Radiographs of 12-year-old girl with high-grade IV isthmic dysplastic spondylolisthesis. Patient has small amount of sciatic scoliosis on coronal view (A and B). Sacrum is vertical on sagittal radiograph (C), and she is positioned with her trunk anterior to her pelvis, showing anterior sagittal imbalance. Patient had posterior decompression, partial reduction, sacral dome osteotomy, and posterolateral fusion with instrumentation from L5 to sacrum. One week later, she had anterior fibular dowel graft placement from L5 to sacrum. Radiographs D to F show improved position of L5 on sacrum and excellent alignment in overall coronal (D) and sagittal (E) radiographs. F, Arrow points to anterior edge of fibular graft. SEE TECHNIQUE 44.54.