The article describes osteonecrosis of the femoral head in elderly people as a separate pathophysiological unit, different from classical osteonecrosis. This condition is caused by a combination of vascular fragility, impaired mechanical bone adaptation, and systemic chronic inflammation associated with aging. Key factors are endothelial cell senescence, microvascular dysfunction, increased fat mass in the bone marrow, reduced perfusion, and reduced ability to form new bone mass. Clinical manifestations often mimic osteoarthritis, leading to frequent diagnostic delays. Molecular and biomechanical studies show that subchondral bone fractures contribute to head collapse. Traditional joint-preserving treatments are often not effective in elderly patients, so new options such as senolytics, vasculoprotective drugs and mechanical support are being explored in the early stages. The article emphasizes the need for tailored diagnosis and treatment that takes into account the specifics of aging and geriatric comorbidities.