Purpose

This systematic review and meta-analysis evaluated the clinical and radiological effectiveness of extracorporeal shock wave therapy (ESWT) for Osteonecrosis of the femoral head (ONFH).

Methods

We systematically searched PubMed, Embase, and CENTRAL for studies evaluating ESWT in adults with ONFH, adhering to PRISMA guidelines. The primary outcomes analyzed were changes in visual analogue scale (VAS) for pain and Harris hip score (HHS) for function, along with radiological changes. A meta-analysis was performed using fixed or random-effects models to calculate pooled standardized mean differences (SMD). Study quality was critically appraised using the RoB 2 and ROBINS-I tools.

Results

Twenty-six studies, encompassing 1584 patients (2241 hips), met the inclusion criteria. The pooled analysis demonstrated that ESWT was associated with a significant reduction in pain on the VAS (SMD, 4.01; 95% CI 3.53–4.50; p < 0.0001) and a significant improvement in hip function on the HHS (SMD, 18.97; 95% CI 15.60–22.33; p < 0.0001). Direct comparisons also favored ESWT over non-ESWT control interventions. While pooled data showed no significant change in ARCO stage, ESWT was linked to reduced bone marrow edema and a low rate of conversion to total hip arthroplasty. The quality assessment, however, revealed that a majority of studies presented a moderate to serious risk of bias.

Conclusion

ESWT is a potential non-operative treatment for early-stage ONFH, delivering significant pain relief and functional improvement. The considerable heterogeneity and methodological limitations across the evidence base highlight an urgent need for standardized treatment protocols and large-scale, high-quality randomized controlled trials.