Systematic Review on Medical and Surgical Management of Rickets in Children With Deformities

Background: Rickets remain a leading cause of skeletal deformities in children, particularly in settings where vitamin D and calcium deficiency, hereditary phosphate-wasting, and renal osteodystrophy are prevalent. Although etiology-specific medical therapies have advanced, many children still develop progressive limb deformities that compromise gait and long-term joint integrity, and optimal integration of medical, non-surgical, and surgical management remains uncertain. Objective: This systematic review aimed to evaluate etiology-specific medical and surgical strategies for managing deformities in children with rickets, and to integrate mechanistic insights from vertebrate models of growth-plate plasticity. Methods: A systematic search of MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library was conducted for articles published between 2000 and 2025. Eligible studies included pediatric clinical reports, guidelines, case reports, practice surveys, and vertebrate experimental studies that addressed rickets or rickets-like skeletal deformities and described medical, non-surgical, or surgical management and skeletal outcomes. Study selection, data extraction, and qualitative appraisal were performed in duplicate. Given heterogeneity of designs and outcomes, a narrative synthesis was undertaken, grouping findings by etiology and management domain. Results: Ten studies met inclusion criteria: one clinical narrative review, one etiology-based guideline, one XLH case report, one nationwide orthopedic surgeon survey, and six vertebrate experimental or observational studies. Nutritional rickets responded well to timely vitamin D and calcium supplementation, with potential for spontaneous remodeling of mild deformities, while hereditary phosphate-wasting and renal forms often exhibited persistent malalignment despite biochemical control. The XLH case report suggested that early orthotic intervention in combination with pharmacologic therapy can substantially correct lower-limb deformities without early osteotomy, whereas the nationwide survey revealed wide variation in diagnostic work-up, referral patterns, and use of guided growth and osteotomy among orthopedic surgeons. Vertebrate models consistently showed that mineral imbalance, micronutrient deficiency, toxicant exposure, and altered mechanical loading induce predictable skeletal deformities, supporting the importance of early metabolic correction and mechanical optimisation. Conclusion: Current evidence supports a multidisciplinary, etiology-based approach in which early biochemical normalisation is systematically coupled with orthopedic surveillance, selective orthotic strategies, and timely guided growth or osteotomy. However, high-quality comparative data on the timing and combination of these interventions remain scarce, underscoring the need for prospective, multicenter studies and standardised care pathways.