Different surgical procedures have been recommended for osteonecrosis of the femoral head to prevent or delay the need for arthroplasty. Core decompression is a commonly used treatment in the early stages of the disease, but the published efficacy has varied markedly. Only a few comparisons of different techniques have been reported. The aim of this study was to evaluate and compare the results of 2 commonly used procedures, core decompression and intertrochanteric osteotomy, using Cox regression and survivorship analysis. A total of 177 cases with a mean age of 41 years at surgery were treated for osteonecrosis (94 core decompressions, 83 osteotomies). Any further surgery was defined as failure and endpoint. Significant risk factors for treatment failure were age > 40 years at surgery (P = .022), corticosteroid intake (P < .001), advanced stage of necrosis (Steinberg stage > or =III, P=.04), and core decompression (P = .084). To analyze the influence of the surgical procedure, patients with corticosteroid treatment were excluded, and survival analysis was performed. This analysis revealed survival rates of 74% after osteotomy and 78% after core decompression 6 years postoperatively in early, precollapse stages (P = .819). In advanced stages, the rate of survival for hips after core decompression was lower (56%) than in hips after osteotomy (76%) (P = .056). Our results indicate that core decompression may be as effective as intertrochanteric osteotomy in precollapse stages but is less traumatizing and is cost-effective. For postcollapse hips, intertrochanteric osteotomy should be considered.