Principles of Treating the Sequelae of Perthes Disease

Objectives: The overall main purpose of this study is to add some knowledge on the treatment of LCPD, with a main focus on the comparison between conservative and surgical treatments of Legg-Calve-Perthes Disease (LCPD). And a brief overview of the complications of these treatments. Methods: A retrospective cohort method was used in this study. A total number of 53 patients were registered with LCPD, at the first affiliated hospital of Xinjiang Medical University. Out of these 53 patients, 39 patients were included in this study, rest of 14 patients couldn’t be included due to missed data or loss of contact. For the comparison of results, a modified form of the Harris Hip Score (HHS) was used for the clinical assessment of hip function. Radiographs were also used for the evaluation. The radiological assessment was made by the use of CE and CCD angles. The main classification system, which was used for the evaluation, staging, and prognosis of hip function, was Stulberg’s classification. Statistical analysis was done by using the SPSS 23.0 version. A simple t-test was used for data analysis. Results: The clinical results supported our hypothesis that surgical treatment is a better choice of treatment than conservative treatment in patients with LCPD. However, the statistical data from radiographic assessment showed no significant difference between conservative and surgical treatment in patients with LCPD. The statistical data showed that both conservative and surgical treatment had significant p-values (<0.05) when compared results at the final follow-up check with that before starting treatment. So conservative treatment can be used as an alternative to surgical treatment in patients with Legg-Calve-Perthes Disease. Conclusion: From the statistical analysis of data, we concluded that there is no significant difference between outcomes of conservative and surgical treatment in patients with Legg-Calve-Perthes Disease (LCPD). So conservative treatment can be ........

Objective To investigate the clinical efficiency and safety of femoral head reduction osteotomy for young patients with coxa magna or coxa plana. Methods Between June 2012 and September 2015, the clinical characteristics of 12 patients (13 hips) with coxa magna or coxa plana who underwent femoral head reduction osteotomy were analyzed retrospectively. There were 6 males (7 hips) and 6 females (6 hips) with average age 18.1 years (range, 10-25 years). The etiology of the femoral head deformity was multiple epiphyseal dysplasia in 6 hips and Legg-Calve-Perthes sequela in 7 hips. The head reduction osteotomy was conducted through the surgical hip dislocation approach combined with extended retinacular soft-tissue flap extending technique. All patients underwent simultaneous periacetabular osteotomy and relative lengthening of the femoral neck, of which four also underwent proximal femur derotational osteotomy. All patients received the standardized rehabilitation procedures. The postoperative complications, gaits, the range of motion (ROM) of the hip, Harris hip scores, iHOT scores and VAS were analyzed postoperatively. In addition, the lateral center-edge (LCE) angle, sphericity index and coverage rate of femoral head were assessed as well. Results The average follow-up duration was 28.8 months (range, 12-45 months). All patients achieved osteotomy healing of the femoral head and greater trochanter with average healing time 3.7 months (range, 3-7 months). Nine of 12 patients had significant gaits improvement. The Harris hip scores (81.08±12.36 vs. 88.38±8.96, t=2.41, P=0.033), iHOT score (51.90±15.07 vs. 67.69±8.70, t=3.63, P=0.003), LCE angle (-1.82°±16.57° vs. 36.02°±7.72°, t=10.52, P=0.000), sphericity index of anteroposterior pelvic radiographs (71.08%±10.32% vs. 81.22%±8.61%, t=7.17, P=0.000) and the coverage index (48.79%±11.85% vs. 87.46%±10.44%, t=8.56, P=0.000) were all significantly improved when compared to those preoperatively. The VAS score (4.46±2.37 vs. 1.23±0.93, t=4.25, P=0.001) was significantly decreased when compared with that preoperatively. However, for the sphericity index of 65° false profile (78.96%±10.39% vs. 80.36%±8.42%, t=0.411, P=0.688) and the average hip ROM (264.62°±32.05° vs. 255.00°±40.31°, t=0.89, P=0.391), they did not achieve statistical significant difference. One case of femoral head necrosis site was localized at the lateral-superior part of femoral head, and there was no progression after 3 years follow-up. Moreover, no revision or total hip arthroplasty were observed due to other complications (osteoarthritis, hip pain or non-union). Conclusion The femoral head reduction osteotomy can correct deformity, improve femoral head sphericity, relieve pain and improve gaits and hip function. This procedure leads to satisfied clinical outcomes for patients with coxa magna or coxa plana in early follow-up. Key words: Osteochondrodysplasias; Legg-Calve-Perthes disease; Reconstructive surgical procedures; Hip dislocation, congenital

Femoral head incongruency at skeletal maturity is associated with the development of osteoarthritis in early adulthood. Containment of the femoral head provides a larger surface area for remodelling of the collapsed femoral head and the development of spherical congruency. Triple pelvic osteotomy has a role to play in Legg-Calve-Perthes' disease by improving femoral head containment and preventing subluxation. This is traditionally a two-incision approach with significant associated morbidity. In our unit we perform triple osteotomies through a single anterolateral incision. To retrospectively review the clinical and radiographic outcome of children who had triple osteotomies performed through a single incision over a 4-year period. In our unit from 2003 to 2006 we performed eight triple osteotomies through a single incision in children aged between 6 and 12 years with Legg-Calve-Perthes' disease. The procedure was performed through a single anterolateral incision made beneath the middle of the iliac crest and carried forward according to Salter's osteotomy. Image intensification was used to confirm iliac, pubic and ischial cuts. After performing a standard Salter's osteotomy the acetabular fragment was free to rotate anteriorly and laterally. None of the children were casted and all were allowed immediate mobilization nonweight bearing with crutches for 6 weeks. Clinical results and hip function were measured preoperatively and postoperatively using the modified Harris hip score. The average length of hospital stay was 4.7 days. None of the children had a nonunion. The centre edge angle of Wiberg was measured on all preoperative and postoperative anteroposterior pelvic radiographs. In all our patients there was an improvement in the centre edge angle of Wiberg and in the modified Harris hip score. The preoperative modified Harris hip scores ranged from 38 to 60 and postoperatively ranged from 77 to 92. The preoperative centre edge angle of Wiberg ranged from 9 to 24 whereas postoperative scores ranged from 25 to 46. Triple osteotomy has been advocated in Legg-Calve-Perthes' disease after the closure of the triradiate cartilage. Using a single incision is a safer alternative to the traditional two-incision approach. We believe that the single incision approach reduces operative time and potential morbidity associated with the steel triple osteotomy with comparable clinical and radiographic outcomes.

Background: Legg-Calvé-Perthes disease (LCPD) is an idiopathic pediatric hip disorder associated with avascular necrosis of the femoral head. Although there is no standardized and optimal treatment protocol for patients with LCPD, there are three primary treatment strategies: symptomatic treatment, nonsurgical containment using orthotic devices, and surgical containment.Objective: This study aimed to describe the demographic characteristics, management and outcome of pediatric patients with LCPD at our center between 2005 and 2015.Material and Methods: In this retrospective study, 23 patients with LCPD who represented all patients with LCPD treated at King Abdul-Aziz Medical City, Jeddah, Saudi Arabia between 2005 and 2015 were enrolled. Their demographic and clinical characteristics, treatment methods, and outcomes were evaluated.Results: Descriptive statistics showed that most of the patients were males (87.0%), with a mean age of 7.1±2.4 years. None of the patients had a family history of LCPD. Approximately two-thirds of the patients reported hip pain as the chief concern. LCPD was observed in the left hip in 60.9% of patients, the right hip in 21.7% of patients, and both hips in 17.4% of patients. Approximately half of the patients (55.3%) were treated with physiotherapy, and 10.6% were treated with orthotics. Despite that, 10 patients (43.4%) required surgical management after the conservative approach, and six of them underwent pelvic Salter innominate osteotomy.Conclusion: These results highlight the experience of a single center in managing patients with LCPD. Treatment was different based on patient age; non-surgical treatment, mainly physiotherapy, was predominant in younger children. However, regardless of the type of treatment, the earlier interventions have proven to provide better outcomes in patients with this health condition.

Legg Calve Perthes disease is a pediatric hip condition that leads to early hip degeneration. The efficacy of operative and nonoperative treatment is not well defined in the literature. Using the rate of total hip arthroplasty as a surrogate measure for symptomatic hip degeneration, the rate of total hip arthroplasty was compared in Legg Calve Perthes disease patients with and without previous surgical intervention in the province of Manitoba, Canada. A retrospective review was conducted using de-identified, individual-level administrative records of health services for the entire population of Manitoba. Codes for Legg Calve Perthes disease, femoral osteotomies, pelvic osteotomies, adductor tenotomies, and total hip arthroplasty were searched from 1984 to 2018. The rate of total hip arthroplasty in patients with Legg Calve Perthes disease was determined for two groups: (1) patients with earlier surgical intervention and (2) patients with no previous surgical intervention. Of the 202 patients included in the study, 180 had no prior surgery and 22 had prior surgery. The rate of total hip arthroplasty between the previous operative and nonoperative groups was found to be 32% and 40%, respectively (p = 0.458). There was no significant difference in rates of total hip arthroplasty in the operative and nonoperative groups. Further prospective studies are required to elucidate the differences in outcomes between operative and nonoperative treatment groups in patients with Legg Calve Perthes disease.

Despite having known of the condition for over 100 years, Legg-Calve-Perthes (LCP) disease remains a challenging hip condition to treat. Its etiology remains unclear and treatment continues to be controversial. To minimize the risk of premature hip arthritis, the immediate goals of treatment include maintaining hip motion and articulating surface sphericity by containing the femoral head within the acetabulum during its biologically plastic phase and thereby providing the best chance for joint remodeling. However, the best ways to achieve these goals remain elusive. While there appears to be increasing interest in timing of the surgical treatment and outcomes, there is a need for a deformity index that can be measured on a linear scale as opposed to categorical outcomes (such as those of Mose [5] and Stulberg et al. [6]) and a need for functional outcome measures that will reflect long-term durability. These will help in well-powered comparative studies to compare outcomes from different treatments/interventions. Several biologic treatments are being explored. Fig. 1 Harish S. Hosalkar, MD, is shown. Fig. 2 Kishore Mulpuri, MBBS, MS(Ortho), MHSc(Epi), is shown. Long-term studies have provided the current view that most patients with LCP disease will do well until the fifth or sixth decade of life before experiencing a decline in their hip function, with many eventually requiring THA [2, 4, 6]. Larson et al. [3] in a recent prospective multicenter study of LCP disease looked at functional and radiographic outcomes of nonoperative treatment at a mean followup of 20.4 years (range, 16.3–24.5 years) after enrollment. Thirty of the 58 hips studied had no osteoarthritis or mild (Tonnis Grade 1) osteoarthritis whereas 24 had moderate to severe osteoarthritis (Tonnis Grade 2 or 3). Of the remaining four, three patients had required hip arthroplasty and one patient had required a pelvic osteotomy. This study suggests only about 50% of patients had good to excellent clinical outcomes (based on Nonarthritic Hip Scores and the Iowa Hip Scores) and radiographic outcomes (≤ Tonnis Grade 1) at 22 to 35 years of age, a period in life when one expects high-level musculoskeletal function [3]. In the current era of improved understanding of the concept of femoroacetabular impingement, we have more rigorous standards of examining the hip motion, function, and radiographic involvement [1]. Also, the expectations of patients in a modern urban, athletically driven culture are far greater for high-level musculoskeletal function compared with the expectations of patients from a prior, more rural era [7]. Modern expectations for high-level hip function into midadulthood, even in patients who have had substantial childhood hip disease, will continue as individuals place greater work and recreational demands on their hips. This has likely led to an increase in surgical procedures to correct the hip morphology, rectify the impingement, and hopefully provide an environment to delay the progression of arthritis while providing a better function and quality of life in the interim. The current symposium has an excellent potpourri of scientific articles covering various topics, including risk factors, natural evolution, classification systems, bisphosphonate treatment, and surgical interventions, such as femoral osteotomies, innominate osteotomies, and shelf and triple pelvic osteotomies. Several papers included in the symposium outline how reduced ROM of the hip in LCP disease relates to extra- and intraarticular impingement and the role of surgical dislocation of the hip and joint-preserving procedures in the current era.

Perthes disease is a hip lesion caused by vascular disorders in the femoral head of children. Although the disease is a self-limited disease, but often residualvary degrees of femoral head deformity, leading to early osteoarthritis. It is currently believed that the lesions of Perthes disease are mainly located in the femoral head.However, some studies demonstrated that patients with Perthes disease also appearvary degrees of acetabular morphological changes. In recent years, the acetabular retroversions were found in 31-60% of patients with Perthes disease. The acetabular retroversion is a pathological anatomical variation of the acetabulum in the horizontal plan. It is related to the occurrence of the femoracetabular impingement and osteoarthritis. Many studies showed that the patients with poor prognosis (Stulberg III, IV or V) are associated with a higher prevalence of acetabular retroversion.The grading and the age of onset of Perthes disease are important factors affectingprognosis. Although existing studies illustrate that the lateral column grading, gender and age are not associated with the acetabular retroversion of Perthes disease significantly, the cases of the studies are limited and further researches are expected. Surgery containment therapy is an important wayto treat Perthes disease. The pelvic osteotomy can directly change the shape of the acetabulum and cause the acetabular retroversion, which result inthe femoracetabular impingement. The acetabular retroversion should be avoided as much as possible intra-operatively. Further research should be focused on whether the surgical interventions and the subsequent biomechanical changes could induce the acetabular retroversion. The cause of the acetabular retroversion in patients with Perthes disease is unclear. In order to elucidate the occurrence and development of acetabular retroversionin Perthes disease, some scholars found thataccompanying femoral head deformity, acetabular anteversion angleand inclinationdecreased significantly, and thecoverage angle in the superior, posterior, and inferior quadrants alsogradually reduced in animal studies. This is similar to clinical observations. This article reviews the progress of acetabular retroversion in Perthes disease by summarizing the relevant literatures. We hope to givenew insights for the etiology and pathology of Perthes disease, and provide new ideas for the treatment and prevention of the femoracetabular impingement and early osteoarthritis.

Late-onset Perthes disease, particularly in children older than nine years, is known to have a more aggressive course and a less favorable prognosis, often progressing to osteoarthritis by the fourth decade of life if left untreated. While younger children are usually managed conservatively, and those aged 6-9 years may benefit from surgical intervention, the optimal treatment strategy for children aged 8 years and above remains controversial. This case series evaluates the clinical and radiological outcomes of varus derotation osteotomy (VDRO) in 12 children (10 males, 2 females) with a mean age of 9.4 years, treated at the Department of Orthopaedics, Government Medical College, Kota, between 2020 and 2025. All patients were classified as stage IB, IIA, or IIB based on the modified Elizabethtown classification and presented with restricted hip abduction and internal rotation. Hip pain was reported in 58.33% of cases, and 75% had a limp. VDRO was performed approximately three weeks after diagnosis. Five patients (41.67%) were older than 10 years at presentation. Outcomes were assessed at an average follow-up of 3.4 years. Radiological evaluation included the caput index (CI), epiphyseal quotient (EQ), and articulotrochanteric distance, while clinical assessment used range of motion and the Harris Hip Score. Significant improvements were observed in CI (p=0.000) and EQ (mean postoperative value 0.606; p=0.0000). Favorable results were seen in all patients with stage IB and IIA disease, and in 50% of those with stage IIB. VDRO appears to be an effective option for late-presenting Perthes disease in this age group.

LEGG-CALVÉ-PERTHES DISEASE: 100 YEARS

Osteochondritis dissecans (OCD) is estimated to occur in 2% to 7% of patients with Legg-Calvé-Perthes disease (LCPD). Unstable osteochondral fragments secondary to LCPD may produce mechanical symptoms requiring surgical intervention. Reattachment of the fragment with open reduction and internal fixation (ORIF) may provide good clinical outcomes. The purpose of this study is to report short-term clinical and radiographic results of ORIF for the treatment of symptomatic osteochondral lesions resulting from LCPD. Clinical data including patient demographics and patient-reported outcome scores were collected prospectively. All patients underwent preoperative radiographs and magnetic resonance imaging confirming an unstable OCD fragment as well as postoperative radiographs at regular intervals. Indications for ORIF of the OCD fragment were hip pain and mechanical symptoms with radiographic evidence of LCPD and a magnetic resonance imaging demonstrating an OCD fragment of the femoral head. Osteochondral fragment instability was confirmed intraoperatively. Preoperative and postoperative physical examination findings were documented. All patients failed a course of nonsurgical treatment (activity modification, anti-inflammatories, and physical therapy). From a total of 64 consecutive patients treated with hip preservation surgery for LCPD, 7 patients with symptomatic OCD secondary to LCPD were treated with surgical hip dislocation and ORIF of the femoral head osteochondral fragment. OCD size lesion ranged from 200 to 625 mm. All patients reported marked clinical improvement, with resolution of both pain and mechanical symptoms. Radiographs at final follow-up demonstrated complete osteochondral fragment healing without implant failure. Mean follow-up was 4.6 years (range, 1.1 to 7.4 y). There was a significant postoperative improvement in measured internal rotation in flexion (5.0±5.0 to 16.4±9.8; P=0.02). Modified Harris Hip Score markedly improved from baseline to final follow-up (47.8 to 82.7; [INCREMENT]34.9; minimal clinically important difference, 11; P=0.002), with all patients meeting minimal clinically important difference for modified Harris Hip Score. There were no complications and no progression of osteoarthritis in all patients at final follow-up. We have demonstrated both predictable radiographic healing and marked clinical improvement following ORIF of symptomatic post-Perthes OCD lesions. We advocate ORIF for symptomatic osteochondral lesions as a first-line surgical treatment for these patients due to the advantages of native osteochondral tissue preservation, predictable healing, and marked clinical improvement. Level IV-case series.

BackgroundIn a previous study, we reported clinical and radiographic results of our modified Salter innominate osteotomy technique in 16 hips affected by Legg-Calvé-Perthes disease (LCPD) with an average follow-up of 31.8 months. In this study, we present the long-term results of the osteotomy in LCPD patients followed until physeal closure.MethodsThirty hips of 29 patients were followed until skeletal maturation after modified Salter innominate osteotomy. The mean follow-up duration was 12.9 years (range, 9.1 to 16.0 years). Eleven hips (36.7%) were classified as Catterall group III and 19 (63.3%) as Catterall group VI. Stable interposition of a bone block was achieved using one biodegradable screw in nine hips and without any fixation device in 21 hips by simply changing the direction of osteotomy. The Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and hip function were evaluated at the last follow-up. Radiological outcomes were evaluated using Wiberg's center-edge angle, the Mose method, and Stulberg classification, and osteoarthritic changes were evaluated using the Tonnis classification.ResultsMean HHS and WOMAC score were 80.2 points and 54 points, respectively, preoperatively and these were improved to 96.2 points and 28 points, respectively, at the last follow-up. Clinical results, according to Robinson's criteria, were good in 18, fair in seven, and poor in five hips. Radiological results assessed using the Mose method were good in 18, fair in six, and poor in six hips, and according to the Stulberg classification, nine hips were class I, nine were class II, eight were class III, and four were class IV. The mean center-edge angle improved from 19.7° preoperatively to 29.6° at the final follow-up. According the Tonnis classification, three hips were grade 2, five were grade 1, and 22 were grade 0. Of the three grade 2 hips, two underwent Chiari osteotomy 12.1 and 8.8 years postoperatively, and the other underwent total hip arthroplasty 12.9 years postoperatively.ConclusionsThe modified Salter innominate osteotomy produced relatively satisfactory long-term clinical and radiological results.

To assess the long-term effect of distal trochanteric transfer (DTT) on the clinical and radiographic outcomes of patients with Legg-Calvé-Perthes' disease (LCPD) following a varus derotational osteotomy (VDRO). For this single centre cross-sectional retrospective study we analysed the data of 22 patients (24 hips) with LCPD who had greater trochanteric overgrowth (GTO), following a VDRO performed in our institution between 1959 and 1983. GTO was defined as an articular trochanteric distance (ATD) of < 5 mm. We compared the radiographic and clinical outcomes of patients who underwent DTT for GTO (ten patients, ten hips) with those who did not (12 patients, 14 hips). Age at presentation was 6.9 years (4 to 10) and 8.0 years (3.2 to 12) respectively. Symptoms associated with the hip and general quality of life were assessed using the Harris hip score (HHS) and the Short Form (SF)-36 questionnaires. At long-term follow-up of the DTT group, the ATD was 21.7 mm (standard deviation (sd) 9.8) and the centro-trochanteric distance (CTD) was 13.8 mm (sd 8.3). In the control group the ATD was -0.6 mm (sd 7.8) and the CTD was 32.5 mm (sd 10.2). These differences were statistically significant (p < 0.001). The mean HHS and SF-36 scores were 68.4 (sd 25.0) and 62.0 (sd 27.7) for the DTT group and 73.2 (sd 24.2) and 73.3 (sd 21.5) for the control group, respectively. There was no statistically significant difference in the HHS (p = 0.63) or SF-36 score (p = 0.25). There were four patients who had undergone hip arthroplasty in the DTT group (40%) and one patient (7.1%) in the control group (p = 0.07). The mean age at the time of arthroplasty was 45.3 years (42.1 to 56.5) and 43.6 years respectively. Six patients in the DTT group suffered from moderate to severe osteoarthritis (Tönnis grade 2 or 3) compared with eight patients in the control group (60% versus 57.1%, p = 0.61). Although DTT improved the radiographic results in the long-term follow-up of patients with GTO following VDRO, there was no clinical benefit seen in the HHS, SF-36 or incidence of osteoarthritis compared with patients who had not undergone DTT. Cite this article: Bone Joint J 2017;99-B:987-92.

Introduction. The purpose of this study is to signify any clinical and radiological correlation, if present, in patients of Legg-Calve-Perthes’ disease (LCPD) who underwent an ambulatory conservative method of containment and their final outcome. Material and methods. Retrospective study over an 8-year period including patients of LCPD who were treated by an ambulatory conservative method showing signs of healing in the last radiological assessment was done. Clinically, gait, limb length discrepancy, range of motion of the hip, and Harris hip score were noted. The radiological parameters assessed in this study were epiphyseal index, epiphyseal quotient, acetabular head index, and epiphyseal extrusion index. Stulberg criteria was used to assess final outcome. Results. A total of 24 patients (17 males, 7 females) with a mean age of 7.9±3 years (5–9 years) who had a clinic-radiological diagnosis of LCPD were included in the study. There was a significant improvement of range of motion of the hip joint along with Harris hip score (t(18)= -16.77, p&lt;0.001) but no significant changes in the radiological parameters during the course of the disease. There was no correlation between radiological parameters and Harris hip score. 79.1% (19/24) had a good outcome at final follow up. Conclusion. The function and clinical outcome during the course and healing of LCPD does not correlate with the radiographic changes and ambulatory conservative management leads to satisfactory improvement in functional activity. Age at onset and lateral pillar classification are important factors influencing final outcome in LCPD.

Paper 30: The Outcome of Hip Arthroscopy in Teenagers - A Review of 96 Cases

Bernese-type triple pelvic osteotomy (BTPO) combines periacetabular and triple innominate osteotomy techniques. However, studies that evaluate the clinical and radiographic outcomes of BTPO are scarce. The aim of this study is to report on the clinical and radiographic outcomes of ambulatory children with developmental dysplasia of the hip (DDH) or Legg-Calvé-Perthes disease (LCPD) managed with BTPO that were older than fiveyears of age at the time of surgery. We retrospectively reviewed the records of 27 consecutive patients with DDH or LCPD (mean age 7.6 ± 1.8; 28 hips) who were treated with the reported technique. All patients had regular clinical and radiographic follow-up. Post-operatively, changes in the acetabular index (AI) and centre-edge angle of Wiberg (CEA) were measured in all patients. The presence/absence of avascular necrosis of the femoral epiphysis was also noted in patients with DDH. Final radiographic results were evaluated with the Severin and Stulberg classifications. The Harris hip score was used in the functional evaluation of all patients. In patients with DDH, the mean age at the time of surgery was 7.5 ± 1.8years and the mean follow-up time was 22.2 ± 10.7months. Prior to surgery, the mean AI was 37.9° ± 7.6°. At their final follow-up visit, the mean AI and CEA were 10.8° ± 5.4° and 40.9° ± 8.6°, respectively. Moreover, 66.7% of hips (14/21) were graded as Severin type I, and 33.3% (7/21) were graded as type II. The overall AVN rate was 14.3% (3/21). The mean Harris score was 92.1 ± 7.7. In patients with LCPD, the mean age at the time of surgery was 7.9 ± 1.8years, and the mean follow-up time was 18.4 ± 6.1months. Prior to surgery, 85.7% of hips were graded as Herring C, and 14.3% were graded as grade B. Prior to surgery, the mean AI and CEA were 19.4° ± 5.3° and 19.1° ± 12.6°, respectively. At the final follow-up visit, the mean AI and CEA were 5.8° ± 3.4° and 50.3° ± 12.0°, respectively, and 57.1% of hips were graded as Stulberg II. The mean Harris score was 94 ± 5.4. Ischial osteotomy non-unions were recorded in three patients (10.7%). BTPO through a modified anterior Smith-Peterson approach is an alternative treatment for DDH and LCPD in older children who are skeletally immature. It not only provides for a large acetabular correction but also achieves good biomechanical stability.