Stage IV osteonecrosis of the femoral head is characterized by progressive worsening of joint pain, even at rest, with joint stiffness and weakness. All imaging studies show non-specific secondary osteoarthritic changes, histological evidence of femoral head collapse, secondary osteoarthritic destruction and numerous subchondral cystic changes seen on the femur and acetabular side. At this stage of progression, conservative treatment and drug therapy do not play a significant role in the development of the disease and control of clinical symptoms, and hip preservation surgery such as medullary decompression and bone grafting is not effective due to the severe damage to the cartilage on the surface of the joint and the large extent of necrotic foci. Clinicians generally use femoral head surface replacement arthroplasty to treat patients with early femoral head collapse, especially young patients, and joint surface replacement is a satisfactory transitional therapy with little surgical trauma and short operation time to gain time before total hip replacement, while the treatment results of clinical use in recent years show that surface replacement is not ideal for cases with a wide range of lesions. When the lesion of femoral head necrosis reaches an irreversible stage, collapse and osteoarthritis occur, total hip arthroplasty is the only surgical option for end-stage femoral head necrosis in order to stop pain and improve joint function. However, for young patients, they need to face second or even third revision surgery in the future, so total hip arthroplasty should be chosen carefully for young patients. For patients younger than 20 years old, although they present with stage IV femoral head necrosis, we still believe that hip preservation treatment is needed and that good results can still be achieved by applying femoral headplasty, or femoral neck reconstruction.