Tibial Tubercle Apophyseal Stage to Determine Skeletal Age in Pediatric Patients Undergoing ACL Reconstruction: A Validation and Reliability Study

Background: Anterior cruciate ligament (ACL) injuries demand individualized treatments based on an accurate estimation of the child’s skeletal age. Wrist radiographs, which have traditionally been used to determine skeletal age, have a number of limitations, including cost, radiation exposure, and inconvenience. Purpose: To evaluate the reliability and validity of a radiographic staging system using tibial apophyseal landmarks as hypothetical proxies for skeletal age to use in the preoperative management of pediatric ACL tears. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The study included children younger than 16 years of age who underwent ACL reconstruction between July 2008 and July 2018 and received both skeletal age radiography and knee radiography within 3 months of each other. Skeletal age was calculated from hand and wrist radiographs using the Greulich and Pyle atlas. Tibial apophyseal staging was categorized into 4 stages: cartilaginous stage (stage 1), apophyseal stage (stage 2), epiphyseal stage (stage 3), and bony/fused stage (stage 4). Data were collected by 2 independent assessors. The analysis was repeated 1 month later with the same assessors. We calculated descriptive statistics, measures of agreement, and the correlation between skeletal age and apophyseal stage. Results: The mean chronological age of the 287 patients included in the analysis was 12.9 ± 1.9 years; 164 (57%) of the patients were male. The overall Spearman r between skeletal age and tibial apophyseal staging was 0.69 (0.77 in males; 0.60 in females). The interrater reliability for the tibial apophyseal staging was substantial (Cohen κ = 0.66), and the intrarater reliability was excellent (Cohen κ = 0.82). The interrater reliability for skeletal age was excellent (intraclass correlation coefficient [ICC] = 0.93), as was the intrarater reliability (ICC = 0.97). Conclusion: The observed correlation between skeletal age and tibial apophyseal staging as well as observed intra- and interrater reliabilities demonstrated that tibial apophyseal landmarks on knee radiographs may be used to estimate skeletal age. This study supports the validity of knee radiographs in determining skeletal age and provides early evidence in certain clinical presentations to simplify the diagnostic workup and operative management of pediatric knee injuries, including ACL tears.

Correlation between craniofacial growth and upper and lower body heights in subjects with Class I occlusion

ABSTRACT Objective: To correlate skeletal age, standing height, upper and lower body lengths, and selected craniofacial growth features in a sample of growing individuals, and to model craniofacial growth using multivariate regression. Methods: This was a retrospective cross-sectional study with 447 African black boys and girls, between the ages 8 and 16 years, who attended the dental clinic at one hospital. The skeletal maturational age was determined from hand-wrist radiographs using the Greulich and Pyle atlas. Craniofacial measurements representing maxillary length (Ar-ANS), mandibular length (Ar-Gn), and lower facial height (ANS-Me) were calculated from lateral cephalograms in habitual occlusion. Body lengths were clinically measured in centimeters. Results: Moderate correlations (r=0.42 to 0.68) were observed between skeletal age and the three selected craniofacial measurements. Statistically significant correlations were also found between the craniofacial measurements and both upper and lower body lengths. The mandibular length had a stronger correlation with the upper body length than with the lower body length. Multiple regression analyses to determine maxillary and mandibular lengths suggested that sex, upper and lower body lengths might be used to determine maxillary length; while skeletal age, upper and lower body lengths might help determine mandibular length. Conclusions: Based on the relatively strong correlation between upper body length and mandibular length, further research in this area may warrant its use as a predictor for mandibular growth modification timing.

The reliability of the Greulich and Pyle atlas when applied to a Southern Turkish population

ABSTRACT Objective: The aim of this study was to evaluate the applicability of Greulich and Pyle (GP) method for Southern Turkish population. Materials and Methods: Hand and wrist radiographs of 535 patients (276 females, 259 males aged from 10 to 18 years) selected retrospectively from the archive. Skeletal age (SA) estimation was performed according to GP atlas. The chronological age (CA) and SA were compared using the Paired t-test. Results: The mean difference between the CA and SA ranged from 0.07 to 1.11 years. These differences between the CA and estimated SA were statistically significant in group I (10–10.90 years) (P < 0.001), group II (11–11.90 years) (P < 0.050), group III (12–12.90 years) (P < 0.001), group IV (13–13.90 years) (P < 0.010), and group V (14–14.90 years) (P < 0.001) for females. The mean difference between the CA and SA ranged from −0.41 to −1.79 years for females. These differences between the CA and estimated SA were statistically significant in all age groups. Conclusions: Statistically significant differences were found in the CA and SA assessed by GP method for the Southern Turkish sample. SA was significantly over-predicted in the 10–15 year ages in males and for 10–18 year ages for females. It is appropriate to use GP method in Southern Turkish children; however, a revision is needed for better results and to minimize the mistakes.