Systematic Review on Pelvic vs Femoral Osteotomy in Children with Perthes Disease

Background: Legg–Calvé–Perthes disease (LCPD) is a pediatric osteonecrosis of the femoral head in which surgical containment aims to maintain femoroacetabular congruence and facilitate spherical remodeling. Femoral and pelvic osteotomies are established options, but optimal selection—particularly in older children or severe deformity—remains debated. Objective: To synthesize comparative evidence on outcomes, indications, and complications of femoral versus pelvic osteotomy, and selective combined procedures, in children with LCPD. Methods: A PRISMA 2020–guided search of MEDLINE, Embase, Scopus, Web of Science, Cochrane CENTRAL, and publisher platforms (2008–2025) included pediatric studies (4–12 years) reporting ≥24-month outcomes after femoral, pelvic, or combined osteotomies. The primary outcome was radiographic result at latest follow-up (Stulberg I/II vs III–V); secondary outcomes included range of motion, pain/functional scores, complications, reoperation, and hip survival/THA. Given heterogeneity, a narrative synthesis was performed; study quality was appraised using MINORS and considered qualitatively in interpretation. Results: Twelve studies met criteria. Across appropriately selected patients, femoral and pelvic osteotomies yielded broadly similar radiographic containment and functional improvement. Femoral osteotomy was favored in younger children, particularly lateral pillar B/B–C; pelvic osteotomy was preferred in older children with acetabular deficiency or hinge abduction. Combined osteotomy was reserved for severe multiplanar deformity, offering at most modest incremental benefit with greater operative complexity and higher complication exposure. Common sequelae included mild limb-length discrepancy and abductor weakness after femoral procedures, and overcoverage/impingement risk after pelvic reorientation; hip survival correlated more with age and severity than with technique. Conclusion: Procedure choice should be phenotype-driven, prioritizing age, lateral pillar status, and the dominant locus of deformity. Standardized, prospective comparative cohorts with patient-reported outcomes and survivorship endpoints are needed to refine algorithms and evaluate 3D planning–assisted strategies.