Aims. The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes’ disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care. Methods. A two-round, modified Delphi study was conducted online. An advisory group of children’s orthopaedic specialists consisting of physiotherapists, surgeons, and clinical nurse specialists designed a survey. In the first round, participants also had the opportunity to suggest new statements. The survey included statements related to ‘Exercises’, ‘Physical activity’, ‘Education/information sharing’, ‘Input from other services’, and ‘Monitoring assessments’. The survey was shared with clinicians who regularly treat children with Perthes’ disease in the UK using clinically relevant specialist groups and social media. A predetermined threshold of ≥ 75% for consensus was used for recommendation, with a threshold of between 70% and 75% being considered as ‘points to consider’. Results. A total of 40 participants took part in the first round, of whom 31 completed the second round. A total of 87 statements were generated by the advisory group and included in the first round, at the end of which 31 achieved consensus and were removed from the survey, and an additional four statements were generated. A total of 60 statements were included in the second round and 45 achieved the threshold for consensus from both rounds, with three achieving the threshold for ‘points to consider’. The recommendations predominantly included self-management, particularly relating to advice about exercise and education for children with Perthes’ disease and their families. Conclusion. Children’s orthopaedic specialists have reached consensus on recommendations for non-surgical treatment in Perthes’ disease. These statements will support decisions made in clinical practice and act as a foundation to support clinicians in the absence of robust evidence. The dissemination of these findings and the best way of delivering this care needs careful consideration, which we will continue to explore. Cite this article: Bone Joint J 2024;106-B(5):501–507

Aims. There is a lack of high-quality research investigating outcomes of Ponseti-treated idiopathic clubfeet and correlation with relapse. This study assessed clinical and quality of life (QoL) outcomes using a standardized core outcome set (COS), comparing children with and without relapse. Methods. A total of 11 international centres participated in this institutional review board-approved observational study. Data including demographics, information regarding presentation, treatment, and details of subsequent relapse and management were collected between 1 June 2022 and 30 June 2023 from consecutive clinic patients who had a minimum five-year follow-up. The clubfoot COS incorporating 31 parameters was used. A regression model assessed relationships between baseline variables and outcomes (clinical/QoL). Results. Overall, 293 patients (432 feet) with a median age of 89 months (interquartile range 72 to 113) were included. The relapse rate was 37%, with repeated relapse in 14%. Treatment considered a standard part of the Ponseti journey (recasting, repeat tenotomy, and tibialis anterior tendon transfer) was performed in 35% of cases, with soft-tissue release and osteotomies in 5% and 2% of cases, respectively. Predictors of relapse included duration of follow-up, higher initial Pirani score, and poor Evertor muscle activity. Relapse was associated with poorer outcomes. Conclusion. This is the first multicentre study using a standardized COS following clubfoot treatment. It distinguishes patients with and without relapse in terms of clinical outcomes and QoL, with poorer outcomes in the relapse group. This tool allows comparison of treatment methods and outcomes, facilitates information sharing, and sets family expectations. Predictors of relapse encourage us to create appropriate treatment pathways to reduce relapse and improve outcome. Cite this article: Bone Joint J 2024;106-B(7):735–743

Aims. The diagnosis of developmental dysplasia of the hip (DDH) is challenging owing to extensive variation in paediatric pelvic anatomy. Artificial intelligence (AI) may represent an effective diagnostic tool for DDH. Here, we aimed to develop an anteroposterior pelvic radiograph deep learning system for diagnosing DDH in children and analyze the feasibility of its application. Methods. In total, 10,219 anteroposterior pelvic radiographs were retrospectively collected from April 2014 to December 2018. Clinicians labelled each radiograph using a uniform standard method. Radiographs were grouped according to age and into ‘dislocation’ (dislocation and subluxation) and ‘non-dislocation’ (normal cases and those with dysplasia of the acetabulum) groups based on clinical diagnosis. The deep learning system was trained and optimized using 9,081 radiographs; 1,138 test radiographs were then used to compare the diagnoses made by deep learning system and clinicians. The accuracy of the deep learning system was determined using a receiver operating characteristic curve, and the consistency of acetabular index measurements was evaluated using Bland-Altman plots. Results. In all, 1,138 patients (242 males; 896 females; mean age 1.5 years (SD 1.79; 0 to 10) were included in this study. The area under the receiver operating characteristic curve, sensitivity, and specificity of the deep learning system for diagnosing hip dislocation were 0.975, 276/289 (95.5%), and 1,978/1,987 (99.5%), respectively. Compared with clinical diagnoses, the Bland-Altman 95% limits of agreement for acetabular index, as determined by the deep learning system from the radiographs of non-dislocated and dislocated hips, were -3.27° - 2.94° and -7.36° - 5.36°, respectively (p < 0.001). Conclusion. The deep learning system was highly consistent, more convenient, and more effective for diagnosing DDH compared with clinician-led diagnoses. Deep learning systems should be considered for analysis of anteroposterior pelvic radiographs when diagnosing DDH. The deep learning system will improve the current artificially complicated screening referral process. Cite this article: Bone Joint J 2020;102-B(11):1574–1581

Aims

Given the possible radiation damage and inaccuracy of radiological investigations, particularly in children, ultrasound and superb microvascular imaging (SMI) may offer alternative methods of evaluating new bone formation when limb lengthening is undertaken in paediatric patients. The aim of this study was to assess the use of ultrasound combined with SMI in monitoring new bone formation during limb lengthening in children.

Aims. The health-related quality of life (HRQoL) of paediatric patients with orthopaedic conditions and spinal deformity is important, but existing generic tools have their shortcomings. We aim to evaluate the use of Paediatric Quality of Life Inventory (PedsQL) 4.0 generic core scales in the paediatric population with specific comparisons between those with spinal and limb pathologies, and to explore the feasibility of using PedsQL for studying scoliosis patients’ HRQoL. Methods. Paediatric patients attending a speciality outpatient clinic were recruited through consecutive sampling. Two groups of patients were included: idiopathic scoliosis, and paediatric orthopaedic upper and lower limb condition without scoliosis. Patients were asked to complete PedsQL 4.0 generic core scales, Youth version of 5-level EuroQol-5-dimension questionnaire, and Refined Scoliosis Research Society 22-item (SRS-22r) questionnaire. Statistical analyses included scores comparison between scoliosis and limb pathology patients using independent-samples t-test, and correlation tests of PedsQL and SRS-22r. Results. A total of 566 paediatric patients were recruited: 357 (63.0%) having idiopathic scoliosis, and 209 (37.0%) with limb conditions. Patients with limb pathology had lower functioning scale, summary, and total scores of PedsQL than scoliosis patients (p < 0.05 to p < 0.001). No floor or ceiling effects (< 15%) were detected for PedsQL Psychosocial Health Summary and total scores in both groups. PedsQL was sensitive in differentiating patients with/without problems in their daily lives (p < 0.05 to p < 0.01). PedsQL summary and total scores correlated with SRS-22r total score. Conclusion. PedsQL is an effective HRQoL measure for both paediatric orthopaedic groups with minimal ceiling and floor effects, and is capable of detecting worse HRQoL in patients with limb pathology. The multidimensional PedsQL is sensitive in differentiating among those with daily life problems, especially for scoliosis patients. Cite this article: Bone Joint J 2020;102-B(7):890–898

Purpose. There is concern that the positive predictive value (PPV) of neonatal screening for instability may have deteriorated over recent years, this study aims to evaluate this. Method. This is a prospective observational longitudinal study from 2012 – 2016. Patients that were referred from paediatric neonatal screening with hip instability (Ortolani / Barlow positive, clunks) were identified and underwent ultrasound and clinical examination in the one stop hip clinic by the senior author. Referrals were taken from a range of screeners from paediatric doctors to midwives and advanced neonatal practitioners. Syndromic or neurological dislocated hips were excluded. The outcome measures were the presence of a subluxated / dislocated hip on ultrasound as per Graf and Harcke classification and a positive provocative manoeuvre on examination. This allowed a PPV to be evaluated for both ultrasound and clinical examination. Results. 139 neonates were referred for a suspected dislocated or dislocatable hip from paediatric screening services. These were seen at a mean 14.0 days (95% C I, 12.28 to 15.72). 20 patients had a Graf type 4 hip on ultrasound and 5 had a positive provocative test on examination. This represents an ultrasound PPV of 14.4% and clinical exam PPV of 3.6% . This has deteriorated from 15 year data from our unit (PPV 24% clinical, 49% sonographic). Our overall surgical rate for DDH has increased to 1.07 per 1000, and our overall rate of open reductions has increased to 0.7 per 1000. This is based upon figures from 2012 – 2014. Conclusion. The PPV of screening has decreased over the last 5 years. The concern is too many screeners who, with regards screening the paediatric hip, are poorly trained, inexperienced, not adequately supervised. We need to learn the lessons of Sweden and ensure better quality screening by limiting screening to a small number of experienced practitioners

Over a 15-year prospective period, 201 infants with a clinically unstable hip at neonatal screening were subsequently reviewed in a ‘one stop’ clinic where they were assessed clinically and sonographically. Their mean age was 1.62 weeks (95% confidence interval (CI) 1.35 to 1.89). Clinical neonatal hip screening revealed a sensitivity of 62% (mean, 62.6 95%CI 50.9 to 74.3), specificity of 99.8% (mean, 99.8, 95% CI 99.7 to 99.8) and positive predictive value (PPV) of 24% (mean, 26.2, 95% CI 19.3 to 33.0). Static and dynamic sonography for Graf type IV dysplastic hips had a 15-year sensitivity of 77% (mean, 75.8 95% CI 66.9 to 84.6), specificity of 99.8% (mean, 99.8, 95% CI 99.8 to 99.8) and a PPV of 49% (mean, 55.1, 95% CI 41.6 to 68.5). There were 36 infants with an irreducible dislocation of the hip (0.57 per 1000 live births), including six that failed to resolve with neonatal splintage. Most clinically unstable hips referred to a specialist clinic are female and stabilise spontaneously. Most irreducible dislocations are not identified from this neonatal instability group. There may be a small subgroup of females with instability of the hip which may be at risk of progression to irreducibility despite early treatment in a Pavlik harness. A controlled study is required to assess the value of neonatal clinical screening programmes. Cite this article: Bone Joint J 2015;97-B:265-9

Aims. High-quality clinical research in children’s orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children’s orthopaedics. Methods. A modified Delphi technique was used, which involved an initial scoping survey, a two-round Delphi process and an expert panel formed of members of the British Society of Children’s Orthopaedic Surgery. The survey was conducted amongst orthopaedic surgeons treating children in the United Kingdom and Ireland. Results. A total of 86 clinicians contributed to both rounds of the Delphi process, scoring priorities from one (low priority) to five (high priority). Elective topics were ranked higher than those relating to trauma, with the top ten elective research questions scoring higher than the top question for trauma. Ten elective, and five trauma research priorities were identified, with the three highest ranked questions relating to the treatment of slipped capital femoral epiphysis (mean score 4.6/ 5), Perthes’ disease (4.5) and bone infection (4.5). Conclusion. This consensus-based research agenda will guide surgeons, academics and funders to improve the evidence in children’s orthopaedic surgery and encourage the development of multicentre clinical trials. Cite this article: Bone Joint J 2018;100-B:680–4

The aim of this study was determine if the detection of pathology in children with a limp can be optimised by screening with blood tests for raised inflammatory markers. The entry criteria for the study were children (0–15 years) presenting to our hospital Emergency Department from 2012–2015 with a non-traumatic limp or pseudoparalysis of a limb, and no sign of fracture or malignancy on plain radiographs. ESR and CRP blood tests were performed along with other standard investigations. Children with ESR or CRP over 10 underwent MRI scan of their area of pain or tendernesss, with those under 7 years old having general anaesthetic. MRI provided the diagnosis in cases of osteomyelitis, pyomyositis, fasciitis, cellulitis, discitis, as well as non-infective conditions such as malignancy and fracture not visible on plain radiographs. Where a joint effusion was present, the diagnosis of septic arthritis was made from organisms cultured following surgical drainage, or high white cell count in joint fluid if no organisms were cultured. The study was completed once data from 100 consecutive children was available. 64% of children had an infective cause for their symptoms (osteomyelitis, septic arthritis, pyomyositis, fasciitis, cellulitis or discitis). A further 11% had positive findings on MRI from non-infective causes (juvenile idiopathic arthritis, cancer, or occult fracture). The remaining 25% had either a normal scan, or transient synovitis. ESR was a more sensitive marker than CRP, since ESR was raised in 97% of those with abnormal scans, but CRP in only 70%. There were no complications from any of the GA MRI scans. Conclusion: This shows that MRI imaging of all children with a limp and either raised ESR or CRP is a sensitive method to minimise the chance of missing important pathology in this group, and is not wasteful of MRI resources

We report the radiological outcomes, and short-term clinical results, of 47 periacetabular osteotomies undertaken through both the traditional bikini incision, and a minimally invasive approach. 47 periacetabular osteotomies have been undertaken in 45 patients, by the senior author, between 2005 and 2013. There were 10 male and 35 female patients. The mean age at operation was 28.2 years. Since 2010 surgery has been performed through a 7-cm skin incision (31 hips), an incision coined as minimally invasive by Søballe et al when they described their trans-sartorial approach for acetabular surgery. Clinical data was collected prospectively; primary outcome measures included the young adult hip score and the hip disability and osteoarthritis outcome score. Pre- and post-operative radiographs were analysed for achieved acetabular reorientation. At the time of follow-up the median young adult hip score had improved significantly from pre-operative values. Mean scores were 35.4 pre-operatively, and 64.25 post-operatively. Improvement in the anterior and lateral centre-edge angle was 32 and 32.9 degrees respectively through a traditional incision, and 27.1 and 30 degrees through the minimally invasive approach (p>0.05). No major complications occurred in any patient. Four patients complained of lateral cutaneous nerve hypoaesthesia, in two patients there was delayed union of the pubic osteotomy and in one non-union. Two patients have gone on to total hip replacement. The minimally invasive approach is safe and allows for accurate reorientation of the acetabulum whilst minimizing tissue damage. The scar is cosmetically appealing to patients, especially the predominantly female group treated with this condition. We did not see the evidence of reduced surgical stay that has been reported by other groups utilizing a minimally invasive approach. Level of evidence: II

The aim was to compare the efficacy of selective ultrasound-screening (SUSS) for developmental dysplasia of the hip (DDH) to clinical screening alone, by comparing outcomes in a contemporary group with those from a 40 year old cohort. This was a retrospective cohort study. The department's DDH and surgical databases were used to identify all cases of DDH, and all cases of surgery for DDH during the study period (2009–13). Patients born outside our region, and teratologic cases were excluded from analysis. The Obstetric database provided the total number of live births over the five-year period. This data was used to calculate the incidence of late-diagnosis (age over 3 months) DDH and the rate of surgery for DDH in our region. These results were compared to those of a similar study from our institution published in 1977, after the introduction of universal clinical screening. Relative risk (RR) was calculated for the two groups, and analysed for statistical significance. The incidence of late-diagnosis DDH over the recent 5-year study period was 0.66/1000 live births, compared to 0.6/1000 in the control group. The RR for late-diagnosis DDH was not significantly different between the two groups (RR 1.14, 95% CI 0.6 to 2.2). The rate of surgery for DDH was 0.86/1000, compared to 0.9/1000 live births in the control group. The RR for surgery for DDH in the current study population compared to the historic control was 0.97, but this difference was not statistically significant (95% C.I. 0.57 to 1.68; p=0.92). Despite advances in screening for DDH over the last 40 years, neither the incidence of late diagnosis DDH, nor rates of surgery for DDH in our region have changed. Whilst previous studies have demonstrated that SUSS does not eliminate late-presenting DDH, this study suggests it confers no advantage over clinical screening alone

Purpose. Clinical coding is used to record information from patient admissions in the form of coded data used for monitoring the provision of health services and trends, research, audit and NHS financial planning. Method. A sample of 105 cases admitted to Southampton General paediatric orthopaedic department from 2006-9 was used. 31 admissions were grouped using HRG4 and the remaining 74 using HRG3.5. Accuracy of coding was calculated by establishing correct discharge coding and comparing them with coding records. The correct codes were run through HRG 3.5 and 4 payment groupers and their outcomes were compared financially to the HRG codes these admissions were actually grouped under. Results. There were 800 interventions which should have been coded over 148 patient episodes. Of these 442 (55%) were not coded, 189 (24%) were coded inappropriately and 169 (21%) were coded correctly. The HRG3.5 group was coded 18% correctly, the HRG4 29% correctly. However, 70% of the HRG4 and 49% of the HRG 3.5 group were inaccurately grouped. The resulting deficit was a £54,352 (HRG4-£36,711, HRG3.5-£17,641) an average of £507 per patient stay. A conservative estimate of 150 ward admissions monthly means a projected loss of £912,600 per annum. The fractured radius and ulna group (one of the most common causes of admission) suffered greatest financial losses. Additional losses come from paediatric/orthopaedic top-ups (63% and 14% respectively) as only one can be applied to each HRG. Conclusion. The implementation of HRG4 means accuracy is crucial as smaller inaccuracies result in bigger costing discrepancies than with HRG 3.5. Financial losses are larger with paediatric orthopaedics from inadequate top-ups. This system of Payment by Estimates not Results is only acceptable if financial underestimates are balanced with financial overestimates. These results strongly suggest this is not happening

The aim was to examine the descriptive epidemiology of Slipped Capital Femoral Epiphysis, with respect to geography and time. We extracted all children with a diagnosis of Slipped Capital Femoral Epiphysis from the Clinical Practice Research Database between 1990 and 2014 (24 years). CPRD is the world's largest database of primary care, which encompasses 8% of the UK population. CPRD was linked to Hospital Episode Statistics, and a validation algorithm applied to maximise sensitivity and specificity of the cases finding methodology. Poisson confidence intervals were calculated, and poison regression used. 596 cases of SCFE were identified. The internal validation algorithm supported a SCFE diagnosis in 88% cases. The age and sex distribution of cases mirrored that in the literature, offering external validity to the cases identified. There was no significant change in the incidence of SCFE over the 24-year study period, with the overall incidence being 4.8 cases per 100,00 0–16 year olds. There was no significant geographic variation in SCFE within the UK. There was a positive association with rising socioeconomic deprivation (p<0.01). There was no seasonal variation in presentation. This study found no evidence to support the common belief that SCFE incidence is increasing, and for the first time demonstrated an association with socioeconomic deprivation. The results are important for considering the feasibility of intervention studies, and offer insights into the disease aetiology

We performed CT to investigate how treatment may modify the basic skeletal pathology of congenital club foot. Two homogenous groups of patients treated by one of the authors (EI) or under his supervision were studied. The first included 32 patients with 47 club feet reviewed at a mean age of 25 years and treated by manipulation, application of toe-to-groin plaster casts and an extensive posteromedial release. The second included 32 patients with 49 club feet reviewed at a mean age of 19 years and treated by the Ponseti manipulation technique, application of toe-to-groin plaster casts and a limited posterior release. At follow-up the shape of the subtalar, talonavicular and calcaneocuboid joints was found to be altered in many feet in both groups. This did not appear to be influenced significantly by the type of treatment performed. Correction of the heel varus and the increased declination angle of the neck of the talus was better in the club feet of the second group, whereas reduction of the medial subluxation of the navicular was better in the first. There was a marked increase in the external ankle torsion angle in the first group and a moderate increase of this angle in the second group, in which medial subluxation of the cuboid on the anterior apophysis of the calcaneum was always corrected. Equinus was corrected in both groups but three-dimensional CT reconstruction of the whole foot showed that cavus, supination and adduction deformities were corrected much better in the second group

Achilles tenotomy is a recognised step in the Ponseti technique for the correction of idiopathic congenital talipes equinovarus in most percutaneous cases. Its use has been limited in part by concern that the subsequent natural history of the tendon is unknown. In a study of 11 tendons in eight infants, eight tendons were shown to be clinically intact and ten had ultrasonographic evidence of continuity three weeks after tenotomy. At six weeks after tenotomy all tendons had both clinical and ultrasonographic evidence of continuity

Objectives

The development of tibiofemoral angle in children has shown ethnic variations. However this data is unavailable for our population.

Aim. Kite manipulation and casting for congenital talipes equinovarus (CTEV) was noted to require a subsequent posteromedial release (PMR) in almost all of the children treated, with variable outcomes including overcorrection and stiffness. Introduction of the Ponseti serial manipulation and casting technique dramatically reduced the need for PMR. This study assesses the medium term outcomes in these two treatment groups. Methods. We retrospectively identified patients treated for idiopathic CTEV between 1997 and 2007 under a single surgeon. Two cohorts with a minimum 4 years' follow-up were treated with Kite (1997–2001) and Ponseti (2002–2007) manipulation and casting. The entire Kite cohort (14 patients) and none of the Ponseti cohort (16 patients) required PMR. All patients were assessed by clinical and functional examination, questionnaire and medical notes review. There was a total of 40 feet (10 bilateral and 20 unilateral) with 20 feet in each cohort. Results. 7 feet (35%) in each cohort required further surgical procedures. Of these, 6 feet in the Kite/PMR group required bony surgical correction compared with none in the Ponseti group. There was a significant difference between the Kite/PMR and Ponseti groups in; calf circumference difference (mean 24mm vs 13mm p<0.05), subtalar movement (mean 15° vs 25° p<0.05), and ankle plantar flexion (mean 20° vs 45° p<0.05). There were also functional differences between the two cohorts (Kite/PMR vs Ponseti) with regard to; being very satisfied with the outcome (55% vs 95%), never limiting activities (50% vs 95%), never painful (60% vs 95%), and the ability to toe walk (35% vs 100%). Conclusions. Since the introduction of the Ponseti method for treating CTEV in our unit, the outcome for children with this condition has improved significantly with regard to function, cosmesis and a greatly reduced risk of further surgical intervention

We examined 204 children (137 boys and 67 girls) aged 12 years and under with septic arthritis. Their mean age was 31.1 months (1 to 144; SD 41.6). The most common joints affected were the knees and shoulders. Joints in the upper limb were affected more often in younger children and in the lower limb in those who were older. The mean age for an infection was 12 months in the shoulder and 73 months in the hip. The most common organisms cultured were species of Salmonella.

Between 1978 and 1997 all newborns in the Austrian province of Tyrol were reviewed regarding hip dysplasia and related surgery. This involved a mean of 8257 births per year (7766 to 8858). Two observation periods were determined: 1978 to 1982 (clinical examination alone) and 1993 to 1997 (clinical examination and universal ultrasound screening). A retrospective analysis compared the number and cost of interventions due to hip dysplasia in three patient age groups: A, 0 to < 1.5 years; B, ≥ 1.5 to < 15 years; and C, ≥ 15 to < 35 years.

In group A, there was a decrease in hip reductions from a mean of 25.2 (sd 2.8) to 7.0 (sd 1.4) cases per year. In group B, operative procedures decreased from a mean of 17.8 (sd 3.5) to 2.6 (sd 1.3) per year. There was a 75.9% decrease in the total number of interventions for groups A and B.

An increase of €57 000 in the overall cost per year for the second period (1993 to 1997) was seen, mainly due to the screening programme. However, there was a marked reduction in costs of all surgical and non-surgical treatments for dysplastic hips from €410 000 (1978 to 1982) to €117 000 (1993 to 1997). We believe the small proportional increase in costs of the universal ultrasound screening programme is justifiable as it was associated with a reduction in the number of non-surgical and surgical interventions. We therefore recommend universal hip ultrasound screening for neonates.

Aims. Perthes’ disease is an idiopathic avascular necrosis of the developing femoral head, often causing deformity that impairs physical function. Current treatments aim to optimize the joint reaction force across the hip by enhancing congruency between the acetabulum and femoral head. Despite a century of research, there is no consensus regarding the optimal treatment. The aim of this study was to describe the experiences of children, their families, and clinicians when considering the treatment of Perthes’ disease. Methods. A qualitative study gathered information from children and their families affected by Perthes’ disease, along with treating clinicians. Interviews followed a coding framework, with the interview schedule informed by behavioural theory and patient and public involvement. Transcripts were analyzed using the framework method. Results. A total of 24 interviews took place, with 12 child/family dyads and 12 clinicians from UK NHS centres. Interviews identified widespread variation of routine care. Children/their families recounted positive experiences when included in the decision-making process for treatment. There is a strong desire from clinicians and children/families for consistent guidance from everyone involved in care, which should be based on clinical consensus. Conclusion. This is the first study to describe how children/families and clinicians experienced receiving or providing treatment in Perthes’ disease. The results indicate the need for robust evidence to support treatment decisions. Children and families valued feeling involved in the clinical decision-making process. Clinicians acknowledged the central importance of providing patient-centred care, particularly in the absence of robust evidence to guide the optimal treatment decisions. This study will inform a future Delphi project to develop clinical consensus guidelines for the treatment of Perthes’ disease. Cite this article: Bone Jt Open 2023;4(10):735–741