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Background/Objectives. The correct identification of the different stages of skeletal maturity is a crucial issue in orthodontic diagnosis and treatment planning decisions. The hand-wrist analysis and cervical vertebral maturation (CVM) methods are the most frequently employed methods for determining the stage of skeletal maturity in orthodontics. Since these methods require X-ray exposure, a new objective and less invasive method is needed. The aim of this study was to develop other models for prediction of cervical vertebral maturational stages and also growth phases using chronological age (CA), salivary insulin-like growth factor-1 (IGF-1), and alkaline phosphatase (ALP). Subjects and Methods. In this cross-sectional study, 55 healthy subjects in the age range of 7 to 20 years were included. Their skeletal maturity was assessed through Baccetti’s 6-stage CVM method. In addition, their salivary IGF-1 level, salivary ALP level, and CA were determined. Multinomial logistic regressions were utilized to predict the cervical stage and also growth phase based on CA, salivary IGF-1, and salivary ALP in 7 different models. Results. A strong positive correlation was found between CA and cervical stages ( r = 0.836 , P < 0.001 ). Based on the regression model analysis, the model which combined IGF-1, ALP, and CA provided the best prediction at P < 0.001 with McFadden’s pseudo R 2 value of 0.552 for cervical stage prediction and 0.646 for growth phase prediction. In particular, its predictive ability for the prepubertal, pubertal, and postpubertal growth phases was 95%, 80%, and 90%, respectively. Conclusions. A new model with the combination of salivary IGF-1 and ALP with CA can be used as a less invasive method to determine the cervical stage and also growth phase with high predictive ability in healthy subjects.

BACKGROUND: Radiographic methods to assess skeletal maturity (SM) have a key role in adolescent idiopathic scoliosis (AIS) management, allowing to predict risk of spinal curve progression. Cervical vertebral maturation (CVM) has been recently introduced as an alternative tool to assess skeletal maturity; however, its clinical role is still debated. OBJECTIVE: This systematic review aimed to investigate the reliability of CVM in the SM assessment of growing subjects, comparing it to hand wrist maturation (HVM). METHODS: PubMed, Scopus, and Web of Science databases were systematically searched from inception until 31st December 2020 to identify observational studies presenting: growing subjects as participants; CVM methods as intervention; HVM methods as comparator; reliability for SM assessment as outcome. A 10-item quality tool has been used to assess study quality. RESULTS: Out of 205 papers, 12 papers were included in the data synthesis. We classified 10 studies (83.3%) as medium-quality studies and 2 studies (16.7%) as high-quality studies. Eight studies reported a significant correlation between CVM Baccetti and different HWM methods. CONCLUSION: Taken together, these findings suggested that CVM might be considered as reliable SM assessment method compared to HWM in growing subjects. However, further studies are warranted to confirm these findings.

Objectives Constitutional delay of growth (CDG) is usually associated with a delay in pubertal onset (CDGP) and a catch-up growth after puberty. Some individuals, however, have earlier-than-expected pubertal onset resulting in a shorter adult height. We investigated the current incidence of such individuals and that of 30 years ago. Methods The study subjects are 1,312 consecutive Japanese children referred to Osaka City General Hospital (OCGH) for short stature during 2010–2018, and a cohort of 11,256 individuals in the Ogi Growth Research (OGR, 1979–1992). Individuals with the height standard deviation score Results From the OCGH cohort, 55 children (38 boys, 17 girls) met the criteria, and earlier-than-expected onset was observed in 34.2% of boys and 29.4% of girls. In the 73 short individuals with delayed bone age in the OGR cohort, earlier-than-expected onset was less common (13.0% for boys and 14.8% for girls). There was no significant association between the timing of pubertal growth onset and the BA/CA ratio, IGF-1, and midparental height. Conclusions Earlier-than-expected pubertal growth onset is common in CDG and possibly increasing.

Bone age is one of biological indicators of maturity used in clinical practice and it is a very important parameter of a child’s assessment, especially in paediatric endocrinology. The most widely used method of bone age assessment is by performing a hand and wrist radiograph and its analysis with Greulich-Pyle or Tanner-Whitehouse atlases, although it has been about 60 years since they were published. Due to the progress in the area of Computer-Aided Diagnosis and application of artificial intelligence in medicine, lately, numerous programs for automatic bone age assessment have been created. Most of them have been verified in clinical studies in comparison to traditional methods, showing good precision while eliminating inter- and intra-rater variability and significantly reducing the time of assessment. Additionally, there are available methods for assessment of bone age which avoid X-ray exposure, using modalities such as ultrasound or magnetic resonance imaging.

Study design Cost-utility analysis. Objective This study aimed to investigate the cost-utility of bracing versus observation in patients with thoracic scoliosis who would be indicated for bracing. Summary of background data There is high-quality evidence that bracing can prevent radiographic progression of spinal curvature in adolescent idiopathic scoliosis (AIS) patients with curves between 25° and 40° and Risser 0 to 2 skeletal maturity index. However, to our knowledge, the cost-utility of bracing in AIS has not been established. Methods A decision-analysis model comparing bracing versus observation was developed for a hypothetical 10-year old girl (Risser 0, Sanders 3) with a 35° main thoracic curve. We estimated the probability, cost, and quality-adjusted life years (QALY) for each node based on comprehensive review of the literature. Costs were adjusted for inflation based on Consumer Price Index and reported in terms of 2020 real dollars. Incremental net monetary benefit (INMB) was calculated based on a probabilistic sensitivity analysis using Monte Carlo simulations of 1000 hypothetical patients. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates. Results Our decision-analysis model revealed that bracing was the dominant treatment choice over observation at $50,000/QALY willingness to pay threshold. In simulation analysis of a hypothetical patient cohort, bracing was associated with lower net lifetime costs ($60,377 ± $5,340 with bracing vs. $85,279 ± $4543 with observation) and higher net lifetime QALYs (24.1 ± 2.0 with bracing vs. 23.9 ± 1.8 with observation). Bracing was associated with an INMB of $36,093 (95% confidence interval $18,894-$55,963) over observation over the patient's lifetime. The model was most sensitive to the impact of bracing versus observation on altering the probability of requiring surgery, either as an adolescent or an adult. Conclusion Cost-utility analysis supports scoliosis bracing as the preferred choice in management of appropriately indicated AIS patients with thoracic scoliosis.Level of Evidence: 5.

Background: In managing pediatric knee conditions, an accurate bone age assessment is often critical for diagnostic, prognostic, and treatment purposes. Historically, the Greulich and Pyle atlas (hand atlas) has been the gold standard bone age assessment tool. In 2013, a shorthand bone age assessment tool based on this atlas (hand shorthand) was devised as a simpler and more efficient alternative. Recently, a knee magnetic resonance imaging (MRI) bone age atlas (MRI atlas) was created to circumvent the need for a left-hand radiograph. Purpose: To create a shorthand version of the knee MRI atlas. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A shorthand bone age assessment method was created utilizing the previously published MRI atlas, which utilizes several criteria that are visualized across a series of images. The MRI shorthand draws on characteristic criteria for each age that are best observed on a single MRI scan. For validation, we performed a retrospective assessment of skeletally immature patients. One reader performed the bone age assessment using the MRI atlas and the MRI shorthand on 200 patients. Then, 4 readers performed the bone age assessment with the hand atlas, hand shorthand, MRI atlas, and MRI shorthand on a subset of 22 patients in a blinded fashion. All 22 patients had a knee MRI scan and a left-hand radiograph within 4 weeks of each other. Interobserver and intraobserver reliability, as well as variability among observers, were evaluated. Results: A total of 200 patients with a mean age of 13.5 years (range, 9.08-17.98 years) were included in this study. Also, 22 patients with a mean age of 13.3 years (range, 9.0-15.6 years) had a knee MRI scan and a left-hand radiograph within 4 weeks. The intraobserver and interobserver reliability of all 4 assessment tools were acceptable (intraclass correlation coefficient [ICC] ≥ 0.8; P < .001). When comparing the MRI shorthand with the MRI atlas, there was excellent agreement (ICC = 0.989), whereas the hand shorthand compared with the hand atlas had good agreement (ICC = 0.765). The MRI shorthand also had perfect agreement in 50% of readings among all 4 readers, and 95% of readings had agreement within 1 year, whereas the hand shorthand had perfect agreement in 32% of readings and 77% agreement within 1 year. Conclusion: The MRI shorthand is a simple and efficient means of assessing the skeletal maturity of adolescent patients with a knee MRI scan. This bone age assessment technique had interobserver and intraobserver reliability equivalent to or better than the standard method of utilizing a left-hand radiograph.

Despite an extensive number of existing methods, age estimation of human remains is still an unsolved matter in the field of forensic anthropology, especially when it comes to mature adults. The specific aim of this work was to propose a combined method for age estimation, for forensic purposes, by coupling the Suchey-Brooks method and the measure of the pubic bone density. For this purpose, we used an independent test sample comprising 339 CT scans of living individuals aged 15 to 99 years old. Measurement of bone density and staging according to the Suchey-Brooks phases were performed, followed by estimation of ages based on a combined method and an existing virtual reference sample. Results highlighted a significant negative correlation between bone density and age. Good accuracy was obtained for the measurement of pubic bone density for age estimation of men and women, especially concerning mature adults, with an absolute error ranging from 9 to 16 years for all individuals. The authors propose a practical combined method consisting of, first, allocating phases according to the scannographic approach of the Suchey-Brooks method. For phases I to IV, the age estimation is given using the Suchey-Brooks method. For phases V to VI, the pubic bone density measurement is used. Further study will be needed to assess the reproducibility of these results on cadavers and dry bones, as the post-mortem process could interfere with the measurement of mineral bone density.

Objectives Some idiopathic short stature (ISS) patients may have varying degrees of insulin-like growth factor 1 (IGFI) deficiency. Others with growth hormone deficiency (GHD) (peak GH Methods We studied the effect of GH therapy (0.035–0.06 mg/kg/day) on linear growth and weight gain per day (WGPD) in children with ISS (n=13) and those with GHD (n=10) who have low pretreatment IGFISDS (IGF SDS Results At presentation, the height standard deviation score (HtSDS) of children with ISS who had low pretreatment IGFISDS was significantly lower compared to the normal IGFI group. The age, body mass index (BMI), BMISDS, peak GH response to clonidine provocation and bone age did not differ between the two study groups. After 1 year of treatment with rhGH (0.035–0.06 mg/kg/day) IGFISDS increased significantly in both groups (p Conclusions IGFI deficiency represents a low anabolic state. Correction of IGFI level (through rhGH and/or improved nutrition) in short children (ISS and GHD) was associated with increased linear growth and WGPD denoting significant effect on bone growth and muscle protein accretion.

BACKGROUND: Multiple systems using radiographic skeletal markers to measure development have been described, including the Greulich and Pyle Atlas (GP), the Fels Method (Fels), and the Sanders Hand Classification (Sanders). The purpose of this study was to quantitatively assess whether the integration of skeletal maturity assessment methods and demographic variables improves the accuracy of pediatric growth predictions over the use of skeletal markers or chronologic age alone. METHODS: The Brush Inquiry contains prospectively collected longitudinal data on children who lived in Cleveland, Ohio between 1926 and 1942. A total of 16 boys and 29 girls were selected for study. All had age, height, and an anteroposterior radiograph of the hand at each of 3 visits. Those visits occurred at 85%, 90%, and 95% of final height. We determined the growth completed at each visit by dividing the height observed by the final height at skeletal maturity. Boys and girls were analyzed separately using chronologic age, height, GP, Fels, and Sanders. The residual difference between the height predicted and actual height, as well as the SD of the prediction error of the cohort at each time point was calculated. To account for multiple visits from each subject, all linear models were produced using the generalized estimating equations (GEEs) procedure. RESULTS: For boys, age, GP, and Fels performed similarly in predicting growth remaining at all 3 time points. For girls, age, GP, and Fels performed similarly in predicting growth remaining at the 85% and 95% time points; however, the Fels Method demonstrated improved performance at the 90% time point compared with chronologic age (P = 0.0076) and GP alone (P = 0.0155). For both boys and girls, the most accurate multivariate GEE model with the lowest SD of prediction error integrated Fels, age, GP, Sanders, and height. CONCLUSIONS: The most accurate multivariate GEE model of growth prediction for both boys and girls integrated Fels, age, GP, Sanders, and height. When calculating the amount of growth remaining, it is prudent to integrate multiple systems for greater predictive accuracy. LEVEL OF EVIDENCE: Level III.

Background Several methods are available to estimate leg lengths at maturity to facilitate the determination of timing of epiphysiodesis. We compared the Paley multiplier, Sanders multiplier, and White-Menelaus methods in an epiphysiodesis-aged cohort. We assessed intra- and interrater reliability for Sanders skeletal stages and Greulich and Pyle atlas skeletal age. Methods Actual growth was recorded in healthy, unoperated femoral and tibial segments from an epiphysiodesis database. The predicted and actual lengths were compared with use of the Paley multiplier and White-Menelaus methods, Greulich and Pyle skeletal age, and the Sanders multiplier using Sanders stages. Intra- and interrater reliability were assessed in a separate group of 76 skeletal age films. Results The cohort included 148 femora and 195 tibiae in 197 patients. Femoral length at maturity was slightly underestimated by the Sanders multiplier and staging, was overestimated by the Paley multiplier and skeletal age, and was most accurately predicted with use of the White-Menelaus formula and skeletal age. All methods overestimated tibial length at maturity. The whole-leg prediction accuracy of the Sanders multiplier and White-Menelaus formula were comparable and were more accurate than that of the Paley multiplier. For Sanders skeletal staging, the interrater reliability varied from 0.86 to 0.88 and the intrarater reliability varied from 0.87 to 0.96. For Greulich and Pyle skeletal age, the interrater reliability varied from 0.87 to 0.89 and the intrarater reliability varied from 0.91 to 0.95. Conclusions Use of the Sanders multiplier and skeletal stages was more accurate than the Paley multiplier and skeletal age in this cohort. Use of the White-Menelaus formula and skeletal age was slightly more accurate in predicting femoral length and slightly less accurate in predicting tibial length compared with the Sanders multiplier. Intra- and interrater reliability were similar between Sanders skeletal stages and Greulich and Pyle atlas skeletal age. The White-Menelaus formula and skeletal age was the recommended method for predicting lower-extremity segment lengths at maturity and epiphysiodesis effect. Although easier to recall without referencing an atlas and not sex-specific, Sanders skeletal staging does not correspond directly to years of growth remaining, and thus cannot be used with the White-Menelaus formula. Clinical relevance The Greulich and Pyle atlas to determine skeletal age and the White-Menelaus formula to determine growth remaining are reliable predictors of epiphysiodesis effect in the lower extremities.

Bone age is considered an indicator for the diagnosis of precocious or delayed puberty and a predictor of adult height. We aimed to evaluate the performance of a deep neural network model in assessing rapidly advancing bone age during puberty using elbow radiographs. In all, 4437 anteroposterior and lateral pairs of elbow radiographs were obtained from pubertal individuals from two institutions to implement and validate a deep neural network model. The reference standard bone age was established by five trained researchers using the Sauvegrain method, a scoring system based on the shapes of the lateral condyle, trochlea, olecranon apophysis, and proximal radial epiphysis. A test set (n = 141) was obtained from an external institution. The differences between the assessment of the model and that of reviewers were compared. The mean absolute difference (MAD) in bone age estimation between the model and reviewers was 0.15 years on internal validation. In the test set, the MAD between the model and the five experts ranged from 0.19 to 0.30 years. Compared with the reference standard, the MAD was 0.22 years. Interobserver agreement was excellent among reviewers (ICC: 0.99) and between the model and the reviewers (ICC: 0.98). In the subpart analysis, the olecranon apophysis exhibited the highest accuracy (74.5%), followed by the trochlea (73.7%), lateral condyle (73.7%), and radial epiphysis (63.1%). Assessment of rapidly advancing bone age during puberty on elbow radiographs using our deep neural network model was similar to that of experts. • Bone age during puberty is particularly important for patients with scoliosis or limb-length discrepancy to determine the phase of the disease, which influences the timing and method of surgery. • The commonly used hand radiographs–based methods have limitations in assessing bone age during puberty due to the less prominent morphological changes of the hand and wrist bones in this period. • A deep neural network model trained with elbow radiographs exhibited similar performance to human experts on estimating rapidly advancing bone age during puberty.

Background The onset of peak height velocity (PHV) guides the timing of interventions in the growing child. The purpose of the present study was to validate the Dimeglio olecranon grading system and to compare these scores with the Risser/triradiate closure (TRC), proximal humerus, and Sanders hand scores. Methods Eighty children with annual serial radiographs were selected from the Bolton-Brush collection. The olecranon apophysis was graded with use of lateral radiographs of the elbow. The mean age to PHV was determined for each stage, and reliability was calculated with use of an intraclass correlation coefficient (ICC). Olecranon stage was combined with age, sex, and height in a generalized estimating equation (GEE) model to predict PHV. Predictive performance of this model was evaluated with use of tenfold cross-validation such that the model was trained on 90% of the radiographs and was asked to predict the PHV of the remaining 10%. Results PHV is closely associated with olecranon stage, with stage 1 occurring 3.0 years before PHV and stage 7 occurring 3.4 years after PHV. Stage 5 was found to occur at PHV. Scoring system reliability was high across an array of observers (ICC = 0.85 ± 0.07). The GEE model showed that this olecranon system outperforms the Risser/TRC system in predicting PHV and is comparable with the humerus and Sanders hand systems. When combined with age and sex, the olecranon system successfully predicted PHV such that 62% of PHV predictions were accurate within 6 months and 90% of PHV predictions were accurate within a year. Conclusions Our data show that stage 5 occurs at PHV, contrary to previously published data. When combined with age and sex, the olecranon system successfully predicts PHV within a year in 90% of cases, establishing a single lateral view of the olecranon as a simple alternative to more complex grading systems. Last, we describe novel 3 variations in olecranon morphology and provide a guide for accurate olecranon staging. Clinical relevance Understanding PHV is critical in the treatment of many pediatric orthopaedic disorders. The revised olecranon staging system will allow for more accurate determination of this variable.

Understanding how a neural network makes decisions holds significant value for users. For this reason, gradient-based saliency mapping was tested on an artificial intelligence (AI) regression model for determining hand bone age from X-ray radiographs. The partial derivative (PD) of the inferred age with respect to input image intensity at each pixel served as a saliency marker to find sensitive areas contributing to the outcome. The mean of the absolute PD values was calculated for five anatomical regions of interest, and one hundred test images were evaluated with this procedure. The PD maps suggested that the AI model employed a holistic approach in determining hand bone age, with the wrist area being the most important at early ages. However, this importance decreased with increasing age. The middle section of the metacarpal bones was the least important area for bone age determination. The muscular region between the first and second metacarpal bones also exhibited high PD values but contained no bone age information, suggesting a region of vulnerability in age determination. An end-to-end gradient-based saliency map can be obtained from a black box regression AI model and provide insight into how the model makes decisions.

The aim of this study was to comparatively evaluate hand-wrist bones, cervical vertebrae and tooth development stages according to skeletal classification.The orthodontic initial records of 297 patients were used and separated into three groups according to the skeletal malocclusion. Three groups including 99 people each were sampled representing malocclusions with Angle classes I, II and III, respectively. The panoramic, cephalometric and hand-wrist radiographs of all patients included in this study were used to compare dental and skeletal maturation indicators. Calcification of teeth was rated according to the system of Demirjian. To evaluate the stage of skeletal maturation hand-wrist radiographs were analyzed according to the Grave and Brown method. Also, Hassel and the Farman method was used to classifying vertebral developmental stages. Spearman rank correlation tests, as well as Fisher exact χHand-wrist, vertebral and dental development stages showed a statistically significant relationship (p 0.01) for both genders and in all malocclusions. The association between the different maturation indicators used in this study and the type of malocclusion was also statistically significant for both genders. It was observed that the peak period of skeletal maturation according to the hand-wrist radiograph findings correlated with the cervical vertebrae stage C3 in girls (63.2%) and C2-C3 in boys (43.5-43.5%). The weakest correlation was seen between the dental development stages and the skeletal developmental stages in the class II group (r = 0.443-0.220 [girls]; r = 0.604-0.410 [boys]).The use of the dental development stage as a reliable indicator of maturation was limited. According to the Demirjian method, the calcification stage of the second molar might indicate that the individual is in the pubertal peak period.ZWECK: Ziel dieser Studie war es, Handwurzelknochen, Halswirbel und Zahnentwicklungsstadien nach Skelettklassifikation vergleichend zu bewerten.Die kieferorthopädischen Erstaufzeichnungen von 297 Patienten wurden verwendet und entsprechend der skelettalen Malokklusion in 3 Gruppen unterteilt. Es wurden 3 Gruppen mit jeweils 99 Personen beprobt, die Angle-Klasse‑I-, -II- bzw. -III-Malokklusionen repräsentierten. Anhand der Orthopantomogramme sowie der kephalometrischen Aufnahmen und der Handwurzelröntgenaufnahmen aller in die Studie aufgenommenen Patienten wurden Indikatoren für die Zahn- und Skelettreifung verglichen. Der dentale Mineralisationsgrad wurde nach dem System von Demirjian bewertet. Zur Beurteilung des Skelettalters wurden Handwurzelröntgenbilder nach der Methode von Grave und Brown analysiert. Ferner wurde die Hassel-Farman-Methode verwendet, um vertebrale Entwicklungsstadien zu klassifizieren. Für den Vergleich kategorialer Variablen wurden Spearman-Rangkorrelationstests sowie exakte Fisher‑χHandwurzelknochen‑, Wirbelkörper- und Zahnentwicklungsstadien zeigten eine statistisch signifikante Beziehung (p 0,01) für beide Geschlechter und bei allen Malokklusionen. Der Zusammenhang zwischen den verschiedenen in dieser Studie verwendeten Reifungsindikatoren und der Art der Malokklusion war für beide Geschlechter ebenfalls statistisch signifikant. Es wurde beobachtet, dass die Spitzenzeit der Skelettreifung gemäß den Befunden des Handwurzelknochenröntgenbildes mit dem Halswirbelstadium C3 bei Mädchen (63,2 %) und C2–C3 bei Jungen (43,5–43,5 %) korrelierte. Die schwächste Korrelation wurde zwischen den Zahnentwicklungsstadien und den Skelettentwicklungsstadien in der Klasse-II-Gruppe beobachtet (r = 0,443–0,220 [Mädchen] bzw. r = 0,604–0,410 [Jungen]).Die Verwendung des Zahnentwicklungsstadiums als verlässlicher Indikator für die Reifung war begrenzt. Nach der Demirjian-Methode könnte der Mineralisierungsgrad des zweiten Molaren darauf hinweisen, dass sich das Individuum in der Hochphase der pubertären Wachstumsphase befindet.

Purpose The aim of this study was to assess the impact of arm position in computed tomography (CT) of the clavicle performed for forensic age estimation on clavicular position, image noise, and radiation dose. Methods and materials Forty-seven CT scans of the medial clavicular epiphysis performed for forensic age estimation were conducted with either hands and arms held upwards (CTHU, 28 persons) or positioned at the body (CTHD, 19 persons). Presets were identical for both positions (70 mAs/140 kVp; Brilliance iCT, Philips). Each CT scan was reconstructed with an iterative algorithm (i-Dose 4) and evaluated at the middle of the sternoclavicular joint. Clavicular angle was measured on a.p. topograms in relation to a horizontal line. Quantitative image noise was measured in air at the level of medial clavicular epiphysis. Effective dose and scan length were recorded. Results Hands-up position compared with hands-down position resulted in a lower lateral body diameter (CTHU 41.1 ± 3.6 cm vs. CTHD 44.6 ± 3.1 cm; P = 0.03), a reduced quantitative image noise (CTHU: 39.5 ± 9.2; CTHD: 46.2 ± 8.3; P = 0.02), and lower CTDIvol (5.1 ± 1.4 mGy vs. 6.7 ± 1.8 mGy; P = 0.001). Scan length was longer in patients examined with hands up (HU: 8.5 ± 3.4 cm; HD: 6.2 ± 2.1 cm; P = 0.006). Mean effective dose for CTHU was 0.79 ± 0.32 mSv compared with 0.95 ± 0.38 mSv in CTHD (P = 0.12). Clavicular angle was 17° ± 6° in patients with hands down and 32° ± 7° in patients with hands up (P < 0.001). Conclusion By elevated arm positioning, the image quality of clavicular CT scans can be improved while maintaining radiation dose compared with hands down. Clavicular position differs according to the hand position. Thus, positioning patients with elevated hands is advisable for forensic clavicular CT examinations, but multiplanar CT reconstructions should be adjusted to clavicular position and scan length should be reduced to a minimum.

Since forensic age estimation is not a valid medical indication, research on the use of nonionizing methods is increasing. Ultrasonography is a radiological approach that protects patients from radiation exposure and offers special convenience to them. In this study, ultrasonography was used for age estimation by investigating the degree of ossification of the distal radial epiphysis. Its applicability on the Turkish population was investigated. The left wrist of 688 (322 males, 366 females) patients between the ages of 9 and 25 years was prospectively evaluated by ultrasonography. The intra- and interobserver reliabilities in evaluating the distal radial epiphysis and Cohen’s kappa statistics show that the interobserver error was very low, and the kappa value was found to be 0.919. Stage 3 and 4 ossification of the distal radial epiphysis was first detected at age 14.3 and 15.3 years in males and 12.7 and 14.8 years in females, respectively. The data obtained may help determine legally critical age limits of 14 and 15. Although it does not seem useful for the age of 18, ultrasonography may be recommended in selected cases as a fast, inexpensive, frequently reproducible radiological method without concern about radiation and without a predictable health risk.

Introduction Forensic age estimation is performed via clinical examination and utilizing various imaging modalities. Currently, radiography and CT are used. In this study we aim to evaluate if magnetic resonance imaging (MRI) can be used to determine stages of fusion in the epiphysis of the tibia and femur, and if these stages are significantly different regarding the mean age of subjects classified in each one. Methods A total of 193 subjects were included in the study. Knee MR imaging was performed on all of the patients, and the patients were categorized based on imaging findings of the tibial and femoral epiphysis. Tukey multiple comparison test and analysis of variance were used to assess if the difference in the mean age of the groups were significantly different. Results Analysis of variance revealed that the mean of the five groups, both in tibia and femur imaging were significantly different. Analysis of variance showed that in most of the cases, the groups mean age significantly differed from the other groups. Tukey multiple comparison tests showed that although the differences between stages I–III could not be regarded as significant, MR imaging was suitable in distinguishing stages IV–V from stages I–III. Conclusion MR imaging of the knee may be a suitable imaging modality to assess an individual's age, does not involve ionizing radiation, and that with imaging a single anatomical location, at least two epiphyses could be used to determine the age. Implications for practice Utilization of knee MRI by clinicians as a safe and practical age estimation method.

Background The ability to estimate skeletal maturity using a knee radiograph would be useful in anterior cruciate ligament (ACL) injuries and limb-length discrepancy in immature patients. Currently, a quick, accurate, and reproducible method is lacking. Methods Serial knee radiographs made 3 years before to 2 years following the chronologic age associated with 90% of final height (an enhanced skeletal maturity gold standard compared with peak height velocity) were analyzed in 78 children. The Pyle and Hoerr (PH) knee method was simplified by developing discrete stages for the distal part of the femur, the proximal part of the tibia, the proximal part of the fibula, and the patella. The Roche-Wainer-Thissen (RWT) knee method was simplified from the 36 original parameters to 14 parameters by removing parameters that were poorly defined, were not relevant to the peripubertal age range, were poorly correlated with 90% final height, or were poorly reliable on a 20-radiograph pilot analysis. We also compared the recently described central peak value (CPV) of the distal part of the femur. The Greulich and Pyle (GP) left-hand bone age was included for comparison. Results In this study, 326 left knee radiographs from 41 girls (age range, 7 to 15 years) and 37 boys (age range, 9 to 17 years) were included. Stepwise linear regression showed higher correlation in predicting years from 90% final height using the modified RWT and demographic characteristics (R2 = 0.921) compared with demographic characteristics alone (R2 = 0.840), CPV and demographic characteristics (R2 = 0.866), GP and demographic characteristics (R2 = 0.899), and PH and demographic characteristics (R2 = 0.902). Seven parameters were excluded from the RWT and demographic characteristics model using stepwise linear regression and generalized estimating equations analysis, leaving 7 parameters (2 femoral, 4 tibial, and 1 fibular) in the final model. Compared with RWT and demographic characteristics (R2 = 0.921), there were minimal incremental increases by adding CPV (R2 = 0.921), GP (R2 = 0.925), or PH (R2 = 0.931). Conclusions This large analysis of knee skeletal maturity systems isolated 7 discrete radiographic knee parameters that theoretically outperform the GP bone age in estimating skeletal maturity. Clinical relevance We present a modified knee skeletal maturity system that can potentially preclude the need for additional imaging of the hand and wrist in reliably estimating skeletal maturity.

Objective The aim of this study was to develop a prediction model that combines the information derived from chronological age (analysed as a curvilinear variable), gender and the CVM method to predict mandibular growth. Settings and sample population 50 participants (29 females, 21 males) were selected from the AAOF Craniofacial Growth Legacy Collection, the Michigan Growth Study and the Denver Child Growth study. Materials and methods In this investigation, 456 lateral cephalograms were analysed by applying a mixed effect model. The outcome variable was the annualized increment in total mandibular length (Co-Gn) during the year following the lateral cephalogram on which the cervical stage and chronological age were evaluated. The predictive variables were chronological age up to the fifth order, gender, stage of cervical vertebral maturation, as well as interactions between age and gender, age and cervical stage, and gender and cervical stage. Results Cervical stage, chronological age up to the fourth order, gender, and the interaction between age and gender were significant predictors of annualized increments in mandibular length. The annualized increment in Co-Gn was significantly greater for CS 3 when compared to all other cervical stages. Further, annualized increments in Co-Gn for CS 1 and CS 2 were significantly greater when compared to CS 5. Conclusions Cervical stage, chronological age and gender can be used jointly to predict the annualized increment in mandibular growth. Cervical stage 3 exhibited the greatest annualized increase in mandibular length.

BACKGROUND The incidence of supracondylar humerus (SCH) fracture declines and fracture types change as children grow. Optimal treatment method is unclear in older children. The aim of the study was to determine if fracture type and configuration of distal humerus fractures changes as patients approach skeletal maturity, and to assess the success of closed reduction and percutaneous pin (CRPP) in extra-articular SCH fractures in this transitional age group. METHODS Inclusion criteria for this retrospective review were (1) distal humerus fractures with extension types 2 and 3, flexion type, T-type; (2) surgically managed, and (3) modified Sauvegrain score ≥1. Reviewed parameters included fracture type and configuration, grade of skeletal maturity, fixation technique, and loss of reduction. Primary analysis was to determine the distribution of fracture type and configuration with age or grade of skeletal maturity. Secondary analysis was used to determine the factors affecting treatment success of CRPP in extra-articular fractures. RESULTS A total of 142 patients were included (58 males and 84 females). Fracture types revealed significant changes with increased age (P=0.031) and skeletal maturity grade (P

Age estimation is a crucial element of forensic medicine to assess the chronological age of living individuals without or lacking valid legal documentation. Methods used in practice are labor-intensive, subjective, and frequently comprise radiation exposure. Recently, also non-invasive methods using magnetic resonance imaging (MRI) have evaluated and confirmed a correlation between growth plate ossification in long bones and the chronological age of young subjects. However, automated and user-independent approaches are required to perform reliable assessments on large datasets. The aim of this study was to develop a fully automated and computer-based method for age estimation based on 3D knee MRIs using machine learning. The proposed solution is based on three parts: image-preprocessing, bone segmentation, and age estimation. A total of 185 coronal and 404 sagittal MR volumes from Caucasian male subjects in the age range of 13 and 21 years were available. The best result of the fivefold cross-validation was a mean absolute error of 0.67 ± 0.49 years in age regression and an accuracy of 90.9%, a sensitivity of 88.6%, and a specificity of 94.2% in classification (18-year age limit) using a combination of convolutional neural networks and tree-based machine learning algorithms. The potential of deep learning for age estimation is reflected in the results and can be further improved if it is trained on even larger and more diverse datasets.

BACKGROUND The purpose of this investigation was to develop a quantitative and reproductible method for estimating skeletal maturity based on measurements of the height of the bony greater trochanter (GT) using timing to 90% of final height as a gold standard. METHODS Bony GT height was measured using serial anteroposterior pelvic radiographs in 76 healthy pediatric patients obtained from the Bolton-Brush (BB) Study with corresponding Greulich-Pyle (GP) bone ages. Chronologic age at 90% of final height was calculated. GT height was then measured in 300 contemporary patients aged 4 to 18 years, evenly divided based on sex and race. Bony GT height was compared between BB and contemporary patients, while linear mixed-effects models were used to examine for potential predictors of years to 90% final height using patient sex, GP bone age and bony GT height measurements. RESULTS Bony GT height was measured in 303 radiographs from the BB Collection (n=37 males; n=39 females) with corresponding GP bone ages, chronological ages, and heights to represent skeletal maturity. Mean age at 90% final height was 13.3±0.6 years for males and 11.4±0.8 years for females. When controlling for patient age and sex, multiple regression analysis revealed that contemporary patients possessed significantly greater bony GT height (mean difference: 1.15 mm; P=0.001) when compared with BB patients. Multivariate analysis showed that combining bony GT height, GP bone age, and sex significantly predicted years to 90% total growth (P

The aim of this study was to determine among young orthodontic patients the relation between the spheno-occipital synchondrosis (SOS) fusion and the cervical vertebral maturation (CVM) and to look for an eventual impact of gender, skeletal class and vertical pattern on their association.CBCT scans and lateral cephalometric radiographs of 117 patients, aged between 8 and 18 years, were selected. SOS fusion was assessed on a mid-sagittal cut of the CBCT scans. CVM was evaluated on the lateral cephalograms as well as ANB and GoGn-SN angles. Spearman correlation test was used to assess the relationship between SOS and CVM. Fisher's exact test was performed at every CVM stage to analyse the association between SOS and other variables (gender, skeletal class, and vertical pattern). Cohen's kappa analysis was used for reliability.A strong correlation was found between SOS maturation and CVM (r=0.852, P001). Fisher's exact test indicated significant association only between gender and SOS in CVM stage 2 group, and between vertical pattern and SOS in CVM stage 4. Cohen's kappa analysis showed moderate inter and intra-rater reliability for CVM index (k=0.50 and 0.53 respectively, P.001), strong inter-rater reliability (k=0.80, P.001) and almost perfect intra-rater reliability (k=0.85, P.001) for SOS index.SOS fusion correlates well with CVM and might be a reliable tool for skeletal maturation assessment. Girls seem to have an earlier fusion of SOS in relation to their respective CVM compared to boys, and the vertical pattern could influence the association between SOS and CVM stages.

To evaluate the agreement between observers using Greulich-Pyle (GP) and Gilsanz-Ratib (GR) methods, between four specialities (radiology, pediatrics, pediatric endocrinology and pediatric radiology) and between observers and automated tool in the bone age estimation. A total of 99 observers participated in this questionnaire-based study. BoneXpert was used for the automated tool. Experienced, senior, and junior observers were defined by their experience, and the bone age determined by experienced observers was regarded as the ground truth. Agreement between observers was evaluated using the coefficient of variance (CV) and intraclass correlation coefficient (ICC), and they were reevaluated after adding BoneXpert to the observers. Agreement of BoneXpert, the senior, and the junior observers was also evaluated using the root-mean-square-error (RMSE) values and Blant Altman method by comparing with the ground truth. The CV ranged from 4.98% to 22.08%. The ICC were 0.980 for GP, 0.980 for GP and BoneXpert, 0.973 for GR, and 0.976 for GR and BoneXpert, and the ICC between four specialities ranged form 0.963 to 0.990. BoneXpert tool had the lowest RMSE values (0.504 years for GP atlas). Automated bone age estimation showed comparable results with GP and GR methods and its utilization may decrease inter-observer variability.

The most commonly used methods for bone age (BA) reading were described in the Caucasian population decades ago. However, there are secular trends in skeletal maturation and different BA patterns between ethnic groups. Automated BA reading makes updating references easier and more precise than human reading. The objective of the present study was to present automated BA reference curves according to chronological age and gender in the Mexican population and compare the maturation tempo with that of other populations.The study included 923 healthy participants aged 5 to 18 years between 2017 and 2018. A hand radio-graph was analyzed using BoneXpert software to obtain the automated BA reading according to Greulich and Pyle (GP) and Tanner-Whitehouse 2 (TW2) references. We constructed reference curves using the average difference between the BA and chronological age according to sex and age.The GP and TW2 automated reference curves showed that Mexican boys exhibit delays in BA during middle childhood by 0.5 to 0.7 (95% confidence intervallsqb;CI], -0.9 to -0.2) years; however, they demonstrate an advanced BA of up to 1.1 (95% CI, 0.8 to 1.4) years at the end of puberty. Mexican girls exhibited a delay in BA by 0.3 to 0.6 (95% CI, -0.9 to -0.1) years before puberty and an advanced BA of up to 0.9 (95% CI, 0.7 to 1.2) years at the end of puberty.Mexican children aged10 years exhibited a delay in skeletal maturity, followed by an advanced BA by approximately 1 year at the end of puberty. This may affect the estimation of growth potential in this population.

Age estimation is a vital aspect of the process of identification. Studying the appearance and fusion of long bones is one of the most commonly used methods for age estimation. Most research conducted on age estimation using the study of the appearance and fusion of ossification centres has been roentgenographic in nature. However, X-ray examination and computed tomography examination are associated with ionisation radiation. The present study investigated the use of ultrasonography (USG) as a means of visualising ossification centres of the elbow and wrist joints for age estimation in 31 Maharashtrian boys from Ahmednagar, India. The Schmeling et al. method of grading was used to score the fusion of ossification centres, and simple and multiple linear regression models were developed for age estimation. It was found that the ossification centres of the elbow and wrist joints followed a set pattern of maturation and fusion. The ossification centres of the elbow joint fused before the ossification centres of the wrist joint. The fusion scores of proximal radial epiphyses had the highest correlation with the decimal age of the participants, making its fusion the best indicator among all the ossification centres examined in this study for age estimation. Regression models to estimate age were generated using all the ossification centres. USG was found to be suitable for the purpose of age estimation based on ease of examination, minimal ionisation risks, its non-invasive nature and clear visualisation of ossification centres.

Knee joint morphology is a known contributor to anterior cruciate ligament (ACL) injury, and the shape of the distal femur condyle is one of the associated factors. However, the relationship between femoral trochlear morphology and ACL injury is unclear, especially in pediatric patients. Therefore, the present study aimed to evaluate the effect of femoral trochlear morphology on ACL injury in pediatric patients and investigate the possibility of gender differences. In total, 116 skeletally immature children aged 3–18 years with primary ACL injuries were matched with a control group of 116 skeletally immature children. Lateral trochlear inclination, trochlear facet asymmetry, trochlear depth, and sulcus angle were evaluated using magnetic resonance imaging (MRI). Differences between patient groups and gender were investigated. Receiver-operating characteristic (ROC) curves were constructed to obtain the sensitivity and specificity of all parameters. A significant difference was observed in the sulcus angle and trochlear inclination between the ACL injury and control groups (p

Aim The aim of the current study was to evaluate the correlation of skeletal age based on cervical vertebrae maturation (CVM) stage and mid-palatal suture (MPS) maturation in an Iranian population. Material and Methods This was a cross-sectional analytic study. A total number of 93 samples were included. Samples were taken from patients who were in CS3 to CS6 stages of CVM who had cone-beam computed tomography and lateral cephalometry based on inclusion criteria. The maturation of MPS was assessed based on the cone-beam computed tomography images. In the classification of maturation of MPS, there are five stages (A–E) and the suture fusion occurs in stage D. In stage E, the suture is fused completely. The CVM stage (CS1–6) was also assessed based on the lateral cephalograms. Data were analyzed using Spearman correlation with a significance level of 0.05. Results A total of 51 female individuals with a mean age of 14.98 ± 4.806 and 42 male individuals with a mean age of 15.79 ± 5.135 participated in this study. The correlation coefficient between the CVM stage and MPS maturation was 0.691 in female and 0.754 in male individuals (P Conclusion The results demonstrated that CVM stages had a significant but moderate positive correlation with the maturation of MPS. Until CS3, the MPS has not been fused and in CS6 the MPS is fused definitely.

Age at death estimation methods, when applied to skeletal remains of adults, have provided inaccurate results. These aging methods often depend on observations of the degenerative changes occurring at specific articulations, however, the effects of the aging process on the human skeleton are only partially known. Therefore a need exists to increase our understanding about the age related metamorphosis process to improve aging methods. The aim of this study is to determine which age-related traits observable on the pelvic bone articulations are correlated and to quantify their shared degenerative variance. Thus it is intended to quantify the degenerative relationship among features within each pelvic joint. Fifteen age related traits were analyzed for the pubic symphysis, eight traits for the auricular surface of the ilium, and six traits for the acetabulum. Age-related traits from the pelvic joints were recorded on adult skeletons from two reference collections the William Bass Donated Skeletal Collection and the Coimbra Collection. A Principal Components Analysis, partial correlation controlling for age, and a Kendall's W coefficient of concordance were calculated to determine the level of dependence among traits. A similar pattern of correlation amongst traits was obtained for both collections. Some of the traits shared a high to moderate correlation. However, some features, such as dense bone at the auricular surface, possessed a high independence from other traits. Results suggest that age estimation methods should take into consideration how age-related traits correlate and their level of dependence, which may possibly assist in the establishment of more effective scoring systems in new and revised age at death estimation methods.

Extant histomorphometric aging methods based on the analysis of the femoral cortex generally report small samples ( N

Background The use of magnetic resonance imaging (MRI) in forensic age estimation has been explored extensively during the past decade. Objective To synthesize the available MRI data for forensic age estimation in living children and young adults, and to provide a comprehensive overview that can guide age estimation practice and future research. Materials and Methods MEDLINE, Embase and Web of Science were searched. Additionally, cited and citing articles and study registers were searched. Two authors independently selected articles, conducted data extraction, and assessed risk of bias. Study populations including living subjects up to 30 years were considered. Results Fifty-five studies were included in qualitative analysis and 33 in quantitative analysis. Most studies suffered from bias, including relatively small European (Caucasian) populations, varying MR-approaches and varying staging techniques. Therefore, pooling of the age distribution data was not appropriate. Reproducibility of staging was remarkably lower in clavicles than in any other anatomical structure. Age estimation performance was in line with the gold standard, which uses radiographs, with mean absolute errors ranging from 0.85 to 2.0 years. The proportion of correctly classified minors ranged from 65% to 91%. Multi-factorial age estimation performed better than based on a single anatomical site. Conclusion More multi-factorial age estimation studies are necessary, together with studies testing if the MRI data can safely be pooled. The current review results can guide future studies, help medical professionals to decide on the preferred approach for specific cases, and help judicial professionals to interpret the evidential value of age estimation results. ispartof: Pediatric Radiology vol:50 issue:12 pages:1-18 ispartof: location:Germany status: published

In forensic age assessment of living individuals, developmental stages of skeletal maturation and tooth mineralization are examined and compared with a reference population. It is of interest which factors can affect the development of these features. We investigated the effect of body mass index (BMI) on the developmental stages of the medial epiphysis of the clavicle, the distal epiphysis of the radius, the distal epiphysis of the femur, the proximal epiphysis of the tibia, and the left lower third molar in a total of 581 volunteers, 294 females and 287 males aged 12–24 years, using 3 T MRI. BMI values in the cohort ranged from 13.71 kg/m2 in a 12-year-old female to 35.15 kg/m2 in an 18-year-old female. The effect of BMI on the development of the characteristics was investigated using linear regression models with multivariable fractional polynomials. In the univariable analysis, BMI was associated with all feature systems (beta between 0.10 and 0.44; p r2 values increased only minimally. For an overall bone ossification score combining all characteristics, the adjusted ß was 0.11 (p = 0.021) and 0.08 (p = 0.23) for females and males, respectively. Low ß and r2 values (0.00 (adjusted)–0.16 (crude)) were present in both models for third molar development already in the unadjusted analyses. In conclusion, our study found no to little effect of BMI on osseous development in young adults. Teeth development in both sexes was completely independent of BMI. Therefore, dental methods should be part of every age assessment.

This cross-sectional study aims to investigate the relationship between the simplified olecranon, simplified digital, and distal radius and ulna (DRU) classifications, and whether they can aid in more comprehensive maturity assessment together. Left hand and wrist and lateral elbow radiographs from pediatric patients were assessed using the three skeletal maturity indices. The association between maturity indices was investigated using Goodman and Kruskal’s gamma, and by mapping of individual grades based on chronological age. Specific maturity grades, at which peak height velocity (PHV) occurs as previously identified, were based upon to explore how the three systems interact. A total of 114 patients (63.2% girls) were studied. Correlations and associations between the three maturity parameters were significant (all at P

In forensic anthropology, age estimation is a major element in the determination of a biological profile and the identification of individuals. Thus, many anatomical structures have been studied, such as the pubic symphysis, which is a source of major interest due to its late maturation. One of the most well-known methods of assessment is the Suchey-Brooks (SB) system based on the morphological characteristics of the pubic symphysis. The aim of this study was to propose linear regression formulae in order to deduce chronological age from bone density, using both Hounsfield unit (HU), and mean bone density (mBD) values of the pubic symphysis. Moreover, we intended to test the reliability and then to explore the feasibility of using HU instead of mBD values for age estimation. We built retrospectively a reference sample of 400 pubic symphyses using computed tomography at a French hospital and a test sample of 120 pubic symphyses. Equations were created to establish linear regression models for age estimation. Inaccuracy and bias were calculated for individuals aged more or less than 40 years. We highlighted homogeneous mean absolute errors for both HU and mBD values, most of them being less than 10 years. Moreover, we reported a moderate overestimation for younger individuals and a very small underestimation for older individuals. This study proposes a correlation between the bone density and age of individuals with a valuable level of reliability. Finally, HU measurements seem to be suitable for linking bone density with the age of individuals in forensic practice.

Summary Objective Cone beam computed tomography (CBCT) images can be useful for estimating cervical vertebrae maturity (CVM). The aim of this study was to evaluate the reliability of cephalograms derived from CBCT versus lateral cephalograms (LC) to estimate the CVM in a Peruvian population. Material and methods The sample evaluated consisted of 40 cephalograms derived from CBCT and 40 LC images from individuals aged 10–19 years. One trained and calibrated observer (Kappa scores ≥ 0.90) interpreted the CBCT and LC images twice. Intra-observer reliability of each maturation stage on CBCT sagittal slices and LC images were analysed using the weighted kappa statistics (α = 0.05). Comparison of CVM stages between CBCT slices and LC images were analysed by the Spearman rank correlation coefficient, p Results The weighted kappa test showed almost perfect intra-observer agreement for the CVM stages using the CBCT sagittal slices (0.873). Considering the LC images, the weighted kappa test showed almost perfect intra-observer agreement too (0.937). In both intra-observer agreement, the difference was limited to one maturation stage of the CVM method. The first and second intra-observer agreement for the CVM stages between the CBCT sagittal slices and LC images were almost perfect (0.937 and 0.874). High correlation values at the first (0.975) and second (0.976) intra-observer agreement for the CVM stages between CBCT sagittal slices and LC images were also found. Conclusion CBCT is a reliable method for CVM assessment and can be used as an alternative method for this purpose. The orthodontists might use the CBCT scans as a valuable tool for CVM method estimation.

Validation of classification system. To externally validate the Proximal Humerus Ossification System (PHOS) as a reliable skeletal maturity scoring system and to assess the learning curve associated with teaching the procedure to individuals of varying levels of experience. Assessment of skeletal maturity is essential for treatment decisions in Adolescent Idiopathic Scoliosis (AIS). PHOS is a five-stage system that uses the proximal humeral physis in assessing skeletal maturity and has been shown to reliably grade skeletal age leading up to and beyond peak growth age (PGA). This system is advantageous in the AIS patient, as it is often captured in standard scoliosis films. A medical student, an orthopedic surgery resident (PGY-2), spine fellow, and experienced scoliosis surgeon in his 25th year in practice were given a three-slide PHOS learning module. Each participant rated 100 X-rays on two separate occasions, separated by 1 week. Intra- and inter-observer reliability, as well as cross-institutional reliability, were calculated using intraclass correlation coefficients (ICC) with 95% confidence intervals [CI95]. Average intra-observer reliability ICC between scoring sessions was 0.94 [0.92, 0.96] and inter-observer reliability by level of training were 0.94 [0.91, 0.96], 0.93 [0.9, 0.95], 0.94 [0.91, 0.96], 0.96 [0.94, 0.97] for the medical student, PGY-2, fellow, and attending, respectively. Reliability across institutions was 0.99 [0.98, 0.99]. Combined rating observations (n = 400) showed 82% exact matches, as well as 17% and 1% mismatches by 1 and 2 stages, respectively. Similar to the PHOS developers, we found PHOS stage 3 to occur immediately after PGA. PHOS is easily learned and employed by raters with varying levels of training. It comprises a five-stage system to reliably measure bone age leading up to PGA and thereafter. This new system relies on visualization of the proximal humerus, which is readily available on standard scoliosis X-rays. Level III.