A comparison of 3 different methods for assessment of skeletal age when treating leg-length discrepancies: an inter- and intra-observer study

Background and purpose — Skeletal maturity is a crucial parameter when calculating remaining growth in children. We compared 3 different methods, 2 manual and 1 automated, in the radiological assessment of bone age with respect to precision and systematic difference. Material and methods — 66 simultaneous examinations of the left hand and left elbow from children treated for leg-length discrepancies were randomly selected for skeletal age assessment. The radiographs were anonymized and assessed twice with at least 3 weeks’ interval according to the Greulich and Pyle (GP) and Sauvegrain (SG) methods by 5 radiologists with different levels of experience. The hand radiographs were also assessed for GP bone age by use of the automated BoneXpert (BX) method for comparison. Results — The inter-observer intraclass correlation coefficient (ICC) was 0.96 for the GP and 0.98 for the SG method. The inter- and intra-observer standard error of the measurement (SEm) was 0.41 and 0.32 years for the GP method and 0.27 and 0.21 years for the SG method with a significant difference (p < 0.001) between the methods and between the experienced and the less experienced radiologists for both methods (p = 0.003 and p < 0.001). In 25% of the assessments the discrepancy between the GP and the SG methodwas > 1 year. There was no systematic difference comparing either manual method with the automatic BX method. Interpretation — With respect to the precision of skeletal age determination, we recommend using the SG method or preferably the automated BX method based on GP assessments in the calculation of remaining growth.

Download Full-text

Ossification of the phalanges of the foot and its relationship to peak height velocity and the calcaneal system

Journal of Children s Orthopaedics ◽

10.1302/1863-2548.12.170164 ◽

2018 ◽

Vol 12 (1) ◽

pp. 84-90 ◽

Cited By ~ 1

Author(s):

M. R. Garcia ◽

A. D. Nicholson ◽

A. M. Nduaguba ◽

J. O. Sanders ◽

R. W. Liu ◽

...

Keyword(s):

Skeletal Maturity ◽

Strong Association ◽

Intraclass Correlation ◽

Bone Age ◽

Peak Height ◽

Height Velocity ◽

Peak Height Velocity ◽

Guided Growth ◽

Significant Difference ◽

Stage System

Purpose There are multiple skeletal maturity grading systems, but none of them utilizes the phalanges of the foot. To minimize radiation, it would be ideal if one could assess the skeletal maturity of a foot based on bones seen on routine foot radiographs, if guided growth is being considered as a treatment option. We developed a system that correlates changes of the appearance of the foot phalanges to peak height velocity (PHV) and the recently described calcaneal apophyseal ossification grading system. Methods We selected 94 children from the Bolton-Brush study, each with consecutive radiographs from age ten to 15 years old. Using the anteroposterior view, we analyzed the ossification patterns of the phalanges and developed a six-stage system. We then determined the PHV for each subject and defined its relationship with our system. Our system was then compared with the previously established calcaneal system. Results We calculated an Intraclass correlation coefficient (ICC) range of 0.957 to 0.985 with a mean of 0.975 and interclass reliability coefficient of 0.993 indicating that this method is reliable and consistent. Our system showed no significant difference between gender with respect to PHV, which makes it a reliable surrogate for determining bone age in paediatric and adolescent patients. Conclusions Our system has a strong association with the calcaneal system. It is a simple six-stage system that is reliable and correlated more strongly with PHV than chronological age. The system requires knowledge of the ossification markers used for each stage but is easily used in a clinical setting.

Download Full-text

MRI KNEE BONE AGE: A NOVEL SHORTHAND APPROACH TO REDUCE BONE AGE RADIOGRAPHS IN CHILDREN

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00180 ◽

2020 ◽

Vol 8 (4_suppl3) ◽

pp. 2325967120S0018

Author(s):

Blake C. Meza ◽

Scott M. LaValva ◽

Christopher J. DeFrancesco ◽

Brendan M. Striano ◽

Julien T. Aoyama ◽

...

Keyword(s):

Radiation Exposure ◽

Medical Training ◽

Skeletal Maturity ◽

Intraclass Correlation ◽

Age Determination ◽

Bone Age ◽

Observer Agreement ◽

Rater Reliability ◽

Knee Mri ◽

The Mean

Background: Determining bone age in skeletally immature patients is critical for proper management and surgical planning. Pennock et al. recently created and validated a bone age atlas using the ossification pattern of the knee on MRI in pediatric patients, obfuscating the need for a hand radiograph and its associated cost, radiation exposure, and clinical inefficiency. Hypothesis/Purpose: We sought to validate and demonstrate reliability of a novel shorthand method of bone age determination using knee MRI across multiple levels of medical training. Methods: We identified patients who underwent knee MRI and hand bone age radiograph within a ninety-day period. In collaboration with a pediatric musculoskeletal radiologist, stepwise algorithms for predicting bone age on knee MRI were developed- one for males and one for females. Six raters at varying levels of training used the algorithm to assign a bone age for each patient. Intraclass correlation coefficient (ICC) was used to compare each rater’s predicted knee bone age to the Greulich and Pyle (G&P) hand bone age and validate the shorthand algorithm. Inter-rater reliability was also calculated using ICC. Results: Thirty-eight patients (44.7% female) underwent a knee MRI at a mean age of 12.8 years (range 9.3-15.7). The mean time between hand bone age x-ray and knee MRI was 20.2 days (range 0-88). The inter-rater reliability for the application of our shorthand algorithm was 0.81 (95% CI: 0.72 – 0.88), indicating good inter-observer agreement. The shorthand methos was shown to be a good predictor of G&P hand bone age, both for each individual rater (ICC range: 0.73 – 0.80) and the mean knee MRI bone age across all raters (ICC 0.81; 95% CI 0.65 – 0.90). It was also shown to be a consistent predictor of hand bone age across level of training, as medical students (ICC 0.77, 95% CI 0.60-0.88), residents (ICC 0.80, 95% CI 0.65-0.89), and attending physicians (ICC 0.80, 95% CI 0.63-0.89) all achieved strong correlation between predicted knee MRI bone age and G&P hand bone age. Conclusions: This novel shorthand algorithm is a reliable and valid way to determine skeletal maturity using knee MRI. It can be utilized clinically across different levels of radiographic and orthopaedic expertise and reduces the need for hand bone age radiographs and consequential radiation exposure in children. [Figure: see text][Figure: see text][Table: see text]

Download Full-text

A Novel Shorthand Approach to Knee Bone Age Using MRI: A Validation and Reliability Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211021582 ◽

2021 ◽

Vol 9 (8) ◽

pp. 232596712110215

Author(s):

Blake C. Meza ◽

Scott M. LaValva ◽

Julien T. Aoyama ◽

Christopher J. DeFrancesco ◽

Brendan M. Striano ◽

...

Keyword(s):

Skeletal Maturity ◽

Intraclass Correlation ◽

Age Determination ◽

Correlation Coefficients ◽

Bone Age ◽

Intrarater Reliability ◽

Level Of Evidence ◽

Knee Mri ◽

Level Of Training ◽

Magnetic Resonance Imaging Mri

Background: Bone-age determination remains a difficult process. An atlas for bone age has been created from knee-ossification patterns on magnetic resonance imaging (MRI), thereby avoiding the need for radiographs and associated costs, radiation exposure, and clinical inefficiency. Shorthand methods for bone age can be less time-consuming and require less extensive training as compared with conventional methods. Purpose: To create and validate a novel shorthand algorithm for bone age based on knee MRIs that could correlate with conventional hand bone age and demonstrate reliability across medical trainees. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Included in this study were adolescent patients who underwent both knee MRI and hand bone age radiographs within 90 days between 2009 and 2018. A stepwise algorithm for predicting bone age using knee MRI was developed separately for male and female patients, and 7 raters at varying levels of training used the algorithm to determine the bone age for each MRI. The shorthand algorithm was validated using Spearman rho ( rS) to correlate each rater’s predicted MRI bone age with the recorded Greulich and Pyle (G&P) hand bone age. Interrater and intrarater reliability were also calculated using intraclass correlation coefficients (ICCs). Results: A total of 38 patients (44.7% female) underwent imaging at a mean age of 12.8 years (range, 9.3-15.7 years). Shorthand knee MRI bone age scores were strongly correlated with G&P hand bone age ( rS = 0.83; P < .001). The shorthand algorithm was a valid predictor of G&P hand bone age regardless of level of training, as medical students ( rS = 0.75), residents ( rS = 0.81), and attending physicians ( rS = 0.84) performed similarly. The interrater reliability of our shorthand algorithm was 0.81 (95% CI, 0.73-0.88), indicating good to excellent interobserver agreement. Respondents also demonstrated consistency, with 6 of 7 raters demonstrating excellent intrarater reliability (median ICC, 0.86 [range, 0.68-0.96]). Conclusion: This shorthand algorithm is a consistent, reliable, and valid way to determine skeletal maturity using knee MRI in patients aged 9 to 16 years and can be utilized across different levels of orthopaedic and radiographic expertise. This method is readily applicable in a clinical setting and may reduce the need for routine hand bone age radiographs.

Download Full-text

Knee Bone Age using MRI: Validation of a Novel Method to Reduce Hand Bone Age Radiographs

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00458 ◽

2020 ◽

Vol 8 (7_suppl6) ◽

pp. 2325967120S0045

Author(s):

Blake Meza ◽

Scott LaValva ◽

Julien Aoyama ◽

Christopher DeFrancesco ◽

Brendan Striano ◽

...

Keyword(s):

Skeletal Maturity ◽

Intraclass Correlation ◽

Age Determination ◽

Bone Age ◽

Observer Agreement ◽

Knee Mri ◽

Novel Method ◽

Absolute Agreement ◽

Level Of Training ◽

Attending Physicians

Objectives: Determining bone age in skeletally immature patients is critical for proper management and surgical planning. Pennock et al. recently created and validated a bone age atlas using the ossification pattern of the knee on MRI in pediatric patients, obfuscating the need for a hand radiograph and its associated cost, radiation exposure, and clinical inefficiency. This aim of this study was to create and validate a shorthand method of bone age determination using knee MRI. Methods: We identified patients who underwent both knee MRI and hand bone age radiograph within a ninety-day period. From the findings of Pennock et al., a stepwise algorithm for predicting bone age on knee MRI was developed for males and females separately, in collaboration with a pediatric musculoskeletal radiologist. Six raters at varying levels of training used the algorithm to assign a bone age to each knee MRI. Intraclass correlation coefficient (ICC) was used to compare each rater’s predicted knee bone age to the Greulich and Pyle (G&P) hand bone age and validate the shorthand algorithm. Inter- (two-way random, absolute agreement) and intra-rater (two-way mixed, absolute agreement ) reliability were also calculated using ICC. Results: Thirty-eight patients (44.7% females) underwent a knee MRI at a mean age of 12.8 years (range 9.3-15.7). The mean time between hand bone age x-ray and knee MRI was 20.2 days (range 0-88). The inter-rater reliability for the application of our shorthand algorithm was 0.81 (95% CI: 0.72 – 0.88), indicating good inter-observer agreement. The shorthand algorithm was also shown to be a reliable predictor of hand bone age across level of training, as medical students (ICC 0.77, 95% CI 0.60-0.88), residents (ICC 0.80, 95% CI 0.65-0.89), and attending physicians (ICC 0.80, 95% CI 0.63-0.89) all achieved strong correlation between predicted knee bone age and G&P hand bone age. All respondents also demonstrated consistency, with intra-rater ICCs between 0.85-0.93. Conclusion: This shorthand algorithm is a consistent, reliable and valid way to determine skeletal maturity using knee MRI in patients aged 10 to 15 and can be utilized across different levels of orthopaedic and radiographic expertise. We believe this method is readily applicable in a clinical setting and may reduce the need for routine hand bone age radiographs. [Figure: see text][Table: see text]

Download Full-text

An Evaluation of the Effects of Elevated Body Mass Index on Skeletal Age

10.21203/rs.3.rs-888046/v1 ◽

2021 ◽

Author(s):

Michael H. French ◽

Michael S. Kung ◽

W. Nathan Holmes ◽

Hossein Aziz ◽

Evelyn S. Thomas ◽

...

Keyword(s):

Chart Review ◽

Pediatric Patients ◽

Intraclass Correlation ◽

Retrospective Chart Review ◽

Skeletal Age ◽

Chronological Age ◽

Age Group ◽

Obese Children ◽

Significant Difference ◽

Hand Radiographs

Abstract BackgroundMany treatment decisions in children’s Orthopaedics are based on age. This study determined whether a discrepancy between chronological age (CA) and skeletal age (SA) is dependent on BMI and if overweight or obese children would have an advanced SA.Materials and Methods120 children between ages 8-17 with an adequate hand radiograph and a correlating BMI were enrolled by retrospective chart review. Stratification based on age, sex, ethnicity, and BMI percentile was performed. For each age group, 6 males and 6 females were selected with 50% of each group having an elevated BMI. Two blinded physicians independently evaluated hand radiographs and recorded the SA. Statistical analyses evaluated inter-rater reliability and any discrepancy between groups.ResultsThe final statistical analysis included 96 children. The Intraclass Correlation Coefficient for SA determined by the two reviewers was excellent at 0.95. A difference of 13 months was found between CA and SA in the elevated BMI cohort versus the non-elevated BMI cohort, (p<0.001). No significant difference was seen between CA and SA for the non-elevated cohort (p=0.72), while matching for age and sex. ConclusionChronological age and skeletal age are not always equivalent especially in pediatric patients who are overweight or obese.

Download Full-text

Analysis of Bone Age Data From National Cooperative Growth Study Substudy VII

PEDIATRICS ◽

10.1542/peds.104.s5.1031 ◽

1999 ◽

Vol 104 (Supplement_5) ◽

pp. 1031-1036

Author(s):

Stephen F. Kemp ◽

Judy P. Sy

Keyword(s):

Age Determination ◽

Bone Age ◽

Strongly Correlated ◽

Growth Study ◽

Gh Therapy ◽

Pubertal Stage ◽

Significant Difference ◽

Clinically Significant ◽

National Cooperative ◽

Age Determinations

National Cooperative Growth Study substudy VII was conducted 1) to compare standardized hand–wrist and knee bone age determinations in pubertal children treated with growth hormone (GH); 2) to compare local determinations of bone ages with centrally determined bone ages; 3) to relate the response to GH therapy to the bone age determinations; and 4) to ascertain the predictive value of each type of bone age determination. Eligible subjects were those in the National Cooperative Growth Study who were at Tanner pubertal stage 2 or greater for breasts (girls) or genitals (boys). Radiographs of the hand–wrist were taken annually, and radiographs of the knee were taken at the beginning and the end of the study. Separate bone age determinations were made from these radiographs. A combined hand–wrist and knee bone age determination also was derived. There were 990 patients in the study; in 925 (677 boys), there were both hand–wrist and knee bone age determinations from the baseline pubertal radiographs. There was only one radiographic assessment in 496 patients, two in 205 patients, and three to eight in the remaining patients. The strongest correlation was between the hand–wrist bone age and the hand–wrist plus knee bone age (r = .995). Also strongly correlated were knee with hand–wrist (r = .872) and knee with hand–wrist plus knee (r = .914). For none of these bone age methods was any statistically significant difference found between the methods. The locally determined bone ages correlated strongly with the centrally determined bone ages for knee (r = .850), hand–wrist (r = .928), and hand–wrist plus knee (r = .930); however, the locally determined knee and hand–wrist values were less (by ∼0.3 year) than the centrally determined values. These differences, however, do not appear to be clinically significant.

Download Full-text

Correlation and Correspondence between Skeletal Maturation Indicators in Hand-Wrist and Cervical Vertebra Analyses and Skeletal Maturity Score in Korean Adolescents

Children ◽

10.3390/children8100910 ◽

2021 ◽

Vol 8 (10) ◽

pp. 910

Author(s):

Ji Yoon Jeon ◽

Cheol-Soon Kim ◽

Jung-Suk Kim ◽

Sung-Hwan Choi

Keyword(s):

Multiple Correspondence Analysis ◽

Rank Order ◽

Skeletal Maturity ◽

Age Determination ◽

Cervical Vertebra ◽

Skeletal Maturation ◽

Lateral Cephalogram ◽

Korean Adolescents ◽

Maturity Score ◽

Significant Difference

This retrospective observational study aimed to examine the correlation and correspondence between skeletal maturation indicators (SMI), cervical vertebral maturation indicators (CVMI), and radius-ulna-short bones (RUS) skeletal maturity scores in Korean adolescents, and to determine whether easily obtainable SMI or CVMI can replace the RUS skeletal maturity score. A total of 1017 participants were included with both hand-wrist radiograph and lateral cephalogram acquired concurrently. From the lateral cephalogram, CVMI was determined; through the hand-wrist radiograph, SMI was categorized, and the RUS skeletal maturity score was evaluated as well. Associations were examined using the Mann–Whitney U test, Spearman’s rank-order correlation analysis, and multiple correspondence analysis. There was no statistically significant difference in chronological age between males and females; however, the SMI, CVMI, and RUS skeletal maturity scores were significantly higher in females. The SMI, CVMI, and RUS skeletal maturity scores showed a statistically significant strong degree of both positive correlation and correspondence. However, a precisely corresponding RUS skeletal maturity score was difficult to obtain for a specific CVMI and SMI stage, implying the absence of a quantitative correlation. In conclusion, detailed evaluation should be conducted using the RUS skeletal maturity score, preferably in cases that require bone age determination or residual growth estimation.

Download Full-text

EVALUATION OF THE SKELETAL AGE METHOD OF ESTIMATING CHILDREN'S DEVELOPMENT

PEDIATRICS ◽

10.1542/peds.13.2.165 ◽

1954 ◽

Vol 13 (2) ◽

pp. 165-173

Author(s):

DONALD MAINLAND

Keyword(s):

Standard Deviation ◽

Assessment Method ◽

Systematic Difference ◽

Skeletal Age ◽

Nutrition Survey ◽

Quick Method ◽

Age Assessment ◽

Variable Error ◽

Significant Difference ◽

The Individual

An observer's variable error in skeletal age assessment of hand RGs (i.e., the irregular ion between independent readings of the same film) was studied on 1,124 readings of 326 films from 233 children aged 16 months to 17 years. seventy-nine of the RGs were full-size reproductions in Macyr's Nutrition and Chemical Growth in Childhood; the remainder were actual films of children in Halifax, Canada (healthy Orphanage residents and children examined in a nutrition survey). There was no significant difference in variable error associated with the atlas (Todd, Greulich-Pyle), age of child, sex, differences between skeletal and chronologic age, differences between children, or differences between RGs of the same child, except for a tendency in the Macy Series for the poorest reproductions to have a larger variable error than the best reproductions. ions. In most readings the individual indicators were assessed separately and the results averaged, but a quicker method (over-all appraisal) did not produce a significantly different variable error. The quick method may be useful in large surveys, although it appears too coarse for the study of individual children. The observer's variable error was expressed by standard deviations of approximately three months (Macy Series—both atlases; Nutritirn Series—Greulich-Pyle atlas) and four months (Orphanage Series—both atlases). With a standard deviation of three months an assessor must affix an error of ± 8.3 months to his estimate of a child's progress in skeletal age, in order to obtain confidence limits with 95% probability. If his standard deviation is four months he must allow ± 11.1 months. For evaluation of the assessment method, many observers' estimates of variable error are needed, and an appeal for data is issued. After more than 1200 readings had been made the observer's practice lapsed for about a year. Reassessment of a random sample of RGs then showed, besides variable error, a mean systematic difference of approximately three months from the previous readings of the same films with the same atlas. To avoid this risk, any two films that are to be assessed for skeletal progress should be read within a few weeks of each other, and special precautions are therefore necessary to secure independence of the two readings.

Download Full-text

Fourteen-year follow-up of a child with acroscyphodysplasia with emphasis on the need for multidisciplinary management: a case report

BMC Medical Genetics ◽

10.1186/s12881-020-01127-6 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Katina Kartalias ◽

Austin P. Gillies ◽

Maria T. Peña ◽

Andrea Estrada ◽

Dorothy I. Bulas ◽

...

Keyword(s):

Distal Femur ◽

Skeletal Maturity ◽

Bone Age ◽

Skeletal Survey ◽

Leg Length ◽

Erect Posture ◽

Surgical Interventions ◽

Feeding Difficulties ◽

Knee Contracture ◽

The Right

Abstract Background Acroscyphodysplasia has been described as a phenotypic variant of acrodysostosis type 2 and pseudohypoparathyroidism. In acrodysostosis, skeletal features can include brachydactyly, facial hypoplasia, cone-shaped epiphyses, short stature, and advanced bone age. To date, reports on this disorder have focused on phenotypic findings, endocrine changes, and genetic variation. We present a 14-year overview of a patient, from birth to skeletal maturity, with acroscyphodysplasia, noting the significant orthopaedic challenges and the need for a multidisciplinary team, including specialists in genetics, orthopaedics, endocrinology, and otolaryngology, to optimize long-term outcomes. Case presentation The patient presented as a newborn with dysmorphic facial features, including severe midface hypoplasia, malar flattening, nasal stenosis, and feeding difficulties. Radiologic findings were initially subtle, and a skeletal survey performed at age 7 months was initially considered normal. Genetic evaluation revealed a variant in PDE4D and subsequent pseudohypoparathyroidism. The patient presented to the department of orthopaedics, at age 2 years 9 months with a leg length discrepancy, right knee contracture, and severely crouched gait. Radiographs demonstrated cone-shaped epiphyses of the right distal femur and proximal tibia, but no evidence of growth plate changes in the left leg. The child developed early posterior epiphyseal arrest on the right side and required multiple surgical interventions to achieve neutral extension. Her left distal femur developed late posterior physeal arrest and secondary contracture without evidence of schypho deformity, which improved with anterior screw epiphysiodesis. The child required numerous orthopaedic surgical interventions to achieve full knee extension bilaterally. At age 13 years 11 months, she was an independent ambulator with erect posture. The child underwent numerous otolaryngology procedures and will require significant ongoing care. She has moderate intellectual disability. Discussion and conclusions Key challenges in the management of this case included the subtle changes on initial skeletal survey and the marked asymmetry of her deformity. While cone-shaped epiphyses are a hallmark of acrodysostosis, posterior tethering/growth arrest of the posterior distal femur has not been previously reported. Correction of the secondary knee contracture was essential to improve ambulation. Children with acroscyphodysplasia require a multidisciplinary approach, including radiology, genetics, orthopaedics, otolaryngology, and endocrinology specialties.

Download Full-text

The Reliability of Fishman and Nolla Methods in Prediction of Chronological Age of Yemeni Children

Brazilian Dental Science ◽

10.14295/bds.2020.v23i3.1976 ◽

2020 ◽

Vol 23 (3) ◽

Author(s):

Maktoom Abdulrakeeb Alqadi ◽

Amal H Abuaffan

Keyword(s):

Correlation Coefficient ◽

Intraclass Correlation Coefficient ◽

Statistical Significance ◽

Intraclass Correlation ◽

Age Determination ◽

Skeletal Age ◽

Wilcoxon Test ◽

Chronological Age ◽

Rank Test ◽

Dental Age

Objective: This cross-sectional school based study aimed to assess the reliability of Fishman and Nolla methods in predicting the chronological age for Yemeni children. Material and Methods: Orthopantomographs and left handwrist radiographs were taken for 358 Yemeni children (193 boys and 165 girls) 8 - 16 years. Skeletal age estimated by Fishman method and dental age estimated by Nolla method were compared to chronological age using SPSS version 21, statistical significance was predetermined at P < 0.05 , using Intraclass Correlation Coefficient- ICC and Wilcoxon signed rank test. Results: The mean chronological, skeletal and dental ages were 12.00 ± 2.25 years, 12.39 ± 1.65 years and 11.32 ± 2.65 years, respectively. Intraclass correlation coefficient showed strong correlation between chronological age and skeletal and dental ages. Wilcoxon test showed Fishman method significantly underestimated the chronological age by 0.44 ± 1.26 years in boys and non-significantly underestimated the chronological age by 0.02 ± 1.08 years in girls. Nolla method significantly underestimated the chronological age by 0.59 ± 1.28 years in boys and 0.78 ± 1.21 years in girls. Conclusions: Chronological age of Yemeni children is highly correlated to skeletal age estimated by Fishman method and dental age estimated by Nolla method. However, the two methods underestimate the chronological age of Yemeni children.KeywordsAge determination by teeth; Orthodontics; Age determination by skeleton; Forensic dentistry; Yemen.

Download Full-text