Treatment of osteonecrosis of the femoral head: everything's new.

Since the 1970s, the mantra of those treating osteonecrosis of the femoral head was to save the head at all costs. Total hip arthroplasty (THA), the only effective surgical treatment once the head has mechanically and clinically failed, had a poor track record for young active patients. Recently, THA using highly cross-linked polyethylene, metal-on-metal bearing surfaces, or ceramic-on-ceramic bearing surfaces have given promising results, changing the "save-at-all-costs" paradigm. Operations that have a low success rate, high complication rate or morbidity, or compromise subsequent THA can no longer be justified. This includes femoral osteotomy and free vascularized fibular graft. Core decompression is justified, when indicated, because of its low morbidity and absence of complications with subsequent THA.