Active Neurotization for Hip Preservation Surgery: From Vascular Reconstruction to Functional Restoration of the “Neuro-Vascular-Bone” Coupling Axis

Vascularized fibular grafting is one of the most widely used hip preservation procedures for young patients with osteonecrosis of the femoral head. However, long-term follow-up data indicate that a substantial proportion of patients ultimately convert to total hip arthroplasty (THA). We hypothesize that recovery of graft or pedicle perfusion may precede restoration of functional sensory-neural signaling within the broader repair region, creating a putative temporal mismatch. Drawing on neurovascular-bone coupling theory, we propose a testable candidate design principle: emerging evidence suggests that neural reinnervation may be a potentially limiting factor in bone repair, and active local reinnervation should be prioritized for empirical testing in hip preservation surgery. We synthesize the potential role of the sensory nerve–calcitonin gene-related peptide (CGRP) axis as a candidate mediator in osteogenesis, vascular maturation, and regulation of the local immune microenvironment.We further propose a tiered neurotization strategy encompassing autologous nerve grafting, bioactive nerve conduits, and stem cell–biomaterial composite systems. Critical issues—including neural source selection, ischemic microenvironmental constraints, risk–benefit trade-offs, and individualized patient eligibility—are also discussed. This article aims to stimulate discussion on a paradigm shift in hip preservation surgery while explicitly framing its central thesis as a hypothesis awaiting empirical validation.