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Summary: This meta-analysis revealed that bisphosphonates could not provide a better clinical outcome in the treatment of osteonecrosis of the femoral head (ONFH) when compared with placebo. Introduction: Bisphosphonates have been recommended to treat ONFH. However, the exact clinical outcomes after treatment are still controversial. Methods: A comprehensive search of PubMed, Embase, and Web of Science databases was undertaken, and only randomized control trials were included. The clinical outcomes consisted of progression to collapse, total hip arthroplasty (THA) incidence, and improvement of Harris hip score (HHS). The heterogeneities between the trials were assessed with the I statistic, and random effects models were used for the meta-analysis. Results: Five eligible trials were identified involving 329 subjects with 920.9 patient-years of follow-up. The clinical outcomes of patients with ONFH was not significantly improved by bisphosphonate therapy (progression to collapse: risk ratio = 0.71 (0.41, 1.24), p = 0.23; THA incidence: risk ratio = 0.61 (0.33, 1.15), p = 0.13; HHS improvement: mean difference = 3.26 (−5.12, 11.64), p = 0.45). The I statistic showed the existence of considerable heterogeneity (all I ≥ 50 %), which was explained by one trial where bisphosphonate alone was used with no additional therapy. However, when this trial was excluded, the clinical outcomes after bisphosphonate therapy were still not significantly improved compared with placebo. Conclusions: The current analysis does not support the use of bisphosphonates for ONFH. As potential serious adverse effects are associated with these drugs, only limited use can be recommended. [ABSTRACT FROM AUTHOR]