Meng Gao, Shuren Wang
Osteonecrosis of the femoral head (ONFH) is a progressive orthopedic disorder that frequently results in femoral head collapse and substantial functional impairment. Hip-preserving surgical procedures remain the primary treatment strategy for early- and mid-stage disease; however, therapeutic outcomes remain variable. Traditional Chinese medicine (TCM) has increasingly been investigated as an adjunctive therapy because of its potential effects on microcirculation, bone remodeling, and inflammatory regulation. This systematic review and meta-analysis evaluated whether adjunctive Chinese herbal medicine combined with hip-preserving surgery improves functional outcomes, imaging-based prognosis, and safety profiles compared with hip-preserving surgery alone or routine perioperative care in patients with ONFH. A comprehensive literature search of PubMed, Embase, Scopus, Cochrane CENTRAL, CNKI, Wanfang, VIP, and SinoMed identified randomized controlled trials (RCTs) published through August 2024. Standardized mean differences, odds ratios, and risk ratios with corresponding 95% confidence intervals were pooled using random-effects models. Seventeen RCTs involving 1,144 participants were included. Adjunctive TCM combined with hip-preserving surgery significantly improved Harris Hip Score outcomes and imaging-based improvement compared with surgery alone or routine care. Functional improvement was observed across multiple TCM formulations, including Bushen Huoxue Decoction, syndrome differentiation-based therapy, and Huoxue Shengu Decoction. Adjunctive TCM interventions were also associated with lower adverse-event rates, while publication-bias assessment demonstrated minimal evidence of significant asymmetry. These findings suggest that adjunctive TCM combined with hip-preserving surgery may improve functional recovery, enhance radiographic stability, and reduce adverse events in patients with early- and mid-stage ONFH. Further large-scale multicenter RCTs using standardized TCM formulations and extended follow-up periods are required to strengthen the evidence base for clinical application.