[Objective] To investigate the clinical efficacy of one-stage hip replacement and hip preservation for bilateral femoral head necrosis with different degrees of collapse. [Methods] From October 2018 to June 2019, 28 patients with bilateral different degrees of femoral head necrosis were treated in our hospital. All patients were treated with one-stage hip replacement and hip preservation. Perioperative period, follow-up and imaging data of both sides were compared. [Results] All patients completed the operation successfully. The operative time, incision length, intraoperative blood loss and postoperative drainage of the hip preserving side were significantly lower than those of the hip replacement side, with statistical significance (P<0.05). As time went on, VAS scores on both sides were significantly lower than those before surgery (P<0.05), and hip flexor-extension range of motion (ROM), internal-external rotation ROM and Harris scores were significantly increased (P<0.05). There was no significant difference in VAS scores and Harris scores between the two sides in 6 months after surgery and the last follow-up (P>0.05). The hip flexor-extension ROM and the internal - external rotation ROM at the hip replacement side were better than those at the hip preservation side (P<0.05). In terms of imaging, by the time of the latest follow-up, PDIT and FO at the hip replacement side were significantly increased (P<0.05), while there was no significant change at the hip preservation side (P>0.05). There were no significant differences in PDIT and FO between the two sides at the last follow-up (P>0.05). [Conclusion] One-stage hip replacement and hip preservation in the treatment of bilateral femoral head necrosis with different degrees of collapse can achieve the same clinical effect as hip replacement, and can delay or even avoid joint replacement.