femoral head (ONFH) frequently affects young and middle-aged adults and may progress to collapse. This guideline provides evidence-informed, expert-panel recommendations for minimally invasive hip preservation in adults, generally aged 60 years or younger, with early- to mid-stage nontraumatic ONFH. METHODS: A multidisciplinary panel formulated nine clinical questions. PubMed/MEDLINE, Europe PMC, and OpenAlex were searched from inception to May 1, 2025. Systematic reviews, clinical trials, observational studies, prognostic cohorts, case series, and relevant guidelines were included. Evidence was graded using the 2009 Oxford Centre for Evidence-Based Medicine framework, and recommendations were finalized through expert consensus. The guideline primarily applies to adults aged ≤ 60 years with glucocorticoid-associated, alcohol-associated, or idiopathic ONFH at ARCO stages I-IIIA. RESULTS: Nine recommendations were developed; all were graded C or D. Individualized ONFH hip-preserving regimens shall be built into dynamic multi-dimensional pathways centered on disease staging with integrated consideration of patient age, lesion classification and personal demands. Asymptomatic hips require imaging-based risk stratification, and surgery is not indicated solely because a lesion is asymptomatic. Routine combined postoperative pharmacological therapy is not supported. Core decompression is mainly indicated for pre-collapse disease and is preferably combined with regenerative or structural augmentation when appropriate. Bone grafting is one of the key methods to reinforce or reconstruct the lateral pillar, though relevant recommendations on bone grafting and surgical approaches are only low-level expert consensus principles. Osteotomy may be considered in selected young patients when sufficient intact weight-bearing surface can be restored. Post-operative evaluation should combine imaging and patient-reported clinical outcomes. CONCLUSION: These evidence-informed recommendations provide a nonmandatory framework for selected adults with nontraumatic ONFH. Most statements rely on heterogeneous or indirect evidence and should be applied through individualized assessment and shared decision-making.