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 medication do not play a significant role in the development of the disease and control of clinical symptoms. Medullary decompression and bone grafting are 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 operative time to gain time before total hip replacement, while some experts emphasize 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, in order to stop pain and improve joint function, total hip arthroplasty is the only surgical option for advanced femoral head necrosis. In recent years, with the development of total hip arthroplasty, the improvement of orthopedic surgeons’ surgical techniques and the improvement of medical equipment, total hip arthroplasty has been increasingly accepted by patients and doctors, and It has helped many patients with advanced femoral head necrosis to reduce their pain and improve their quality of life, but for young patients, they need to face a second or even three revision surgeries in the future, so total hip arthroplasty should be chosen with caution 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.