Background:Urine exosomal microRNAs (miRNAs) play vital roles in the occurrence and development of various diseases. However, less is known about miRNAs in steroid-induced osteonecrosis of the femoral head (SONFH). Here, we aimed to determine the value of miRNAs in urinary exosomes in the diagnosis of SONFH.Methods:RNA was extracted from urinary exosomes from 9 SONFH patients and 9 hip osteoarthritis (HOA) patients with age and gender matched and then miRNAs were analyzed by next generation sequencing. Next, the putative target genes of dysregulated miRNAs were predicted by miRNA databases. Furthermore, GO function, KEGG pathway, miRNAs-mRNAs network and protein-protein interaction (PPI) network were also constructed to analyze potentially pathological mechanisms. qRT-PCR and area under curve (AUC) analysis were performed to determine the diagnostic value of miRNAs. This study was approved by ethics review board in 1st Affiliated Hospital, Guangzhou University of Chinese Medicine.Results:Intriguingly, 15 miRNAs including hsa-miR-200b-3p and hsa-miR-206 were significantly upregulated in exosomes from SONFH patients. Furthermore, qRT-PCR and area under curve (AUC) analysis of an independent cohort of 30 SONFH patients, 10 HOA patients and 10 healthy donors confirmed that hsa-miR-200b-3p and hsa-miR-206 were upregulated in SONFH samples which AUC values were 0.938 (95 % CI: 0.828-1) and 0.926 (95 % CI: 0.806-1) respectively. The enriched functions and pathways included Hippo, PI3K-Akt, TGF-β and Wnt signaling pathways. The top five hub genes (MAPK1, EP300, RHOA, PIK3CA, and CBL) were selected from PPI network, which consisted of 180 nodes and 518 edges. Conclusions:Collectively, our results showed that hsa-miR-200b-3p and hsa-miR-206 in urinary exosomes which might serve as non-invasive biomarkers for SONFH.