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.

非创伤性股骨头坏死（NONFH）是一种严重影响生活质量的致残性骨科疾病。人工全髋关节置换虽能有效治疗严重塌陷的终末期病变，但对于年轻、活跃患者而言，延缓或避免关节置换、保留自身关节功能的保髋治疗才是最终目标，这也是临床与基础研究的热点与难点。在此背景下，正确认识NONFH的临床特征与病理过程以及采用何种保髋治疗方法具有重要意义。本文立足于当前NONFH的研究现状，首先剖析了NONFH临床特征与病理过程的关联性，提出首次出现髋部疼痛预示着股骨头内已发生软骨下骨骨折或股骨头塌陷；基于"坏死-修复-塌陷-骨关节炎"的NONFH病理过程，发现了囊性变在NONFH的修复与塌陷中具有关键作用，靶向调控囊性变内的微环境来促进修复和避免塌陷是非手术保髋获得满意疗效的核心。其次总结了预测塌陷的影像学方法，基于股骨头前外侧负重区正常骨质保留量，提出股骨头前侧和外侧保留角概念，可以精确地评估塌陷风险以及塌陷是否会停止。最后分析了非手术保髋治疗方法、手术保髋治疗方法和新兴技术治疗方法目前的实际应用现状以及面临的挑战。提出NONFH的精准诊断（预测股骨头塌陷或塌陷是否会停止）对及时采取精确的保髋治疗至关重要，采取哪种保髋治疗取决于股骨头负重区是否会发生塌陷，而根据股骨头前侧和外侧保留角，既可以预测塌陷，也可以确定保髋治疗适应证。在适应证明确的前提下，运用现有治疗手段，联合多技术、多模式制订重建力学传导路径的个体化综合保髋治疗方案，是目前临床应用较成熟的方法。随着生物技术与再生医学的不断发展创新，以及通过高质量临床研究不断优化治疗路径，保髋治疗的成功率有望得到进一步提升。