This communication presents the author's perspective on recent advances in the study of osteonecrosis, explores the controversies that have arisen in the literature relating to treatment alternatives, and suggests an approach to the use of core decompression in the early stages of osteonecrosis that can prove useful to the practicing orthopaedist. Currently available diagnostic measures can identify osteonecrosis at very early stages of femoral head involvement. Quantitation of femoral head involvement on magnetic resonance imaging can differentiate lesions by the volume of head involvement and the location of the involvement relative to the weight-bearing articular surface. Although it is not yet known whether lesion size determines the effectiveness of treatment with core decompression in disease that is not yet radiographically apparent, bigger lesions are likely to respond differently then small lesions. The author applies this rationale to stage I and early stage II disease, for which core decompression is the preferred treatment. Core decompression without supplementary steps does not appear adequate for larger stage II lesions or more advanced disease. A technique that is safe and predictable should provide proper placement of the core tract, biopsy of the lesional area (desirable), and is chosen for the appropriate patient. All willing patients should be encouraged to enter into randomized prospective treatment protocols.