Nontraumatic osteonecrosis of the femoral head (NONFH) is a disabling orthopedic condition that predominantly affecting quality of life. Although total hip arthroplasty effectively treats end-stage lesions with significant collapse, for young and active patients, the ultimate goal is hip preservation—delaying or avoiding joint replacement and preserving native joint function. This remains a challenge in both clinical practice and basic research. In this context, a correct understanding of the clinical characteristics and pathological processes of NONFH, along with the appropriate selection of hip preservation strategies, is of great significance. Based on the current research of NONFH, this article first analyzes the correlation between its clinical features and pathological progression, proposing that the initial onset of hip pain indicates the occurrence of subchondral bone fracture or femoral head collapse. By examining the pathological course of "necrosis-repair-collapse-osteoarthritis" in NONFH, it identifies the critical role of cystic lesion in the repair and collapse processes. Targeting the microenvironment within cystic lesion to promote repair and prevent collapse is central to achieving satisfactory outcomes with non-surgical hip preservation. Secondly, the article summarizes methods for predicting collapse and introduces the concept of the anterior and lateral femoral head preservation angles based on the residual healthy bone in the anterolateral weight-bearing region. These angles enable precise assessment of collapse risk. Finally, it reviews the current application and challenges of non-surgical hip preservation, surgical hip preservation, and emerging technological therapies. It emphasizes that accurate diagnosis of NONFH, specifically predicting femoral head collapse or its arrest, is crucial for implementing precise and timely hip preservation. The choice of hip preservation strategy depends on whether the weight-bearing region of the femoral head is at risk of collapse. The anterior and lateral femoral head preservation angles not only predict collapse but also define the indications for hip preservation. Under well-defined indications, utilizing existing treatment modalities and integrating multi-technique, multi-modal approaches to develop individualized comprehensive hip preservation plans aimed at reconstructing mechanical conduction pathways represents a mature strategy in current clinical practice. With continued innovation in biotechnology and regenerative medicine, along with the optimization of treatment pathways through high-quality clinical research, the success rate of hip preservation is expected to further improve.