Abstract: Background and Objectives: Osteonecrosis of the femoral head (ONFH) is an incapacitating disease that frequently results in the collapse of the femoral head and secondary osteoarthritis. The diagnosis and staging of this pathology, which usually rely on imaging studies, are challenging. Currently, conventional radiography is the basis of the initial diagnostic assessment. In recent decades, however, radiographs have been considered insensitive to early changes in ONFH and thus, a suboptimal diagnostic tool. Paradoxically, the imaging features of radiographs are often profuse, substantial, and characteristic. This study aimed to elucidate the real limitations of this radiologic tool by assessing the diagnostic reliability of the key radiologic features and staging. Methods: This was a retrospective study in which radiographs from 28 idiopathic ONFH confirmed cases who underwent hip arthroplasty were analyzed by eight observers who were asked to identify the presence or absence of ONFH universally reported imaging features in AP hip radiographs. Results: Concordance analysis revealed a poor agreement between observers for most of the assessed imaging features. Only the identification of femoral head flattening and osteoarthritis signs exhibited moderate agreement with statistical significance. In contrast, the detection of radiological osteoporosis and the loss of trabeculation showed the lowest reliability, with negative kappa coefficients. Conclusion: There is a lack of agreement between qualified observers, even for the identification of the most characteristic ONFH radiographic features. The reliability of plain radiography for the detection of basic radiological elements is even weaker in the early stages of the disease.

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