Molecular Pathogenesis of and Regenerative Strategies for Osteonecrosis of the Femoral Head

Abstract

Osteonecrosis of the femoral head (ONFH) is a progressive, multifactorial bone disease characterized by ischemia-induced osteocyte death, microenvironmental imbalance, and failed tissue regeneration. According to recent advances in pathophysiological understanding, vascular injury, oxidative stress, and inflammatory storms form a pathogenic cascade leading to osteogenic dysfunction, adipogenic lineage drift of mesenchymal stem cells (MSCs), and epigenetic alterations that exacerbate bone degeneration. Despite improvements in early detection, traditional interventions—including bisphosphonates, hyperbaric oxygen therapy, and surgical decompression—have limited efficacy, particularly in the mid-to-late stages. This review systematically synthesizes emerging regenerative approaches across three domains: (1) Cellular and molecular therapies: Autologous MSC transplantation, exosomes, and apoptotic extracellular vesicles restore osteogenesis, modulate immunity, and promote angiogenesis, while gene-editing technologies such as CRISPR/Cas9 enhance MSC functionality. (2) Nanobiomaterial synergy: Enzyme-mimetic nanozymes and multifunctional polymeric scaffolds improve lesion targeting, reactive oxygen species clearance, and microenvironmental regulation. (3) Advanced bioengineering: Organoid models and 3D-bioprinted living joint prostheses enable the integration of vascularization, mechanical support, and precise drug delivery, representing transformative strategies in personalized repair. Together, these innovations highlight a future paradigm shift from passive support to active, mechanism-targeted regeneration, offering new hope for structural and functional reconstruction in ONFH. Multidisciplinary integration—bridging materials science, stem cell biology, and digital medicine—will be essential for successfully developing functional cures.

Impact Statement

This review articulates a paradigm shift in osteonecrosis of the femoral head management, from palliative care to proactive, mechanism-driven regeneration. By integrating breakthroughs in cell therapy, nanobiomaterials, and bioengineering, it charts a path for true structural and functional joint restoration. These integrated strategies—precisely targeting the pathogenic triad of ischemia, oxidative stress, and inflammation—hold the transformative potential to halt disease progression and achieve biological joint reconstruction.