Introduction: Recently, a “new paradigm” for the treatment of osteonecrosis (ON) was suggested by Hungerford. Steinberg stage I and II (pre-collapse) ON patients should be treated with conservative measures that do not violate femoral geometry while total hip arthroplasty using newer bearing materials should be considered for Steinberg stage IV (post-collapse) and beyond.

Methods: This strategy has been employed by the senior author since 2000 and results have been favorable.

Results: Twenty-six hips (19 patients) have been treated with core decompression and/or bone grafting when the surface of the femoral head was documented to be intact. Out of these 26 hips treated conservatively, 6 hips required further treatment and 20 (77%) did not. For the treatment of post-collapse disease, twenty-two total hip arthroplasties (19 patients), 1 femoral head resurfacing and 2 hemiarthroplasties (1 patient) have been used.

One of these total hip arthroplasties has been revised for incomplete femoral fixation leading to a 96% survival rate at an average follow-up of 22 months (range: 2 – 74 months). The average Harris Hip Score for these patients at the most recent follow-up was 87.

Discussion: This strategy has proven effective to date, but suggests the need to further refine conservative treatment methods for pre-collapse ON.