Surgical Indications, Reported Decision Thresholds, and Outcomes in Pediatric Lower-Limb Rotational Deformities: A Systematic Review

Background/Objectives: This systematic review evaluated reported indications and decision thresholds for pediatric lower-limb derotational surgery and summarized postoperative clinical, gait, patient-reported, and safety outcomes across the full historical evidence base. Methods: PubMed, Web of Science Core Collection, Scopus, and Ovid MEDLINE were searched from database inception through 14 August 2026, without a lower publication-date restriction. Eligible studies involved patients aged 18 years or younger at operative treatment; mixed-age cohorts required separately extractable pediatric data. Studies were synthesized by diagnosis and assessment modality. Meta-analysis was not undertaken because outcomes, denominators, measurement methods, and follow-up were not sufficiently comparable. Risk of bias or methodological quality was assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I), the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Series, the Quality In Prognosis Studies (QUIPS) tool for the prognostic-factor study, or Cochrane Risk of Bias 2 (RoB 2), as appropriate to the evidence contribution. Outcome-domain certainty was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Results: Sixty-five reports published between 1980 and 2026 were included, comprising 64 non-randomized reports and one randomized prospective comparative report. Across 64 reports with patient denominators, 2108 patient observations were represented in cohorts receiving the rotational intervention of interest; one additional report described 36 operated legs without a patient denominator. These are report-level observations, not unique patients. Exact operative sex counts were available in 40 reports (588/1115 female, 52.74%). Primary procedural focus was femoral in 44 reports, tibial in 18, and combined or mixed femoral–tibial in three. Clinical rotational assessment was documented in 61/65 reports, instrumented walking-gait analysis in 33/65, and computed tomography (CT) torsion/version assessment in 12/65. Seventeen of 18 ROBINS-I assessments were at serious overall risk of bias; the prognostic-factor report was at high risk using QUIPS, and the randomized report was at high risk using RoB 2. GRADE certainty remained very low across the principal outcome domains. Conclusions: No universal operative threshold is supported. Very-low-certainty evidence favors individualized, diagnosis-specific decision-making that integrates persistent symptoms and functional impairment with age-appropriate clinical examination, selective imaging, and dynamic gait assessment rather than defining new universal operative cutoffs.