Osteonecrosis of the femoral head (ONFH) represents a debilitating progressive disorder driven by multifactorial etiologies that impair osseous vascularization and trigger osteocyte death, with no definitive therapeutic intervention currently established. Pathological progression involves apoptotic cascades within osteocytic networks and trabecular microarchitectural deterioration, culminating in catastrophic biomechanical failure of the femoral head through subchondral collapse and articular cartilage disintegration. Contemporary management prioritizes early-stage joint preservation strategies to decelerate disease advancement and avert structural collapse. Core decompression (CD), while serving as the cornerstone surgical modality for necrotic debridement, paradoxically destabilizes subchondral mechanical integrity, thereby potentiating collapse acceleration. To mitigate this iatrogenic risk, CD is increasingly augmented with osteoconductive grafts or synthetic bone substitutes to simultaneously reconstitute load-bearing frameworks and stimulate endogenous osteogenesis. Modern synthetic bone scaffolds have gained prominence in ONFH therapy due to their exceptional biocompatibility, osteogenic potential, and scalable manufacturing. Recent paradigm shifts in material design transcend conventional paradigms of biocompatibility and passive osteoconduction, instead prioritizing convergent engineering approaches that synchronize osteoimmunomodulatory precision with biomechanical resilience. This strategic integration aims to orchestrate a harmonious equilibrium between immunometabolic bone niche modulation and structural reinforcement. The present review critically evaluated state of the art innovations in bioengineered bone substitutes for ONFH, offering evidence-based perspectives to refine clinical translation and material optimization.